Archive for August, 2019
High-intensity step training that mimics real-world conditions may better improve walking ability in stroke survivors compared to traditional, low-impact training, according to new research published in the American Heart Association’s journal Stroke.
“People who suffer strokes often have difficulty walking and impaired balance. Rehabilitation after a stroke traditionally focuses on patients practicing low-intensity walking, usually only in a forward direction, which does not provide enough of a challenge to the nervous system to enable patients to negotiate real-world situations, such as uneven surfaces, stairs or changing direction,” says study author T. George Hornby, PhD, professor of physical medicine and rehabilitation at Indiana University School of Medicine in Indianapolis, in a media release from the American Heart Association.
“Our study suggests that stroke patients can perform higher-intensity walking exercises and more difficult tasks than previously thought possible. We need to move beyond traditional, low-intensity rehabilitation to challenge the nervous and cardiovascular systems so patients can improve function and perform better in the real world.”
Researchers evaluated 90 people, 18- to 85-years-old with weakness on one side of the body who had survived a stroke at least six months prior.
Participants received training of either high-intensity stepping performing variable, difficult tasks; high-intensity stepping performing only forward walking; or low-intensity stepping of variable tasks. Variable tasks included walking on uneven surfaces, up inclines and stairs, over randomly placed obstacles on a treadmill and across a balance beam.
The researchers observed the following, the release explains:
- Survivors in both the high-intensity, variable training and high-intensity, forward walking groups walked faster and farther than the low-intensity, variable training group.
- For all walking outcomes, 57% to 80% of participants in the high-intensity groups had important clinical gains, while only 9% to 31% of participants did so following low-intensity training.
- High-intensity variable training also resulted in improved dynamic balance while walking and improved balance confidence.
Hornby notes that no serious adverse events occurred during the training sessions, suggesting stroke survivors can be pushed to higher-intensity walking with more variable tasks during rehabilitation.
“Rehabilitation that allows walking practice without challenging the nervous system doesn’t do enough to make a statistical or clinically significant difference in a patient’s recovery after a stroke,” Hornby suggests.
“We found that when stroke patients are pushed harder, they see greater changes in less time, which translates into more efficient rehabilitation services and improved mobility.”
Ultimately, their goal is to incorporate high-intensity variable step training into regular clinical rehabilitation protocols.
The study was small compared to larger, multicenter clinical trials. Hornby adds in the release that the next step would be to test high-intensity, variable step training in larger patient populations in a large, multicenter clinical trial.
[Source(s): American Heart Association, Science Daily]
[Abstract] Design and Implementation of a Wearable Device for Motivating Patients With Upper and/or Lower Limb Disability Via Gaming and Home Rehabilitation
In the early ‘90s, psychologist Albert “Skip” Rizzo was trying to rehabilitate cognitive function in brain injury patients with workbooks and pen-and-paper exercises – tools one might expect more from a special education class than a psychiatric treatment center. Then one patient, a frontal lobe-impaired 22-year-old, came in with a Game Boy, playing “Tetris.”
“This is a guy I couldn’t motivate for more than five minutes to stay focused, but there he was lasered in on this Game Boy,” Rizzo recalls. “That was the first lightbulb that we could start using digital technology to motivate and engage people.”
He became one of many medical professionals at the time to recognize the early potential of virtual reality (VR) to help diagnose and treat a wide range of mental health issues. In 1995, Rizzo accepted a research director position at USC’s Institute for Creative Technologies to launch a new kind of cognitive rehab, supplementing the old analog and talk therapy tools with VR simulations.
“Now the technology has caught up with the vision,” he says.
So, what is the vision? Given that most health concerns are inseparable from one’s environment, Rizzo calls VR “the ultimate Skinner box,” meaning it can create safe yet emotionally evocative experiences to serve virtually any assessment or treatment approach imaginable. These therapeutic programs could be uniquely reliable for evaluating patients in the subjective world of mental health, wherein up to 85 percent of conditions can go undetected, according to the World Health Organization.
VR could bridge this gap in awareness and improve diagnoses by letting providers monitor patients’ physiological reactions to virtual scenarios, resulting in better treatment outcomes down the line. At Exeter University, a “mirror game” requiring subjects to duplicate the movements and expressions of a virtual avatar aided early detection of schizophrenia. In a similar vein, University of Oxford researchers are developing a VR-based test that gauges subjects’ reactions to neutral social situations for instances of paranoid thinking. Another study from Cambridge University diagnosed early Alzheimer’s-related spatial impairments more accurately than the current gold standard method, just by having participants don an HTC Vive and retrace their steps along an unmarked L-shaped path.
Another area where VR offers proven advantages is “extinction learning,” a method for overcoming fear and emotional trauma by gradually desensitizing one to the source of their anxiety. Though patients know these experiences aren’t real, that doesn’t change the preconscious response and fear activation of their limbic systems, manifesting in increased heart rate and production of the stress hormone cortisol. Our emotional command centers naturally suspend disbelief even when our logical minds know better, putting VR on par with real-life exposure therapy in clinical effectiveness, but with none of the travel costs or physical danger.
While early programs were calibrated to extinguish common phobias like fear of heights (balancing on a plank between skyscrapers), flying (sitting on the runway in a commercial aircraft) and spiders (progressing through increasingly realistic arachnid encounters), advancements in tech have allowed researchers to tailor more complex experiences, like crowded streets to stimulate social anxiety or traumatic memories for PTSD.
Starting in 2003, Rizzo modified a VR shooter game into an exposure tool called “BRAVEMIND” for veterans to reprocess their traumatic experiences, whether relating to IED blasts or sexual assault, with a therapist virtually recreating the memory as described.
“Most treatments out there for PTSD don’t have a lot of empirical evidence,” explains Rizzo. “The ones that do so far are ones that help a person focus on addressing the trauma, not avoiding it.”
The same principle seems to apply for another trial use of VR to treat schizophrenia. Traditionally, therapists advise patients to ignore auditory hallucinations, but a University of Montreal research team instead helped them create and interact with virtual avatars for the voices in their heads. While four of 19 subjects quit after the first session, the remaining 15 rated each interaction less frightening than the last, and their hallucination-related distress dropped an average of 5 points on a scale of 20 by the study’s end.
More recently, Rizzo and others have taken VR a step further, exploring something increasingly unheard of in American healthcare – prevention.
“BRAVEMIND” was retooled into the award-winning training simulation “STRIVE,” or Stress Resilience In Virtual Environments, preparing military members for the trials and traumas of combat before they’re deployed. Standing atop a vibrating platform in an immersive headset, recruits experience 15-minutes episodes at the midpoint of which an “emotionally challenging” event occurs based on real combat situations, such as the death of a civilian child or beating of a woman for infidelity. The scenario pauses, and a virtual “mentor” pulls players aside to help them process the event and teach physiological coping strategies, like deep breathing with a pair of onscreen lungs.
“We’re trying to engage people in stuff they normally get by way of death by PowerPoint,” says Rizzo. “We know experiential learning with a story sticks in the brain way more than somebody telling you in a lecture.”
Other psychological applications where VR has shown promise include weakening cravings that drive addiction and relapse, reducing body size overestimation in anorexia patients, imparting job interview skills to the autistic or formerly incarcerated, distracting from acutely discomforting procedures like chemotherapy and teaching mindfulness in ways that can engage and offer relief for even chronic pain sufferers. Some VR treatments are already rolling out to clinicians’ offices and consumers – “BRAVEMIND” and “STRIVE” are being donated by the charity SoldierStrong to VA offices across America, while the company Limbix offers $200 monthly subscriptions for a headset with their range of medical-grade VR apps.
Yet this ability to literally shape and heal human minds has mainly been overshadowed by commercial excitement for VR video games, not that Rizzo minds. Gaming industry investment has driven the technology to new heights in sensory immersion and new lows in cost – from $15k for a full setup in the ‘90s to $200 for a standalone headset today – giving it a clinical edge over pricier techniques like neuroimaging.
Now, however, Rizzo considers the incubation period for VR over and stresses the need to distinguish between entertainment versus health-related applications, lest business motives get in the way of credible science and set back public acceptance of the technology. There are many ethical considerations still to be sorted out as well, like ensuring providers have adequate training on the tech as well as patients’ needs and establishing safeguards for self-administered VR treatments.
“We’re not building games here,” Rizzo emphasizes, “we’re building experiences.”
But at the same time, that gaming element may be the key to VR’s revolutionary potential for healthcare. Effective treatment means nothing if people don’t use it, and the allure of VR, demonstrated time and time again in preliminary studies, could actually drive engagement and education in mental health as a whole. Just as the introduction of flight training simulators in the ‘30s led to a precipitous drop in aircraft accidents, this could be another immersive practice tool to minimize real-world distress, but with a universal scope and appeal well beyond that of any Game Boy.
[Abstract] Effectiveness of Post-Hospital Intensive Residential Rehabilitation after Acquired Brain Injury: Outcomes of 256 Program Completers Compared to Participants in a Residential Supported Living Program
Post-hospital residential brain injury rehabilitation outcomes research is a complicated undertaking because of the custom-tailoring of interventions needed to meet the complex and unique need of each individual. As such, there tends to be great variability across program settings, which generally limits large-scale intervention studies. Growing literature demonstrates that post-hospital residential programs are beneficial. The main criticisms of this work include the absence of randomized-controlled studies, lack of clear definition of treatment types/settings, and small sample sizes. This study is a retrospective analysis of program evaluation data for a large, multi-site, national provider of post-hospital residential brain injury rehabilitation services. Specifically, outcome of participants completing Intensive Residential Rehabilitation (IRR) were compared to participants in the Residential Supported Living (RSL) program. Results demonstrate that participants in the IRR program improve and that participants in the RSL group preserve functional ability over time, suggesting that each program is effective in achieving its intended outcome. The IRR treatment group achieved significantly better outcomes than those in the same setting not receiving the intervention. To isolate treatment effects of IRR, a subsample of participants across program types were matched on time post-injury, age, and sex. The treatment effect of IRR was strengthened in this analysis, suggesting that chronicity alone does not account for the variance between the two groups.
via Effectiveness of Post-Hospital Intensive Residential Rehabilitation after Acquired Brain Injury: Outcomes of 256 Program Completers Compared to Participants in a Residential Supported Living Program | Journal of Neurotrauma
Results from a clinical trial testing the MyoRegulator device for the non-invasive treatment of spasticity, published recently in Bioelectronic Medicine, suggest evidence for using MyoRegulator to treat upper extremity spasticity in subjects with chronic stroke, PathMaker Neurosystems Inc announces.
PathMaker Neurosystems Inc is a clinical-stage bioelectronic medicine company that develops non-invasive systems for the treatment of patients with spasticity and paralysis. The MyoRegulator is an investigational medical device and is limited by US Federal law to investigational use only.
The device is based on PathMaker’s proprietary DoubleStim technology (combining anodal trans-spinal direct current stimulation (tsDCS) and peripheral nerve direct current stimulation (pDCS)), which provides simultaneous non-invasive stimulation intended to suppress hyperexcitable spinal neurons involved with spasticity, the company explains in a media release.
“Current pharmacological approaches to managing spasticity have, at best, short-term efficacy, are confounded by adverse effects, and are often unpleasant for the patient,” said co-author Zaghloul Ahmed, PhD, professor and chairman, Department of Physical Therapy and Professor, Center for Developmental Neuroscience, CUNY and Scientific Founder of PathMaker Neurosystems.
“The initial study results demonstrate the potential of a novel, non-invasive treatment to reduce spasticity and improve functional recovery in patients with upper motor neuron syndrome after stroke.”
The single-blind, sham-controlled, crossover design study, authored by researchers at Feinstein Institute for Medical Research at Northwell Health (and led by Bruce Volpe, MD, included patients with upper limb hemiparesis and wrist spasticity at least 6 months after their initial stroke to test whether MyoRegulator treatment reduces chronic upper-extremity spasticity.
Twenty subjects received five consecutive 20-minute daily treatments with sham stimulation followed by a 1-week washout period, then five consecutive 20-minute daily treatments with active stimulation. Subjects were told that the order of active or sham stimulation would be randomized.
Clinical and objective measures of spasticity and motor function were collected before the first session of each condition (baseline), immediately following the last session of each condition, and weekly for 5 weeks after the completion of active treatments.
The results demonstrated significant group mean reductions from baseline in both Modified Tardieu Scale scores (summed across the upper limb, P<0.05), and in objectively measured muscle resistance at the wrist flexor (P<0.05) following active treatment as compared to following sham treatment.
Motor function also improved significantly (measured by the Fugl-Meyer and Wolf Motor Function Test; P<0.05 for both tests) after active treatment, even without additional prescribed activity or training. The effect of the active MyoRegulator treatment was durable for the 5-week follow-up period, the release continues.
“We are highly encouraged by these clinical results which demonstrate the potential of MyoRegulator to improve outcomes for patients suffering from spasticity, without the need for surgery or drugs,” says Nader Yaghoubi, MD, PhD, president and chief executive officer of PathMaker.
“Building on these results and our ongoing clinical trial in Europe, we expect to initiate a US multi-center, pivotal, double-blind clinical trial supported by the National Institute of Neurological Disorders and Stroke (NINDS) in early 2020.”
[Source: PathMaker Neurosystems Inc]
Dr Nemechek Discusses the Vagus Nerve Stimulator, how it’s used and what it can do for a patient.
[ARTICLE] Factors That Contribute to the Use of Stroke Self-Rehabilitation Technologies: A Review – Full Text
Background: Stroke is increasingly one of the main causes of impairment and disability. Contextual and empirical evidence demonstrate that, mainly due to service delivery constraints, but also due to a move toward personalized health care in the comfort of patients’ homes, more stroke survivors undergo rehabilitation at home with minimal or no supervision. Due to this trend toward telerehabilitation, systems for stroke patient self-rehabilitation have become increasingly popular, with many solutions recently proposed based on technological advances in sensing, machine learning, and visualization. However, by targeting generic patient profiles, these systems often do not provide adequate rehabilitation service, as they are not tailored to specific patients’ needs.
Objective: Our objective was to review state-of-the-art home rehabilitation systems and discuss their effectiveness from a patient-centric perspective. We aimed to analyze engagement enhancement of self-rehabilitation systems, as well as motivation, to identify the challenges in technology uptake.
Methods: We performed a systematic literature search with 307,550 results. Then, through a narrative review, we selected 96 sources of existing home rehabilitation systems and we conducted a critical analysis. Based on the critical analysis, we formulated new criteria to be used when designing future solutions, addressing the need for increased patient involvement and individualism. We categorized the criteria based on (1) motivation, (2) acceptance, and (3) technological aspects affecting the incorporation of the technology in practice. We categorized all reviewed systems based on whether they successfully met each of the proposed criteria.
Results: The criteria we identified were nonintrusive, nonwearable, motivation and engagement enhancing, individualized, supporting daily activities, cost-effective, simple, and transferable. We also examined the motivation method, suitability for elderly patients, and intended use as supplementary criteria. Through the detailed literature review and comparative analysis, we found no system reported in the literature that addressed all the set criteria. Most systems successfully addressed a subset of the criteria, but none successfully addressed all set goals of the ideal self-rehabilitation system for home use.
Conclusions: We identified a gap in the state-of-the-art in telerehabilitation and propose a set of criteria for a novel patient-centric system to enhance patient engagement and motivation and deliver better self-rehabilitation commitment.
Stroke has become a global problem . One new case is reported every 2 seconds, and the number of stroke patients is predicted to increase by 59% over the next 20 years [ ]. In the United Kingdom alone, more than 100,000 stroke cases are reported annually [ ], with impairment or disability affecting two-thirds of the 1.2 million stroke survivors [ ]. In the United Kingdom, only 77% of stroke survivors are taken directly to the stroke unit. Due to the high number of patients, in England, for example, the social care costs are almost £1.7 billion per annum. The social care cost varies with the age of the patient: the older the patient, the higher the cost. The cost for a person who has had a stroke was reported in 2017 to be around £22,000 per annum. Thus, cost is one of the main drives for service delivery practices. In that respect, early discharge units have been used due to better outcomes and greater success on rehabilitation. Early discharge units consist of specialized personnel who offer an intensive rehabilitation program to the patient. However, after this intensive program of relatively short duration, the patient is discharged and continues the rehabilitation at home. This is expected to reduce costs by £1600 over 5 years for every patient, according to a 2017 report [ ].
Due to increasing pressure to discharge patients early from hospital , they rely increasingly on home rehabilitation to improve their condition after discharge. As a result, the need has been increasing for home rehabilitation systems that are not dependent on specialist or clinician operators [ , , ] while providing service similar to a clinical environment. Technological advances in home rehabilitation have been mainly focused on motor control impairments due to their prevalence in the patient population (85% worldwide [ ]).
Rehabilitation in a home environment can prove more efficient than that in a clinical environment, as the home environment supports patient empowerment through self-efficacy [, ]. The presence of supportive family members and a familiarity with the space are significant contributors to motivation. Additionally, rehabilitation in cooperation or in competition with family members demonstrates higher level of engagement [ ].
Though rehabilitation in the comfort of a patient’s home seems an attractive option, home environments have limitations that can affect the use of clinical devices. The most prevalent limitations are related to space and the lack of qualified personnel to operate devices. The number of occupants; the patient’s mobility, individual personality, and mood disorders following stroke; and sound insulation, home modification requirements, and cost [, ] also contribute to limitations of home rehabilitation. Finally, different age groups react differently to technology and devices; for example, elderly survivors often do not engage with wearable devices or video games [ ]. As a result, stroke rehabilitation requires a person-centric approach that is suitable for the home environment and that does not require infrastructure change in the home.
The success of stroke rehabilitation depends heavily on personal commitment and effort. Recent studies, for example, on applied psychology in behavior change theories for stroke rehabilitation [– ], do support that the self-esteem of the patient is limited after stroke. In addition, there is an extended sedentary period due to disability and, thus, different programs of activities are set to motivate the patients. Thus, the patient’s motivation and engagement have a critical impact on the success of any routine that is to be encouraged [ ]. This is especially critical for devices used at home, since patients are usually interacting with them alone without frequent checks. Indeed, if a device does not provide a high level of engagement or motivation enhancement, it is more likely to be abandoned within 90 days [ ]. Motivation levels depend on the individual, their achievements, and their needs at each given point in time. For example, once the patients achieve their physiotherapy exercise targets, they lose motivation for further practice. There are 3 main approaches to enhancing patients’ motivation: (1) goal-setting theory, (2) self-efficacy improvement theory, and (3) possible selves theory.
This approach has been proved effective for stroke survivors. According to the goal-setting theory, the patient’s motivation can be increased through setting small goals or targets. These need to be realistic, manageable, and well defined for the individual patient. However, they also need to be sufficiently challenging for the patient to be engaged [, – ]. presents the main components contributing to motivation enhancement based on the goal-setting theory.
To treat a traumatic brain injury, researchers are thinking outside the box.
A traumatic brain injury can range from mild to severe, but is usually caused by a harsh bump or blow to the head. A patient may experience a moment of dysfunction on the mild end, to unconsciousness and loss in brain function on the severe end of injury.”
Kevin Ward, M.D., a professor of emergency medicine and biomedical engineering at Michigan Medicine and director of the Michigan Center for Integrative Research in Critical Care (MCIRCC)
According to the Centers for Disease Control and Prevention, TBI is a serious public health problem in the United States. In 2014, there were approximately 2.87 million TBI-related emergency department visits, hospitalizations and deaths throughout the nation.
“Unfortunately, the current diagnosis, monitoring and treatment strategies for TBI have not significantly progressed over the last 30 years and have been ineffective at reducing the extent of the injury,” Ward says.
Massey TBI Grand Challenge
Thanks to funding from the Joyce and Don Massey Family Foundation, MCIRCC hopes to improve treatment and survival rates for patients that experience a TBI. The Massey family had their own experience with TBI after a car accident injured mother and wife, Joyce Massey.
“Funding from the Massey Family Foundation has allowed us to institute the Massey TBI Grand Challenge,” Ward says.
“The Grand Challenge aims to bring interdisciplinary teams together to create high-risk, high-impact, milestone-driven solutions that address the golden hours of care, or the treatment administered during the initial hours after injury, plus the 24 to 48 hours of care after a severe traumatic brain injury.”
The funding also allows MCIRCC to host the Joyce Massey TBI Summit each fall. The conference brings together the nation’s leading experts and researchers to discuss the most pressing challenges facing TBI care and how to work together to find innovative solutions.
The Massey TBI Grand Challenge encourages researchers to come up with “innovative and disruptive” TBI solutions and pitch them to an independent panel of clinicians, innovation and commercialization experts, national TBI experts and Department of Defense representatives.
“All of these great minds come together to push past the borders of typical TBI care,” Ward says. “What starts as an idea, evolves and starts to take shape. Then the team participates in our Wolverine Den, or a U-M version of Shark Tank,pitching day with research behind their idea and support that it should be funded, as it could help potentially guide future treatments.”
Five projects were selected for funding this year:
Using light wavelengths to target cells
Thomas Sanderson, Ph.D., an associate professor of emergency medicine and molecular and integrative physiology at Michigan Medicine, says that while the molecular events happening in the body during a TBI are complex and can vary, mitochondria, or the organelles in cells that help them stay energized, appear to be a common contributor to brain injury.
The research team proposed a non-invasive therapy that uses light wavelengths to target mitochondria and alter the molecular events happening inside cells during a brain injury.
Project and researcher: Evaluating Non-Invasive Mitochondrial Modulation in a Translational Model of TBI; Thomas Sanderson, Ph.D.
Valproic acid in TBI patients
Valproic acid is a type of medication generally used to treat patients with epilepsy and psychiatric disorders. Now, researchers hope it could be used to treat TBI.
The funded project will further investigate if valproic acid can successfully be used to treat patients with TBI and if so, the funds will help support an Investigational New Drug application.
Project and researchers: Valproic Acid Treatment for Varying Severities of Traumatic Brain Injury; Ben Biesterveld, M.D., Hasan Alam, M.D., Manjunath Pai, PharmD, Jason Fawley, M.D., Aaron Williams, M.D., George Velmahos, M.D., Martin Sillesen, M.D., Glenn Wakam, M.D., and Michael Kemp, M.D.
Point-of-care device to monitor and measure biomarkers in real-time
Cerebrospinal fluid, the fluid found in the brain and spinal cord that protects them from trauma, and blood contain biomarkers that researchers say could play a role in how a TBI is diagnosed and monitoring the progression of the injury.
Mark Burns, Ph.D., and Frederick Korley, M.D., Ph.D., proposed a portable, point-of-care device that could measure biomarkers in the fluid and blood and display the results on a handheld device, such as a smartphone, within 15 minutes.
Project and researchers: Device for High Frequency and Real-Time Measurement of Biofluid Biomarkers; Mark Burns, Ph.D., Frederick Korley, M.D., Ph.D.
Intranasal insulin therapy to protect the brain
Intranasal insulin, or insulin nasal spray, is already in clinical trials for Alzheimer’s disease and stroke, but researchers hope to prove it can successfully protect the brain when a high-dose is given to a TBI patient soon after injury.
The nasal spray speeds up the ability for the hormone to get to the brain through small blood vessels in the nose, instead of waiting for it to enter and go through the bloodstream when administered in the arm or stomach.
The research team will study the neuroprotective effects of an early dose and a treatment strategy where non-medical providers could administer the dose to a TBI patient right after the injury takes place.
Project and researcher: Neuroprotection with Intranasal Insulin after Traumatic Brain Injury; Tulasi Ram Jinka, DVM, Ph.D., and Robert Neumar, M.D., Ph.D.
Device to measure and monitor systolic blood pressure
Systolic blood pressure indicates the amount of pressure in the arteries when the heart pushes blood through the arteries to the rest of the body. A drop of systolic blood pressure below certain levels can dramatically worsen TBI. Unfortunately, monitoring critical levels of systolic blood pressure is very difficult.
The research team previously developed a device that provides automated, targeted systolic blood pressure monitoring. In this project, the group will refine and test the next iteration of their device to ensure it can provide continuous readings of a patient with TBI’s systolic blood pressure and keep it at a level needed for optimal TBI management.
Project and researchers: STAT: Systolic Target Assessment Tool; David Hackenson, M.D., Hakam Tiba, M.D., and Kevin Ward, M.D.
MCIRCC encourages researchers, clinicians and stakeholders to attend its future TBI events.
“By working collaboratively, we can pioneer a new path to transform TBI care,” Ward says.
“We hope the innovations our MCIRCC members are researching now, will result in improved care in the near future.”