Archive for July, 2016

[Abstract] Surface Electromyography for Game-Based Hand Motor Rehabilitation.

Abstract

Computer systems such as virtual environments and serious games are being used as a tool to enhance the process of user rehabilitation. These systems can help motivate and provide means to assess the user’s performance undertaking an exercise session. To do that, these systems incorporate motion tracking and gesture recognition devices, such as natural interaction devices like Kinect and Nintendo Wii. These devices, originally developed for the games market, allowed the development of low cost and minimally invasive rehabilitation systems, allowing the treatment to be taken to the patient’s residence. With the advent of natural interaction based on electromyography, devices that use electromyographic signals can also be used to construct these systems. The aim of this work is to show how electromyographic signals could be used as a tool to capture user gestures and incorporated into home-based rehabilitation systems by adopting a low-cost device to capture these gestures. The process of creation of a serious game to show some of these concepts is also present.

Source: IEEE Xplore Abstract – Surface Electromyography for Game-Based Hand Motor Rehabilitation

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[Abstract] On the use of wearable sensors to enhance motion intention detection for a contralaterally controlled FES system.

During the last years, there has been a relevant progress in motor learning and functional recovery after the occurrence of a brain lesion. Rehabilitation of motor function has been associated to motor learning that occurs during repetitive, frequent and intensive training.

Contralaterally controlled functional electrical stimulation (CCFES) is a new therapy designed to improve the recovery of paretic limbs after stroke, that could provide repetitive training-based therapies and has been developed to control the upper and lower limbs movements in response to user’s intentionality.

Electromyography (EMG) signals reflect directly the human motion intention, so it can be used as input information to control a CCFES system. Implementation of the EMG-based pattern recognition is not easy to be accomplished due to some difficulties, among them that the activity level of each muscle for a certain motion is different between each person. Inertial Measurement Units (IMU) is a kind of wearable sensors that are used to gather movement data. IMUs could provide valuable kinematic information in an EMG-based pattern recognition process to improve classification.

This work describes the use of IMUS to improve detecting motion intention from EMG data. Results shows that myoelectric algorithm using information from IMUs was better in classification of seven movements at the upper-limb level that algorithm using only EMG data.

Source: IEEE Xplore Abstract (Abstract) – On the use of wearable sensors to enhance motion intention detection for a contralaterally controlle…

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[Abstract] Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review.

Abstract

Objective: To systematically review randomized controlled trials of botulinum neurotoxin for limb spasticity to determine whether different injection techniques affect spasticity outcomes.

Methods: MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human randomized controlled trials from 1990 to 13 May 2016. Studies were assessed in duplicate for data extraction and risk of bias using the Physiotherapy Evidence Database scale and graded according to Sackett’s levels of evidence.

Results: Nine of 347 studies screened met selection criteria. Four categories of botulinum neurotoxin injection techniques were identified: (1) injection localization technique; (2) injection site selection; (3) injectate volume; (4) injection volume and site selection. There is level 1 evidence that: ultrasound, electromyography, and electrostimulation are superior to manual needle placement; endplate injections improve outcomes vs. multisite quadrant injections; motor point injections are equivalent to multisite injections; high volume injections are similar to low volume injections; and high volume injections distant from the endplate are more efficacious than low volumes closer to the endplate.

Conclusion: Level 1 evidence exists for differences in treatment outcomes using specific botulinum neurotoxin injection techniques. Findings are based on single studies that require independent replication and further study.

Source: Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review

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[REVIEW] Powered robotic exoskeletons in post-stroke rehabilitation of gait: a scoping review – Full Text

Abstract

Powered robotic exoskeletons are a potential intervention for gait rehabilitation in stroke to enable repetitive walking practice to maximize neural recovery. As this is a relatively new technology for stroke, a scoping review can help guide current research and propose recommendations for advancing the research development.

The aim of this scoping review was to map the current literature surrounding the use of robotic exoskeletons for gait rehabilitation in adults post-stroke. Five databases (Pubmed, OVID MEDLINE, CINAHL, Embase, Cochrane Central Register of Clinical Trials) were searched for articles from inception to October 2015. Reference lists of included articles were reviewed to identify additional studies. Articles were included if they utilized a robotic exoskeleton as a gait training intervention for adult stroke survivors and reported walking outcome measures.

Of 441 records identified, 11 studies, all published within the last five years, involving 216 participants met the inclusion criteria. The study designs ranged from pre-post clinical studies (n = 7) to controlled trials (n = 4); five of the studies utilized a robotic exoskeleton device unilaterally, while six used a bilateral design. Participants ranged from sub-acute (<7 weeks) to chronic (>6 months) stroke. Training periods ranged from single-session to 8-week interventions. Main walking outcome measures were gait speed, Timed Up and Go, 6-min Walk Test, and the Functional Ambulation Category.

Meaningful improvement with exoskeleton-based gait training was more apparent in sub-acute stroke compared to chronic stroke. Two of the four controlled trials showed no greater improvement in any walking outcomes compared to a control group in chronic stroke.

In conclusion, clinical trials demonstrate that powered robotic exoskeletons can be used safely as a gait training intervention for stroke. Preliminary findings suggest that exoskeletal gait training is equivalent to traditional therapy for chronic stroke patients, while sub-acute patients may experience added benefit from exoskeletal gait training. Efforts should be invested in designing rigorous, appropriately powered controlled trials before powered exoskeletons can be translated into a clinical tool for gait rehabilitation post-stroke.

Background

Stroke is a leading cause of acquired disability in the world, with increasing survival rates as medical care and treatment techniques improve [1]. This equates to an increasing population with stroke-related disability [1, 2], who experience limitations in communication, activities of daily living, and mobility [3]. A majority of this population ranks recovering the ability to walk or improving walking ability among their top rehabilitation goals [4, 5]; furthermore, the ability to walk is a determining factor as to whether an individual is able to return home after their stroke [6]. However, 30 – 40 % of stroke survivors have limited or no walking ability even after rehabilitation [7, 8] and so there is an ongoing need to advance the efficacy of gait rehabilitation for stroke survivors.

Powered robotic exoskeletons are a recently developed technology that allows individuals with lower extremity weakness to walk [9]. These wearable robots strap to the legs and have electrically actuated motors that control joint motion to automate overground walking. Powered exoskeletons were originally designed to be used as an assistive device to allow individuals with complete spinal cord injury to walk [10]. However, because they allow for walking without overhead body weight support or a treadmill, they have gained attention as an alternate intervention for gait rehabilitation in other populations such as stroke where repetitive gait training has been shown to yield improvements in walking function [11, 12]. Several powered exoskeletons are already commercially available, such as the Ekso (Ekso Bionics, USA), Rewalk (Rewalk Robotics, Israel), and Indego (Parker Hannifin, USA) exoskeletons, with more being developed.

There have been many forms of gait retraining proposed for stroke survivors. Conventional physical therapy gait rehabilitation leads to improvements in speed and endurance [13], particularly when conducted early post-stroke [14]. However, conventional gait retraining using hands-on assistance can be taxing on therapists; the number of steps actually taken in a session reflects this and has been shown to be low in sub-acute hospital rehabilitation [15]. Many of the proposed technology-based gait intervention strategies have focused on reducing the physical strain to therapists while increasing the amount of walking repetition that individuals undergo. For example, body weight-supported treadmill training (BWSTT) allows therapists to manually move the hemiparetic limb in a cyclical motion while the patient’s trunk and weight are partially supported by an overhead harness system; this has shown improvements in stroke survivors’ gait speed and endurance compared to conventional gait training [16], yet still places a high physical demand on therapists. Advances in technology have led to treadmill-based robotics, such as the Lokomat (Hocoma, Switzerland), LOPES (University of Twente, Netherlands), and G-EO (Reha-Technology, Switzerland), which have bracing that attaches to the patient’s legs to take them through a walking motion on the treadmill. The appeal of this technology is that it can provide substantially higher repetitions for walking practice than BWSTT without placing strain on therapists; however, there is conflicting evidence regarding the efficacy of treadmill-based robotics for gait training compared to conventional therapy or BWSTT. Some studies have shown that treadmill robotics improve walking independence in stroke [17, 18] but do not improve speed or endurance [18, 19]. There has been some sentiment that such technology has not lived up to the expectations originally predicted based on theory and practice [20]. One argument is that these treadmill robotics with a pre-set belt speed, combined with body weight support, create an environment where the patient has less control over the initiation of each step [21]; another argument against treadmill-based gait training is the lack of variability in visuospatial flow, which is an essential challenge of overground walking [20]. Powered robotic exoskeletons, though similar in structure to treadmill-based robotics, differ in that they require active participation from the user for both swing initiation and foot placement; for example, some exoskeletons have control strategies which will only assist the stepping motion when it detects adequate lateral weight-shifting [9]. Furthermore, because the powered exoskeletons are used for overground walking, it requires the user to be responsible for maintaining trunk and balance control, as well as navigating their path over varying surfaces.

While these powered exoskeletons hold promise, the literature surrounding their use for gait training is only just beginning to gather, with the majority focusing on spinal cord injury [22, 23, 24]. Several [25, 26, 27] systematic reviews have shown safe usage, positive effects as an assistive device, and exercise benefits for individuals with spinal cord injury. Only one systematic review [28] specifically focusing on powered exoskeletons has included studies involving stroke participants, though studies in spinal cord injury and other conditions were also included. This review focused exclusively on the Hybrid Assistive Limb (HAL) exoskeleton (Cyberdyne, Japan), (which currently is not approved for clinical use outside of Japan), and found beneficial effects on gait function and walking independence; however, the results were combined generally across all included patient populations and not specifically for stroke.

Given that this is a relatively new intervention for stroke, the objective of this scoping review was to map the current literature surrounding the use of powered robotic exoskeletons for gait rehabilitation in post-stroke individuals and to identify gaps in the research. The second objective of this scoping review was to preliminarily explore the efficacy of exoskeleton-based gait rehabilitation in stroke. As this is a relatively new technology for stroke, a scoping review can help guide current research and propose recommendations for advancing the technology.

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Continue —> Powered robotic exoskeletons in post-stroke rehabilitation of gait: a scoping review | Journal of NeuroEngineering and Rehabilitation | Full Text

 

https://tbirehabilitation.files.wordpress.com/2016/07/12984_2016_162_fig1_html.gif

Fig. 1 Study results: A flowchart of selection process based on inclusion/exclusion criteria

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[SLIDESHOW/PDF] Successes and Barrier of Implementing Telehealth Models of Rehabilitation with Children and Adults – The Ohio State University

Learning Objectives

  1. Understand the terminology related to telehealth/ telerehabilitation
  2. Describe evidence-based clinical applications of telehealth in OT

  3. Discuss how the use of telehealth technologies may contribute to a world of health and well being

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[Abstract] The Effects of Stroke Type, Locus, and Extent on Long-Term Outcome of Gait Rehabilitation

Abstract

Background. Paresis in stroke is largely a result of damage to descending corticospinal and corticobulbar pathways. Recovery of paresis predominantly reflects the impact on the neural consequences of this white matter lesion by reactive neuroplasticity (mechanisms involved in spontaneous recovery) and experience-dependent neuroplasticity, driven by therapy and daily experience. However, both theoretical considerations and empirical data suggest that type of stroke (large vessel distribution/lacunar infarction, hemorrhage), locus and extent of infarction (basal ganglia, right-hemisphere cerebral cortex), and the presence of leukoaraiosis or prior stroke might influence long-term recovery of walking ability. In this secondary analysis based on the 408 participants in the Locomotor Experience Applied Post-Stroke (LEAPS) study database, we seek to address these possibilities.

Methods. Lesion type, locus, and extent were characterized by the 2 neurologists in the LEAPS trial on the basis of clinical computed tomography and magnetic resonance imaging scans. A series of regression models was used to test our hypotheses regarding the effects of lesion type, locus, extent, and laterality on 2- to 12-month change in gait speed, controlling for baseline gait speed, age, and Berg Balance Scale score.

Results. Gait speed change at 1 year was significantly reduced in participants with basal ganglia involvement and prior stroke. There was a trend toward reduction of gait speed change in participants with lacunar infarctions. The presence of right-hemisphere cortical involvement had no significant impact on outcome.

Conclusions. Type, locus, and extent of lesion, and the loss of substrate for neuroplastic effect as a result of prior stroke may affect long-term outcome of rehabilitation of hemiparetic gait.

Source: The Effects of Stroke Type, Locus, and Extent on Long-Term Outcome of Gait Rehabilitation

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[ARTICLE] Effectiveness of botulinum toxin type A on gait and quality of life in adult post-stroke patients with lower limb spasticity: a systematic review protocol – Full Text

Abstract

Review question/objective: The objective of this review is to examine the current best available evidence on the effectiveness of botulinum toxin type A on gait (velocity and distance) and quality of life (QoL) in adult post-stroke patients with lower limb spasticity.

More specifically, this review aims to determine the effectiveness of botulinum toxin type A on adult post-stroke patients with lower limb spasticity in relation to:

* Gait velocity

* Walking distance

* QoL.

Background

Stroke is a leading cause of mortality and morbidity globally. It is the third most common cause of disability globally among people over 65 years of age.1 Post-stroke spasticity is one of the important impairments following stroke along with cognitive and other sensory motor problems. Prevalence post-stroke spasticity ranges from 4% to 42.6%.2

Spasticity is one of the upper motor neuron symptoms experienced by the stroke survivors and defined as a motor disorder characterized by a velocity-dependent increase in tonic stretch reflex (muscle tone) with exaggerated tendon jerks, resulting from hyperexcitability of the stretch reflex (muscle tone) as one component of the upper motor neuron syndrome.1

Post-stroke spasticity typically affects one-half of the body, usually the upper and the lower limb, giving rise to spastic hemiparesis. Spasticity can significantly impair functions, such as mobility and activities of daily living of stroke survivors. In the lower limb, post-stroke spasticity manifests as adducted hip, stiff knee and most commonly equinovarus foot.3 Equinovarus deformity in the ankle and foot is caused by spastic or overactive gastrocnemius, soleus and/or tibialis posterior muscles. Other foot muscles, such as flexor hallucis longus and flexor digitorum longus can also be involved causing clawing of toes. The other spastic lower limb muscles, such as the quadriceps, can cause stiff knee gait,4 hamstrings knee flexion and the hip adductors (adductor magnus, brevis and longus) adduction of the hip. Spastic lower limb gives rise to the characteristic hemiplegic or circumducting gait.

Lower limb muscles are important for transferring from bed to chair, standing from a sitting position and maintaining standing balance before taking steps to walk. The deformities caused by the spastic lower limb muscles in isolation or with other impairments can potentially impede all aspects of mobility as outlined. Post-stroke spasticity can also result in spasm, pain and contracture (permanent deformity), further compounding mobility. Inability to move and lack of independence give rise to activity limitation and participation restriction, leading to poor quality of life (QoL). In some cases, spasticity associated with weakness and lack of voluntary control can lead to adverse health outcomes such as falls and fractures.5 The burden of post-stroke spasticity is high on the stroke survivor’s active function, QoL and also on the carer. Besides the human cost, there is a significant economic cost associated with post-stroke spasticity.6

Spasticity is managed by multidisciplinary rehabilitation team and by oral antispasticity medications such as baclofen, dantrolene, diazepam and clonidine and by blocking nerves with phenol or alcohol. The evidence on the efficacy of oral medications is marginal and their use is associated with adverse effects.7 Botulinum toxin type A is an important adjunctive treatment along with stretching, strengthening exercise and bracing intervention for spasticity.

Botulinum toxin (BT) is a neurotoxin and works by blocking the acetylcholine at the neuromuscular junction weakens the muscle. This is a reversible action which lasts for two to four months8, and the injection has to be repeated. There are three varieties of botulinum toxin type A – onabotulinum toxin or Botox (by Allergan), abobotulinum toxin or Dysport (Ipsen) and incobotulinum toxin or Xeomin (Merz), the first two of which are used widely. A number of studies have shown that the botulinum toxin is safe and effective in reducing focal spasticity.8,9 It has been argued that the botulinum toxin should be the first-line treatment for post-stroke spasticity.10

Botulinum toxin is expensive and the licensed indication in many countries is often restricted to the post-stroke upper limb spasticity.11 There is a number of studies demonstrating a reduction of upper limb spasticity measured by the Modified Ashworth Scale and associated disability with botulinum toxin.12 The effectiveness of the toxin in improving function is less certain – more so in the lower limbs.8 Studies have revealed strong evidence that the BT in the lower limb reduces spasticity. There have not been many randomized controlled trials (RCTs) in the lower limb showing improvement in lower limb functioning such as gait (velocity and/or distance) and improving the QoL. This may be the reason the toxin is still not approved by the pharmaceutical benefit scheme for use in the lower limb in many countries including Australia. A systematic review and meta-analysis revealed that use of BT was associated with a small but statistically significant increase in gait velocity.3 Since then, some RCTs have been carried out with BT in lower limb. From a stroke survivor’s perspective, the ability to walk remains one of the most important goals. Botulinum toxin is also useful for passive functions such as hygiene, preventing contracture and lessening the carer’s burden and in combination with physiotherapy is found to reduce the economic cost in patients with post-stroke spasticity.6 There is a recent systematic review and meta-analysis using on the efficacy of botulinum toxin type A for improving activity restriction and QoL of patients using the GRADE approach.13 This systematic review included RCTs comprising a heterogeneous group of patients with spasticity in upper or lower limb from different causes and was not specific to post stroke lower limb spasticity. Currently, no systematic review is available synthesizing evidence from RCTs focusing on the efficacy of botulinum toxin in improving gait and walking distance and QoL among post-stroke patients with lower limb spasticity.

Hence, the present systematic review aims to synthesize and evaluate the current best available evidence, drawn from RCTs, on the effectiveness of botulinum toxin type A therapy on gait velocity, walking distance and QoL, specifically in adult post-stroke patients with lower limb spasticity. The studies to be included in this review will not be restrictive of the injection technique or dosage of botulinum toxin A used to enable a comprehensive assessment of the effectiveness of the treatment. Findings from the present review will serve to inform the usefulness of botulinum toxin type A in improving the functional outcomes of patients with post-stroke lower limb spasticity over the course of rehabilitation.

Continue —> Effectiveness of botulinum toxin type A on gait and quality… : JBI Database of Systematic Reviews and Implementation Reports

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[ARTICLE] Efficacy and safety of non-immersive virtual reality exercising in stroke rehabilitation (EVREST): a randomised, multicentre, single-blind, controlled trial – Full Text PDF

Summary

Background Non-immersive virtual reality is an emerging strategy to enhance motor performance for stroke rehabilitation. There has been rapid adoption of non-immersive virtual reality as a rehabilitation strategy despite the limited evidence about its safety and eff ectiveness. Our aim was to compare the safety and effi cacy of virtual reality with recreational therapy on motor recovery in patients after an acute ischaemic stroke.

Methods In this randomised, controlled, single-blind, parallel-group trial we enrolled adults (aged 18–85 years) who had a first-ever ischaemic stroke and a motor defi cit of the upper extremity score of 3 or more (measured with the ChedokeMcMaster scale) within 3 months of randomisation from 14 in-patient stroke rehabilitation units from four countries (Canada [11], Argentina [1], Peru [1], and Thailand [1]). Participants were randomly allocated (1:1) by a computer-generated assignment at enrolment to receive a programme of structured, task-oriented, upper extremity sessions (ten sessions, 60 min each) of either non-immersive virtual reality using the Nintendo Wii gaming system (VRWii) or simple recreational activities (playing cards, bingo, Jenga, or ball game) as add-on therapies to conventional rehabilitation over a 2 week period. All investigators assessing outcomes were masked to treatment assignment. The primary outcome was upper extremity motor performance measured by total time to complete the Wolf Motor Function Test (WMFT) at the end of the 2 week intervention period, analysed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NTC01406912.

Findings The study was done between May 12, 2012, and Oct 1, 2015. We randomly assigned 141 patients: 71 received VRWii therapy and 70 received recreational activity. 121 (86%) patients (59 in the VRWii group and 62 in the recreational activity group) completed the fi nal assessment and were included in the primary analysis. Each group improved WMFT performance time relative to baseline (decrease in median time from 43·7 s [IQR 26·1–68·0] to 29·7 s [21·4–45·2], 32·0% reduction for VRWii vs 38·0 s [IQR 28·0–64·1] to 27·1 s [21·2–45·5], 28·7% reduction for recreational activity). Mean time of conventional rehabilitation during the trial was similar between groups (VRWii, 373 min [SD 322] vs recreational activity, 397 min [345] ; p=0·70) as was the total duration of study intervention (VRWii, 528 min [SD 155] vs recreational activity, 541 min [142]; p=0·60). Multivariable analysis adjusted for baseline WMFT score, age, sex, baseline Chedoke-McMaster, and stroke severity revealed no signifi cant diff erence between groups in the primary outcome (adjusted mean estimate of diff erence in WMFT: 4·1 s, 95% CI –14·4 to 22·6). There were three serious adverse events during the trial, all deemed to be unrelated to the interventions (seizure after discharge and intracerebral haemorrhage in the recreational activity group and heart attack in the VRWii group). Overall incidences of adverse events and serious adverse events were similar between treatment groups.

Interpretation In patients who had a stroke within the 3 months before enrolment and had mild-to-moderate upper extremity motor impairment, non-immersive virtual reality as an add-on therapy to conventional rehabilitation was not superior to a recreational activity intervention in improving motor function, as measured by WMFT. Our study suggests that the type of task used in motor rehabilitation post-stroke might be less relevant, as long as it is intensive enough and task-specifi c. Simple, low-cost, and widely available recreational activities might be as eff ective as innovative non-immersive virtual reality technologies

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[WEB SITE] UT Southwestern researchers find potential mechanism to prevent epileptic seizures following TBI.

UT Southwestern Medical Center researchers have found that halting production of new neurons in the brain following traumatic brain injury can help reduce resulting epileptic seizures, cognitive decline, and impaired memory.

Injury to the brain stimulates the production of new neurons, but these new cells are sometimes hyperexcitable, disrupting neural circuits and causing recurring seizures, researchers with UT Southwestern’s Texas Institute for Brain Injury and Repair reported in Nature Communications.

Effectively stopping the process in genetically modified mice resulted in fewer seizures. In addition, eliminating the development of new neurons – a process called neurogenesis ? appeared to reduce cognitive decline and impairment of memory, common effects of seizures.

“Understanding the mechanisms that promote aberrant neurogenesis caused by traumatic brain injury and subsequent seizures may open new therapeutic avenues to prevent epilepsy and associated memory problems caused by impact,” said senior author Dr. Jenny Hsieh, Associate Professor of Molecular Biology and a member of the UT Southwestern Hamon Center for Regenerative Science and Medicine.

Halting development of new neurons resulted in a roughly 40 percent reduction in seizure frequency in the mice, but did not alter the duration of individual seizures. However, the researchers found that stopping neurogenesis before the development of seizures had a long-lasting effect, suppressing chronic seizure frequency for nearly one year, even at a late stage of the disease.

An estimated 3 million Americans and 65 million people worldwide currently live with epilepsy, costing an estimated $15.5 billion annually, according to the Centers for Disease Control and Prevention. Traumatic brain injury accounts for 20 percent of epileptic seizures, but how or why recurring seizures develop after a severe brain injury has thus far been unclear. Some drugs can help control seizures, but there is no drug to prevent or cure epilepsy.

Degenerative diseases of the heart, brain, and other tissues represent the largest cause of death and disability in the world, affecting virtually everyone over the age of 40 and accounting for the lion’s share of health care costs. Regenerative medicine represents a new frontier in science, which seeks to understand the mechanistic basis of tissue aging, repair, and regeneration and to leverage this knowledge to improve human health.

UT Southwestern’s Hamon Center for Regenerative Science and Medicine, led by Molecular Biology Chair Dr. Eric Olson, was established in 2014 with a $10 million endowment gift from the Hamon Charitable Foundation. The Center’s goals are to understand the basic mechanisms underlying tissue and organ formation, and then to use this knowledge to regenerate, repair, and replace tissues damaged by aging and injury.

The Hsieh lab studies the cellular and molecular mechanisms of neurogenesis to understand how stem cells become mature, functioning nerve cells, and how aberrant neurogenesis contributes to seizure formation, an unwarranted side effect of neuroregenerative strategies.

Source: UT Southwestern researchers find potential mechanism to prevent epileptic seizures following TBI

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