Behavioral self-management strategies for practice and exercise should be included in neurologic rehabilitation trials and care.

REVIEW URRENT C O PINION Behavioral self-management strategies for practice and exercise should be included in neurologic rehabilitation trials and care Bruce H. Dobkin Purpose of review Rehabilitation trials and postacute care to lessen impairments and disability after stroke, spinal cord injury, and traumatic brain injury almost never include training to promote long-term self-management of skills practice, strengthening and fitness. Without behavioral training to develop self-efficacy, clinical trials, and home-based therapy may fail to show robust results. Recent findings Behavioral theories about self-management and self-efficacy for physical activity have been successfully incorporated into interventions for chronic diseases, but rarely for neurologic rehabilitation. The elements of behavioral training include education about the effects of practice and exercise that are relevant to the person, goal setting, identification of possible barriers, problem solving, feedback about performance, tailored instruction, decision making, and ongoing personal or social support. Mobile health and telerehabilitation technologies offer new ways to remotely enable such training by monitoring activity from wearable wireless sensors and instrumented exercise devices to allow real-world feedback, goal setting, and instruction. Summary Motivation, sense of responsibility, and confidence to practice and exercise in the home can be trained to increase adherence to skills practice and exercise both during and after formal rehabilitation. To optimize motor learning and improve long-term outcomes, self-management training should be an explicit component of rehabilitation care and clinical trials. Keywords exercise, mHealth, self-efficacy, stroke rehabilitation, wearable sensors INTRODUCTION Experimental models and clinical trials of stroke and traumatic brain and spinal cord injury strongly point to the motor learning-related neural adaptions induced by task-related practice of pro- gressive difficulty at a high enough dose to drive goal-directed gains, especially early, but also at any time after injury [1,2,3 ]. Aerobic and resistance exercise also induce neuroplasticity by modulation of similar molecular, cellular, synaptic and genetic adaptations. Thus, efforts to increase walking and affected upper extremity practice, as well as exercise for fitness and strengthening during and beyond the time of formal rehabilitation have a compelling theoretical basis. The results of clinical trials built upon present concepts of motor learning, however, have been less than robust, in part because of their design [4]. One contributing cause may be the lack of home and community practice and exercise to supplement the modest intensity of usual formal training. Another is that little emphasis has been placed on providing timely behavioral training that can lead to self-directed practice and exercise, such as feedback about the quality and quantity of practice, as well as personalized communication to increase motivation, sense of competence, Geffen School of Medicine at the University of California Los Angeles, Reed Neurologic Research Center, Los Angeles, California, USA Correspondence to Dr Bruce H. Dobkin, MD, Professor of Neurology, Geffen School of Medicine at the University of California Los Angeles, Reed Neurologic Research Center, 710 Westwood Plaza, Los Angeles, CA 90095, USA. Tel: +1 310 2066500; e-mail: bdobkin@mednet.ucla.edu Curr Opin Neurol 2016, 29:693–699 DOI:10.1097/WCO.0000000000000380 1350-7540 Copyright s 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-neurology.com Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.