Archive for April, 2016

[WEB SITE] AAN’s updated guideline on botulinum toxin use covers four neurologic disorders

Published on April 19, 2016 at 12:32 PM 

The updated guideline covers four neurologic disorders: spasticity in adults, which is muscle tightness that interferes with movement typically following a stroke, spinal cord or other neurologic injury; cervical dystonia, a disorder of the brain affecting neck muscle control that causes involuntary head tilt or neck movement; blepharospasm, a movement disorder that causes the eyes to close uncontrollably; and chronic and episodic migraine. Chronic migraine is defined as attacks that occur 15 or more days per month, with at least eight of those attacks having migraine features. In episodic migraine, attacks occur less often.

Botulinum toxin is made by a certain type of bacteria. The drug works to block release of substances at nerve endings, which, from effects in different nerves, will lead to reduced muscle contraction and less transmission of pain signals. Four preparations of botulinum toxin are available in the United States, and they are not interchangeable. The guideline update assessed each formulation separately for each condition. To develop the guideline, researchers reviewed all available scientific studies on the topic.

The guideline determined that botulinum toxin is generally safe and effective for treating spasticity in adults, cervical dystonia, blepharospasm and chronic migraine, according to guideline author David M. Simpson, MD, with the Icahn School of Medicine at Mount Sinai in New York, NY, and a Fellow of the American Academy of Neurology.

One change from the earlier guidelines is the recommendation on chronic migraine. In 2008, not enough evidence was available to make any recommendation on the use of botulinum toxin for chronic migraine. Now there are well-designed studies that support the effectiveness of onabotulinumtoxinA to reduce how often migraine headaches occur. However, the studies showed that the benefit from the drug was small. In the four weeks after the first treatments, people had about 15 percent fewer days of headache compared with a placebo or dummy injection.

Spasticity has many causes, including multiple sclerosis, stroke and head or spinal cord trauma. For upper limb spasticity, three of the drug formulations—abobotulinumtoxinA, incobotulinumtoxinA, and
onabotulinumtoxinA— are effective in reducing excess muscle tone and should be offered. One formulation, rimabotulinumtoxinB, is probably effective and should be considered. For lower limb spasticity, abobotulinumtoxinA and onabotulinumtoxinA are effective and should be offered.

For cervical dystonia, abobotulinumtoxinA and rimabotulinumtoxinB are effective and should be offered. OnabotulinumtoxinA and incobotulinumtoxinA are probably effective and should be considered.

Few well-designed studies have been done on blepharospasm. The guideline states that onabotulinumtoxinA and incobotulinumtoxinA are probably effective and should be considered. AbobotulinumtoxinA is possibly effective and may be considered.
The 2008 guidelines also covered other disorders such as essential tremor, hemifacial spasm and disorders of the voice. For those other disorders, no new evidence was available at the time the guideline update was initiated that would change the conclusions, so they were not included in this update.

Source: American Academy of Neurology (AAN)

Source: AAN’s updated guideline on botulinum toxin use covers four neurologic disorders

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[WEB SITE] Muscle Relearning in Stroke Rehab With Electrical Stimulation.

A stroke victim having a consultation with a therapist. Photo Credit Wavebreakmedia Ltd/Wavebreak Media/Getty Images

Electrical stimulation, or ES, can enhance your recovery of muscle strength and function and reduce spasticity following a stroke. By providing a shock to specific muscles or muscle groups, ES allows the stroke survivor to better utilize affected arms or legs to perform motor skills. Physical and occupational therapists use ES as part of post-stroke rehabilitation programs in hospitals or outpatient centers. There also are a number of available ES products for home use.


When a person has a stroke, a blood vessel in the brain either ruptures or is blocked by a clot. Damage occurs to the brain tissue where oxygen is deprived, and often the motor cortex is affected. Because the brain is unable to send adequate messages, or electrical impulses, to the muscles of the affected area, the muscles may appear flaccid or spastic. The person may have complete or partial paralysis, and decreased range of motion in the joints can result. It is critical to begin therapy early following a stroke to maximize recovery and prevent complications.

Types of Electrical Stimulation

Electrical stimulation for stroke rehabilitation is different than electrical stimulation for pain reduction and acute muscle injuries. Functional electrical stimulation refers to ES in combination with use of a prosthesis. Transcutaneous electrical nerve stimulation provides pain relief and is not typically used for stroke rehabilitation. Electromyographic, or EMG, triggered neuromuscular electrical stimulation is a newer technology specific to muscle relearning in stroke rehabilitation. The EMG registers subtle muscle contractions when a patient attempts to move paralyzed muscles, and the electrodes then stimulate a stronger contraction.

Muscle Relearning with ES

Muscle relearning refers to the neurological process of perceiving and generating muscle contractions. Since strokes generally occur on either the right or left side of the brain, the result is that the person is impaired on one side of the body, or hemiplegia. The brain must relearn movements and sensations, and often the unaffected arm or leg works harder to compensate. EMG triggered neuromuscular ES applies biofeedback methods, so that the patient becomes more aware of subtle muscle contractions in the affected limb. This can result in improved voluntary muscle control. Traditional ES also is effective in muscle relearning simply by allowing the patient to feel the muscles contract.

Research on Electrical Stimulation in Stroke Rehabilitation

In general, research supports use of electrical stimulation in patients who have had a stroke. In a 1999 randomized clinical trial published in “Stroke,” ES to the wrist extensor muscles resulted in significant increases in grip strength and upper extremity function. A 2010 study published in the journal “Stroke” recommends a minimum of 10 hours of ES per week as part of an acute rehabilitation program but found no significant differences in dosage. Functional ES with a neuroprosthesis may be more beneficial if you have minimal movement in your hand. EMG triggered NMES shows promising improvements in walking and hand function.
Source: Muscle Relearning in Stroke Rehab With Electrical Stimulation | LIVESTRONG.COM

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A bi-articular model for scapular-humeral rhythm reconstruction through data from wearable sensors | Journal of NeuroEngineering and Rehabilitation | Full Text



Patient-specific performance assessment of arm movements in daily life activities is fundamental for neurological rehabilitation therapy. In most applications, the shoulder movement is simplified through a socket-ball joint, neglecting the movement of the scapular-thoracic complex. This may lead to significant errors. We propose an innovative bi-articular model of the human shoulder for estimating the position of the hand in relation to the sternum. The model takes into account both the scapular-toracic and gleno-humeral movements and their ratio governed by the scapular-humeral rhythm, fusing the information of inertial and textile-based strain sensors.


To feed the reconstruction algorithm based on the bi-articular model, an ad-hoc sensing shirt was developed. The shirt was equipped with two inertial measurement units (IMUs) and an integrated textile strain sensor. We built the bi-articular model starting from the data obtained in two planar movements (arm abduction and flexion in the sagittal plane) and analysing the error between the reference data – measured through an optical reference system – and the socket-ball approximation of the shoulder. The 3D model was developed by extending the behaviour of the kinematic chain revealed in the planar trajectories through a parameter identification that takes into account the body structure of the subject.


The bi-articular model was evaluated in five subjects in comparison with the optical reference system. The errors were computed in terms of distance between the reference position of the trochlea (end-effector) and the correspondent model estimation. The introduced method remarkably improved the estimation of the position of the trochlea (and consequently the estimation of the hand position during reaching activities) reducing position errors from 11.5 cm to 1.8 cm.


Thanks to the developed bi-articular model, we demonstrated a reliable estimation of the upper arm kinematics with a minimal sensing system suitable for daily life monitoring of recovery.


Reaching activity, Scapular girdle movement,Hand posture estimation,Scapular-humeral rhythm, Wearable sensing

Continue —> A bi-articular model for scapular-humeral rhythm reconstruction through data from wearable sensors | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 1 Sensor location (strain sensor and IMUs), placed on the sensing garment and used to evaluate the shoulder movement. The system is completed with the markers of the optical acquisition system (on the trochlea, the acromion and the sternum)

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[Patent Application] Devices, Systems, and Methods for Administering Therapy – FalconWorks

Devices, systems, and methods for administering therapy to restore limb motion to patients in need are disclosed. The system may include a motion capture device to capture an exercise performed by a therapist. The exercise may be retrieved by the patient and used to generate a visual display used to guide the patient through the exercise in real time.
What is claimed is:

1. A physical therapy administration system for a remote administration of at least one physical therapy session to a patient, the system comprising: a computing device comprising at least one processor; at least one dataset; a CRM configured with a physical therapy administration application comprising a plurality of modules executable by the at least one processor, the plurality of modules comprising: a exercise administration module to record at least one exercise comprising a target limb trajectory using a motion capture device; an exercise module configured to: retrieve an exercise of the at least one exercises; generate a visual display representing the exercise; record a patient response comprising a patient limb trajectory performed to follow the visual display using the motion capture device; calculate a difference between the patient response and the exercise; and signal the patient if the difference exceeds a threshold difference; a performance module to calculate at least one performance score for the patient response according to at least one scoring rule; a monitoring module to review the patient response and the at least one performance score; and the motion capture device.

Continue —>  Devices, Systems, and Methods for Administering Therapy – FalconWorks

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[Abstract] Deficits in motor abilities for multi-finger force control in hemiparetic stroke survivors.


The ability to control redundant motor effectors is one of hallmarks in human motor control, and the topic has been studied extensively over several decades since the initial inquiries proposed by Nicholi Bernstein. However, our understanding of the influence of stroke on the control of redundant motor systems is very limited.

This study aimed to investigate the effect of stroke-related constraints on multi-finger force control abilities in a visuomotor task. Impaired (IH) and less-impaired hands (LH) of 19 hemiparetic stroke survivors and 19 age-matched control subjects were examined. Each hand repeatedly produced isometric forces to match a target force of 5 N shown on a computer screen using all four fingers. The hierarchical variability decomposition (HVD) model was used to separate force-matching errors (motor performance) into task-relevant measures (accuracy, steadiness, and reproducibility). Task-irrelevant sources of variability in individual finger force profiles within and between trials (flexibility and multiformity) were also quantified. The IH in the stroke survivors showed deficits in motor performance attributed mainly to lower accuracy and reproducibility as compared to control hands (p < 0.05). The LH in stroke survivors showed lower reproducibility and both hands in stroke also had higher multiformity than the control hands (p < 0.05).

The findings from our HVD model suggest that accuracy, reproducibility, and multiformity were mainly impaired during force-matching task in the stroke survivors. The specific motor deficits identified through the HVD model with the new conceptual framework may be considered as critical factors for scientific investigation on stroke and evidence-based rehabilitation of this population.

Source: Deficits in motor abilities for multi-finger force control in hemiparetic stroke survivors – Online First – Springer

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[ARTICLE] Teaching Training Method of a Lower Limb Rehabilitation Robot – Full Text HTML


This paper presents a new lower limb rehabilitation robot (hereafter, referred to as LLR-Ro) to help patients with lower limb disorder recover their movement function. Based on the ergonomics and kinematics principle, the motion of a human lower limb is analysed, which provides a theoretical basis for the leg mechanism design of LLR-Ro.

This paper also proposes a teaching training method for improving the training performance of LLR-Ro. When a physician trains the lower limb of a patient, the acceleration data of the patient’s lower limb motion will be collected through a wireless data acquisition system. The data can reproduce the movement trajectory of the physician rehabilitation training and this can be used as the training trajectory of LLR-Ro.

The experiment results of this study demonstrate that the teaching training method is feasible. The theory analysis and experimental research of LLR-Ro lay the foundations for the future clinical application of this method.

1. Introduction

Rehabilitation robotics is an application of robotic technology for people with limb disabilities [1, 2]. Elderly people are the most subject to cerebral vascular disease, hemiplegia and paraplegia. These diseases may cause limb motor dysfunction [3]. According to the statistics of the World Health Organization (WHO), by 2050, the world population of people over 60 will be double and the number of people disabled by disease will also increase [4]. Thus, there is an urgent increase in the demand for rehabilitation robots [5]. In recent years, research on rehabilitation robots has become an active topic [6, 7]. Several kinds of lower limb rehabilitation robots have been developed. These can be divided into trainers with single degree of freedom, wearable trainers, suspended gait trainers and sitting/lying gait trainers. As trainers with a single degree of freedom have a poor training effect and wearable trainers need the patient to be able to walk independently, this paper will only discuss suspended gait trainers and sitting/lying gait trainers.

Continue —> Teaching Training Method of a Lower Limb Rehabilitation Robot | InTechOpen

FIGURE 1. Lower limb analysis of an ordinary adult

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[WEB SITE] Toward quieting the brain – promising anti-seizure strategies – Medical News Today


Published: Tuesday 19 April 2016

Chronic brain diseases such as epilepsy involve disturbances of the brain’s electrical activity. Finding new and better ways to correct them is the dream of millions of patients, their physicians and researchers.

An international team of investigators from Brazil, Scotland and Germany is expanding the research base on the brain’s complex suite of connections known as neural networks using computer simulations and a technique called cluster analysis. Basically, they built a computer model of a cat brain’s corticocortical network separated into 65 areas and connected by fibers of different densities. The areas were separated into four clusters, or cognitive regions: visual, auditory, somatosensory-motor, and frontolimbic.

The researchers subjected the computer model to seizure-like conditions and tested three different ways to control or avert seizure-like electrical patterns in the computer model. Their results appear in the current edition of the journal Chaos, from AIP Publishing. In it, the team reports results of its investigation into the specific seizure-related problem known as synchronization suppression using cluster analysis to evaluate three interventions.

Results show that of the three methods with therapeutic potential for correcting electrical disorders in the brain, the delayed feedback control is the most productive for synchronization suppression. The other two methods for achieving synchronization suppression that the team analyzed were external time-periodic driving and activation of selected neurons.

“We investigated the destruction of synchronization in a realistic neural network model whose connecting architecture is formed by a cluster of sub-network, and we found the most significant and interesting aspect to be the verification that the efficiency of synchronization suppression by delayed feedback control is higher and more efficient than for the two other methods: external time-periodic driving and activation of selected neurons. And importantly, the delayed feedback control is an intervention that does not damage the neurons,” said Antonio M. Batista, Ph.D., the team leader of the study from the Department of Mathematics and Statistics at State University of Ponta Grossa, Brazil.

Cluster analysis refers to an algorithm-based method commonly used to identify, classify and compare objects being studied into structures – clusters – that share a similar measure. It is broadly used in many disciplines to analyze a range of characteristics, from pattern recognition to economic data to textual analysis and biological parameters, in this case analyzing the brain’s electrical output.

It has long been documented that the mammalian brain has a cerebral cortex that features complex networks, and is involved in cognitive functions and complex perceptual tasks. There is also substantial literature on cortical networks in the cat cerebral cortex. Clinical evidence points to problems with synchronization of a small group of neurons as playing a key role in some pathological conditions such asParkinson’s disease, tremor, and epilepsy.

“For this reason, it is important to study ways to control or suppress neuronal phase synchronized bursting rhythms to restore normal spiking-bursting activity in a neuronal network,” Batista said. Their hope is that a novel analytic approach using cluster analysis will have high practical value in identifying productive potential paths for future treatments. “Studies about suppression of synchronization are important due to their link with mental illness,” Batista explained.

Source: Toward quieting the brain – promising anti-seizure strategies – Medical News Today

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[WEB SITE] Women with epilepsy have likelihood of achieving successful pregnancy just as healthy peers.

Published on April 18, 2016 at 2:19 PM<

Women with epilepsy are just as likely to achieve a successful pregnancy as women without the neurological disorder, according to a new study led by research teams at multiple centers, including NYU Langone Medical Center.

In a prospective study, women with epilepsy had a comparable likelihood of achieving pregnancy, time taken to get pregnant, and pregnancy outcomes such as miscarriage, compared to a group of healthy peers. These findings, presented April 17 at the American Academy of Neurology’s 68th Annual Meeting in Vancouver, contradict previously held beliefs in the medical community regarding the fertility of women with epilepsy.

More than 1.1 million U.S. women with epilepsy are of childbearing age and approximately 24,000 babies are born to women with epilepsy each year, according to figures from The Epilepsy Foundation, which funded the new research.

Previous studies have found infertility rates up to two to three times higher for women with epilepsy, or that as many as one-third of women with epilepsy may experience difficulty with pregnancy. But, a comprehensive study has not been done to date to confirm this until now, according to the researchers.

“We hope our findings reassure women with epilepsy and clinicians who are counseling these women on family planning,” says Jacqueline French, MD, professor of Neurology and Director of Translational Research and Clinical Trials at NYU Langone’s Comprehensive Epilepsy Center, and the study’s first author and co-principal investigator.

The researchers led a multicenter observational study called The Women with Epilepsy: Pregnancy Outcomes and Deliveries (WEPOD) from 2010 to 2015. Women with epilepsy and healthy control participants who were between the ages of 18 and 41 seeking pregnancy and less than six months removed from contraception were followed throughout the duration of their pregnancy. Electronic diaries captured use of anti-epileptic medications, seizures and facts about participants’ sexual activity and menstruation cycles.

In total, 89 women with epilepsy and 109 healthy controls with similar demographics were compared for the study. The proportion of women who achieved pregnancy was 70 percent for women with epilepsy and 67.1 percent for healthy controls.

Average time to pregnancy in women with epilepsy was 6.03 months, compared with 9.05 months for healthy controls, and after controlling for age, body mass index, parity and race, there was no difference across groups for time to pregnancy.

Of the pregnancies that occurred, a similar proportion resulted in live birth (81.8 percent women with epilepsy and 80 percent controls), miscarriage (12.7 percent women with epilepsy and 20 percent controls), or other outcomes (5.4 percent women with epilepsy compared to 0 percent healthy controls).

Source: NYU Langone Medical Center / New York University School of Medicine

Source: Women with epilepsy have likelihood of achieving successful pregnancy just as healthy peers


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[ARTICLE] “FIND Technology”: investigating the feasibility, efficacy and safety of controller-free interactive digital rehabilitation technology in an inpatient stroke population: study protocol for a randomized controlled trial – Full Text HTML



Stroke results in significant disability, which can be reduced by physical rehabilitation. High levels of repetition and activity are required in rehabilitation, but patients are typically sedentary. Using clinically relevant and fun computer games may be one way to achieve increased activity in rehabilitation.


A single-blind randomized controlled trial will be conducted to evaluate the feasibility, efficacy and safety of novel stroke-specific rehabilitation software. This software uses controller-free client interaction and inertial motion sensors. Elements of feasibility include recruitment into the trial, ongoing participation (adherence and dropout), perceived benefit, enjoyment and ease of use of the games. Efficacy will be determined by measuring activity and using upper-limb tasks as well as measures of balance and mobility. The hypothesis that the intervention group will have increased levels of physical activity within rehabilitation and improved physical outcomes compared with the control group will be tested.


Results from this study will provide a basis for discussion of feasibility of this interactive video technological solution in an inpatient situation. Differences in activity levels between groups will be the primary measure of efficacy. It will also provide data on measures of upper-limb function, balance and mobility.


In the US alone, one person per minute has a stroke, and although death rates have declined over the last decade, the burden of disease remains high [13]. Physical rehabilitation has the potential to positively impact functional outcomes and improve this burden; however, this requires a high dose of therapy. A significant factor limiting rehabilitation outcomes is low levels of patient activity [10]. Observational studies in different countries have found that patients after stroke in rehabilitation are surprisingly inactive for the vast majority of the waking day. For example, only 13 % of a stroke unit patient’s day is typically spent in activities related to functional outcome, such as active therapy or walking practice [2]. Many rehabilitation activities, aimed at stimulating neuroplasticity, are by their very nature repetitive and tend to be tedious [19]. One method by which engagement with rehabilitation programs and levels of activity could be improved involves the use of fun and engaging video games.

Commercial, off-the-shelf devices such as the Microsoft Xbox Kinect (Microsoft Corporation, Redmond, WA, USA) are relatively inexpensive and use motion capture and feedback technologies with potential for use in rehabilitation. Interactive video games increase adherence to and enjoyment of exercise in the general population [1] and have the potential to increase the dose of repetitive exercise completed by people with reduced mobility. Exercise-based video games could be used to increase exercise dose during therapy and to enable exercise outside of therapy hours. This is true both in inpatient and outpatient rehabilitation settings as well as at home after discharge from hospital.

In particular, the Kinect for Xbox 360, or simply Kinect, is a “controller-free gaming and entertainment experience” by Microsoft for the Xbox 360 video-game platform and is now also supported by PCs via Windows 8. It enables users to control and interact with the Xbox 360 without the need to touch a game controller, through a user interface using gestures and spoken commands. Kinect enables full-body depth-based three-dimensional motion-capture, facial recognition and voice recognition capabilities. This differentiates it from previous generations of interactive technologies that have been used in rehabilitation.

Despite the promise of such low-cost, consumer-based technologies, many, if not all, off-the-shelf video-game solutions are inappropriate for individuals with functional impairment [16]. There is an opportunity for purpose-built, clinically relevant video game-based rehabilitation to add significant value to current rehabilitation practice. Jintronix, a Montreal-based company, has recently launched a Kinect-based rehabilitation system, Jintronix Rehabilitation System (JRS), which provides an easy-to-use software solution (JRS WAVE) for patients to use. The software solution has been designed in collaboration with physical and occupational therapists and draws upon the motor relearning recommendations by Carr and Shepard [5]. As such, upper limb, sitting balance, standing balance and stepping rehabilitation tasks have been programmed in the JRS WAVE as fun and engaging video games that can be played at a number of different levels of complexity and speed. The system is also capable of automatically measuring changes in the range, speed and quality of motion to give patients instant feedback on their progress.

A second feature of the JRS WAVE is a cloud-based client management telehealth system for clinicians to recommend rehabilitation tasks and track and record performance of those tasks (JRS PORTAL). The PORTAL allows clinicians to provide patients regular updates and information on what has happened to them with daily, weekly or monthly progress reports on their rehabilitation, either face-to-face or remotely.

The proposed project will evaluate the feasibility, efficacy and safety of the JRS WAVE for use in an Australian stroke inpatient rehabilitation context. Elements of feasibility include recruitment into the trial, ongoing participation (adherence and dropout), perceived benefit, and enjoyment and ease of use of the games. Efficacy will be determined by measuring physical activity (using an accelerometer) and using upper-limb tasks as well as measuring changes in balance and mobility over time between the two groups. Adverse events will be monitored and changes in pain and fatigue with the interventions will be used to determine safety of the system. We will test the hypothesis that the intervention group will have increased levels of physical activity within rehabilitation and improved physical outcomes compared with the control group.

Continue —> “FIND Technology”: investigating the feasibility, efficacy and safety of controller-free interactive digital rehabilitation technology in an inpatient stroke population: study protocol for a randomized controlled trial | Trials | Full Text


Fig. 1 Feasibility Interactive Digital (FIND) technology protocol flow diagram

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[Survey] A Survey on Assistive Technology using Natural User Interface(NUI) computing to support and augment therapeutic rehabilitation – Full Text PDF


Therapeutic rehabilitation is a specialty in medical field that deals with diagnosis, evaluation, treatment and management of people with all ages with physical or psychosomatic disabilities due to congenital disorder, accidents or aging problem. It deals with deduction and reduction in disabilities by providing improvement and restoration of movement and functional ability through regular and repetitive physical therapy exercises continued after discharge from the hospital.

However, the efficient treatment sessions are not guaranteed due to lack of therapists and facilities, patients were alone for over 60% of the day, patients engaged in ‘activity’ for only 13% of the day, undergoing some traditional therapies make patients to lose their interest and motivating patients to continue the exercises is lagging, which in turn makes longer time for recovery.

Thus, there is a need to find ways of cost effective, engaging and motivated training to support and improve recovery and rehabilitation. The focus is to use technology as a solution involving various computing techniques as a supplementary treatment to traditional rehabilitation and continued assessment of disabled patients.

Natural User Interface (NUI) is the emerging technique with the ability to interact with computers or smart devices using the human body. NUI computing is powered by human touch, gesture, voice, thoughts and senses.

This paper is a survey on assistive technology using emerging NUI computing techniques like touch computing, gesture computing, surface computing, brain computing and applications of virtual reality and augmented reality to support and augment therapeutic rehabilitation.

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