Archive for March, 2018

[Review] Evolution of Cognitive Rehabilitation After Stroke From Traditional Techniques to Smart and Personalized Home-Based Information and Communication Technology Systems: Literature Review – Full Text

ABSTRACT

Background: Neurological patients after stroke usually present cognitive deficits that cause dependencies in their daily living. These deficits mainly affect the performance of some of their daily activities. For that reason, stroke patients need long-term processes for their cognitive rehabilitation. Considering that classical techniques are focused on acting as guides and are dependent on help from therapists, significant efforts are being made to improve current methodologies and to use eHealth and Web-based architectures to implement information and communication technology (ICT) systems that achieve reliable, personalized, and home-based platforms to increase efficiency and level of attractiveness for patients and carers.

Objective: The goal of this work was to provide an overview of the practices implemented for the assessment of stroke patients and cognitive rehabilitation. This study puts together traditional methods and the most recent personalized platforms based on ICT technologies and Internet of Things.

Methods: A literature review has been distributed to a multidisciplinary team of researchers from engineering, psychology, and sport science fields. The systematic review has been focused on published scientific research, other European projects, and the most current innovative large-scale initiatives in the area. A total of 3469 results were retrieved from Web of Science, 284 studies from Journal of Medical Internet Research, and 15 European research projects from Community Research and Development Information Service from the last 15 years were reviewed for classification and selection regarding their relevance.

Results: A total of 7 relevant studies on the screening of stroke patients have been presented with 6 additional methods for the analysis of kinematics and 9 studies on the execution of goal-oriented activities. Meanwhile, the classical methods to provide cognitive rehabilitation have been classified in the 5 main techniques implemented. Finally, the review has been finalized with the selection of 8 different ICT–based approaches found in scientific-technical studies, 9 European projects funded by the European Commission that offer eHealth architectures, and other large-scale activities such as smart houses and the initiative City4Age.

Conclusions: Stroke is one of the main causes that most negatively affect countries in the socioeconomic aspect. The design of new ICT-based systems should provide 4 main features for an efficient and personalized cognitive rehabilitation: support in the execution of complex daily tasks, automatic error detection, home-based performance, and accessibility. Only 33% of the European projects presented fulfilled those requirements at the same time. For this reason, current and future large-scale initiatives focused on eHealth and smart environments should try to solve this situation by providing more complete and sophisticated platforms.[…]

Continue —> JRAT-Evolution of Cognitive Rehabilitation After Stroke From Traditional Techniques to Smart and Personalized Home-Based Information and Communication Technology Systems: Literature Review | Cogollor | JMIR Rehabilitation and Assistive Technologies

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[ARTICLE] Quantification of Upper Limb Motor Recovery and EEG Power Changes after Robot-Assisted Bilateral Arm Training in Chronic Stroke Patients: A Prospective Pilot Study – Full Text PDF

Background. Bilateral arm training (BAT) has shown promise in expediting progress toward upper limb recovery in chronic stroke patients, but its neural correlates are poorly understood.

Objective. To evaluate changes in upper limb function and EEG power after
a robot-assisted BAT in chronic stroke patients.

Methods. In a within-subject design, seven right-handed chronic stroke patients with upper limb paresis received 21 sessions (3 days/week) of the robot-assisted BAT. The outcomes were changes in score on the upper limb section of the Fugl-Meyer assessment (FM), Motricity Index (MI), and Modified Ashworth Scale (MAS) evaluated at the baseline (T0), posttraining (T1), and 1-month follow-up (T2). Event-related desynchronization/synchronization were calculated in the upper alpha and the beta frequency ranges.

Results. Significant improvement in all outcomes was measured over the course of the study. Changes in FM were significant at T2, and in MAS at T1 and T2. After training,
desynchronization on the ipsilesional sensorimotor areas increased during passive and active movement, as compared with T0.

Conclusions. A repetitive robotic-assisted BAT program may improve upper limb motor function and reduce spasticity in the chronically impaired paretic arm. Effects on spasticity were associated with EEG changes over the ipsilesional sensorimotor network.

1. Introduction

Poststroke upper limb impairment strongly influences
disability and patients’ quality of life [1, 2]. Considering that
up to two-thirds of stroke survivors suffer from upper limb
dysfunctions, one of the main goals of rehabilitation is to
improve recovery of upper limb functioning. Many
rehabilitation approaches have been put forward [3–5].
However, there is strong evidence that the conceptual evolution
of stroke rehabilitation promotes high-intensity, taskspecific,
and repetitive training [3, 5, 6]. To this end, the
application of robot-assisted therapy has steadily gained
acceptance since the 1990s [7, 8]. Robotic devices, in fact,
allow repetitive, interactive, high-intensity, and task-specific

upper limb training across all stages of recovery and neurological
severity as well [6].
A meta-analysis has shown significant, homogeneous
positive summary effect sizes (SESs) for upper limb motor
function improvements and muscle strength with the use of
elbow-wrist robots in a bilateral mode [5]. Although subgroup
analysis revealed no significant differences between
phases post stroke [5], bilateral arm training (BAT) has
shown great promise in expediting progress toward poststroke
recovery of upper limb functioning even in the chronic
phase [6, 9–11].
BAT is a form of training in which both upper limbs perform
the same movements simultaneously and independently
of each other [12]. It can be undertaken in different
modes (in-phase, antiphase) and training modalities (i.e.,
active, passive, and active-passive) [13]. The beneficial effects
of BAT are thought to arise from a coupling effect in which
both limbs adopt similar spatio-temporal movement parameters
leading to a sort of coordination [14]. Active-passive
BAT of the wrist has been investigated in behavioral and neurophysiological
studies [11, 15]. It consists of rhythmic, continuous
bimanual mirror symmetrical movements during
which the patient actively flexes and extends the “unaffected”
wrist, while the device assists the movement of the “affected”
wrist in a mirrored, symmetrical pattern via mechanical coupling
[15–19]; that is, movement of the affected upper limb is
facilitated by the unaffected one [12]. Previous studies have
reported that this pattern of coordinated movement leads
to improvements in upper limb function [11, 16, 19, 20] associated
with an increase in ipsilesional corticomotor excitability
[11]. In addition, passive BAT of the forearm and the wrist
has been shown to lead to a sustained reduction of muscle
tone in hemiparetic patients with upper limb spasticity [20].
Current evidence indicates that the neural correlates of
BAT are poorly understood [13]. The limitations of previous
studies are threefold. First, patient characteristics such as
type and site of stroke lesion were not consistently reported
[21], precluding full understanding of motor and neural
responses to BAT. Second, different BAT modalities (i.e.,
in-phase, antiphase, active, and active-passive) combined or
not with other interventions (i.e., functional tasks or free
movements with rhythmic auditory cues) have been
reported. As different training modalities are thought to
exploit different clinical effects and neural mechanisms
[22], the relationship between each of these specific modes
(delivered as a single intervention) and brain activity patterns
needs to be more precisely explored [13]. Finally, a wide
range and variation of neurophysiological and neuroimaging
measures have been used among studies.
Essentially, transcranial magnetic stimulation (TMS)
and functional magnetic resonance imaging (fMRI) studies
have been used to investigate the neural correlates of BAT.
Strength and weakness might be acknowledged for both
techniques when applied in a neurorehabilitation setting
[23]. TMS is an important tool that fits in the middle of
the functional biology continuum for assessment in stroke
recovery. However, it has the disadvantage of not being as
relevant as other biologic measures in gathering information
on brain activity during different states (or tasks) [23],
unless electroencephalography (EEG) is recorded simultaneously
[24].
Functional imaging and related techniques ((fMRI),
positron emission tomography (PET), EEG, magnetoencephalography
(MEG), and near-infrared spectroscopy (NIRS))
are important tools to determine the effects of brain injury
and how rehabilitation can change brain systems [23].
fMRI is the most widely used technique for studying brain
function. Several fMRI studies have described movementrelated
changes in motor cortical activation during partial
recovery of the affected limb in stroke patients [25], and
many studies have described the effects of various rehabilitative
treatments on motor activation.
fMRI shows difficulties when exploring brain functions
during robot-assisted sensorimotor tasks because only a few
devices are MRI compatible [26–28] and their use in the clinical
setting is limited by regulation (i.e., CE marking).
The EEG technique, conversely, has considerable
advantages over other methods in the rehabilitation setting
[17, 18, 29] being portable and readily operable with different
robotic devices. Finally, the higher temporal resolution of
EEG than fMRI signals allows monitoring brain activity during
movement execution [30–32]. EEG alpha and beta band
powers decrease during motor execution over the premotor
and primary sensorimotor cortex; at the end of the movement,
a rebound of beta activity is observed over the ipsilesional
side. These power changes are termed, respectively,
event-related desynchronization (ERD)—that is, power band
decrease—and event-related synchronization (ERS)—that is,
power band increase [33].
To the best of our knowledge, no study has addressed
changes in EEG power alongside changes in upper limb
motor function after passive robot-assisted BAT (RBAT).
Therefore, the aim of this pilot study was to evaluate
changes in both EEG power by investigating the
topographical distribution of event ERD/ERS, and upper
limb recovery of function after passive R-BAT in chronic
stroke patients. Conducting a small-scale pilot study
before the main study can enhance the likelihood of success
of the main study. Moreover, information gathered
in this pilot study would be used to refine or modify
the research methodology and to develop large-scale studies
[34]. The work hypothesis was that R-BAT would
improve recovery of upper limb function and that these
effects would be associated with an increase in activation of
the ipsilesional hemisphere.[…]

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[Abstract] Pregnancy outcomes among women with epilepsy: A retrospective cohort study

Abstract

Objective

The objective of this study was to compare adverse pregnancy outcomes between pregnancies that involve epilepsy and those that do not and are identified as normal for the purposes of this paper.

Methods

A retrospective cohort study was carried out by accessing the maternal–fetal medicine (MFM) database to identify and review records of singleton pregnancies with epilepsy but with no other underlying disease (study group). A parallel group of low-risk pregnancies was randomly allocated as the control group. The adverse outcomes between the two groups were compared. The primary outcomes included rates of spontaneous abortion, small for gestational age (SGA), preterm birth (PTB), low birth weight (LBW), and preeclampsia.

Results

From a total of 44,708 deliveries, 148 pregnancies involving mothers with epilepsy and a control group of 1480 normal pregnancies were compared. The rates of spontaneous abortion, PTB, LBW, and cesarean section were slightly but significantly higher in the study group with a relative risk of 6.6 (95% confidence interval (CI): 1.9–23.3), 1.6 (95% CI: 1.1–2.2), 1.6 (95% CI: 1.1–2.3), and 1.5 (95% CI: 1.1–2.1), respectively, whereas other adverse outcomes were comparable. In the subgroup analysis, adverse outcomes tended to be higher in women with active epilepsy. However, only the rates of SGA in the group in which the disorder is active and PTB in the presence of seizures within 6 months of conception were significantly increased.

Conclusions

Pregnancies with epilepsy, even in cases with multidisciplinary care and no other risk factors, are still significantly associated with higher adverse outcomes.

 

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[WEB SITE] Bioness Receives FDA Clearance for myBioness™ iOS app for mobile control of the L300 Go™ System

VALENCIA, Calif.March 26, 2018 /PRNewswire/ — Bioness, Inc., the leading provider of cutting-edge, clinically supported rehabilitation therapies, today announced that it received clearance from the U.S. Food and Drug Administration (FDA) for the myBionessTM mobile app for use with the L300 Go System.

The new myBioness™ mobile iOS application allows home users to control their L300 Go system including ability to change stimulation modes between gait and training along with adjusting personal pre-set intensities to meet their daily activity demands. The app has been designed to keep users engaged in the rehabilitation process and motivated to meet their recovery goals with ability to track activity, set personal goals and review their progress over time using dynamic reporting capabilities.

Gait movement disorders, such as foot drop and knee instability, are often associated with an upper motor neuron disease such as stroke and multiple sclerosis as well as injuries to the brain and spinal cord. Individuals with an impaired gait have less control over their lower extremity muscles and are at an increased risk for falls. The L300 Go is the first functional electrical stimulation (FES) system to offer 3D motion detection of gait events and muscle activation using data from a 3-axis gyroscope and accelerometer.  Patient movement is monitored in all three kinematic planes and stimulation is deployed precisely when needed during the gait cycle.  An adaptive, learning algorithm accommodates changes in gait dynamics, and a high speed processor that deploys stimulation within 10 milliseconds of detecting a valid gait event.  This rapid, reliable response is critical and supports user confidence.

“Technological innovations including 3D motion detection and multi-channel stimulation work together to improve treatment efficiency and promote patient mobility,” said Todd Cushman, President and CEO of Bioness. “At Bioness, we are focused on improving the lives of patients through technology and are proud to add the myBioness mobile application to the L300 Go portfolio of products.”

The L300 Go System was cleared by the U.S. Food and Drug Administration on January 27, 2017 with formal approval of the upgraded mobile application clearance dated March 9, 2018.  The system is indicated to provide ankle dorsiflexion in adult and pediatric individuals with foot drop and/or assist knee flexion or extension in adult individuals with muscle weakness related to upper motor neuron disease/injury (e.g., stroke, damage to pathways to the spinal cord). The L300 Go System electrically stimulates muscles in the affected leg to provide ankle dorsiflexion of the foot and/or knee flexion or extension; thus, it also may improve the individual’s gait.

Bioness will begin commercial release of the myBionessTM mobile app in the spring of 2018.   The L300 Go Systems are commercially available since the summer of 2017.

About Bioness, Inc.
Bioness is the leading provider of innovative technologies helping people regain mobility and independence. Bioness solutions include implantable and external neuromodulation systems, robotic systems and software based therapy programs providing functional and therapeutic benefits for individuals affected by pain, central nervous system disorders and orthopedic injuries. Currently, Bioness offers six medical devices within its commercial portfolio which are distributed and sold on five continents and in over 25 countries worldwide. Our technologies have been implemented in the most prestigious and well-respected institutions around the globe with approximately 90% of the top rehabilitation hospitals in the United States currently using one or more Bioness solution.  Bioness has a singular focus on aiding large, underserved customer groups with innovative, evidence-based solutions and we will continue to develop and make commercially available new products that address the growing and changing needs of our customers. Individual results vary. Consult with a qualified physician to determine if this product is right for you. Contraindications, adverse reactions and precautions are available online at www.bioness.com.

Media Relations Contact Information
Next Step Communications
bioness@nextstepcomms.com
781.326.1741

All trademarks and copyrights here within are © Bioness. | http://www.bioness.comRx Only for applicable products.

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[Abstract] Longitudinal Recovery of Executive Control Functions After Moderate-Severe Traumatic Brain Injury: Examining Trajectories of Variability and Ex-Gaussian Parameters

Background. Executive control deficits are deleterious and enduring consequences of moderate-severe traumatic brain injury (TBI) that disrupt everyday functioning. Clinically, such impairments can manifest as behavioural inconsistency, measurable experimentally by the degree of variability across trials of a reaction time (RT) task (also known as intraindividual variability [IIV]). Growing research on cognition after TBI points to cognitive deterioration in the chronic stages postinjury. Objective. To examine the longitudinal recovery of RT characteristics (IIV and more detailed ex-Gaussian components, as well as the number of impulsively quick responses) following moderate-severe TBI. Methods. Seventy moderate-severe TBI patients were assessed at 2, 5, 12, and 24+ months postinjury on a go/no-go RT task. RT indices (ex-Gaussian parameters mu and sigma [mean and variability of the normal distribution component], and tau [extremely slow responses]; mean, intraindividual coefficient of variation [ICV], and intraindividual standard deviation [ISD]) were analyzed with repeated-measures multivariate analysis of variance. Results. ICV, ISD, and ex-Gaussian tau significantly decreased (ie, improved) over time in the first year of injury, but worsened from 1 to 2+ years, as did the frequency of extremely fast responses. These quadratic patterns were accentuated by age and shown primarily in tau (extremely slow) and extremely fast (impulsive) responses. Conclusions. The pattern of early recovery followed by decline in executive control function is consistent with growing evidence that moderate-severe TBI is a progressive and degenerative disorder. Given the responsiveness to treatment of executive control deficits, elucidating the trajectory and underpinnings of inconsistent behavioral responding may reveal novel prognostic and clinical management opportunities.

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via Longitudinal Recovery of Executive Control Functions After Moderate-Severe Traumatic Brain Injury: Examining Trajectories of Variability and Ex-Gaussian Parameters – Brandon P. Vasquez, Jennifer C. Tomaszczyk, Bhanu Sharma, Brenda Colella, Robin E. A. Green, 2018

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[ARTICLE] A customized home-based computerized cognitive rehabilitation platform for patients with chronic-stage stroke: study protocol for a randomized controlled trial – Full Text

Abstract

Background

Stroke patients usually suffer primary cognitive impairment related to attention, memory, and executive functions. This impairment causes a negative impact on the quality of life of patients and their families, and may be long term. Cognitive rehabilitation has been shown to be an effective way to treat cognitive impairment and should be continued after hospital discharge. Computerized cognitive rehabilitation can be performed at home using exercise programs that advance with predetermined course content, interval, and pace. We hypothesize that computerized rehabilitation might be improved if a program could customize course content and pace in response to patient-specific progress. The present pilot study is a randomized controlled double-blind crossover clinical trial aiming to study if chronic stroke patients with cognitive impairment could benefit from cognitive training through a customized tele-rehabilitation platform (“Guttmann, NeuroPersonalTrainer”®, GNPT®).

Methods/design

Individuals with chronic-stage stroke will be recruited. Participants will be randomized to receive experimental intervention (customized tele-rehabilitation platform, GNPT®) or sham intervention (ictus.online), both with the same frequency and duration (five sessions per week over 6 weeks). After a washout period of 3 months, crossover will occur and participants from the GNPT® condition will receive sham intervention, while participants originally from the sham intervention will receive GNPT®. Patients will be assessed before and after receiving each treatment regimen with an exhaustive neuropsychological battery. Primary outcomes will include rating measures that assess attention difficulties, memory failures, and executive dysfunction for daily activities, as well as performance-based measures of attention, memory, and executive functions.

Discussion

Customized cognitive training could lead to better cognitive function in patients with chronic-stage stroke and improve their quality of life.

Background

Stroke, the most common cerebrovascular disease, is a focal neurological disorder of abrupt development due to a pathological process in blood vessels [1]. There are three main types of stroke, namely transient ischemic attack, characterized by a loss of blood flow in the brain and which reverts in less than 24 h without associated acute infarction [2]; ischemic stroke, characterized by a lack of blood reaching part of the brain due to the obstruction of blood vessels and causing tissue damage (infarction), wherein cells die in the immediate area and those surrounding the infarction area are at risk; and a hemorrhagic stroke, where either a brain aneurysm bursts or a weakened blood vessel leaks, resulting in blood spillage into or around the brain, creating swelling and pressure, and damaging cells and tissue in the brain [3].

In 2013, according to the World Health Organization (WHO) and the Global Burden of Disease study, worldwide, there were 11–15 million people affected by stroke and almost 1.5 million deaths from this cerebrovascular disease [45]. Moreover, in 2013, the total Disability-Adjusted Life Years (years of healthy life lost while living with a poor health condition) from all strokes was 51,429,440. In Spain, in 2011, the National Institute of Statistics reported 116,017 cases of stroke, corresponding to an incidence of 252 episodes per 100,000 inhabitants [6]. Although stroke incidence increases with advancing age, adults aged 20–64 years comprise 31% of the total global incidence.

Stroke often results in cognitive dysfunction, and medical treatment may cause great expense on a personal, family, economic, and social level. Depending on the area of the brain affected and the severity of lesions, stroke patients may suffer cognitive impairment, and alteration in emotional and behavioral regulation [7]. Generally, cognitive impairment derived from stroke includes alterations in attention, memory, and executive function [8].

Recent reports have begun to show positive results from the use of computerized cognitive rehabilitation systems (CCRS) for stroke patients to improve attention, memory, and executive functions. Nevertheless, more research is needed to better control variables and improve training designs in order to reduce heterogeneity and increase control of the intensity and level of performance during treatments [9101112].

CCRS allow adjustment of the type of exercises administered to the specific cognitive impairment profile of each patient, but within a fixed set of possible exercises such that heterogeneity of therapy choice is minimized. This can improve studies by allowing better categorization of patient groups that execute similar training sessions in a similar range of responses [13]. Further, CCRS offers the possibility of applying cognitive rehabilitation at home, while patient adherence and performance can be monitored online, so that patients do not need to live near, lodge near, or travel to a rehabilitation center to receive therapy. Because CCRS therapy is entirely digitized, it generates objective data that can be analyzed to determine the relative effectiveness of these interventions. We hypothesize that by allowing a trained professional to oversee an automated customization program that stratifies the level of difficulty, duration, and stimulus speed of presentation, we will reduce the heterogeneity of traditional cognitive training and improve the efficacy of intervention in chronic stroke patients.

The first objective of this pilot study is to assess if chronic stroke patients with cognitive impairment could benefit from cognitive training through a customized tele-rehabilitation platform (“Guttmann, NeuroPersonalTrainer”®, GNPT ® ) [14] intended to increase the control of experimental variables (cognitive impairment profile, adherence, and performance) traditionally identified as a source of experimental heterogeneity. The study aims to assess if this benefit could translate into an improvement of the trained cognitive domains (attention, memory, and executive functions).

The second objective is focused on generalization, namely the ability to use what has been learned in rehabilitation contexts and apply it in different environments [15]. Transfer of learning is included within the concept of generalization when specifically referring to the ability to apply specific strategies to related tasks [16]. Two types of transfer have been proposed – near transfer and far transfer [17]. By near transfer we mean that, through the training of a task within a given cognitive domain, improved function in other similar, untrained tasks may be observed in the same cognitive domain. For instance, a patient who performs selective attention exercises and improves execution through the training might improve their performance in other selective attention exercises too. By far transfer we mean that training in a given cognitive domain may improve performance of tasks in other cognitive domains. Such improvement will be observable in tasks that are structurally dissimilar from the ones used in the training. For instance, if a patient performs selective attention exercises, they may also improve their performance in memory tasks.

It has been demonstrated that computerized cognitive training can lead to the phenomenon of transfer, as previously studied in stroke patients [18]. Thus, our research aims to note whether the application of patient-customized tele-rehabilitation can give rise to an improvement in other functions that are based on cognitive domains related to those that have been trained (near transfer) as well as in different ones (far transfer).

Finally, the third objective is to assess the variables of demography (age, sex, years of education) and etiology (ischemic stroke or hemorrhage) and their impact on rehabilitation outcome, given the need to understand the patient characteristics that may influence treatment effectiveness [19].[…]

 

Continue —> A customized home-based computerized cognitive rehabilitation platform for patients with chronic-stage stroke: study protocol for a randomized controlled trial | Trials | Full Text

 

Fig. 4Sham intervention (ictus.online) screenshots. a To access to the platform, the user must enter their username and password. b Each exercise begins with an instruction screen. c The user watches a 10-min video. d When finished, the user accesses a three-question quiz with four response options. e When the quiz is finished, a results screen is displayed. In each session, three videos with their corresponding quiz are presented

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[Abstract] Application of Commercial Games for Home-Based Rehabilitation for People with Hemiparesis: Challenges and Lessons Learned

Objective: To identify the factors that influence the use of an at-home virtual rehabilitation gaming system from the perspective of therapists, engineers, and adults and adolescents with hemiparesis secondary to stroke, brain injury, and cerebral palsy.

Materials and Methods: This study reports on qualitative findings from a study, involving seven adults (two female; mean age: 65 ± 8 years) and three adolescents (one female; mean age: 15 ± 2 years) with hemiparesis, evaluating the feasibility and clinical effectiveness of a home-based custom-designed virtual rehabilitation system over 2 months. Thematic analysis was used to analyze qualitative data from therapists’ weekly telephone interview notes, research team documentation regarding issues raised during technical support interactions, and the transcript of a poststudy debriefing session involving research team members and collaborators.

Results: Qualitative themes that emerged suggested that system use was associated with three key factors as follows: (1) the technology itself (e.g., characteristics of the games and their clinical implications, system accessibility, and hardware and software design); (2) communication processes (e.g., preferences and effectiveness of methods used during the study); and (3) knowledge and training of participants and therapists on the technology’s use (e.g., familiarity with Facebook, time required to gain competence with the system, and need for clinical observations during remote therapy). Strategies to address these factors are proposed.

Conclusion: Lessons learned from this study can inform future clinical and implementation research using commercial videogames and social media platforms. The capacity to track compensatory movements, clinical considerations in game selection, the provision of kinematic and treatment progress reports to participants, and effective communication and training for therapists and participants may enhance research success, system usability, and adoption.

 

via Application of Commercial Games for Home-Based Rehabilitation for People with Hemiparesis: Challenges and Lessons Learned | Games for Health Journal

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[ARTICLE] What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes – Full Text

Abstract

Background

Virtual-reality based rehabilitation (VR) shows potential as an engaging and effective way to improve upper-limb function and cognitive abilities following a stroke. However, an updated synthesis of the literature is needed to capture growth in recent research and address gaps in our understanding of factors that may optimize training parameters and treatment effects.

Methods

Published randomized controlled trials comparing VR to conventional therapy were retrieved from seven electronic databases. Treatment effects (Hedge’s g) were estimated using a random effects model, with motor and functional outcomes between different protocols compared at the Body Structure/FunctionActivity, and Participation levels of the International Classification of Functioning.

Results

Thirty-three studies were identified, including 971 participants (492 VR participants). VR produced small to medium overall effects (g = 0.46; 95% CI: 0.33–0.59, p < 0.01), above and beyond conventional therapies. Small to medium effects were observed on Body Structure/Function (g = 0.41; 95% CI: 0.28–0.55; p < 0.01) and Activityoutcomes (g = 0.47; 95% CI: 0.34–0.60, p < 0.01), while Participationoutcomes failed to reach significance (g = 0.38; 95% CI: -0.29-1.04, p = 0.27). Superior benefits for Body Structure/Function (g = 0.56) and Activity outcomes (g = 0.62) were observed when examining outcomes only from purpose-designed VR systems. Preliminary results (k = 4) suggested small to medium effects for cognitive outcomes (g = 0.41; 95% CI: 0.28–0.55; p < 0.01). Moderator analysis found no advantage for higher doses of VR, massed practice training schedules, or greater time since injury.

Conclusion

VR can effect significant gains on Body Structure/Function and Activity level outcomes, including improvements in cognitive function, for individuals who have sustained a stroke. The evidence supports the use of VR as an adjunct for stroke rehabilitation, with effectiveness evident for a variety of platforms, training parameters, and stages of recovery.

Background

Stroke is one of the leading global causes of disability [12], with over 17 million individuals worldwide sustaining a stroke each year [2]. Although stroke mortality is decreasing with improvements in medical technology [3], the neurological trauma resulting from stroke can be devastating, and the majority of stroke survivors have substantial motor [45], cognitive [6789] and functional rehabilitation needs [31011], and much reduced quality of life [31213]. Targeted rehabilitation can help address some of these post-stroke deficits, however, historically, many individuals, in particular patients with cognitive impairment, have difficulty engaging in standard therapies [141516] at a level that will produce meaningful and lasting improvements [16171819]. Enriched and interactive rehabilitation programs are clearly needed to minimize functional disability [1320], increase participation in age-appropriate roles and activities [21], lead to greater motivation and treatment compliance [1722], and reduce the long-term expense of care in stroke survivors [202324].[…]

 

Continue —> What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes | Journal of NeuroEngineering and Rehabilitation | Full Text

 

Fig. 1 Population, Intervention, Comparison, Outcome (PICO) Question and the main variables included in the systematic literature review and meta-analysis

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[Slideshow] Comparing the Safety of Antiepilepsy Drugs in Pregnancy

Comparing the Safety of Antiepilepsy Drugs in Pregnancy

Mar 26, 2018

What are the risks of birth defects and perinatal outcomes for infants exposed to various AEDs in utero?

Source: http://www.neurologytimes.com/slideshows/comparing-safety-antiepilepsy-drugs-pregnancy

 

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[WEB SITE] Glossary of Brain Injury Terms

Browse our extensive glossary of brain injury terms, or search for a specific term.

A

ADL: Activities of daily living. Routine activities carried out for personal hygiene and health (including bathing, dressing, feeding) and for operating a household.

Acute Care: The phase of managing health problems which is conducted in a hospital on patients needing medical attention.

Acute Rehabilitation Program: Primary emphasis is on the early phase of rehabilitation which usually begins as soon as the patient is medically stable. The program is designed to be comprehensive and based in a medical facility with a typical length of stay of 1‑3 months. Treatment is provided by an identifiable team in a designated unit. See Program/Service Types.

Adaptive/Assistive Equipment: A special device which assists in the performance of self‑care, work or play/leisure activities, or physical exercise. See also adaptive equipment catalog.

Affect: The observable emotional condition of an individual at any given time. See also frontal lobe.

Agitation: Excessive restlessness, including increased physical activity which is usually non-purposeful and repetitious.

Agnosia: Failure to recognize familiar objects although the sensory mechanism is intact. May occur for any sensory modality.

Agrammatism: An inability to produce words in correct sequence.

Agraphia: Inability to express thoughts in writing. See also parietal lobe.

Alexia: Inability to read. See also parietal lobe.

Ambulate: To walk.

Amnesia: Lack of memory about events occurring during a particular period of time. See also: anterograde amnesia, retrograde amnesia, post‑traumatic amnesia.

Aneurysm: A balloon‑like deformity in the wall of a blood vessel. The wall weakens as the balloon grows larger, and may eventually burst, causing a hemorrhage.

AFO: Ankle-foot Orthosis. A below the knee brace that keeps the foot in a neutral position.

Anomia: Inability to recall names of objects. Persons with this problem often can speak fluently but have to use other words to describe familiar objects. See also parietal lobe.

Anosmia: Loss of the sense of smell.

Anoxia: A lack of oxygen. Cells of the brain need oxygen to stay alive. When blood flow to the brain is reduced or when oxygen in the blood is too low, brain cells are damaged.

Anterograde Amnesia: Inability to consolidate information about ongoing events. Difficulty with new learning.

Anticonvulsant: Medication used to decrease the possibility of a seizure (e.g., Dilantin, Phenobarbital, Mysoline, Tegretol). See also pharmacology guide.

Antidepressants: Medication used to treat depression. See also pharmacology guide.

Apathy: Absence of feelings or emotions. Person is indifferent.

Aphasia: Loss of the ability to express oneself and/or to understand language. There are many different kinds of aphasia. Receptive aphasia refers to the inability to understand what someone else is saying. This is often associated with damage in the temporal area of the brain. Expressive aphasia refers to an inability to express oneself. Some patients may know what they want to say, but many of the words they say may not “make sense”. Expressive aphasia is often associated with the left frontal area of the brain.

Apraxia: Inability to perform purposeful movements when paralysis is not present. Particularly refers to inability to use objects. For example, a patient may be unable to put together the proper movements to sit cross-legged on the floor or may not know what to do when handed a broom.

Aprosodia: A condition in which there is a loss of production or comprehension of the meaning of different tones of voice.

Arousal: Being awake. Primitive state of alertness managed by the reticular activating system (extending from medulla to the thalamus in the core of the brain stem) activating the cortex. Cognition is not possible without some degree of arousal. See also brain stem.

Articulation: Movement of the lips, tongue, teeth and palate into specific patterns for purposes of speech. Also, a movable joint.

Aspiration: When fluid or food enters the lungs through the wind pipe. Can cause a lung infection or pneumonia.

Astereognosia: Inability to recognize things by touch. See also parietal lobe.

Ataxia: Inability to coordinate muscle movements or having irregular muscle movements. This can interfere with the person’s ability to walk, talk, eat, perform self-care tasks, and work.

Attendant Care: Provision of assistance in activities of daily living for a person with disability. Daily number of hours of required assistance, either physical or supervisory.

Atrophy: A wasting away or decrease in size of a cell, tissue, organ, or part of the body caused by lack of nourishment, inactivity or loss of nerve supply.

Attention/Concentration: The ability to focus on a given task or set of stimuli for an appropriate period of time. The ability to remain alert, focused and to maintain attention to the environment. Includes ability to selectively attend to appropriate things and screen out unimportant information, shift attention from one activity to another and attend to several things at one time.

Audiologist: One who evaluates hearing defects and who aids in the rehabilitation of those who have such defects.

Auditory Comprehension: The ability to understand what is said.

Augmentative and Alternative Communication: Use of forms of communication other than speaking, such as: sign language, “yes, no” signals, gestures, picture board, and computerized speech systems to compensate (either temporarily or permanently) for severe expressive communication disorders.

Automatic Speech: Preservation of overly learned speech such as counting, alphabet, days of the week or songs.

B

Balance: The ability to use appropriate righting and equilibrium reactions to maintain an upright position. It is usually tested in sitting and standing positions.

Behavior: The total collection of actions and reactions exhibited by a person. See also Working with Behavior Disorders.

Bilateral: Pertaining to both right and left sides.

Brain Injury, Acquired: The implication of this term is that the individual experienced normal growth and development from conception through birth, until sustaining an insult to the brain at some later time which resulted in impairment of brain function.

Brain Injury, Closed (CHI): Occurs when the head accelerates and then rapidly decelerates or collides with another object (for example the windshield of a car) and brain tissue is damaged, not by the presence of a foreign object within the brain, but by violent smashing, stretching, and twisting, of brain tissue. Closed brain injuries typically cause diffuse tissue damage that result in disabilities which are generalized and highly variable.

Brain Injury, Mild: A patient with a mild traumatic brain injury is a person who has had a traumatically‑induced physiological disruption of brain function, as manifested by at least one of the following: 1) any period of loss of consciousness, 2) any loss of memory for events immediately before or after the accident, 3) any alteration in mental state at the time of the accident (e.g., feeling dazed, disoriented, or confused), 4) focal neurological deficit(s) which may or may not be transient; but where the severity of the injury does not exceed the following: a) loss of consciousness of approximately 30 minutes or less; b) after 30 minutes, an initial Glasgow Coma Scale score of 13‑15; c) Post Traumatic Amnesia not greater than 24 hours.

Brain Injury, Traumatic (TBI): Damage to living brain tissue caused by an external, mechanical force. It is usually characterized by a period of altered consciousness (amnesia or coma) that can be very brief (minutes) or very long (months/indefinitely). The specific disabling condition(s) may be orthopedic, visual, aural, neurologic, perceptive/cognitive, or mental/emotional in nature. The term does not include brain injuries that are caused by insufficient blood supply, toxic substances, malignancy, disease‑producing organisms, congential disorders, birth trauma or degenerative processes.

Brain Plasticity: The ability of intact brain cells to take over functions of damaged cells; plasticity diminishes with maturation.

Brain Scan: An imaging technique in which a radioactive dye (radionucleide) is injected into the blood stream and then pictures of the brain are taken to detect tumors, hemorrhages, blood clots, abscesses or abnormal anatomy.

Brain Stem: The lower extension of the brain where it connects to the spinal cord. Neurological functions located in the brain stem include those necessary for survival (breathing, heart rate) and for arousal (being awake and alert). It also houses the reticular formation which controls consciousness, drowsiness, and attention.

C

Cerebellum: The portion of the brain which is located below the cortex. The cerebellum is concerned with coordinating movements.

Case Management: Facilitating the access of a patient to appropriate medical, rehabilitation and support programs, and coordination of the delivery of services. This role may involve liaison with various professionals and agencies, advocacy on behalf of the patient, and arranging for purchase of services where no appropriate programs are available.

Catheter: A flexible tube for withdrawing fluids from, or introducing fluids into, a cavity of the body. Frequently used to drain the urinary bladder (Foley catheter).

Cerebellum: The portion of the brain (located at the back) which helps coordinate movement. Damage may result in ataxia.

Cerebral‑Spinal Fluid (CSF): Liquid which fills the ventricles of the brain and surrounds the brain and spinal cord.

Chronic: Marked by long duration or frequent recurrence.

Circumlocution: Use of other words to describe a specific word or idea which cannot be remembered.

Client: A person under the protection of another; one who engages the professional advice or services of another. See Consumer and Patient.

Clonus: A sustained series of rhythmic jerks following quick stretch of a muscle.

Cognition: Knowing, awareness, perceiving objects, thinking, remembering ideas. The learned set of rules on which all thinking is based.

Cognitive Rehabilitation: Therapy programs which aid persons in the management of specific problems in perception, memory, thinking and problem solving. Skills are practiced and strategies are taught to help improve function and/or compensate for remaining deficits. The interventions are based on an assessment and understanding of the person’s brain‑behavior deficits and services are provided by qualified practitioners.

Coma: A state of unconsciousness from which the patient cannot be awakened or aroused, even by powerful stimulation; lack of any response to one’s environment. Defined clinically as an inability to follow a one‑step command consistently; Glasgow Coma Scale score of 8 or less.

Communicative Disorder: An impairment in the ability to 1) receive and/or process a symbol system, 2) represent concepts or symbol systems, and/or 3) transmit and use symbol systems. The impairment may be observed in disorders of hearing, language, and/or speech processes.

Community Skills: Those abilities needed to function independently in the community. They may include: telephone skills, money management, pedestrian skills, use of public transportation, meal planning and cooking.

Comprehension: Understanding of spoken, written, or gestural communication.

Concentration: Maintaining attention on a task over a period of time; remaining attentive and not easily diverted.

Concrete Thinking: A style of thinking in which the individual sees each situation as unique and is unable to generalize from the similarities between situations. Language and perceptions are interpreted literally so that a proverb such as “a stitch in time saves nine” cannot be readily grasped.

Concussion: The common result of a blow to the head or sudden deceleration usually causing an altered mental state, either temporary or prolonged. Physiologic and/or anatomic disruption of connections between some nerve cells in the brain may occur. Often used by the public to refer to a brief loss of consciousness.

Confabulation: Verbalizations about people, places, and events with no basis in reality. May be a detailed account delivered. Patient appears to make up stories about events that occurred. Patient actually believes what he or she is saying and is not trying to lie or deceive. Stories are used to fill in for information gaps or memory loss.

Confusion: A state in which a person is bewildered, perplexed, or unable to self‑orient.

Conjugate Movement: Both eyes move simultaneously in the same direction. Convergence of the eyes toward the midline (crossed eyes) is a disconjugate movement.

Continent: Voluntary control over bowel and bladder function.

Contracture: Loss of range of motion in a joint due to abnormal shortening of soft tissues.

Contra-coup: When the brain is hit with sufficient force, causing it to “bounce” against the opposite side of the skull, thereby causing injury to both the site of the impact and the part of the brain opposite the impact. (For example, if the impact is to the left frontal area, contra-cup damage may occur to the right occipital area.)

Convergence: Movement of two eyeballs inward to focus on an object moved closer. The nearer the object, the greater is the degree of convergence necessary to maintain single vision. See also vision after head injury.

Coordination: Harmonious working together of muscles or muscle groups to perform complicated movements.

Cortical Blindness: Loss of vision resulting from a lesion of the primary visual areas of the occipital lobe. Light reflex is preserved.

CT Scan/Computerized Axial Tomography: A series of X‑rays taken at different levels of the brain that allows the direct visualization of the skull and intracranial structures. A scan is often taken soon after the injury to help decide if surgery is needed. The scan may be repeated later to see how the brain is recovering.

D

Decerebrate Posture (Decerebrate Rigidity): Exaggerated posture of extension as a result of a lesion to the prepontine area of the brain stem, and is rarely seen fully developed in humans. In reporting, it is preferable to describe the posture seen.

Decorticate Posture (Decorticate Rigidity): Exaggerated posture of upper extremity flexion and lower extremity extension as a result of a lesion to the mesencephalon or above. In reporting, it is preferable to describe the posture seen.

Decubitus: Pressure area, bed sore, skin opening, skin breakdown. A discolored or open area of skin damage caused by pressure. Common areas most prone to breakdown are buttocks or backside, hips, shoulder blades, heels, ankles and elbows.

Diffuse Axonal Injury (DAI): A shearing injury of large nerve fibers (axons covered with myelin) in many areas of the brain. It appears to be one of the two primary lesions of brain injury, the other being stretching or shearing of blood vessels from the same forces, producing hemorrhage.

Diffuse Brain Injury: Brain damage which covers many areas of the brain rather than one specific location. Diffuse damage is common in closed-head injuries due to the brain moving about and tissue being torn, stretched and bruised.

Diplopia: Seeing two images of a single object; double vision. See also vision after head injury.

Discipline: When referring to health care or education it means a particular field of study, such as medicine, occupational therapy, nursing, recreation therapy or others.

Disinhibition: The inability to control or inhibit impulses and emotions.

Disorientation: Not knowing where you are, who you are, or the time. Often, professions use the term “oriented in all three spheres” or “oriented times three” which refers to person, place, and time.

Diplopia: Seeing two images of a single object – “double vision”

Dysarthria: Difficulty forming or articulating words. This may be caused by damage to the motor areas of the cortex or damage to the brain stem. Dysarthria may include speech that is slurred, talking extremely fast or slow, or improper pitch.

Dysphagia: A swallowing disorder characterized by difficulty in oral preparation for the swallow, or in moving material from the mouth to the stomach. This also includes problems in positioning food in the mouth.

Dyslexia: Difficulty with reading ability.

Dysphagia: Swallowing difficulties.

E

Edema: Collection of fluid in the brain tissue causing swelling.

Electroencephalogram (EEG): A procedure that uses electrodes on the scalp to record electrical activity of the brain. Used for detection of epilepsy, coma, and brain death.

Electromyography (EMG): An insertion of needle electrodes into muscles to study the electrical activity of muscle and nerve fibers. It may be somewhat painful to the patient. Helps diagnose damage to nerves or muscles.

Emotional Lability: Exhibiting rapid and drastic changes in emotional state (laughing, crying, anger) inappropriately without apparent reason.

Endotracheal Tube: A tube that serves as an artificial airway and is inserted through the patient’s mouth or nose. It passes through the throat and into the air passages to help breathing. To do this it must also pass through the patient’s vocal cords. The patient will be unable to speak as long as the endotracheal tube is in place. It is this tube that connects the respirator to the patient.

Evoked Potential: Registration of the electrical responses of active brain cells as detected by electrodes placed on the surface of the head at various places. The evoked potential, unlike the waves on an EEG, is elicited by a specific stimulus applied to the visual, auditory or other sensory receptors of the body. Evoked potentials are used to diagnose a wide variety of central nervous system disorders.

Executive functions: Skills that are necessary to be competent on a job such as initiation, self control, self evaluation, self correction, goal setting, prioritizing, flexibility, time management and leadership skills.

Expressive Language: Ability to communicate using spoken or printed words.

Extended Care Facility‑Basic: Residential facility which supplies 24‑hour nursing care and supervision and assistance with activities of daily life. See Program/Service Types.

Extended Care Facility‑Skilled: A residential facility for the patient who requires 24‑hour nursing care (IV, intramuscular injections, special feeding tubes, skin care, oxygen) and rehabilitative therapy, such as physical therapy, occupational therapy, or speech therapy on a less intensive basis than as an inpatient in a comprehensive rehabilitation center. An extended care facility can be a short‑term alternative (a few months) prior to placement at home (with outpatient therapy) or in a nursing home. See Program/Service Types.

Extremity: Arm or leg.

F

Fading: A teaching device in which a prompt is gradually removed.

Figure‑Ground: The differentiation between the foreground and the background of a scene; this refers to all sensory systems, including vision, hearing, touch.

Flaccid: Lacking normal muscle tone; limp.

Flexion: Bending a joint.

Foley Catheter: This is a tube inserted into the urinary bladder for drainage of urine. The urine drains through the tube and collects into a plastic bag.

Frontal Lobe: The areas of the brain located at the front on both the left and right sides. This area plays a role in controlling emotions, motivation, social skills, expressive language (in an area on the left side referred to as Broca’s area), and inhibition of impulses. The motor strip, controlling movement and motor integration, runs along the posterior (back) of the frontal lobe.

Frustration Tolerance: The ability to persist in completing a task despite apparent difficulty. Individuals with a poor frustration tolerance will often refuse to complete tasks which are the least bit difficult. Angry behavior, such as yelling or throwing things while attempting a task is also indicative of poor frustration tolerance.

G

Gainful Occupation: Includes employment in the competitive labor market, practice of a profession, farm or family work (including work for which payment is “in kind” rather than in cash), sheltered employment, work activity (to the extent that there is net pay), and home industries or other home‑bound work.

Gait Training: Instruction in walking, with or without equipment; also called “ambulation training.”

GI Tube (G-Tube): A tube inserted through a surgical opening into the stomach. It is used to introduce liquids, food, or medication into the stomach when the patient is unable to take these substances by mouth.

Generalization: The tendency, after learning a response to one stimulus, to make that response also to other similar stimuli.

Glasgow Coma Scale: A standardized system used to assess the degree of brain impairment and to identify the seriousness of injury in relation to outcome. The system involves three determinants: eye opening, verbal responses and motor response all of which are evaluated independently according to a numerical value that indicates the level of consciousness and degree of dysfunction. Scores run from a high of 15 to a low of 3. Persons are considered to have experienced a `mild’ brain injury when their score is 13 to 15. A score of 9 to 12 is considered to reflect a `moderate’ brain injury and a score of 8 or less reflects a ‘severe’ brain injury.

H

Head Injury: Refers to an injury of the head and/or brain, including lacerations and contusions of the head, scalp and/or forehead. See also Brain Injury.

Hematoma: The collection of blood in tissues or a space following rupture of a blood vessel. Regarding Brain:

Epidural‑‑Outside the brain and its fibrous covering, the dura, but under the skull.

Subdural‑‑Between the brain and its fibrous covering (dura).

Intracerebral‑‑In the brain tissue.

Subarachnoid‑‑Around the surfaces of the brain, between the dura and arachnoid membranes.

Hemianopsia Hemianopia: Visual field cut. Blindness for one half of the field of vision. This is not the right or left eye, but the right or left half of vision in each eye. See also vision after head injury.

Hemiparesis: Weakness of one side of the body (or part of it) due to injury to the motor areas of the brain.

Hydrocephalus: Enlargement of fluid‑filled cavities in the brain, not due to brain atrophy.

Hyperplegia: Paralysis on one side of the body.

Hyperphasia: Voracious food seeking or overeating.

Hypertonic: Abnormal increase in muscle tone. Extremely tense or unrelaxed.

Hypoxia: Insufficient oxygen reaching the tissues of the body.

I

Impulse Control: Refers to the individual’s ability to withhold inappropriate verbal or motor responses while completing a task. Persons who act or speak without first considering the consequences are viewed as having poor impulse control.

Incontinent: Inability to control bowel and bladder functions. Many people who are incontinent can become continent with training. See also Bowel and Bladder Training manual.

Inflexibility: The inability to adjust to everyday changes in routines, usually related to injury to the frontal lobes. Some head-injured persons may have little difficulty following a structured routine but may exhibit sudden frustration and confusion when their routine is changed.

Initiative: Refers to the individual’s ability to begin a series of behaviors directed toward a goal.

Interdisciplinary Approach: A method of diagnosis, evaluation, and individual program planning in which two or more specialists, such as medical doctors, psychologists, recreational therapists, social workers, etc., participate as a team, contributing their skills, competencies, insights, and perspectives to focus on identifying the developmental needs of the person with a disability and on devising ways to meet those needs.

Intracranial Pressure (ICP): Cerebrospinal fluid (CSF) pressure measured from a needle or bolt introduced into the CSF space surrounding the brain. It reflects the pressure inside of the skull.

J

Jargon: Spoken language that has a normal rate and rhythm but is full of nonsense words.

Job Analysis: Involves the systematic study of an occupation in terms of what the worker does in relation to data, people, and things; the methods and techniques employed, the machines, tools, equipment, and work aids used; the materials, products, subject matter or services which result, and the traits required of the worker.

Judgment: The process of forming an opinion, based on an evaluation of the situation at hand. “Good” judgment refers to choosing the most optimal course available. Judgment involves cognitive skills, personal values and preferences, and insight into what our abilities and disabilities are. For example, a client with judgment deficits may be able to make decisions, but the decisions may be unsafe or unsuccessful.

K

Kinesthesia: The sensory awareness of body parts as they move (see Position Sense and Proprioception).

L

Lability: State of having notable shifts in emotional state (e.g., uncontrolled laughing or crying).

Leg Bag: A small, thick plastic bag that can be tied to the leg and collects urine. It is connected by tubing to a catheter inserted into the urinary bladder. See also Bowel and Bladder Training manual.

Locked‑in Syndrome: A condition resulting from interruption of motor pathways in the ventral pons, usually by infarction. This disconnection of the motor cells in the lower brain stem and spinal cord from controlling signals issued by the brain leaves the patient completely paralyzed and mute, but able to receive and understand sensory stimuli; communication may be possible by code using blinking, or movements of the jaw or eyes, which can be spared.

Lower Extremity: The lower limbs including the hip, thigh, calf, ankle and foot.

M

Magnetic Resonance Imaging (MRI): A type of diagnostic radiography using electromagnetic energy to create an image of soft tissue, central nervous system and musculoskeletal systems.

Malingering: To pretend inability so as to avoid duty or work.

Memory: The process of perceiving information, organizing and storing it, and retrieving it at a later time as needed. Memory is a complex function that involves many parts of the brain working together. There are different types of memory, including immediate (repeating a phone number just related), recent (recalling what occurred the previous day), and remote (recalling the name of a childhood friend).

Memory, Episodic: Memory for ongoing events in a person’s life. More easily impaired than semantic memory, perhaps because rehearsal or repetition tends to be minimal.

Memory, Immediate: The ability to recall numbers, pictures, or words immediately following presentation. Patients with immediate memory problems have difficulty learning new tasks because they cannot remember instructions. Relies upon concentration and attention.

Memory, Long Term: In neuropsychological testing, this refers to recall thirty minutes or longer after presentation. Requires storage and retrieval of information which exceeds the limit of short term memory.

Memory, Short Term: Primary or ‘working’ memory; its contents are in conscious awareness. A limited capacity system that holds up to seven chunks of information over periods of 30 seconds to several minutes, depending upon the person’s attention to the task.

Modeling: Exhibiting a behavior which is intended to teach someone else through the observer’s imitation of the desired behavior.

Money Management: Ability to distinguish the different denominations of money, count money, make change, budget.

Motor Control: Regulation of the timing and amount of contraction of muscles of the body to produce smooth and coordinated movement. The regulation is carried out by operation of the nervous system.

Motor Planning: Action formulated in the mind before attempting to perform.

Muscle Tone: Used in clinical practice to describe the resistance of a muscle to being stretched. When the peripheral nerve to a muscle is severed, the muscle becomes flaccid (limp). When nerve fibers in the brain or spinal cord are damaged, the balance between facilitation and inhibition of muscle tone is disturbed. The tone of some muscles may become increased and they resist being stretched – a condition called hypertonicity or spasticity.

N

Nasogastric Tube (NG Tube): A tube that passes through the patient’s nose and throat and ends in the patient’s stomach. This tube allows for direct “tube feeding” to maintain the nutritional status of the patient or removal of stomach acids.

Neglect: Paying little or no attention to a part of the body.

Neologis: Nonsense or made‑up word used when speaking. The person often does not realize that the word makes no sense.

Neurologist: A physician who specializes in the nervous system and its disorders.

Neuropsychologist: A psychologist who specializes in evaluating (by tests) brain/behavior relationships, planning training programs to help the survivor of brain injury return to normal functioning and recommending alternative cognitive and behavioral strategies to minimize the effects of brain injury. Often works closely with schools and employers as well as with family members of the injured person.

Non‑ambulatory: Not able to walk.

Nystagmus: Involuntary horizontal, vertical, or rotary movement of the eyeballs. See also vision after head injury.

O

Occipital Lobe: Region in the back of the brain which processes visual information. Damage to this lobe can cause visual deficits.

Occupational Therapy: Occupational Therapy is the therapeutic use of self‑care, work and play activities to increase independent function, enhance development and prevent disability; may include the adaptation of a task or the environment to achieve maximum independence and to enhance the quality of life. The term occupation, as used in occupational therapy, refers to any activity engaged in for evaluating, specifying and treating problems interfering with functional performance.

Oral/Motor Function: Movement of the tongue, lips, jaw and palate.

Orientation: Awareness of one’s environment and/or situation, along with the ability to use this information appropriately in a functional setting. Awareness of who and where one is, who others are, time and events, etc.

Orthopedics: The branch of medicine devoted to the study and treatment of the skeletal system, its joints, muscles and associated structures.

Orthosis: Splint or brace designed to improve function or provide stability.

Outpatient: The patient residing outside the hospital but returning on a regular basis for one or more therapeutic services.

Overlearning: Continuing to work and memorizing material beyond the point which it is adequately mastered.

P

Paraphasia: A speech problem where there is a substitution or transposition of one sound, syllable or word for another.

Paraplegia: Paralysis of the legs (from the waist down).

Parietal lobe: The upper middle lobe of each side of the brain, involved in receiving and understanding sensations, and closely linked to speech fluency and writing.

Perception: The ability to make sense of what one sees, hears, feels, tastes or smells. Perceptual losses are often very subtle, and the patient and/or family may be unaware of them.

Perseveration: Becoming “stuck” on one work or task and not being able to switch back and forth or go on to the next word/task. (For example, a patient may be asked to draw a circle on a piece of paper. He may then be asked to draw a square, but continues drawing circles.)

Persistent Vegetative State (PVS): A long‑standing condition in which the patient utters no words and does not follow commands or make any response that is meaningful.

Phonation: The production of sound by means of vocal cord vibration.

Physiatrist: Pronounced Fizz ee at’ rist. A physician who specializes in physical medicine and rehabilitation. Some physiatrists are experts in neurologic rehabilitation, trained to diagnose and treat disabling conditions. The physiatrist examines the patient to assure that medical issues are addressed; provides appropriate medical information to the patient, family members and members of the treatment team. The physiatrist follows the patient closely throughout treatment and oversees the patient’s rehabilitation program.

Physical Therapist: The physical therapist evaluates components of movement, including: muscle strength, muscle tone, posture, coordination, endurance, and general mobility. The physical therapist also evaluates the potential for functional movement, such as ability to move in the bed, transfers and walking and then proceeds to establish an individualized treatment program to help the patient achieve functional independence.

Pica: Ingestion of nonfood substances.

Plasticity: The ability of cellular or tissue structures and their resultant function to be influenced by an ongoing activity.

Plateau: A temporary or permanent leveling off in the recovery process.

Polypharmacy: Indiscriminant, symptomatic prescribing of medications by one, and sometimes multiple physicians with little or no consideration given to the etiology of the symptom(s). This is very common in the treatment of remote TBI, where the brain injury may not be mentioned in current medical records, having been replaced by psychiatric diagnoses.

Post Traumatic Amnesia (PTA): A period of hours, weeks, days or months after the injury when the patient exhibits a loss of day‑to‑day memory. The patient is unable to store new information and therefore has a decreased ability to learn. Memory of the PTA period is never stored; therefore things that happened during that period cannot be recalled. May also be called Anterograde Amnesia.

Posture: The attitude of the body. Posture is maintained by low‑grade, continuous contraction of muscles which counteract the pull of gravity on body parts. Injury to the nervous system can impair the ability to maintain normal posture, for example holding up the head.

Pre‑Morbid Condition: Characteristics of an individual present before the disease or injury occurred.

Presupposition: Ability to identify a problem, consider relevant information, explore possible solutions, and select the best solution for a given situation.

Problem‑Solving Skill: Ability to consider the probable factors that can influence the outcome of each of various solutions to a problem, and to select the most advantageous solution. Individuals with deficits in this skill may become “immobilized” when faced with a problem. By being unable to think of possible solutions, they may respond by doing nothing.

Prognosis: The prospect as to recovery from a disease or injury as indicated by the nature and symptoms of the case.

Program/Service Types: The following program/service categories describe the array of organized services (not mutually exclusive) and not an exhaustive list available for the rehabilitation of persons with brain injury:

Acute Rehabilitation: Based in a medical facility; accepts patient as soon as medically stable; focuses on intensive physical and cognitive restorative services in early months after injury; typical length of stay one week to several months (short term); identifiable team and program with specialized unit.

Behavior Disorders: For the patient exhibiting patterns of behavior preventing participation in active rehabilitation, including destructive patient behavior to self and others; continuum of controlled settings.

Community Integration Program: Provides services designed to accomplish functional outcomes focused on home and community integration, including productive activity. Services may be provided in residential facilities, day treatment programs, and the consumer’s home. They may be of short‑term (several weeks) or long‑term duration (several months).

Independent Living: Community‑based to maximize a person’s ability to be empowered and self‑directed; allows an individual to live in one’s own home with maximum personal control over how services are delivered, combined with the opportunity to work as appropriate.

Lifelong Living: For persons discharged from rehabilitation who need ongoing lifetime supports; located in residential or skilled nursing environment; structured activities available on individual and group basis.

Residential Services: Assumes a 24‑hour residential environment outside the home and includes 24‑hour provision of or access to support personnel capable of meeting the client’s needs. (Adopted by the PostAcute Committee of ISIG on Head Injury October 28, 1991.)

Subacute: May follow a period of acute rehabilitation; not necessarily hospital based; typical length of rehabilitation stay 6‑24 months (short to intermediate term); stay based on demonstrated improvement; identifiable team and program with specialized unit.

Supervised Living: Setting is a home which is like other homes in the neighborhood in terms of size and number of residents. Consumers are provided individualized care, supervision, support and training services to maximize and/or maintain function and self‑direction. Staff is present at night and other times when the consumer is present.

Supported Independent Living: Setting is a home chosen by the consumer who is primarily independent. Program offers support to assist the resident in maximizing and/or maintaining independence and self‑direction. Staff is available as needed and at planned intervals to offer assistance and support but not to provide supervision.

Transitional Living: Non‑medical residential program providing training for living in a setting of greater independence. The primary focus is on teaching functional skills and compensating for abilities that cannot be restored.

Vocational Evaluation: An organized and comprehensive service staffed by specialists who systematically and comprehensively utilize work activities (real or simulated) and/or educational services as the focal point for educational and vocational assessment and exploration. In addition, psychological testing, counseling, social summaries, occupational information, etc., are other evaluation tools that are used. It incorporates the medical, psychological, social, vocational, educational, cultural, and economic data for establishment and attainment of individual goals.

Prone: Lying on one’s stomach.

Proprioception: The sensory awareness of the position of body parts with or without movement. Combination of kinesthesia and position sense.

Proximal Instability: Impaired strength or muscle tone of the trunk, shoulder girdle, or hip girdle. This can cause poor posture, abnormal movement of the limbs, inability to sit up and inability to hold one’s head up, caused by damage to the motor strip of the brain.

Problem Solving: The ability to evaluate all of the factors involved when faced with a problem, and to generate and evaluate possible solutions. Clients with deficits in this area may “freeze” when faced with a problem; i.e. they may not be able to think of possible solutions and instead will respond by doing nothing.

Post-Traumatic Amnesia (PTA): A loss of memory that occurs immediately after injury, and which may continue for weeks or months. During this time, many clients are unable to organize or retrieve information. The length of PTA is regarded as an indicator of eventual recovery.

Psychologist: A professional specializing in counseling, including adjustment to disability. Psychologists use tests to identify personality and cognitive functioning. This information is shared with team members to assure consistency in approaches. The psychologist may provide individual or group psychotherapy for the purpose of cognitive retraining, management of behavior and the development of coping skills by the patient/client and members of the family.

Q

Quadriparesis: A weakness which involves all four limbs.

R

Range of Motion (ROM): Refers to movement of a joint (important to prevent contractures).

AROM — The amount of motion at a joint when the person uses his/her muscle strength to move it.

PROM — The amount of motion at a joint when someone else passively moves it.

Reasoning, Abstract: Mode of thinking in which the individual recognizes a phrase that has multiple meanings and selects the meaning most appropriate to a given situation. The term “abstract” typically refers to concepts not readily apparent from the physical attributes of an object or situation.

Reasoning, Concrete: The ability to understand the literal meaning of a phrase.

Reasoning, Problem‑Solving: The ability to analyze information related to a given situation and generate appropriate response options. Problem‑solving is a sequential process that typically proceeds as follows: identification of problem; generation of response options; evaluation of response option appropriateness; selection and testing of first option; analysis as to whether solution has been reached. A patient/client may discontinue making a cup of coffee because the sugar bowl is empty, even though sugar is readily available in a nearby cabinet. A patient/client may easily navigate his way into a room crowded with furniture, but request staff assistance to navigate his way out.

Reasoning, Sequencing: The ability to organize information or objects according to specified rules, or the ability to arrange information or objects in a logical, progressive manner. Nearly every activity, including work and leisure tasks, requires sequencing. For example, in cooking certain foods it is important that ingredients be added and mixed in a specified order; in dressing, undergarments must be put on prior to outer garments.

Recreation Therapist: Individual within the facility responsible for developing a program to assist persons with disabilities plan and manage their leisure activities; may also schedule specific activities and coordinate the program with existing community resources.

Rehabilitation: Comprehensive program to reduce/overcome deficits following injury or illness, and to assist the individual to attain the optimal level of mental and physical ability.

Rehabilitation Counselor: Also called Vocational Counselor. A specialist in social and vocational issues who helps the patient develop the skills and aptitudes necessary for return to productive activity and the community.

Rehabilitation Facility: Agency of multiple, coordinated services designed to minimize for the individual the disabling effects of one’s physical, mental, social, and/or vocational difficulties and to help realize individual potential.

Rehabilitation Nurse: A nurse specializing in rehabilitation techniques as well as basic nursing care. Nurses assist the patient and family in acquiring new information, developing skills, achieving competence and exhibiting behaviors that contribute to the attainment of a healthy state.

Reinforcement: A consequence of a response that increases the probability of that response occurring again.

Retrograde Amnesia: Inability to recall events that occurred prior to the accident; may be a specific span of time or type of information.

S

Seizure: An uncontrolled discharge of nerve cells which may spread to other cells nearby or throughout the entire brain. It usually lasts only a few minutes. It may be associated with loss of consciousness, loss of bowel and bladder control and tremors. May also cause aggression or other behavioral change.

Sensation: Feeling stimuli which activate sensory organs of the body, such as touch, temperature, pressure and pain. Also seeing, hearing, smelling and tasting.

Sensorimotor: Refers to all aspects of movement and sensation and the interaction of the two.

Sensory Integration: Interaction of two or more sensory processes in a manner that enhances the adaptiveness of the brain.

Sequencing: Reading, listening, expressing thoughts, describing events or contracting muscles in an orderly and meaningful manner.

Shaping: Inducing an individual to make a completely new response by reinforcing gradually closer and closer approximations to it.

Sheltered Workshop: A work setting certified as such by the Wage & Hour Division. It provides transitional and/or long‑term employment in a controlled and protected working environment for those who are unable either to compete or to function in the open job market due to their disabilities. May provide vocational evaluation and work adjustment services.

Shunt: A procedure to draw off excessive fluid in the brain. A surgically‑placed tube running from the ventricles which deposits fluid into either the abdominal cavity, heart or large veins of the neck.

Somatosensory: Sensory activity having its origin elsewhere than in the special sense organs (such as eyes and ears) and conveying information to the brain about the state of the body proper and its immediate environment.

Spasticity: An involuntary increase in muscle tone (tension) that occurs following injury to the brain or spinal cord, causing the muscles to resist being moved. Characteristics may include increase in deep tendon reflexes, resistance to passive stretch, clasp knife phenomenon, and clonus. An abnormal increase in muscle tone, causing the muscles to resist being stretched. A client with spasticity may look “curled up,” with arms held close to his chest, or may appear very stiff.

Spatial Ability: Ability to perceive the construction of an object in both two and three dimensions. Spatial ability has four components: the ability to perceive a static figure in different positions, the ability to interpret and duplicate the movements between various parts of a figure, the ability to perceive the relationship between an object and a person’s own body sphere, and the ability to interpret the person’s body as an object in space.

Speech‑language Pathology Services: A continuum of services including prevention, identification, diagnosis, consultation, and treatment of patients regarding speech, language, oral and pharyngeal sensorimotor function.

Spontaneous Recovery: The recovery which occurs as damage to body tissues heals. This type of recovery occurs with or without rehabilitation and it is very difficult to know how much improvement is spontaneous and how much is due to rehabilitative interventions. However, when the recovery is guided by an experienced rehabilitation team, complications can be anticipated and minimized; the return of function can be channeled in useful directions and in progressive steps so that the eventual outcome is the best that is possible.

Subdural: Beneath the dura (tough membrane) covering the brain and spinal cord.

Supine: Lying on one’s back.

Suppository: Medicine contained in a capsule which is inserted into the rectum so that the medicine can be absorbed into the blood stream.

T

Tactile Defensiveness: Being overly sensitive to touch; withdrawing, crying, yelling or striking when one is touched.

Tangential Response: A correct response is elicited from the person and it is followed by excessive extraneous information which is not related to the response or stimulus.

Task Analysis: Breakdown of a particular job into its component parts; information gained from task analysis can be utilized to develop training curricula or to price a product or service.

Temporal Lobes: There are two temporal lobes, one on each side of the brain located at about the level of the ears. These lobes allow a person to tell one smell from another and one sound from another. They also help in sorting new information and are believed to be responsible for short‑term memory.

Right Lobe‑‑Mainly involved in visual memory (i.e., memory for pictures and faces).

Left Lobe‑‑Mainly involved in verbal memory (i.e., memory for words and names).

Token Economy: An arrangement for behavior modification in which appropriate behavior is reinforced with tokens that can later be exchanged for desired activities, objects, or treats (reinforcers).

Tracheostomy: A temporary surgical opening at the front of the throat providing access to the trachea or windpipe to assist in breathing.

Tracking, Visual: Visually following an object as it moves through space. See also vision after head injury.

Tremor, Intention: Course, rhythmical movements of a body part that become intensified the harder one tries to control them.

Tremor, Resting: Rhythmical movements present at rest and may be diminished during voluntary movement.

U

Unilateral Neglect: Paying little or no attention to things on one side of the body. This usually occurs on the side opposite from the location of the injury to the brain because nerve fibers from the brain typically cross before innervating body structures. In extreme cases, the patient may not bathe, dress or acknowledge one side of the body.

Urinary Tract Infection: When bacteria have reproduced to a large number in the bladder. This can cause fever, chills, burning on urination, urgency, frequency, incontinence or foul smelling urine.

V

Verbal Apraxia: Impaired control of proper sequencing of muscles used in speech (tongue, lips, jaw muscles, vocal cords). These muscles are not weak but their control is defective. Speech is labored and characterized by sound reversals, additions and word approximations.

Vestibular: Pertaining to the vestibular system in the middle ear and the brain which senses movements of the head. Disorders of the vestibular system can lead to dizziness, poor regulation of postural muscle tone and inability to detect quick movements of the head.

Visual Field Deficit: Not visually perceiving information in a specific area of the visual field. Often this involves either the left or right half of the field of vision, but may involve a quarter of the visual field, etc.

 

via Glossary of Brain Injury Terms | FINR

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