More than 1.5 million people suffer a stroke in Europe per year and more than 70% of stroke survivors experience limited functional recovery of their upper limb, resulting in diminished quality of life. Therefore, interventions to address upper-limb impairment are a priority for stroke survivors and clinicians. While a significant body of evidence supports the use of conventional treatments, such as intensive motor training or constraint-induced movement therapy, the limited and heterogeneous improvements they allow are, for most patients, usually not sufficient to return to full autonomy. Various innovative neurorehabNIBSilitation strategies are emerging in order to enhance beneficial plasticity and improve motor recovery. Among them, robotic technologies, brain-computer interfaces, or noninvasive brain stimulation (NIBS) are showing encouraging results. These innovative interventions, such as NIBS, will only provide maximized effects, if the field moves away from the “one-fits all” approach toward a “patient-tailored” approach. After summarizing the most commonly used rehabilitation approaches, we will focus on and highlight the factors that limit its widespread use in clinical settings. Subsequently, we will propose potential biomarkers that might help to stratify stroke patients in order to identify the individualized optimal therapy. We will discuss future methodological developments, which could open new avenues for poststroke rehabilitation, toward more patient-tailored precision medicine approaches and pathophysiologically motivated strategies.
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[Abstract] Post-stroke spasticity management including a chosen physiotherapeutic methods and improvements in motor control – review of the current scientific evidence.
Cerebrovascular diseases based on stroke etiology concern millions of people worldwide, and annual rates of disease are still increasing. In the era of an aging society and suffering from a number of risk factors, in particular those modifiable, strokes and muscles’ spastic paresis, subsequently resulting in damage of upper motor neuron structures will become a serious problem for the entire health care system. Effective management and physiotherapy treatment for post-stroke spasticity persisted, both in the acute and chronic, is still a significant medical problem in the interdisciplinary aspect. Care procedures for this type of patient becomes a kind of challenge for specialists in neurology, internal medicine, cardiology, dermatology or neurosurgery, but also for physiotherapists in their everyday clinical practice. The aim of this paper is to present the issues of cerebral stroke and resulting spastic hypertonia in terms of current pharmacological treatment and surgery, and primarily through the use of effective physiotherapy methods, the use of which was confirmed in the way of reliable scientific research in accordance with the principles of Evidence Based Medicine and Physiotherapy (EBMP).
[Abstract] Neurotech: Robotic Assist Devices Show Gains in Walking for Crouch Gait in Cerebral Palsy and Post-Stroke Hemiparesis
ARTICLE IN BRIEF
Three novel robotic assistance devices, one for hemiparetic gait following stroke, and two for crouch gait in children with cerebral palsy, have each demonstrated improved walking in preliminary clinical trials.
For stroke patients, a robotic exosuit made of a soft, clothing-like anchor attached to motorized cables was shown to increase the paretic limb’s forward propulsion and the paretic ankle’s swing phase dorsiflexion in both treadmill and over-ground walking.
For children with crouch gait due to cerebral palsy, one trial used a cable-driven robot called a Tethered Pelvic Assist Device, or TPAD. The laboratory-based device is designed to strengthen the extensor muscles, especially the soleus in the calves, by putting downward pressure on them during training. After six weeks of practice with the device, the children’s posture was more upright, with greater step length and toe clearance, when walking without it.
Also for children with crouch gait, the third study examined the use of a wearable exoskeleton that provides a burst of knee extension assistance at just the right moment when a child or adolescent is walking. None of the seven participants, age 5 to 17, fell while using it, and six of the seven showed postural improvements equivalent to those previously reported from surgery.
While promising, the devices will require far more testing in randomized trials before their true value can be known, said a leading specialist in neurological rehabilitation.
“These are foundational studies; they’re just beginning to get started,” said Bruce H. Dobkin, MD, FRCP, distinguished professor of clinical neurology and director of the Neurological Rehabilitation and Research Program at the Geffen School of Medicine at the University of California, Los Angeles. “The cost, safety, user-friendliness, and ability to use at differing levels of disability severity — all those are major challenges.”
Even so, each of the three devices employs a new kind of robotic assistance unlike any existing on the market.
“Most robotics for neurological injuries are heavy, power-hungry exosuits for people with spinal cord injuries who can’t walk at all,” said a coauthor of the study for stroke patients, Terry D. Ellis, PT, PhD, NCS, director of the Center for Neurorehabilitation at Boston University. “But there’s a whole bunch of people who have disabilities, who can walk, but don’t walk well. They need facilitation or augmentation to restore some of the normal components of walking.”
A ROBOT POST-STROKE
Published in the July 26 edition of Science Translational Medicine, the study of a robotic exosuit tested in nine post-stroke patients used what it called “garment-like, functional textile anchors” rather than a hard, metallic exterior. Worn on only the paretic limb, the suit was designed to be as unobtrusive as possible.
“It’s much more compatible with the real world than a rigid device would be,” said the first author of the paper, Louis N. Awad, PT, DPT, PhD, an assistant professor of physical therapy at Boston University, and a research faculty member at Spaulding Rehabilitation Hospital. “Ordinary clothes are made of soft material. We don’t don a metallic pair of pants and walk out the door. That’s our goal — robotic clothing that helps people with difficulty walking.”
Attached to cables tethered to a belt worn around the hips, the exosuit functioned in synchrony with a wearer’s paretic limb to facilitate an immediate increase in the paretic ankle’s swing phase dorsiflexion and forward propulsion (p< 0.05), according to the paper.
The improved movements resulted in a 20 percent reduction in forward propulsion interlimb asymmetry and a 10 percent reduction in the energy cost of walking, which together were equivalent to a nearly one-third lower metabolic burden — a 32 percent reduction — while walking.
Although the study did include some over-ground walking, it was not designed to test whether the exosuit had any therapeutic effects that might carry over to when patients are not wearing it.
“This is a proof of concept paper,” said Dr. Ellis. “Down the road we need to conduct trials in more ecologically valid environments, and to see if it has therapeutic value. For now we wanted to demonstrate that the device can facilitate more normal walking.”
While applauding the study as “clever,” Dr. Dobkin said it remained to be seen whether the robotic exosuit would prove to have significant therapeutic effects that would stand up in randomized trials in natural environments. He pointed to randomized trials published in recent years showing that peroneal nerve functional electrical stimulators have no greater therapeutic effect than do standard ankle-foot orthoses.
“It’s similar to all the work that was done using the electrical stimulation of the ankle,” Dr. Dobkin said. “The real question is whether it will lead to improved function when you walk over-ground. Walking on a treadmill is not terribly natural.”
He also pointed out that the nine patients in the study were able to walk on average at about two miles per hour. “That’s already pretty fast,” he said. In addition, he said, the 20 percent reduction in interlimb asymmetry is relatively modest.
But, said Dr. Dobkin, people can improve their gait by 20 percent just by sustained practice. “When you see modest changes like this with the device, you wonder if the same changes couldn’t have been achieved without it,” he said.
Steven L. Wolf, PhD, PT, FAPTA, FAHA, professor in the department of rehabilitation medicine at Emory University School of Medicine, pointed out that existing robotic devices to help people who are completely unable to walk can cost patients up to $250,000. Perhaps the exosuit might become an improvement over what presently exists both in terms of function and cost, he said.
“Most existing devices are beautiful but incredibly expensive,” Dr. Wolf said. “Is the bang in the buck? Not as yet, in my opinion. The evidence for persistent benefit from these device is just not there.”
IMPROVING CROUCH GAIT IN CP
The first of the two studies using robotic devices to improve crouch gait in children with cerebral palsy was published on July 26 in Science Robotics, led by senior author Sunil K. Agrawal, PhD, professor of mechanical engineering and rehabilitation medicine at Columbia University.
Rather than directly straighten the children’s posture, Dr. Agrawal’s seemingly contradictory approach was to increase the downward force on their pelvis as they attempted to walk on a treadmill. The tension in each wire, attached to a belt on the pelvis, is modulated in real time by a motor placed around the treadmill in response to motion capture data from cameras. Unlike other robotic devices that have been tested for treating crouch gait, the TPAD has no rigid links to the body, permitting free movement of the legs.
After training in the device for 15 sessions of 16 minutes each over the course of six weeks, the six participants showed enhanced upright posture, improved muscle coordination, increased step length, range of motion of the lower limb angles, toe clearance, and heel-to-toe pattern.
“You can see a marked difference before and after,” Dr. Agrawal said. “We heard from families and the children themselves that they were walking faster, with better posture. Now we have to see if we should use a higher magnitude of downward pull, how long each training session should be, and for how many sessions.”
Commenting on the TPAD study, Dr. Dobkin said, “The kids who were selected for inclusion were not necessarily the kind who get surgery. They had less of a crouch, a little bit more of a push-off. The question is whether training like this will lead to good over-ground walking. They got a hint of that.”
The second crouch-gait study, published on August 23 in Science Translational Medicine, involved a wearable exoskeleton designed for over-land use, and was described by the authors as the first robotic device designed specifically to treat a gait disorder in children and adolescents. Rather than force the lower limb to move in a particular way, “the exoskeleton dynamically changed the posture by introducing bursts of knee extension assistance during discrete portions of the walking cycle, a perturbation that resulted in maintained or increase knee extensor muscle activity during exoskeleton use,” the paper stated.
“In the last decade, there’s been a groundswell of work on exoskeletons, but a majority of them are designed to permit mobility after spinal injury in adults who have lost the ability to walk,” said senior author Thomas Bulea, PhD, a staff scientist in the functional and applied biomechanics section of the rehabilitation medicine department at the National Institutes of Health Clinical Center in Bethesda, MD. “There hasn’t been much done for the pediatric population who just need to improve their walking.”
A coauthor of the paper, Diane L. Damiano, PT, PhD, chief of the section in which Dr. Bulea works, said the purpose of the wearable exoskeleton is different than that of the TPAD device developed by Dr. Agrawal.
“His device is designed to strengthen the calf muscles by increasing the resistance on them,” she said. “His results were good, but this is very different from what we are doing. We have a wearable device. It’s not meant to be used in a lab for training. We’re not necessarily trying to strengthen them, although that would be a desired outcome; we are instead trying to assist their abilities to help them practice being more upright while they walk. This is something that they would wear throughout the day for several months with the goal that their posture will ultimately be improved without the device.”
A surprising observation, she added, was that some children saw it as something cool to wear.
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Institute of Neurology, University College London, National Hospital for Neurology and Neurosurgery, Queen Square, London, and National Society for Epilepsy, Chalfont St Peter, Bucks. London, and National Society for Epilepsy, Chalfont St Peter, Bucks. September 2005. This article can be reproduced for educational purposes.
Epilepsy has a complex association with sleep. Certain seizures are more common during sleep, and may show prominent diurnal variation. Rarely, nocturnal seizures are the only manifestation of an epileptic disorder and these can be confused with a parasomnia. Conversely, certain sleep disorders are not uncommonly misdiagnosed as epilepsy. Lastly, sleep disorders can exacerbate epilepsy and epilepsy can exacerbate certain sleep disorders. This chapter is thus divided into four sections: normal sleep physiology and the relationship to seizures; the interaction of sleep disorders and epilepsy; and the importance of sleep disorders in diagnosis.
Normal sleep physiology and the relationship to seizures
Adults require on average 7 – 8 hours sleep a night. This sleep is divided into two distinct states – rapid eye movement (REM) sleep and non-REM sleep. These two sleep states cycle over approximately 90 minutes throughout the night with the REM periods becoming progressively longer as sleep continues. Thus there is a greater proportion of REM sleep late on in the sleep cycles. REM sleep accounts for about a quarter of sleep time. During REM sleep, dreams occur; hypotonia or atonia of major muscles prevents dream enactment. REM sleep is also associated with irregular breathing and increased variability in blood pressure and heart rate. Non-REM sleep is divided into four stages (stages I – IV) defined by specific EEG criteria. Stages I/II represent light sleep, while stages III/IV represent deep, slow-wave sleep.
Gowers noted that in some patients, epileptic seizures occurred mainly in sleep. Sleep influences cortical excitability and neuronal synchrony. Surveys have suggested that 10 – 45% of patients have seizures that occur predominantly or exclusively during sleep or occur with sleep deprivation. EEG activation in epilepsy commonly occurs during sleep, so that sleep recordings are much more likely to demonstrate epileptiform abnormalities. These are usually most frequent during non-REM sleep and often have a propensity to spread so that the epileptiform discharges are frequently observed over a wider field than is seen during the wake state. Sleep deprivation (especially in generalised epilepsies) can also ‘activate’ the EEG, but can induce seizures in some patients. Thus many units perform sleep EEGs with only moderate sleep deprivation (late night, early morning), avoidance of stimulants (e.g. caffeine-containing drinks) and EEG recording in the afternoon. Sleep-induced EEGs in which the patient is given a mild sedative (e.g. chloral hydrate) are also useful.
Sleep and generalised seizures
Thalamocortical rhythms are activated during non-REM sleep giving rise to sleep spindles. Since similar circuits are involved in the generation of spike-wave discharges in primary generalised epilepsy, it is perhaps not surprising that non-REM sleep often promotes spike-wave discharges. Epileptiform discharges and seizures in primary generalised epilepsies are both commonly promoted by sleep deprivation. Furthermore, primary generalised seizures often occur within a couple of hours of waking, whether from overnight sleep or daytime naps. This is most notable with juvenile myoclonic epilepsy in which both myoclonus and tonic-clonic seizures occur shortly after waking, and the
syndrome of tonic-clonic seizures on awakening described by Janz. Seizure onset in this syndrome is from 6 – 35 years and the prognosis for eventual remission is good.
Certain epileptic encephalopathies show marked diurnal variation in seizure manifestation and electrographic activity. An example is the generalised repetitive fast discharge during slow-wave sleep occurring in Lennox-Gastaut syndrome. Another example is electrical status epilepticus during sleep (ESES). This is characterised by spike and wave discharges in 85 – 100% of non-REM sleep. This phenomenon is associated with certain epilepsy syndromes, including Landau-Kleffner, Lennox-Gastaut syndrome, continuous spikes and waves during sleep and benign epilepsy of childhood with rolandic spikes. ESES can thus be a component of a number of different epilepsy syndromes with agedependent onset, many seizure types, and varying degrees of neuropsychological deterioration. Indeed, ESES has been described in the setting of an autistic syndrome alone with no other
manifestation of epilepsy.
Sleep and partial epilepsies
Inter-ictal epileptiform abnormalities on the EEG occur more frequently during sleep, especially stage III/IV sleep (slow-wave sleep). The discharges have a greater propensity to spread during sleep, and thus are often seen over a wider field than discharges occurring during wakefulness. Temporal lobe seizures are relatively uncommon during sleep, while frontal lobe seizures occur often predominantly (sometimes exclusively) during sleep. Nocturnal frontal lobe seizures can be manifest as: brief stereotypical, abrupt arousals; complex stereotypical, nocturnal movements; or episodic nocturnal wanderings with confusion. Inherited frontal lobe epilepsies can manifest with only nocturnal events that can be confused with parasomnias (see below). Autosomal dominant nocturnal frontal lobe epilepsy is such an epilepsy. This has been associated with mutations in alpha-4 and beta-2 subunits of the neuronal nicotinic acetylcholine receptor. Onset is usually in adolescence with seizures occurring frequently, sometimes every night. The seizures are provoked by stress, sleep deprivation and menstruation, and often respond well to carbamazepine.
The interaction of sleep disorders and epilepsy
Seizures can disrupt sleep architecture. Complex partial seizures at night disrupt normal sleep patterns, decrease REM sleep and increase daytime drowsiness. Daytime complex partial seizures can also decrease subsequent REM sleep, which may contribute to impaired function. Antiepileptic drugs (AEDs) can also disrupt normal sleep patterns, although there are conflicting data (this is partially due to drugs having different short-term and long-term effects). Carbamazepine, for example, given acutely reduces and fragments REM sleep, but these effects are reversed after a month of treatment. The GABAergic drugs can have a profound effect on sleep; phenobarbitone and benzodiazepines prolong non-REM sleep and shorten REM sleep, while tiagabine increases slow-wave sleep and sleep efficiency. Gabapentin and lamotrigine may both increase REM sleep.
Certain sleep disorders are more common in patients with epilepsy. This is particularly so with obstructive sleep apnoea which is more common in patients with epilepsy and can also exacerbate seizures. Indeed, sleep apnoea is approximately twice as common in those with refractory epilepsy than in the general population. The reasons why this is so are unknown, but may relate to increased body weight, use of AEDs, underlying seizure aetiology or the epilepsy syndrome itself.
Patients with obstructive sleep apnoea often find that seizure control improves with treatment of the sleep apnoea. Topiramate may also be a particularly useful drug in these cases.
The importance of sleep disorders in differential diagnosis
On occasions nocturnal seizures can be misdiagnosed as a primary sleep disorder (see above). Conversely, certain sleep disorders can be misdiagnosed as epilepsy and the more common of these will be discussed below. Sleep disorders tend to occur during specific sleep phases and thus usually occur at specific times during the night, while seizures usually occur at any time during the night. There may also be other clues in the history, including age of onset, association with other symptoms (see below) and the stereotypy of the episodes (seizures are usually stereotypical).
In cases where there is some uncertainty, video-EEG polysomnography is the investigation of choice. There are, however, instances in which the diagnosis can be difficult even after overnight video-EEG telemetry as frontal lobe seizures can be brief with any EEG change obscured by movement artefact, and it is often the stereotypy of the episodes that confirms the diagnosis.
Abnormalities of sleep are divided into three main categories: 1) dysomnias or disorders of the sleepwake cycle; 2) parasomnias or disordered behaviour that intrudes into sleep, and 3) sleep disorders associated with medical or psychiatric conditions. Although there is an extensive list of conditions within each of these categories, we will confine ourselves to the clinical features of the more common conditions that can be confused with epilepsy.
Narcolepsy is a specific, well-defined disorder with a prevalence of approximately one in 2000. It is a life-long condition usually presenting in late teens or early 20s. Narcolepsy is a disorder of REM sleep and has as its main symptom excessive daytime sleepiness. This is manifest as uncontrollable urges to sleep, not only at times of relaxation (e.g. reading a book, watching television), but also at inappropriate times (e.g. eating a meal or while talking). The sleep is itself usually refreshing. The other typical symptoms are cataplexy, sleep paralysis and hypnagogic/hypnopompic hallucinations. These represent REM sleep phenomena such as hypotonia/atonia, and dreams occurring at inappropriate times. Cataplexy is a sudden decrease in voluntary muscle tone (especially jaw, neck and limbs) that occurs with sudden emotion like laughter, elation, surprise or anger. This can manifest as jaw dropping, head nods or a feeling of weakness or, in more extreme cases, as falls with ‘paralysis’ lasting sometimes minutes. Consciousness is preserved. Cataplexy is a specific symptom of narcolepsy, although narcolepsy can occur without cataplexy. Sleep paralysis and hypnagogic hallucinations are not particularly specific and can occur in other sleep disorders and with sleep deprivation (especially in the young). Both these phenomena occur shortly after going to sleep or on waking.
Sleep paralysis is a feeling of being awake, but unable to move. This can last minutes and is often very frightening, so can be associated with a feeling of panic. Hypnagogic/hypnopompic hallucinations are visual or auditory hallucinations occurring while dozing/falling asleep or on waking; often the hallucinations are frightening, especially if associated with sleep paralysis.
Narcolepsy is associated with HLA type. Approximately 90% of all narcoleptic patients with definite cataplexy have the HLA allele HLA DQB1*0602 (often in combination with HLA DR2), compared with approximately 25% of the general population. The sensitivity of this test is decreased to 70% if cataplexy is not present. The strong association with HLA type has raised the possibility that narcolepsy is an autoimmune disorder. Recently loss of hypocretin-containing neurons in the hypothalamus has been associated with narcolepsy, and it is likely that narcolepsy is due to deficiency in hypocretin (orexin).
Since narcolepsy is a life-long condition with possibly addictive treatment, the diagnosis should always be confirmed with multiple sleep latency tests (MSLT). During this test five episodes of sleep are permitted during a day; rapid onset of sleep and REM sleep within 15 minutes in the absence of sleep deprivation are indicative of narcolepsy.
The excessive sleepiness of narcolepsy can be treated with modafinil, methylphenidate or dexamphetamine and regulated daytime naps. The cataplexy, sleep paralysis and hypnagogic/hypnopompic hallucinations respond to antidepressants (fluoxetine or clomipramine are the most frequently prescribed). People with narcolepsy often have fragmented, poor sleep at night, and good sleep hygiene can be helpful.
Sleep apnoea can be divided into the relatively common obstructive sleep apnoea and the rarer central sleep apnoea. Obstructive sleep apnoea is more common in men than women and is associated with obesity, micrognathia and large neck size. The prevalence may be as high as 4% in men, and 2% in women. The symptoms suggestive of obstructive sleep apnoea are loud snoring, observed nocturnal apnoeic spells, waking at night fighting for breath or with a feeling of choking, morning headache, daytime somnolence, personality change and decreased libido. Although the daytime somnolence can be as severe as narcolepsy, the naps are not usually refreshing and are longer. Obstructive sleep apnoea and central sleep apnoea can be associated with neurological disease, but central sleep apnoea can also occur as an idiopathic syndrome. The correct diagnosis requires polysomnography with measures of oxygen saturations and nasal airflow or chest movements. To be pathological a sleep apnoea or hypopnoea (a 50% reduction in airflow) has to last ten seconds and there need to be more than five apnoeas/hypopnoeas per hour (the precise number to make a diagnosis varies from sleep laboratory to sleep laboratory).
Uncontrolled sleep apnoea can lead to hypertension, cardiac failure, pulmonary hypertension and stroke. In addition, sleep apnoea has been reported to worsen other sleep conditions, such as narcolepsy, and to worsen seizure control.
Treatment of sleep apnoea should include avoidance of alcohol and sedatives and weight reduction. Pharmacological treatment is not particularly effective, although REM suppressants such as protriptyline can be helpful. The mainstays of treatment are surgical and include tonsillectomies, adenoidectomy and procedures to widen the airway, and the use of mechanical devices. Dental appliances to pull the bottom jaw forward can be effective in mild cases, but continuous positive airway pressure administered by a nasal mask has become largely the treatment of choice for moderate/severe obstructive sleep apnoea. In cases associated with neuromuscular weakness intermittent positive pressure ventilation is often necessary.
Restless legs syndrome/periodic limb movements in sleep
Restless legs syndrome (RLS) and periodic limb movements in sleep (PLMS) can occur in association or separately. Most people with RLS also have PLMS, but the converse is not true and most people with PLMS do not have RLS. RLS is characterised by an unpleasant sensation in the legs, often described as tingling, cramping or crawling, and an associated overwhelming urge to move the legs. These sensations are usually worse in the evening, and movement only provides temporary relief. RLS affects about 5% of the population. Periodic limb movements in sleep are brief, repetitive jerking of usually the legs that occur every 20 – 40 seconds. These occur in non-REM sleep and can cause frequent arousals. PLMS occurs in about 50% of people over 65 years. These conditions can also be associated with daytime jerks. Both RLS and PLMS can be familial, but can be secondary to peripheral neuropathy (especially diabetic, uraemic and alcoholic neuropathies), iron deficiency, pregnancy and rarely spinal cord lesions.
Symptomatic relief can be achieved with benzodiazepines, gabapentin and opioids, but L-DOPA and dopamine agonists are the mainstay of treatment.
Sleep-wake transition disorders
The most common of these are hypnic jerks or myoclonic jerks that occur on going to sleep or on waking. They are entirely benign in nature, and require no treatment. They can occur in association with other sleep disorders. Rhythmic movement disorder is a collection of conditions occurring in infancy and childhood characterised by repetitive movements occurring immediately prior to sleep onset that can continue into light sleep. One of the most dramatic is headbanging or jactatio capitis nocturna. Persistence of these rhythmic movements beyond the age of ten years is often associated with learning difficulties, autism or emotional disturbance. Sleep-talking can occur during non-REM and REM sleep, but is often seen with wake-sleep transition and is a common and entirely benign phenomenon.
Nocturnal enuresis is a common disorder that can occur throughout the night. Although diagnosis is straightforward, it can recur in childhood, and also occurs in the elderly, with approximately 3% of women and 1% of men over the age of 65 years having the disorder. Thus, on occasions, it can be misdiagnosed as nocturnal epilepsy.
Non-REM parasomnias usually occur in slow-wave (stage III/IV) sleep. These conditions are often termed arousal disorders and indeed can be induced by forced arousal from slow-wave sleep. There are three main non-REM parasomnias – sleepwalking, night terrors and confusional arousal. These disorders often have a familial basis, but can be brought on by sleep deprivation, alcohol and some drugs. They can also be triggered by other sleep disorders such as sleep apnoea, medical and psychiatric illness. Patients are invariably confused during the event, and are also amnesic for the event. These conditions are most common in children, but do occur in adults.
Sleepwalking may occur in up to 25% of children, with the peak incidence occurring from age 11 – 12 years. The condition is characterised by wanderings often with associated complex behaviours such as carrying objects, and eating. Although speech does occur, communication is usually impossible. The episode usually lasts a matter of minutes. Aggressive and injurious behaviour is uncommon, and should it occur then polysomnography may be indicated to exclude an REM sleep parasomnia (see below), and to confirm the diagnosis. Night terrors are less common and are characterised by screaming, and prominent sympathetic nervous system activity – tachycardia, mydriasis and excessive sweating. Both these conditions are usually benign and rarely need treatment. If dangerous behaviour occurs, then treatment may be indicated. Benzodiazepines, especially clonazepam, are usually very effective.
Nightmares are REM phenomena that can occur following sleep deprivation, with certain drugs (e.g. L-DOPA) and in association with psychological and neurological disease. Sleep paralysis (see narcolepsy) is also an REM parasomnia, and may be familial.
Of more concern are REM sleep behaviour disorders. These consist of dream enactment. They are often violent, and tend to occur later in sleep when there is more REM sleep. These are rare and tend to occur in the elderly. In over one-third of cases, REM sleep behaviour disorders are symptomatic of an underlying neurological disease such as dementia, multisystem atrophy, Parkinson’s disease, brainstem tumours, multiple sclerosis, subarachnoid haemorrhage and cerebrovascular disease. In view of this, a history of possible REM sleep behaviour disorder needs to be investigated by polysomnography, and if confirmed, then possible aetiologies need to be investigated. REM sleep behaviour disorders respond very well to clonazepam.
• BAZIL CW (2002) Sleep and epilepsy. Semin Neurol 22(3) , 321-327.
• FOLDVARY-SCHAEFER NJ (2002) Sleep complaints and epilepsy: the role of seizures,
antiepileptic drugs and sleep disorders. Clin Neurophysiol 19(6) , 514-521.
• MALOW BA (2002) Paroxysmal events in sleep. J Clin Neurophysiol 19(6) , 522-534.
• SCHNEERSON J. Handbook of Sleep Medicine . Blackwell Science, Oxford.
ABOUT THE THOMAS HAYDN TRUST
The Thomas Haydn Trust is The Paediatric Epilepsy Charity that aims to serve the needs of Young People, Parents, Carers and Medical Professionals. But to know who we are you need to know why we are.
Providing local services and sharing the rewards globally is the core of THT’s work, weather newly diagnosed or not, you will find THT a valuable source of support, knowledge and news for the epilepsies.
The Thomas Haydn Trust was set up in the wake of Thomas Haydn Smith’s diagnosis of Lennox-Gastaut Syndrome – One of the Most severe forms of Childhood Onset Epilepsies, affecting 1 in 1,000,000 epilepsy sufferer’s worldwide.
In setting up THT our aim was to combat many of the hurdles that Thomas and his family come across while living with LGS. THT strives to ‘Give Something Back’ to organisations that help families and children with severe epilepsies.
We work towards our goals in the following manner:
Raising the need profile for both basic and clinical research into Lennox-Gastaut Syndrome and other childhood Epilepsies.
By providing a free and open forum for sufferers, family and carers’, allowing them to share experiences, build relationships and facilitate peer learning. THT also provides details of leading specialist support organisations of specific Epilepsy conditions – Supporting the specific needs of the child.
Developing an ever-expending resource of research findings and educational materials for the public and medical professionals.
Where possible, fund individuals and organisations involved in support, development and care of families with sick children.
Raising awareness of childhood Epilepsies through various mediums including the internet, press, radio and television. Highlighting the effects of LGS and other childhood onset Epilepsies through our live events – Raising awareness is the key principle on which THT works.
Promoting the advancement of individuals with Epilepsy to speak out against ignorance, predjudice and bigotry that still surrounds conditions of Epilepsy.
Developing links with other national and international organisations to create a coalition of information sharing networks.
30,000+ scientists and professionals gathered for the annual Society for Neuroscience conference in Chicago last month, proving the growing interest and activities to better understand the inner workings of the human brain, and to discover ways and technologies to enhance its health and performance.
Now, which of all those ongoing efforts are closer to touching our lives, to empower consumers, patients and health professionals?
To answer that question, we recently examined the worldwide landscape of Pervasive Neurotechnology patents, given that investment in intellectual property is a crucial signal in the life-cycle of technology commercialization. We paid extra attention to neurotechnologies which, being digital, are scalable and relatively inexpensive, and that, being non-invasive, pose few if any negative side-effects (the main exception to this rule being #10 below, which is why we place it last).
Through our year-long analysis of thousands of patents, we uncovered ten innovative brain health and brain enhancement systems on the cutting edge, that, in our estimation, are likely to go mainstream over the next few years.
10 Neurotechnologies About to Transform Brain Health and Brain Enhancement
1. Big Data-enhanced diagnostics and treatments
As the costs of computing power, cloud accessibility and hardware sensors dwindle, brain health systems can leverage measurements taken from a far broader swath of the population than ever before possible. And this analysis helps understand precisely where an individual’s readings lie on the distribution curve of health to disease, drives the ability to understand with nuance how one’s readings changes over time, and allows better discernment of proper diagnoses and treatments based on the efficacy of treatments with others having similar brain signatures.
Companies like CNS Response and Advanced Brain Monitoring are already deploying systems that harness the power of big data, exemplified by neurometrics-driven report systems such as in the image to the right.
–> Patent Image: Data Illustrating Patient Stimulant Responsiveness Spectrum, by CNS Response
2. Brain-Computer Interfaces for device control
Brain Computer Interfaces (BCIs) link the commands of our thoughts to the devices of the world. The global BCI market is expected to reach 1.5 billion by 2020, of which 85% is estimated to be non-invasive.
Companies like Emotiv and NeuroSky are advancing the state of BCI technology, while other organizations are developing the external systems and ecosystems to interact with BCIs. Phillips has patents describing home medical systems that remotely monitor health via EEG, helping patients suffering from ALS (commonly known as Lou Gehrig’s disease), for example, to control home appliances via BCIs.
–> Example: Philips-Accenture Project to Control Home Devices via the Mind
- User sends brain commands
- Wearable display shows navigation interface
- Digital app reads commands, connects devices
- Smart products are activated
3. Real-time neuromonitoring (plus robotic aids)
A good number of companies, including Medtronic, Neuropace and St. Jude Medical, are developing systems to actively monitor brain activity and respond in real-time with appropriate treatments.
These systems can discern symptoms leading up to an undesirable brain event (such as a seizure), and provide pre-emptive treatments to mitigate or altogether thwart epileptic activity. Some monitoring systems are coupled with other assistive devices, such as robotic aids to enable patients suffering from neurological disorders (such as ALS) to regain lost motor control.
–> Patent Image: Coupling Neural Stimulation with Robotic Assistance.
4. Neurosensor-based vehicle operator systems
Systems employing neural detection devices to monitor vehicle operator alertness (or a lackthereof) and take preventative measures with driver stimulation or vehicle autopilot/ shutdown systems are described by multiple patents.
Whether due to inattentiveness (for example texting while driving) or drowsiness, new vehicle-integrated systems can assess real-time operator fitness. The US Army, automotive companies like Toyota, start-ups like Freer Logic, medical device makers and insurers are all patenting inventions addressing this concern.
–> Patent Image: Vehicle Operator Systems Augmented with EEG Signal Processing
5. Cognitive training videogames
Software applications accessible online and via mobile devices include gaming systems that target specific cognitive and/or emotional systems of the brain.
Companies like Posit Science and Lumos Labs have secured patent protection (and significant market traction) on products in this area. A patent recently issued to Lumos Labs for enhancing fluid intelligence and working memory through mental manipulation of memorized objects is illustrative.
–> Patent Image: Can you determine the pinball path after bumpers (818) disappear?
6. Brain-responsive computing systems
As Microsoft CEO Sataya Nadella states:
We are moving from a world where computing power was scarce to a place where it now is most limitless, and where the true scarce commodity is increasingly human attention.
A recent study by Microsoft finds that 68% of early tech adopters and 67% of heavy social media users really have to concentrate hard to stay focused on tasks. So large tech companies are patenting systems to improve productivity and worker output, for example by using EEG signals to recognize user’s mental state and tailor the computing experience.
–> Patent Image: Classifying user-tasks based on brainwave data
7. Virtual Reality treatments, especially in conjunction with EEG and/ or tDCS
Whether for treating PTSD and phobias through exposure therapy, or assisting surgeons in the operating room, virtual-reality is quickly gaining momentum.
Medical tech companies such as Medtronic and Brainlab, and consumer research firms such as Nielsen are building significant IP portfolios in the area. The following patent by Evoke Neuroscience shows the interplay between virtual reality, EEG and transcranial direct current stimulation (tDCS).
–> Patent Image: Virtual Reality (VR) Neurotechnology
8. “Mindful” wearables
Wearables are being designed to improve not just physical health but mental well-being as well. Meditation apps in tandem with consumer EEGs like InteraXon’s Muse aim to help users build concentration and self-regulation skills.
Even general-purpose fitness wearables are starting to include mental health and training applications. Jawbone (through its subsidiary BodyMedia) has secured patents that consider physiological and contextual factors.
–> Patent Image: Mental Health Applications of Wearable Devices
9. Collaborative cognitive simulations
These are systems that focus on improving learning and skill acquisition across the extended workforce through online interactive platforms and cognitive simulation models. Human capital-intensive organizations such as AT&T and Accenture, and start-ups such as Applied Cognitive Engineering, are developing multiple applications in the area, and securing relevant intellectual property rights.
–> Patent example: System method and article of manufacture for creating collaborative application sharing
10. Electrical and magnetic brain stimulation
These are technologies that can influence brain activity via magnetic fields or electrical impulses, and they are becoming increasingly common. Multiple hospitals and clinics already offer treatments based on brain stimulation, DARPA has awarded contracts to develop systems to augment memory with targeted electrical stimulation techniques, and consumers can buy wearable devices claiming to induce an array of brain states from calming to energizing.
–> Patent Image: Wearable Transdermal Electrical Stimulation Device
This patent comes via Thync, an early-stage company backed by Khosla Ventures. Other companies pushing the boundaries of brain stimulation technology include St. Jude Medical, Brainlab and Neuronetics.
Now that we have reviewed some of the exciting neurotechnologies ahead, we need to step back for a second. Which of these technologies will deliver the most value, and in what context? How will innovative assessments and therapies be validated, adopted, regulated and commercialized? How do we maximize the benefits and minimize the risks?
Those questions constitute, in essence, the Agenda for the 2015 SharpBrains Virtual Summit taking place next week, where over 200 pioneers and experts will gather around a virtual table to discuss the latest, the next, and how to harness it all to improve work and life.
Please consider joining us!
— Alvaro Fernandez, named a Young Global Leader by the World Economic Forum, runs SharpBrains, an independent market research firm tracking health and wellness applications of brain science. He is an internationally-known speaker and expert, and has been quoted by The New York Times, The Wall Street Journal, New Scientist, CNN, and more.
— Nikhil Sriraman is a patent attorney admitted to practice before the United States Patent and Trademark Office (USPTO). Nikhil has held positions at the USPTO, IP law firms and in-house at Fortune 500 companies. He currently serves as Primal’s Vice President of Intellectual Property, as well as SharpBrains’ Intellectual Property Analyst.
Marketing text: This innovative book explores how games can be serious, even though most people generally associate them with entertainment and fun. It demonstrates how videogames can be a valuable tool in clinics and demonstrates how clinicians can use them in physical rehabilitation for various pathologies. It also describes step by step their integration in rehabilitation, from the (gaming) technology used to its application in clinics. Further, drawing on an extensive literature review, it discusses the pros and cons of videogames and how they can help overcome certain obstacles to rehabilitation.
The last part of the book examines the main challenges and barriers that still need to be addressed to increase and improve the use and efficacy of this new technology for patients. The book is intended for physiotherapists and clinicians alike, providing a useful tool for all those seeking a comprehensive overview of the field of serious games and considering adding it to conventional rehabilitation treatment.
“We have accomplished half of the work, which is creating the engineering systems to test this work and now we have to develop the protocol for using it for rehabilitation to see how well it works,” said Alba Perez-Gracia, ISU chair and associate professor of mechanical engineering, and a lead researcher on the project.
The ISU researchers, who are working on this collaborative project with Texas A&M and California State University, Fullerton, first mapped arm motions and digitalized them and then have created a virtual world where people wearing a portable virtual-reality device can use the system as a therapeutic intervention. The researchers will soon be testing the new tool with human subjects.
Subjects wear a virtual reality headset and use it to complete tasks created for the virtual world. The virtual reality system picks up the actual movements of their own arm and displays it as a cartoon figure within the virtual world. The subject may then participate in the virtual world task that include picking up balls and throwing them at a target or stacking cubes using their right or left hand. In addition, the system has been developed to reflect the image of the arm being used.
For example, if a person is using the right arm to complete the task, the virtual reality system reflects the image so that the cartoon arm actions being portrayed look as if it is the left arm performing the task. This reflected image of arm function has the potential to be used as a therapeutic intervention because previous research has shown that observing an action activates the same area of the brain as performing the action.
“It is called the mirror neuron system,” said Nancy Devine, associate dean of the ISU School of Rehabilitation and Communications Sciences, who is a co-researcher on the project. “When you observe body movements, the cells in the brain that would produce that movement are active even though that arm isn’t being used.”
She said if you just look at brain activity, in some areas of the brain you can’t distinguish an active movement from an observed movement.
“So, if you take someone who has had a stroke and can’t use one arm, you can take their arm that is still working and reflect it to the other arm by putting them in this engaging virtual environment and we can be providing an exercise that is effective in helping rehabilitate the damaged areas,” Devine added.
Although the work on this specific project ends at the end of the academic year, ISU’s work on this type of project may continue.
“We have created the portable virtual-reality device that the patient can wear, which projects the motion happening for the patients,” Perez-Gracia said. “We hope it will be a starting point for future projects on using virtual reality and robotics for helping in rehabilitation and training of human motion.”
This research has been taking place at the ISU Robotics Laboratory and the Bioengineering laboratory at the Engineering Research Complex. On this project, Perez-Gracia and Devine have been working with the third researcher of the team, Marco P. Schoen, professor of mechanical engineering, Omid Heidari, a doctoral student in mechanical engineering, master of science students A.J. Alriyadh, Asib Mahmud, Vahid Pourgharibshahi and John Roylance, and undergraduate students Dillan Hoy, Madhuri Aryal and Merat Rezai. Eydie Kendall, assistant professor of physical and occupational therapy, also collaborated on the project.
“We have very good equipment here that we can do experiments with and that is very appealing,” said Heidari, who said the laboratory has become his second home. “Instead of just writing code on computers and stuff, we are actually doing something here that is very practical and very interesting. We did the motion capture, the kinematic part, and now we are working on finishing the virtual reality part of the project. We are getting closer to having a good model of what we want.”
[VIDEO] Henry Hoffman Q&A Video Series: Can Patients Years Following Stroke Actually Make Progress? – YouTube
Saebo, Inc. is a medical device company primarily engaged in the discovery, development and commercialization of affordable and novel clinical solutions designed to improve mobility and function in individuals suffering from neurological and orthopedic conditions. With a vast network of Saebo-trained clinicians spanning six continents, Saebo has helped over 100,000 clients around the globe achieve a new level of independence. In 2001, two occupational therapists had one simple, but powerful goal – to provide neurological clients access to transformative and life changing products. At the time, treatment options for improving arm and hand function were limited. The technology that did exist was expensive and inaccessible for home use. With inadequate therapy options often leading to unfavorable outcomes, health professionals routinely told their clients that they have “reached a plateau” or “no further gains can be made”. The founders believed that it was not the clients who had plateaued, but rather their treatment options had plateaued. Saebo’s commitment – “No Plateau in Sight” – was inspired by this mentality; and the accessible, revolutionary solutions began. Saebo’s revolutionary product offering was based on the latest advances in rehabilitation research. From the SaeboFlex which allows clients to incorporate their hand functionally in therapy or at home, to the SaeboMAS, an unweighting device used to assist the arm during daily living tasks and exercise training, “innovation” and “affordability” can now be used in the same sentence. Over the last ten years, Saebo has grown into a leading global provider of rehabilitative products created through the unrelenting leadership and the strong network of clinicians around the world. As we celebrate our history and helping more than 100,000 clients regain function, we are growing this commitment to affordability and accessibility even further by making our newest, most innovative products more accessible than ever.
via Henry Hoffman Q&A Video Series: Can Patients Years Following Stroke Actually Make Progress? – YouTube
Stroke survivor exhibits remarkable improvement in hand function more than two decades after stroke, disproving theories that recovery window is limited to 6 months.
Charlotte, N.C. – Tuesday, July 25, 2017 – Until recently, researchers believed that if a stroke survivor exhibited no improvement within the first 6 months, then he or she would have little to no chance of regaining motor function in the future. This assumed end of recovery is called a plateau. However, a groundbreaking new article published in the Journal of Neurophysiology discusses a stroke patient’s remarkable improvement decades after suffering a stroke at the age of 15. Doctors Peter Sörös, Robert Teasell, Daniel F. Hanley, and J. David Spence formally dismiss previous theories that stroke recovery occurs within 6 months, reporting that the patient experienced “recovery of hand function that began 23 years after the stroke.”
The patient’s stroke resulted in paralysis on the left side of his body, rendering his left hand completely nonfunctional, despite regular physical therapy. More than twenty years after his stroke, the patient took up swimming when his doctor recommended he lose weight. A year later, he began to show signs of movement on his affected side and returned to physical therapy. Therapists fitted the patient with the SaeboFlex, a mechanical device shown to improve hand function and speed up recovery, and, after only a few months of therapy, he began picking up coins with his previously nonfunctional hand. He also saw notable improvement in hand strength and control with the SaeboGlove, a low-profile hand device recently patented by Saebo.
Functional MRI studies showed the reorganization of sensorimotor neurons in both sides of the patient’s brain more than two decades after his stroke, resulting in a noticeable recovery in both hemispheres and improved motor function. “The marked delayed recovery in our patient and the widespread recruitment of bilateral areas of the brain indicate the potential for much greater stroke recovery than is generally assumed,” the doctors reported. “Physiotherapy and new modalities in development might be indicated long after a stroke.”
“This article highlights what we have seen for the last 15 years with many of our clients,” states Saebo co-founder, Henry Hoffman. “Oftentimes, stroke survivors are told that they have plateaued and no further progress is possible. We believe it is not the client that has plateaued but failed treatment options have plateaued them. In other words, traditional therapy interventions that lack scientific evidence can be ineffective and can actually facilitate the plateau.”
“The SaeboFlex device is a life-changing treatment designed for clients that lack motor recovery and function,” Hoffman continues. “Whether the client recently suffered a stroke or decades later, they can immediately begin using their hand with this device and potentially make significant progress over time. I agree with the authors that the neurorehabilitation community needs to take a hard look at traditional beliefs with respect to the window of recovery following stroke. It is my hope that this article will spark more interest by researchers to investigate upper limb function with clients at the chronic stage using Saebo’s hand technology.”
The abstract and article in its entirety can be viewed at the Journal of Neurophysiology’s website, jn.physiology.org.
Daniel Becker, MD | The Johns Hopkins University School of Medicine and INI October 21, 2017