NeuroRehabilitation - Volume 43, issue 4

Authors: Skoutelis, Vasileios C. | Kanellopoulos, Anastasios | Vrettos, Stamatis | Gkrimas, Georgios | Kontogeorgakos, Vasileios

Article Type: Research Article

Abstract: BACKGROUND: Selective Percutaneous Myofascial Lengthening (SPML) is an innovative minimally invasive surgical procedure, using micro incisions often combined with alcohol nerve block, for managing muscle contractures and stiffness in children with cerebral palsy (CP). There is lack of evidence of effects of a combined intervention of SPML and physiotherapy on gait function and muscle strength in CP. OBJECTIVE: This study investigated the change in gait function and muscle strength in children with CP who underwent gait laboratory assessment before and after SPML, combined with obturator nerve blocks, and 9-month post-surgical functional physiotherapy. METHODS: Ten children with …bilateral spastic CP, Gross Motor Function Classification System (GMFCS) level II-IV, age 5-7 years, participated in this study. The Global Gait Graph Deviation Index (Global GGDI) and isometric muscle strength (hand-held dynamometry) were the primary outcome measures. Changes in spatiotemporal gait parameters, gross motor function and GMFCS level were secondarily examined. RESULTS: A significant improvement of Global GGDI was found (p  < 0.05). The mean strength in hip flexors, extensors and adductors, knee extensors, and ankle dorsiflexors increased significantly (p  < 0.05). Children improved significantly their GMFCS level and gross motor capacity (p  < 0.05). CONCLUSIONS: SPML procedure combined with functional physiotherapy can improve gait function and lower-limb muscle strength. Show more

Keywords: Cerebral palsy, surgical muscle lengthening, functional physiotherapy

DOI: 10.3233/NRE-182468

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 361-368, 2018

Authors: Powell, Elizabeth Salmon | Korupolu, Radha | Westgate, Philip M. | Carrico, Cheryl | Reddy, Lakshmi | Sawaki, Lumy

Article Type: Research Article

Abstract: BACKGROUND: Non-invasive transcranial direct current stimulation has been shown to modulate cortical excitability in various studies. Similarly, recent preliminary studies suggest that transcutaneous spinal direct current stimulation (tsDCS) may engender a modulation effect on spinal and cortical neurons. OBJECTIVE: The purpose of this study was to evaluate the dose-response effects of tsDCS in healthy subjects and thereby lay groundwork for expanding treatment options for patients with spinal cord injury (SCI). METHODS: Nine healthy subjects received each of the following 2 tsDCS conditions: Anodal and cathodal, in random order with at least 1 week washout period between …each session. In order to test safety and dose response, various current intensities were used (2, 2.5 and 3 mA) for 20 minutes. The active electrode was placed vertically over T10–T11, and the reference electrode was placed over the left shoulder. To evaluate corticospinal excitability, motor evoked potentials over soleus muscle elicited by transcranial magnetic stimulation were measured. To assess spinal cord excitability, H- and M- wave over soleus muscle to calculate Hmax / Mmax ratio were measured. RESULTS: Linear regression showed a dose response with cathodal tsDCS on motor evoked potentials measured from the left leg as well as with anodal tsDCS on Hmax / Mmax ratio measured from the left leg. CONCLUSIONS: These findings indicate tsDCS effects are dose-dependent. These effects should be investigated in a larger sample. Show more

Keywords: Neuromodulation, transvertebral spinal direct current stimulation, spinal cord, neurorehabilitation

DOI: 10.3233/NRE-182469

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 369-376, 2018

Authors: Marsh, Nigel V.

Article Type: Research Article

Abstract: OBJECTIVE: This study reports the results from a 5-year longitudinal investigation of the prevalence and severity of cognitive deficits following significant (i.e., ventilation required for > 24 hours) traumatic brain injury. The changes in performance, either improvement or decline, across five domains of cognitive functioning are described. METHOD: A group of 56 adults was assessed at approximately 6 months, 1 year, and 5 years following injury. RESULTS: Impairment was evident on all measures but prevalence and rate of improvement varied. Overall, by 5 years post-injury over 85% of patients were not impaired on measures of general intelligence, simple …attention, and visual perception. However, 28% of patients continued to show some degree of impairment on complex attention and verbal fluency, and performance on verbal memory remained impaired for 60% of patients. There was also evidence for deterioration in complex attention and verbal memory between 1 year and 5 years. ANOVAs showed that improvement occurred on most measures between 6 months and 1 year, but there was both improvement and decline on some measures between 1 year and 5 years. CONCLUSIONS: The findings show that there is considerable heterogeneity in cognitive outcome following TBI, with some deterioration evident over the long term. Show more

Keywords: Cognition, head injury, outcome, longitudinal design, neuropsychological assessment, long-term follow-up

DOI: 10.3233/NRE-182457

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 377-386, 2018

Authors: Ruecker, Michael | Zepharovich, Katharina | Zorowka, Patrick | Matzak, Heinrich | Kofler, Markus | Saltuari, Leopold

Article Type: Research Article

Abstract: INTRODUCTION: Dysphagia is a frequent problem in various neurological disorders. However, knowledge on swallowing function in patients with cerebral hypoxia is sparse. The objective of this study is to report the development of swallowing function in a series of adolescent and young-adult patients with cerebral hypoxia. METHODS: We recruited eight patients (1 male) who were admitted to our institution after the acute phase following cerebral hypoxia. Each patient underwent detailed neurological evaluation, magnetic resonance imaging (MRI), standardized neurophysiological assessment and repeated clinical and fiber-endoscopic evaluation of swallowing. Furthermore, all patients received daily physical and occupational therapy and intensive …logopedic therapy for swallowing. RESULTS: Mean age in this case series was 19.9±3.6 years (range 16-25). All eight patients initially displayed severe swallowing dysfunction, but the reflexive components of swallowing were intact in seven patients without brainstem lesions. The only patient with additional brainstem involvement initially suffered from absence of an intact swallowing reflex and developed silent aspiration. However, follow-up examinations revealed intact swallowing reflexes in all eight patients. DISCUSSION: Dysphagia is common in patients with cerebral hypoxia, mainly resulting in a delayed oral phase consistent with impaired volitional execution of swallowing. Additional lesions in the brainstem may affect the integrity of the central pattern-generating circuitry for swallowing, resulting in additional dysfunction of the non-volitional reflexive component. In conclusion, dysphagia in patients with cerebral hypoxia is a common complication particularly in the early stages of remission, while long-term prognosis with respect to swallowing is often good. Swallowing function should be closely monitored in patients with acquired brain injury. Show more

Keywords: Deglutition, dysphagia, swallowing, cerebral hypoxia, neurorehabilitation

DOI: 10.3233/NRE-182437

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 387-393, 2018

Authors: Alhwoaimel, Norah | Turk, Ruth | Warner, Martin | Verheyden, Geert | Thijs, Liselot | Wee, Seng Kwee | Hughes, Ann-Marie

Article Type: Review Article

Abstract: BACKGROUND: Post-stroke trunk control is reported to be associated with trunk performance and recovery of the upper limb, but the evidence for the influence of trunk exercise on both of these is unclear. OBJECTIVE: To evaluate the effect of trunk exercises on trunk performance post-stroke, and to determine if these exercises result in improved upper limb function. METHODS: A comprehensive search of the literature published between January 1990 and February 2017 was conducted using the following electronic databases; AMED, CINAHL, Cochrane Library, EMBASE, MEDLINE, PsychInfo and SPORTDiscus. Only randomized, controlled trials, published in English, evaluating the …effect of trunk exercises on trunk performance and/or upper limb function post-stroke, were included. RESULTS: A total of 17 studies involving 599 participants were analysed. Meta-analysis showed that trunk exercises had a large significant effect on trunk performance post-stroke. This effect varied from very large for acute stroke to medium for subacute and chronic stroke. None of the included studies had measured the effect of trunk exercise on upper limb impairment or functional activity. CONCLUSIONS: Trunk exercises improve trunk performance for people with acute, subacute and chronic strokes. As yet there is no evidence to support the effect of trunk exercise on upper limb function. Show more

Keywords: Meta-analysis, systematic review, stroke, trunk exercise, trunk, upper limb

DOI: 10.3233/NRE-182446

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 395-412, 2018

Authors: Turville, Megan L. | Matyas, Thomas A. | Blennerhassett, Jannette M. | Carey, Leeanne M.

Article Type: Research Article

Abstract: BACKGROUND: Somatosensory loss occurs often following stroke. A proportional recovery model is proposed for spontaneous motor recovery, with implication for treatment planning. It is currently unknown if initial severity of sensory impairment influences stroke survivors’ response to treatment to improve sensation. OBJECTIVE: To examine if initial (pre-treatment) severity of upper limb somatosensory impairment is related to sensation outcomes following treatment. METHODS: Regression analysis was used to investigate the relationship between initial and post-treatment sensation performance. Data were pooled from two randomized controlled trials of somatosensory discrimination retraining (N  = 80). Upper limb somatosensation was measured using standardized …tests of sensory discrimination: Fabric Matching Test, Wrist Position Sense Test, and functional Tactile Object Recognition Test. RESULTS: Post-treatment somatosensory improvement patterns were proportional to the extent of initial pre-treatment somatosensory impairment (Texture discrimination: B  = 0.74, 95% CIs [0.52, 0.96]; Proprioception: B  = 0.35, 95% CIs [0.24, 0.47]; Object recognition: B  = 0.85, 95% CIs [0.75, 0.95]). CONCLUSIONS: The effect of somatosensory retraining on post-treatment sensation was proportional to the extent of upper limb initial somatosensory impairment. Findings suggest sensory retraining can benefit stroke survivors of varying severity of sensory impairment, including those with more severe somatosensory loss. Show more

Keywords: Stroke, sensation, treatment

DOI: 10.3233/NRE-182439

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 413-423, 2018

Authors: Takeda, Kazuya | Tanabe, Shigeo | Koyama, Soichiro | Shomoto, Koji | Naoi, Yuki | Sakurai, Hiroaki | Kanada, Yoshikiyo

Article Type: Research Article

Abstract: BACKGROUND: The relationship between peak torque of the knee extensor muscles and gait speed was previously investigated in patients with chronic stroke, but whether the rate of force development (RFD), another indicator of muscle strength, affected gait speed remained unknown. OBJECTIVE: To clarify the relationships between the RFD of the knee extensor muscles over multiple time intervals and gait speed in patients with chronic stroke. METHODS: Twenty chronic stroke patients participated in this study. The RFD of affected and unaffected knee extensor muscles was measured. Time intervals of the RFD were set to 0–50 ms, 0–100 ms (100RFD), …0–200 ms (200RFD), and 0–300 ms (300RFD). Gait speed was assessed at comfortable and maximum pace. Pearson correlation coefficient (r) was used to analyze the relationships between RFD and gait speeds. RESULTS: The RFD of affected knee extensor muscles over all intervals was moderately correlated with both comfortable and maximum gait speeds, whereas only limited combinations (100, 200 and 300RFD with maximum gait speed) were correlated on the unaffected side. CONCLUSIONS: The present results suggest that various factors related to the RFD of affected knee extensor muscles, such as neural drive and muscle size, affect gait speed. Show more

Keywords: Stroke, rate of force development, gait speed, correlation

DOI: 10.3233/NRE-182455

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 425-430, 2018

Authors: Laffey, Megan | Darby, Adam J. | Cline, Michael G. | Teng, Edmond | Mendez, Mario F.

Article Type: Research Article

Abstract: BACKGROUND: Repetitive traumatic brain injury (TBI) is associated with chronic traumatic encephalopathy (CTE), a progressive neurodegenerative disorder characterized by Alzheimer-like changes in the brain. CTE has been defined through neuropathological findings among deceased athletes and others exposed to repetitive TBI, but to date there are no definitive clinical criteria for CTE. OBJECTIVE: To evaluate the utility of currently proposed clinical criteria for CTE and suggest improvements. METHODS: We describe two well-characterized patients referred for evaluation of CTE and apply the four major proposed criteria for CTE. These criteria were further assessed in a cohort of patients …referred to a neurobehavior clinic with or without a history of TBI. RESULTS: Without a CTE biomarker, the current criteria were of limited utility when applied to the two patient and the Neurobehavior cohort. Six items were extracted as potentially improving the clinical diagnosis of CTE: length of exposure to head impacts, a progressive course, specific psychiatric symptoms, frontal-executive dysfunction, parkinsonism and tremors, and targeted findings on neuroimaging. CONCLUSIONS: The prevention and neurorehabilitation of CTE depends on clinical diagnosis, but, without a biomarker, the clinical diagnosis of CTE remains difficult. This report suggests that clinical criteria for CTE may be greatly improved with emphasis on several critical historical and clinical correlates of CTE. Show more

Keywords: Chronic traumatic encephalopathy, traumatic brain injury, dementia

DOI: 10.3233/NRE-182452

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 431-441, 2018

Authors: Clare, Linda | Teale, Julia C. | Toms, Gill | Kudlicka, Aleksandra | Evans, Isobel | Abrahams, Sharon | Goldstein, Laura H. | Hindle, John V. | Ho, Aileen K. | Jahanshahi, Marjan | Langdon, Dawn | Morris, Robin | Snowden, Julie S. | Davies, Rhys | Markova, Ivana | Busse, Monica | Thompson-Coon, Jo

Article Type: Review Article

Abstract: BACKGROUND: Despite its potentially significant impact, cognitive disability may be overlooked in a number of progressive neurodegenerative conditions, as other difficulties dominate the clinical picture. OBJECTIVE: We examined the extent, nature and range of the research evidence relating to cognitive rehabilitation, self-management, psychotherapeutic and caregiver support interventions in Parkinsonian disorders, multiple sclerosis (MS), frontotemporal dementias (FTD), motor neuron disease and Huntington’s disease. METHODS: Scoping review based on searches of MEDLINE and CINAHL up to 15 March 2016. RESULTS: We included 140 eligible papers. Over half of the studies, and almost all the randomised controlled …trials, related to MS, while a number of single case studies described interventions for people with FTD. CR interventions addressed functional ability, communication and interaction, behaviour or memory. The majority of psychotherapy interventions involved cognitive behavioural therapy for depression or anxiety. Self-management interventions were mainly available for people with MS. There were few reports of interventions specific to caregivers. Numerous methodological challenges were identified. CONCLUSIONS: The limited range of studies for all conditions except MS suggests a need firstly to synthesise systematically the available evidence across conditions and secondly to develop well-designed studies to provide evidence about the effectiveness of CR and other psychological interventions. Show more

Keywords: Parkinson’s disease, multiple sclerosis, frontotemporal dementia, motor neuron disease, Huntington’s disease, self-management, psychotherapy, caregiver

DOI: 10.3233/NRE-172353

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 443-471, 2018

Authors: Khalil, Hanan | Al-Sharman, Alham | El-Salem, Khalid | Alghwiri, Alia A. | Al-Shorafat, Duha | Khazaaleh, Shada | Abu foul, Lamees

Article Type: Research Article

Abstract: BACKGROUND: Balance deficits are considered a risk factor for falls in MS patients. Therefore, developing innovative approaches such as virtual reality (VR) to improve balance in MS is required. OBJECTIVES: The aims of this study were to develop and evaluate feasibility and acceptability of VR scenarios that target balance in MS using a pilot trial. METHODS: Participants were randomly allocated to either a VR training (i.e. intervention group) (n  = 20) or a control group (n  = 20). Intervention group received VR training for 6 weeks. Control group received home-based traditional balance exercises without the VR. Participants were …assessed at baseline and follow-up on Berg Balance Scale (BBS), Timed Up and Go (TUG), the 10 Meter Walk Test (10-MWT), the 3 Minute Walk Distance (3-MWD), the Modified Fatigue Impact Scale (MFIS) Fall Efficacy Scale- International (FES-I) and the Short Form 36 (SF-36). RESULTS: Six VR scenarios weer developed. Sixteen participants in the intervention and 16 in the control group completed the study. Significant differences between the two groups were observed at on BBS, MFIS and several outcomes of the SF-36 survey (P  < 0.05). Participants reported overall level of satisfaction with the developed VR scenarios. CONCLUSIONS: Findings demonstrated the feasibility and acceptability of a VR-based program in MS individuals. Our findings support the implementation of a larger trial of longer-term VR program. Show more

Keywords: Multiple sclerosis, virtual reality, balance, motor training, rehabilitation

DOI: 10.3233/NRE-182471

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 473-482, 2018

Authors: Jeng, Brenda | Sandroff, Brian M. | Motl, Robert W.

Article Type: Research Article

Abstract: BACKGROUND: The energetic cost of walking (Cw ) is elevated in persons with multiple sclerosis (MS). This may be explained by spasticity and spatiotemporal parameters of gait. OBJECTIVE: To examine the associations among Cw , spasticity of ankle plantarflexors, and spatiotemporal gait parameters in persons with MS who had moderate disability. METHODS: The sample included 44 persons with MS who had moderate disability. Cw was measured over-ground during the 6-Minute Walk using indirect calorimetry and was calculated based on net oxygen consumption and walking speed (i.e., expressed ml·kg– 1 ·m– 1 ). Participants underwent the …Modified Ashworth Scale as a measurement of spasticity and performed 4 trials of walking on a GAITRite electronic walkway for measurement of spatiotemporal gait parameters. RESULTS: Spasticity was positively correlated with Cw (r  = 0.52, p  < 0.05) and inversely correlated with cadence (r  = –.45, p  < 0.05) and step length (r  = –0.40, p  < 0.05). Cadence (r  = –0.59, p  < 0.05) and step length (r  = –0.56, p  < 0.05) were inversely correlated with Cw . The regression analysis indicated that spasticity explained significant variance in Cw , and cadence and step length accounted for the association. CONCLUSIONS: These results suggest that worse spasticity of the ankle plantarflexors and slower cadence and shorter step length, in turn, are responsible for elevated Cw among persons with MS with moderate disability. This supports the development of therapeutic, rehabilitation interventions delivered by clinicians for managing spasticity and the resulting Cw that may interfere with activities of daily living. Show more

Keywords: Multiple sclerosis, energy expenditure, spasticity, walking, rehabilitation

DOI: 10.3233/NRE-182498

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 483-489, 2018

Authors: Foley, T. | McKinlay, A. | Warren, N. | Stolwyk, R.J.

Article Type: Research Article

Abstract: INTRODUCTION: While cognitive impairment is a recognised feature of Parkinson’s disease (PD), few studies have evaluated the validity of brief cognitive screening measures compared to a comprehensive neuropsychological assessment. This studies aim was to evaluate the sensitivity and specificity of the Mini-Mental State Examination (MMSE), Modified Mini-Mental State Examination and Dementia Rating Scale (DRS-2) to detect cognitive impairment in individuals with PD. METHOD: Fifty-eight participants were administered the MMSE, 3MS, DRS-2 and a neuropsychological battery. ROC analyses were conducted to assess their effectiveness in classifying cognitive impairment. RESULTS: None of the three measures demonstrated good sensitivity …or specificity to detect single domain cognitive impairment. For detecting impairment on two or more cognitive domains, the MMSE and DRS-2 yielded excellent sensitivity (88%) and specificity (78% and 76% respectively), at cut-off scores of 28 and 136 respectively. The 3MS demonstrated excellent sensitivity (88%) and good specificity (60%) at cut off score of 94. CONCLUSION: The MMSE and DRS-2 have excellent discriminant ability to classify multi-domain cognitive impairment in PD, however, their ability to detect more focal cognitive impairment is limited. Given that focal domain may be an indicator that could be useful in early detection of cognitive impairment for people with PD, this finding has implication for the use of these measures as screening tools in clinical practice. Show more

Keywords: Parkinson’s disease, screening measures, cognitive impairment

DOI: 10.3233/NRE-182433

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 491-500, 2018

Authors: Al-Jarrah, Muhammed D. | Erekat, Nour S.

Article Type: Research Article

Abstract: BACKGROUND: Induction of Parkinson disease (PD) causes interleukin-1 beta (IL-1β) and tumor necrosis factor-alpha (TNF-α) upregulation in gastrocnemius skeletal muscles. Endurance exercise suppresses iNOS and HSP90 overexpression in PD skeletal muscle. The purpose of this study is to test the impact of treadmill exercise training on PD-associated IL-1β and TNF-α upregulation in the gastrocnemius muscle. METHODS: Thirty normal albino mice were randomly selected and divided into three equal groups: sedentary control (SC), sedentary PD (SPD), and Exercised PD (EPD). Chronic Parkinsonism was induced by treating mice in the SPD and EPD groups with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine and probenecid (MPTP/p). …Gastrocnemius muscles were examined for the expression of IL-1β and TNF-α using immunohistochemistry in the three different groups. RESULTS: Endurance exercise training significantly decreased both IL-1β and TNF-α expression in skeletal muscle in EPD (P value < 0.01) compared with that in the SPD. CONCLUSION: Our present data suggest that PD-induced upregulation of IL-1β and TNF-α in the gastrocnemius muscle could be reversed following endurance exercise training. Accordingly, IL-1β and TNF-α might be considered therapeutically to ameliorate skeletal muscle abnormalities characterizing PD. Show more

Keywords: Parkinson disease, interleukin 1β, gastrocnemius muscle, exercise, immunohistochemistry

DOI: 10.3233/NRE-182492

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 501-507, 2018

Authors: Sung, Wen-Hsu | Liu, Cheng-Chun | Wei, Shun-Hwa | Chuang, Long-Ren | Chuang, Eric | Wang, Kevin A. | Wang, Jia-Chi

Article Type: Research Article

Abstract: BACKGROUND: Traditional Tai Chi is too complex for most elderly individuals. There have been few reports regarding the development of simplified Tai Chi programs to suit the physical needs of elderly adults. However, these programs were not individualized according to the participants’ balance control abilities. OBJECTIVE: Purpose of this study is to develop an individualized Tai Chi program and report the feasibility of the program. METHODS: Phase 1: Five Tai Chi masters performed the Tai Chi movements on a force platform. Based on the results of center of pressure displacement and the individual’s balance abilities, an …individualized program was developed. Phase 2: Ten community-dwelling older adults received 24 half-hour-sessions, using the individualized Tai Chi exercise program. The Berg Balance Scale (BBS) score, Timed Up & Go (TUG) test, forward reach, and strength of the knee extensor were determined before and after intervention. RESULTS: Participants achieved improved performance on balance control as measured with BBS (p ≤0.001), TUG (p  = 0.004) and forward reach (p  = 0.035) as well as knee extensor strength (p  = 0.002) after the program. CONCLUSIONS: This preliminary result suggests that the individualized Tai Chi program is potentially effective to improve balance function and knee extensor strength of the elderly. Show more

Keywords: Exercise therapy, postural balance, rehabilitation, Tai Chi

DOI: 10.3233/NRE-162061

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 509-518, 2018

Authors: dos Santos, Adriana Neves | Rocha, Nelci Adriana Cicuto Ferreira

Article Type: Research Article

Abstract: BACKGROUND: Kinesiotaping (KT) has been commonly used in clinical setting. However, beneficial KT effects have not been proved yet. OBJECTIVE: We aimed to verify the effects of KT in knee extensor torque in children with CP. METHODS: We evaluated three children diagnosed as spastic CP, classified as level I, II and III, according with GMFCS. Knee extensor peak torque was analyzed by isokinetic evaluation (Biodex Multi Joint System). The test was performed at 60°/s in the concentric passive mode and the children performed maximal contractions. Children with CP were evaluated with and without KT under rectus …femoris. RESULTS: After KT application, knee peak torque of the affected limb increased in children with CP. CONCLUSION: KT may increase muscle strength in children with CP. Show more

Keywords: Taping, rehabilitation, strength, isokinetic

DOI: 10.3233/NRE-161921

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 519-523, 2018

Authors: Oral, Aydan

Article Type: Research Article

DOI: 10.3233/NRE-189002

Citation: NeuroRehabilitation, vol. 43, no. 4, pp. 525-528, 2018