Archive for June, 2015

[ARTICLE] Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review – Full Text PDF


Question: In people after stroke, does virtual reality based rehabilitation (VRBR) improve walking speed, balance and mobility more than the same duration of standard rehabilitation? In people after stroke, does adding extra VRBR to standard rehabilitation improve the effects on gait, balance and mobility?

Design: Systematic review with meta-analysis of randomised trials.

Participants: Adults with a clinical diagnosis of stroke.

Intervention: Eligible trials had to include one these comparisons: VRBR replacing some or all of standard rehabilitation or VRBR used as extra rehabilitation time added to a standard rehabilitation regimen. Outcome measures: Walking speed, balance, mobility and adverse events.

Results: In total, 15 trials involving 341 participants were included. When VRBR replaced some or all of the standard rehabilitation, there were statistically significant benefits in walking speed (MD 0.15 m/s, 95% CI 0.10 to 0.19), balance (MD 2.1 points on the Berg Balance Scale, 95% CI 1.8 to 2.5) and mobility (MD 2.3 seconds on the Timed Up and Go test, 95% CI 1.2 to 3.4). When VRBR was added to standard rehabilitation, mobility showed a significant benefit (0.7 seconds on the Timed Up and Go test, 95% CI 0.4 to 1.1), but insufficient evidence was found to comment about walking speed (one trial) and balance (high heterogeneity).

Conclusion: Substituting some or all of a standard rehabilitation regimen with VRBR elicits greater benefits in walking speed, balance and mobility in people with stroke. Although the benefits are small, the extra cost of applying virtual reality to standard rehabilitation is also small, especially when spread over many patients in a clinic. Adding extra VRBR time to standard rehabilitation also has some benefits; further research is needed to determine if these benefits are clinically worthwhile. [Corbetta D, Imeri F, Gatti R (2015) Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review. Journal of Physiotherapy XX: XX-XX]

Full Text PDF


via Rehabilitation that incorporates virtual reality is more effective than standard rehabilitation for improving walking speed, balance and mobility after stroke: a systematic review – Journal of Physiotherapy.

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[WEB SITE] Vision Care for the Brain-Injured Patient

Over the past decade, several factors have resulted in an increasing demand for optometrists trained in brain injury vision rehabilitation (BIVR). To start, there have been a significant number of brain-injured soldiers returning from Iraq and Afghanistan. Other factors include continually improving trauma survival rates due to medical advances, increased awareness of sports-related concussions and the increased incidence of cerebrovascular accidents (CVA) in the aging Baby Boomer population.1

Vision problems are common after brain injury, and recently published research supports the effectiveness of rehabilitative devices and therapy.2-9 As a result, it has become more important for rehabilitation facilities to seek and privilege optometrists trained in BIVR. In addition, ODs in general practice are increasingly likely to encounter patients with an acquired brain injury (ABI), such as a concussion, and asked to provide expert opinion concerning its impact on visual function.

As caring providers, we want to have the knowledge to offer our patients the newest and most effective treatments available for their visual dysfunction. I will discuss inpatient vs. outpatient delivery of care, diagnoses, assessment and treatment for the ABI patient. Currently there is no consensus on the best model for BIVR care, and there is no evidence to support one method over another.

The model described below is one that I developed for my inpatient clinics and was influenced by my early career in private-practice vision therapy, experience in an inner-city academic low vision rehab clinic, hospital-based experi ence with the medical model of rehabilitation and interaction with other optometrists working with the inpatient population.

Continue —>  Review of Optometry® > Continuing Education > Vision Care for the Brain-Injured Patient by Kevin E. Houston OD.

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[VIDEO] The New WalkAide System: Advanced Functional Electrical Stimulation (FES) for Treatment of Foot Drop – YouTube


via The New WalkAide System: Advanced Functional Electrical Stimulation (FES) for Treatment of Foot Dro – YouTube.

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[WEB SITE] Types of Depression Unique to Women

In addition to the major types of depression that affect men and women, women also suffer from unique types of depression due to their special physiology and hormones. Estrogen, the “female sex hormone,” affects more than 300 functions in a woman’s body including regulating menstrual cycles, protecting the heart and maintaining strong bones.

The fluctuating levels of estrogen during menstrual cycles, pregnancy and menopause may impact mood and, in severe cases, trigger depressive episodes.

Unfortunately, these types of depressive episodes in women and girls often are blamed on “being moody,” “that time of the month,” or “the change” and go untreated. It is time to get beyond stereotypes that prevent women from getting medical help;

Premenstrual syndrome (PMS) can be treated or prevented — there is no reason why women need to suffer so needlessly and frequently.

More than half of the women suffering from postpartum depression will experience it again with the birth of another child. It is critical to identify this danger and treat it early.

Rates of suicide for women are highest during the perimenopausal years; these are tragically shortened lives, considering women now live a third of their lives after menopause.

Recent research shows that women’s biology differs from men’s in many more ways than previously thought and these physical differences (such as different levels of estrogen, serotonin, cortisol and melatonin) are beginning to provide clues to why women are so much more susceptible to depression as well as a special type of depression called Seasonal Affective Disorder

Stress plays a major role in depression, and it may be that women and men respond to stress differently — while women are more likely to suffer from “emotional ailments” such as depression, anxiety attacks and eating disorders, men are much more likely to act out aggressively and abuse drugs and alcohol.

Women’s fluctuating hormone levels during menstrual cycles, after childbirth, and during menopause contribute to forms of depression unique to women including Premenstrual Syndrome (PMS), Premenstrual Dysphoric Disorder (PMDD), Postpartum Depression, and Perimenopausal Depression.

The good news is that research is helping us to understand the biological factors for depression in women and identify ways to treat and prevent it. A woman may suffer from depression at any point during her life. Like depression in men, the underlying cause of depression in women is a combination of changes in brain chemistry, stress, trauma and genetics.

The major types of treatment for depression are the same for women and men. Women who have suffered sexual traumas (such as rape and incest) may want to work with a therapist who has training and expertise in this area.

In addition, a woman’s unique biology may predispose her to unique forms of depression not found in men.


via WBHI Think Tank | Types of Depression Unique to Women.

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[Infographic] Rewiring the brain

Rewiring the brain

Rewiring the brain (infographic) |

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[WEB SITE] A Robot That Lets Your Hands Do the Grasping – MIT Technology Review

The latest in assistive technology is a lightweight glove that helps patients with limited mobility grab and pick up objects.

Engineers at Harvard have developed a soft robotic glove that allows people with limited hand mobility to grasp and pick up objects. The device could help the estimated 6.8 million people in the United States who have hand mobility issues, whether from a degenerative condition, stroke, or old age.

Nine patients with ALS, muscular dystrophy, incomplete spinal cord injuries, or complications from a stroke have tested the glove so far.

The goal is to restore independence for people who have lost the ability to grasp, says Conor Walsh, a professor at Harvard’s Wyss Institute for Biologically Inspired Engineering. The project was led by Panagiotis Polygerinos, a technology development fellow in Walsh’s lab. Walsh thinks that within three years the glove will be “suitable for use in the medical environment.”

For hand mobility difficulties, existing robots with hard exoskeletons can act as assistive devices and guide patients through rehabilitation exercises. But a soft robotic glove aligns more flexibly with a patient’s joints, plays nice with soft tissue like human skin, and, since it is much lighter, could eventually be taken home instead of being limited to use in a clinic.

The glove could give patients “the dexterity that they need to perform essential activities of daily life,” says Steve Kelly, president and COO of Myomo, a developer of assistive robotic devices for the arm and hand, who was not involved in the project.

The glove is mechanically programmed to execute a single task, performed with a bending motion of the fingers and a bending and twisting motion of the thumb. The fingers are essentially silicone balloons—pink, rubbery things—with yellow fibers crisscrossed inside. When pressurized water is pumped into the glove from an attached waist pack, the fibers keep the balloon from expanding, so their arrangement programs the finger to bend in a particular way. For example, there are fewer fibers at the knuckles, which induces the finger to bend there.

Polygerinos let me try it out. The outside of the glove is made of a soft neoprene-like fabric, the fingers covered in a wormlike series of clear rubbery rings for grip. I slipped my left hand into the glove, and he flipped the switches. The motor hummed like a belt sander, and without any help from me, my fingers and thumb curled together in a grasping motion. It felt as if someone else’s hand were underneath mine—someone stronger, moving my fingers for me. The glove is customized to fit a patient’s hand so that the joints align properly, and this glove was a little too big for me, but still, it felt comfortable.

“It’s really simple, because all you do is pressurize it and you get this nice complex motion,” says Walsh. “The downside is, it’s that one motion all the time.”

Though that is a limitation, grasping is extremely important and many patients need help with it, says MIT professor Neville Hogan, who creates robots to rehabilitate stroke patients. “Most neurological disorders cause muscle weakness, which leads to impaired grasp strength,” he says. However, stroke patients’ hand muscles are often clenched by default, so Hogan says they often have the most trouble opening their hands. The team says the glove does not currently have enough force to open the hand if the muscles are clenched, but they hope to add that functionality in the future.

They also want to make the device lighter. The glove weighs 10 ounces, and the waist pack containing the battery, controllers, sensors, pump, and water weighs about seven pounds (twice the weight of a 13-inch MacBook Pro).

The glove is operated either by flipping a switch or by voice command. The next step is to design a glove that can move when it detects signals in the patient’s own arm muscles, so that patients can control it more intuitively. Designing such a control system is tricky. Even patients with the same condition have individual variation, and patients have good days and bad days. “So you can go one day, try your electrodes—signals are perfect, you can operate the glove. You go two days later, something is wrong and you don’t get the same signals again,” says Polygerinos.

Kelly thinks the control mechanism will be key. “Whoever has the best control will have the best commercial solution,” he says. “It’s probably reasonable in the five-ish-year time frame to be able to get this as an impaired person,” he estimates.

Asked if he can remember the best thing a patient has said when trying the glove, Polygerinos looks thoughtful, and then his face lights up. “Oh my God, I can pinch again!”

via A Robot That Lets Your Hands Do the Grasping | MIT Technology Review.

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[WEB SITE] Classification and Complications of Traumatic Brain Injury: Practice Essentials, Epidemiology, Pathophysiology

Practice Essentials

Traumatic brain injury (TBI), also known as acquired brain injury, head injury, or brain injury, causes substantial disability and mortality. It occurs when a sudden trauma damages the brain and disrupts normal brain function. TBI may have profound physical, psychological, cognitive, emotional, and social effects.

According to the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, in the United States annually at least 1.4 million people sustain a TBI, and approximately 50,000 people die from such injuries.

See Pediatric Concussion and Other Traumatic Brain Injuries, a Critical Images slideshow, to help identify the signs and symptoms of TBI, determine the type and severity of injury, and initiate appropriate treatment.

Essential update: Metabolic biomarkers may help predict TBI severity and outcome

In a study of 256 consecutive adult patients with acute TBI and 36 control patients with acute orthopedic trauma and no acute or previous brain disorders, presented in October 2014 at the annual meeting of the Congress of Neurological Surgeons, Posti et al found 43 potential metabolic biomarkers that differed significantly in expression patterns between TBI patients and control subjects.[1] These differences were most pronounced among patients with severe TBI.

These metabolic biomarkers included small fatty acids, amino acids, and sugar derivatives.[1] Several metabolites (eg, decanoic acid, octanoic acid, glycerol serine, and 1H-indole-3-acetic acid) were significantly upregulated in cerebrospinal fluid and brain microdialysate samples from newly arrived patients with severe TBI, suggesting disruption of the blood-brain barrier. Marked intergroup differences were still evident in samples taken the day after injury. Metabolic profiles were strongly associated with outcomes, as measured by Glasgow Outcomes Scale scores.


Primary and secondary injuries

  • Primary injury: Induced by mechanical force and occurs at the moment of injury; the 2 main mechanisms that cause primary injury are contact (eg, an object striking the head or the brain striking the inside of the skull) and acceleration-deceleration [2]
  • Secondary injury: Not mechanically induced; it may be delayed from the moment of impact, and it may superimpose injury on a brain already affected by a mechanical injury [2]

Focal and diffuse injuries

These injuries are commonly found together; they are defined as follows:

  • Focal injury: Includes scalp injury, skull fracture, and surface contusions; generally caused by contact
  • Diffuse injury: Includes diffuse axonal injury (DAI), hypoxic-ischemic damage, meningitis, and vascular injury; usually caused by acceleration-deceleration forces

Measures of severity

See the list below:

  • Glasgow Coma Scale (GCS): A 3- to 15-point scale used to assess a patient’s level of consciousness and neurologic functioning [3, 4] ; scoring is based on best motor response, best verbal response, and eye opening (eg, eyes open to pain, open to command)
  • Duration of loss of consciousness: Classified as mild (mental status change or loss of consciousness [LOC] 6 hr)
  • Posttraumatic amnesia (PTA): The time elapsed from injury to the moment when patients can demonstrate continuous memory of what is happening around them [5]


Complications include the following:

  • Posttraumatic seizures: Frequently occur after moderate or severe TBI
  • Hydrocephalus
  • Deep vein thrombosis: Incidence as high as 54% [6]
  • Heterotopic ossification: Incidence of 11-76%, with a 10-20% incidence of clinically significant heterotopic ossification [7]
  • Spasticity
  • Gastrointestinal and genitourinary complications: Among the most common sequelae in patients with TBI
  • Gait abnormalities
  • Agitation: Common after TBI

Long-term physical, cognitive, and behavioral impairments are the factors that most commonly limit a patient’s reintegration into the community and his/her return to employment. They include the following:

  • Insomnia
  • Cognitive decline
  • Posttraumatic headache: Tension-type headaches are the most common form, but exacerbations of migraine-like headaches are also frequent
  • Posttraumatic depression: Depression after TBI is further associated with cognitive decline, [8, 9] anxiety disorders, substance abuse, dysregulation of emotional expression, and aggressive outbursts

Outcome measures

The following tools are commonly used to measure outcome after TBI[10, 11] :

  • Functional Independence Measure (FIM): An 18-item scale used to assess the patient’s level of independence in mobility, self-care, and cognition
  • Glasgow Outcome Scale (GOS)
  • Disability Rating Scale (DRS): Measures general functional changes over the course of recovery after TBI (see the image below)
  • Disability Rating Scale (DRS).

Continue —>  Classification and Complications of Traumatic Brain Injury: Practice Essentials, Epidemiology, Pathophysiology.

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[ARTICLE] Combined transcranial direct current stimulation and home-based occupational therapy for upper limb motor impairment following intracerebral hemorrhage: a double-blind randomized controlled trial


Purpose: To investigate the combined effect of transcranial direct current stimulation (tDCS) and home-based occupational therapy on activities of daily living (ADL) and grip strength, in patients with upper limb motor impairment following intracerebral hemorrhage (ICH).

Methods: A double-blind randomized controlled trial with one-week follow-up. Patients received five consecutive days of occupational therapy at home, combined with either anodal (n = 8) or sham (n = 7) tDCS. The primary outcome was ADL performance, which was assessed with the Jebsen–Taylor test (JTT).

Results: Both groups improved JTT over time (p < 0.01). The anodal group improved grip strength compared with the sham group from baseline to post-assessment (p = 0.025). However, this difference was attenuated at one-week follow-up. There was a non-significant tendency for greater improvement in JTT in the anodal group compared with the sham group, from baseline to post-assessment (p = 0.158).

Conclusions: Five consecutive days of tDCS combined with occupational therapy provided greater improvements in grip strength compared with occupational therapy alone. tDCS is a promising add-on intervention regarding training of upper limb motor impairment. It is well tolerated by patients and can easily be applied for home-based training. Larger studies with long-term follow-up are needed to further explore possible effects of tDCS in patients with ICH.

Implications for Rehabilitation

  • Five consecutive days of tDCS combined with occupational therapy provided greater improvements in grip strength compared with occupational therapy alone.
  • tDCS is well tolerated by patients and can easily be applied for home-based rehabilitation.

via Combined transcranial direct current stimulation and home-based occupational therapy for upper limb motor impairment following intracerebral hemorrhage: a double-blind randomized controlled trial, Disability and Rehabilitation, Informa Healthcare.

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[ARTICLE] Non-invasive electric current stimulation for restoration of vision after unilateral occipital stroke


Occipital stroke often leads to visual field loss, for which no effective treatment exists. Little is known about the potential of non-invasive electric current stimulation to ameliorate visual functions in patients suffering from unilateral occipital stroke. One reason is the traditional thinking that visual field loss after brain lesions is permanent. Since evidence is available documenting vision restoration by means of vision training or non-invasive electric current stimulation future studies should also consider investigating recovery processes after visual cortical strokes. Here, protocols of repetitive transorbital alternating current stimulation (rtACS) and transcranial direct current stimulation (tDCS) are presented and the European consortium for restoration of vision (REVIS) is introduced. Within the consortium different stimulation approaches will be applied to patients with unilateral occipital strokes resulting in homonymous hemianopic visual field defects. One goal is to evaluate effects of the stimulation on vision parameters, vision-related quality of life, and physiological parameters that allow conclude about the mechanisms of vision restoration as induced by electrical current stimulation. These include EEG-spectra and coherence measures, and visual evoked potentials. The design of stimulation protocols involves an appropriate sham-stimulation condition and sufficient follow-up periods to test whether the effects are stable.

This is the first application of non-invasive current stimulation for vision rehabilitation in stroke-related visual field deficits. Positive results of the trials could have far-reaching implications for clinical practice. The ability of non-invasive electrical current brain stimulation to modulate the activity of neuronal networks may have implications for stroke rehabilitation also in the visual domain.


via Non-invasive electric current stimulation for restoration of vision after unilateral occipital stroke.

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[ARTICLE] The impact of transcranial direct current stimulation (tDCS) combined with modified constraint-induced movement therapy (mCIMT) on upper limb function in chronic stroke: a double-blind randomized controlled trial


Purpose: This pilot double-blind sham-controlled randomized trial aimed to determine if the addition of anodal tDCS on the affected hemisphere or cathodal tDCS on unaffected hemisphere to modified constraint-induced movement therapy (mCIMT) would be superior to constraints therapy alone in improving upper limb function in chronic stroke patients.

Methods: Twenty-one patients with chronic stroke were randomly assigned to receive 12 sessions of either (i) anodal, (ii) cathodal or (iii) sham tDCS combined with mCIMT. Fugl–Meyer assessment (FMA), motor activity log scale (MAL), and handgrip strength were analyzed before, immediately, and 1 month (follow-up) after the treatment. Minimal clinically important difference (mCID) was defined as an increase of ≥5.25 in the upper limb FMA.

Results: An increase in the FMA scores between the baseline and post-intervention and follow-up for active tDCS group was observed, whereas no difference was observed in the sham group. At post-intervention and follow-up, when compared with the sham group, only the anodal tDCS group achieved an improvement in the FMA scores. ANOVA showed that all groups demonstrated similar improvement over time for MAL and handgrip strength. In the active tDCS groups, 7/7 (anodal tDCS) 5/7 (cathodal tDCS) of patients experienced mCID against 3/7 in the sham group.

Conclusion: The results support the merit of association of mCIMT with brain stimulation to augment clinical gains in rehabilitation after stroke. However, the anodal tDCS seems to have greater impact than the cathodal tDCS in increasing the mCIMT effects on motor function of chronic stroke patients.

Implications for Rehabilitation

  • The association of mCIMT with brain stimulation improves clinical gains in rehabilitation after stroke.
  • The improvement in motor recovery (assessed by Fugl–Meyer scale) was only observed after anodal tDCS.
  • The modulation of damaged hemisphere demonstrated greater improvements than the modulation of unaffected hemispheres.

via The impact of transcranial direct current stimulation (tDCS) combined with modified constraint-induced movement therapy (mCIMT) on upper limb function in chronic stroke: a double-blind randomized controlled trial – Disability and Rehabilitation –.

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