Jonathan Marsden

EEG‐based neurofeedback (ENF) may be utilised as an intervention for improvement of motor performance in Parkinson's movement impairment. This exploratory study aimed to determine the ability of healthy participants to bidirectionally modulate sensorimotor beta power using ENF in real time and examine learning trends. The protocol trained participants to increase and decrease the amplitude of their individual beta power over C3 using a double‐blind sham‐controlled and within‐subjects design. Fifteen healthy participants completed the study (mean age = 38.9, SD = 14.9, age range = 20–66; nine female and six male). Thirteen participants successfully decreased beta activity, three participants successfully increased it and two participants demonstrated bidirectional control. A Wilcoxon signed‐rank test showed that successful EEG control during real ENF was significantly higher than sham ENF when participants received the sham condition first ( Z = 3.80, p < 0.001). When participants received the real condition first, the difference in success was not statistically significant ( Z = 1.19, p = 0.233), indicating a transfer learning effect from real to sham sessions. ENF performance varied across ENF training based on modulation direction and cognitive variables, including mental strategy, engagement and fatigue. This study showed that initial ENF performance depends critically on how performance is defined and measured. Learning trends between real and sham conditions further suggest that early ENF performance primarily reflects strategy‐dependent, effort‐based control rather than stable neurophysiological plasticity. These findings highlight the need for a more precise framework for ENF evaluation, one that separates transient modulation, strategic learning and durable physiological adaptation.

Aim: A novel interactive exergaming device enables children with cerebral palsy (CP) to exercise whilst standing. A small study showed gains in ankle motion after training with the device. This study explores the feasibility of a community-based randomised controlled trial (RCT) using this device to improve mobility in children with CP (Registered ISRCTN80878394). Method: Fifteen children with CP Gross Motor Function Classification System (GMFCS) levels I-III were randomised 1:1 to either 10-weeks training with the device or usual care. Two potential primary outcome measures were assessed at 10-weeks with 20-week follow up: motion of the centre-of-mass estimate while stepping (Next Step) and Pediatric Balance Scale (PBS). Results: Twenty-one children were assessed for eligibility, three declined to participate, two withdrew and one did not receive the intervention but remained in follow-up. Two serious adverse events occurred (n=2). Participant recruitment was 1.2 per month, limited by device availability. Completion of PBS and Next Step was 100% and 87% at baseline, dropping to 75% and 65% respectively at 10-weeks. The intervention group showed clinically meaningful changes in median (interquartile range) PBS at 10-weeks 2.7 (1) compared to the control 1.7 (0.67). Conclusion: This study found multiple feasibility issues and further work is needed prior to implementing a RCT. There were signs of efficacy of the intervention, but findings are limited by small sample size.

Spasticity, a type of hypertonia characterized by a velocity-dependent increase in muscle tone, is associated with damage to the brain and/or spinal cord in different neurological conditions. However, secondary non-neurological factors, such as soft tissue changes, can complicate the assessment and differentiation of the underlying causes. Accurate assessment is crucial for effective treatment planning, with clinicians relying on passive movement to grade the “feel” of the spastic limb. This review aims to identify and evaluate the feasibility of spasticity models or simulations for clinical teaching. Models based on human spastic limbs were examined, with no restrictions on specific conditions or populations. A comprehensive search of four databases and gray literature was conducted to identify relevant studies. Criteria for inclusion focused on model development, data, and evaluation processes. Study selection and data extraction were carried out by independent reviewers, and data synthesis was performed by systematically mapping model properties, methods, and utility. The quality of the studies was assessed using an adapted framework for health technology assessments. The findings highlight opportunities for the development of simulation models to support training. However, significant limitations to the existing evidence base limit the feasibility of developing spasticity models based on existing literature.

Background: This study aimed to understand the experiences and views of children with cerebral palsy, their parents and physiotherapists participating in the ACCEPT feasibility randomised controlled trial, which explored a 10‐week physiotherapy intervention using an interactive gaming training device. Design: Qualitative methods included semi‐structured interviews, e‐diary and photographs. Nine parent–child dyads and three physiotherapists participated. Children were aged between 7 and 16 years; four had co‐existing additional needs. Interviews were transcribed. Reflexive thematic analysis was used. Results: Five themes covered the breadth of participants’ experiences: (1) Fitting in therapy; (2) Motivation; (3) New opportunities; (4) Physiotherapists out of their comfort zone; and (5) Altruism and challenges. Parents spoke of the challenge of finding time to engage their children in therapeutic exercise. Several children talked about trial‐related procedures (e.g. removal of adhesive markers) that they disliked. Physiotherapists, children and parents supported the gaming aspect of the device to improve motivation to exercise. Conclusions: Overall, the intervention and measures were acceptable to children and parents. Parents were willing to accommodate the device for 10 weeks and children found the gaming aspect both motivating and enjoyable. Physiotherapists required more support to solve technical problems with the device. A full trial evaluating the device requires additional technical support from the supplier and experienced ‘champion’ users. Exercise trainers that encompass gaming may increase motivation and adherence to therapeutic programmes. Patient or Public Contribution: Children, families and care givers were included in the study design. They helped to produce participant facing documents including the e‐diary and interview topic guides. The study steering committee included several parents and one teenager, and provided governance and oversight of the project.

Background: Functional motor disorder often causes persistent disabling symptoms that are associated with high healthcare costs. In recent years, specialist physiotherapy, informed by an understanding of functional motor disorder, has emerged as a promising treatment, but there is an absence of evidence of its effectiveness from large randomised controlled trials. Methods: We conducted a pragmatic, multicentre, randomised controlled trial, comparing specialist physiotherapy for functional motor disorder to treatment as usual, which was defined as community neurological physiotherapy. The primary outcome was the Short Form questionnaire-36 items Physical Functioning domain at 12 months (scale range 0–100, with 100 indicating optimum health). The trial was powered to detect a 9-point difference in the primary outcome with 90% power at the 5% level of significance. Secondary domains of measurement included a patient perception of improvement, health-related quality of life, mobility, anxiety, depression and illness perception. We also completed a health economic analysis with the primary aim of calculating the mean incremental cost per quality-adjusted life-year over 12 months. In prespecified analysis plans, we excluded participants from the primary analysis if they were unable to receive their trial-allocated treatment due to COVID-19 lockdown restrictions. Sensitivity analysis explored the impact of this decision. Results: Between 19 October 2018 and 31 January 2022, 355 adults with functional motor disorder were randomised (1 : 1) to specialist physiotherapy (n = 179) and treatment as usual (n = 176). Eighty-nine participants were excluded due to COVID-19 disruptions. Retention for the primary analysis was 90% for both groups, leaving 241 participants in the primary analysis. At 12 months, there was no between-group difference in the primary outcome (adjusted mean difference 3.5, 95% confidence interval −2.3 to 9.3). However, several secondary outcomes favoured specialist physiotherapy, including the participant perception of improvement, Short Form questionnaire-36 items Mental Health domain, confidence in the diagnosis and two subscales (Personal Control and Illness Coherence) of the Revised Illness Perception Questionnaire. There were no differences in the remaining outcomes. At 6 months, the following outcome measures were significantly different, in favour of specialist physiotherapy: participant perception of improvement, the Short Form questionnaire-36 items Physical Role Limitations, Short Form questionnaire-36 items Social Functioning, Short Form questionnaire-36 items Mental Health, EuroQol-5 Dimensions five-level version utility score, confidence in the diagnosis and three subscales (Timeline Cyclical, Personal Control and Treatment Control) of the Revised Illness Perception Questionnaire. No outcomes significantly favoured treatment as usual. In the health economic analysis, the incremental cost per quality-adjusted life-year gained from a health and social care cost perspective was £4133 with an 86% probability that specialist physiotherapy is cost-effective compared to treatment as usual at a cost-effectiveness threshold of £20,000 per quality-adjusted life-year gained. There were no adverse events related to physiotherapy. Conclusion: Specialist physiotherapy was not superior to treatment as usual for the primary outcome, the Short Form questionnaire-36 items Physical Functioning domain at 12 months. However, a number of secondary outcome measures favoured specialist physiotherapy at 6 and 12 months. There is a high probability that specialist physiotherapy is cost-effective. Limitations: Participants in treatment as usual waited longer to start physiotherapy, which resulted in a shorter time between concluding treatment and completing the primary outcome. Most outcome measures, including the primary outcome, were participant reported, which may have been biased by perceptions of the randomised treatment allocation. Future work: Future work should identify or develop more suitable outcome measures for functional motor disorder research, explore who is most likely to benefit from specialist physiotherapy and identify alternative interventions for those unlikely to benefit from this treatment. Additional work is needed to adapt treatment to meet the needs of minority groups and young people. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 16/31/63.

Background: Vestibular dysfunction occurs in 30% to 70% of cases with multiple sclerosis (MS). Objective: To compare the clinical and cost-effectiveness of a customized vestibular rehabilitation (VR) program with a generic booklet-based VR intervention in people with MS with clinical signs of vestibulopathy. Methods: People with MS and symptoms of vertigo and/or imbalance were screened for vestibulopathy (n = 73). Seventy recruited participants were randomly allocated to a 12-week generic booklet-based home program with telephone support (n = 35) or a 12-week customized VR program (n = 35, 12 face-to-face sessions and a home exercise program). The primary clinical outcome was the Dizziness Handicap Inventory (DHI) at 26 weeks post-randomization. The primary economic endpoint was quality-adjusted life-years (QALYs). Secondary outcomes included vertigo severity, balance, gait, and perceived impact of physical symptoms in MS. Results: There was no significant between-group difference in the DHI: mean reduction −1.76 (95% confidence interval −10.02, 6.50) at week 26 in favor of the customized group ( P = .670). There were significant differences in favor of the customized group for vertigo symptom score, balance confidence, walking, and perceived impact of MS. Primary cost-effectiveness analysis showed customized VR to be less costly and more effective. However, removal of 2 cost outliers in sensitivity analysis resulted in a mean cost-per-QALY of £30 147. Customized VR was also cost-effective from a societal perspective. Discussion: Impairment level improvements did not translate into functional improvements as measured by the DHI perhaps reflecting that vestibular dysfunction is one of several impairments in MS. The findings indicate the potential cost-effectiveness of the customized program. Clinical Trial Registration: ISRCTN27374299.

Functional motor disorder (FMD), a motor-dominant variant of functional neurologic disorder, is a disabling condition associated with high health and social care resource use and poor employment outcomes. Specialist physiotherapy presents a possible treatment option, but there is limited evidence for clinical effectiveness and cost-effectiveness. Physio4FMD is a multicenter randomized controlled trial of specialist physiotherapy for FMD compared with treatment as usual (TAU). The aim of the analysis was to conduct a randomized trial based on economic evaluation of specialist physiotherapy compared with TAU. Eleven centers in England and Scotland randomized participants 1:1 to specialist physiotherapy or TAU (referral to community neurologic physiotherapy). Participants completed the EuroQoL EQ-5D-5L, Client Service Receipt Inventory, and Work Productivity and Activity Impairment Questionnaire at baseline, 6 months, and 12 months. The mean incremental cost per quality-adjusted life year (QALY) for specialist physiotherapy compared with TAU over 12 months was calculated from a health and social care and wider societal perspective. The probability of cost-effectiveness and 95% CIs were calculated using bootstrapping. The analysis included 247 participants (n = 141 for specialist physiotherapy, n = 106 for TAU). The mean cost per participant for specialist physiotherapy was £646 (SD 72) compared with £272 (SD 374) for TAU. Including the costs of treatment, the adjusted mean health and social care cost per participant at 12 months for specialist physiotherapy was £3,814 (95% CI £3,194–£4,433) compared with £3,670 (95% CI £2,931–£4,410) for TAU, with a mean incremental cost of £143 (95% CI £–825 to £1,112). There was no significant difference in QALYs over the 12-month duration of the trial (0.030, 95% CI –0.007 to 0.067). The mean incremental cost per QALY was £4,133 with an 86% probability of being cost-effective at a £20,000 threshold. When broader societal costs such as loss of productivity were taken into consideration, specialist physiotherapy was dominant (incremental cost: £−5,169, 95% CI £–15,394 to £5,056). FMD was associated with high health and social care costs. There is a high probability that specialist physiotherapy is cost-effective compared with TAU particularly when wider societal costs are taken into account. International Standard Randomised Controlled Trial registry, ISRCTN56136713.

Background/Objectives: This study investigates the relationship between movement-related beta synchrony and primary motor cortex (M1) excitability, focusing on the time-dependent inhibition of movement. Voluntary movement induces beta frequency (13–30 Hz) event-related desynchronisation (B-ERD) in M1, followed by post-movement beta rebound (PMBR). Although PMBR is linked to cortical inhibition, its temporal relationship with motor cortical excitability is unclear. This study aims to determine whether PMBR acts as a marker for post-movement inhibition by assessing motor-evoked potentials (MEPs) during distinct phases of the beta synchrony profile. Methods: Twenty-five right-handed participants (mean age: 24 years) were recruited. EMG data were recorded from the first dorsal interosseous muscle, and TMS was applied to the M1 motor hotspot to evoke MEPs. A reaction time task was used to elicit beta oscillations, with TMS delivered at participant-specific time points based on EEG-derived beta power envelopes. MEP amplitudes were compared across four phases: B-ERD, early PMBR, peak PMBR, and late PMBR. Results: Our findings demonstrate that MEP amplitude significantly increased during B-ERD compared to rest, indicating heightened cortical excitability. In contrast, MEPs recorded during peak PMBR were significantly reduced, suggesting cortical inhibition. While all three PMBR phases exhibited reduced cortical excitability, a trend toward amplitude-dependent inhibition was observed. Conclusions: This study confirms that PMBR is linked to reduced cortical excitability, validating its role as a marker of motor cortical inhibition. These results enhance the understanding of beta oscillations in motor control and suggest that further research on altered PMBR could be crucial for understanding neurological and psychiatric disorders.