Archive for July, 2020

[WEB PAGE] Leveling Up with Aquatic Therapy

Leveling Up with Aquatic Therapy

A patient uses the HydroWorx treadmill for gait training in a pool with the water providing an upward force that reduces gravity. The treadmill allows a patient to walk in one direction for an extended period of time while the clinician analyzes gait. The clinician cues a patient to improve muscle activation and overall function.

By Mary Jean McKinnon, PTA, and Carol Green, PT, COMT

PTs and OTs treat multiple orthopedic and neurological diagnoses with great success through aquatic therapy. Water has unique properties which improve the healing process for patients at each level of the diagnostic spectrum. Buoyancy, hydrostatic pressure, and viscosity facilitate the healing process. Buoyancy allows patients to stand upright while experiencing 70% less gravity. Viscosity provides increased resistance. More importantly, hydrostatic pressure assists in venous return, reduces one’s heart rate, and controls inflammation while exercising.

To amplify the natural benefits of water, products have been created that reduce space requirements, improve efficiency, and increase the effectiveness of aquatic therapy. Physical therapy clinics can still aid patients despite increasing property values and lease costs. Two products that benefit patients include underwater jets and underwater treadmills. Jets amplify the benefits of hydrostatic pressure, reducing inflammation and providing analgesic properties. Underwater treadmills allow patients to walk or run in different directions while experiencing decreased body weight and adhering to a variety of weight-bearing precautions.

UNDERWATER TREADMILLS REDUCE SPACE AND EXPAND VERSATILITY

The underwater treadmill helps utilize space efficiently. The patient is unweighted while running forward, backward, or sideways. The therapist assesses patient progress to advance the difficulty of the exercises to improve mobility. In extreme cases after a disk herniation, patients require an assistive device or even a wheelchair for mobility. For faster improvements in function, flexibility, and strength, the pool can be utilized. Typically, hip flexors must be stretched. Hydrostatic pressure relaxes the muscle. Once the hip flexors are relaxed, patients activate the transverse abdominis with greater ease. With the property of buoyancy, the patient weighs 70% less. The patient with a herniated disk can maintain the upright position with less effort. While the properties of water and the skill of the clinician are important, the treadmill aids the process, enabling the patient with the disk herniation to functionally strengthen and re-educate the muscle groups.

Wheelchair-bound patients as well as college or pro athletes can benefit from aquatic therapy. The patient focuses on
technique and experiences the accomplishment of aerobic exercise for an extended period of time. Aquatic therapy
helps all ends of the athletic spectrum experience the positive psychological effects of exercise. Additionally, thoughtful cueing and the skill of the PT or PTA allows the patient to improve movement patterns. Often runners will avoid putting weight on an injured ankle. Cueing for push-off or spending increased time on one foot will typically help runners. Additionally, cueing for transverse abdominis activation and gluteal muscle activation translate to decreased impact when the runner moves to land. The mechanical attributes of the treadmill translate to patient gains with increasing or decreasing speed. They also feel the comfort of knowing rehabilitation is possible.

JETS FOR HEALING

Jets provide the benefits of hydrostatic pressure by increasing the velocity of water, thus increasing the pressure. Greater pressure elongates muscle while also decreasing swelling and reducing stimulus to the nocioceptors, thus improving muscle recruitment. Patients who are status post a hip or knee replacement may have decreased range of motion (ROM) or gait deficits. This may be a result of swelling. The jet reduces swelling quickly. When patients regain normal ROM, they can climb stairs, transition from sitting to standing, or go in and out of a car. While these changes in terms of data aren’t particularly jarring, they are—in terms of function and happiness—life-changing for an individual. For a grandparent, for example, it means enjoying time spent with a grandchild after a hip replacement.

Use of the jet requires the therapist to adjust the speed and dosage. In addition to alleviating edema or relaxing the muscle, the jet also helps relieve neural tension. The pressure of the water brings blood flow to ischemic nerves, which need vast amounts of blood and oxygen. This relieves numbness, tingling, and sharp shooting pain. It can also decrease nerve entrapment by relaxing muscles. When individuals experience nerve symptoms the pain, guarding, and dysfunction cycle begins. Breaking the cycle allows individuals to sit at a desk and make clear work decisions. It also allows individuals to enjoy their relaxation time more and participate in sports like golf or tennis.

In some pools, the flow of the jets is perpendicular to the treadmill. This design benefits all patients. Often elite athletes are overly reliant on type II muscles. Backwards walking or jogging with the jet brings blood flow while relaxing tight lumbar paraspinals, gluteals, and piriformis. Also, multifidus deactivate after a disk herniation. Therefore, lumbar paraspinals tighten to provide the body necessary support. These jets can be set to an increased velocity since they are attached to the walls of the pool. This is extremely helpful for patients after a traumatic car accident who are in an extreme state of muscle guarding. Jets relax muscles, breaking the cycle of dysfunction and pain.

An underwater treadmill helps utilize space efficiently. Likewise, therapeutic jets amplify the benefits of hydrostatic pressure, thereby reducing inflammation and providing analgesic properties.

POOL TOOLS FOR TARGETED TREATMENT

There are tools outside of mechanical advances which ease the healing process. Floats, paddles, and weights combined with the properties of water help the therapist easily target specific muscle groups. Since buoyancy greatly reduces the gravitational pull, one can strengthen opposing muscle groups with movement away from center and movement to center. For example, when strengthening the shoulder, lifting the arm up strengthens the shoulder flexors and moving the arm down strengthens the extensors. The pool can be used for gravity-minimized strengthening for a patient status post a shoulder replacement. The patient can float on the water while abducting the arm to reduce muscle guarding and improve ROM. New blood flow heals tissues. The muscle contraction pumps exudate through the lymphatic system. One can attach a fin to the ankle to strengthen the rotators of the hip while healing the tissue and reducing swelling. In addition to strengthening with different movements, flotation devices can unweight patients.

OUTCOMES AMPLIFIED

While technology amplifies the benefits of water, it is important to remember the properties of water ease the healing process. Since hydrostatic pressure controls inflammation, it allows patients in a chronic inflammatory state to strengthen and desensitize to movement. This has implications for many types of physical therapy clients. For example, a patient who has been involved in a traumatic car accident can begin moving pain-free, or a patient after a total knee or hip replacement can begin to walk and facilitate correct gait patterns. Water provides an excellent opportunity for therapists to improve the ease of a movement and facilitate a patient’s healing. The water itself becomes more versatile as a healing medium by enabling therapists to use tools, such as paddles, that allow for gravity-minimized strengthening. Jets, likewise, increase the effectiveness of water by helping to reduce neural tension and muscle tightness. Similarly, the treadmill helps patients learn to walk.

Product Resources:Pools, spas, and accessories for water-based rehabilitation are available from these manufacturers:

Aquatic Access Inc
www.aquaticaccess.com

Endless Pools
www.endlesspools.com

Hudson Aquatic Systems LLC
www.hudsonaquatic.com

HydroWorx
www.hydroworx.com

Nespa Tiled Spas
www.tiledspas.com

NZ Manufacturing
https://nzcordz.com

Sprint Aquatics
www.sprintaquatics.com

Sure Hands Lift and Care Systems
www.surehands.com

SPRI Products
www.spri.com

SwimEx
www.swimex.com

EQUIPPED FOR AQUATICS

Underwater treadmills that can meet the needs of physical therapy are available from several manufacturers for use with large, in-ground pools, above-ground pools, and compact modular units. One space-saving configuration is the HydroWorx 300 Series from HydroWorx, Middletown, Pa. The 300 Series features portable, above-ground, freestanding underwater treadmills with adjustable water depth and adjustable treadmill speed. They also are equipped with jet resistance technology and options that include underwater cameras and pediatric handrails. The door opens outward so that users do not have to climb in or be lowered into the unit. The HydroWorx 300 Series units are ideal for single users but can comfortably accommodate two people, allowing therapists to work with their patients inside the exercise chamber.

Other products in this category include the AquaFit from Hudson Aquatic Systems, Angola, Ind, which is an underwater treadmill that offers a private exercise chamber and an adjustable-speed treadmill. SwimEx, headquartered in Fall River, Mass, also manufactures therapy pools in a range of sizes that feature paddlewheel technology for adjustable water current in 99 speeds. The company’s pools also offer hydrotherapy jet systems and treadmill options. Aquatic therapy equipment suitable for the physical therapy market is also available through Aston, Pa-based Endless Pools, which offers underwater treadmills with adjustable speeds that can be used in combination with the pools’ swim current feature.

WHEN MORE SPACE IS AVAILABLE

Full-sized pools that accommodate multiple users are available from all of these manufacturers. The HydroWorx 2000 Series can accommodate up to four people and has a variable-depth, moveable floor. The HydroWorx 2000 Series also features an 8-foot x 12-foot underwater treadmill, resistance therapy jets, underwater camera and monitoring systems, and a handheld remote that can control all functions.

The AquaPools from Hudson Aquatic Systems are available in large custom sizes and depths for above-ground or in-ground use and can be equipped with underwater treadmills, viewing windows, and other accessories. Likewise, SwimEx offers the 1000 T and 1500 T aquatic therapy pools that are large enough for therapists to individually treat multiple patients during the same session.

AN OPEN DOOR

In all, water-based therapy provides an open door to an additional dimension of healing. It accomplishes this through the natural properties of water, the skill of the therapist, and products that use space efficiently and improve the healing process. Clinics that add aquatic therapy services to expand their treatment possibilities will discover they have created a valuable liquid asset for themselves and the individuals to whom they provide care. PTP

Mary Jean McKinnon, PTA, practices physical therapy at OrthoCarolina’s SouthPark location in Charlotte, NC. She is a Senior Level PTA, which was earned with mentorship hours, references, article reviews, and multiple CEU courses. Her aquatic experience began in high school. After being a competitive swimmer, McKinnon began coaching and teaching swimming lessons, and continued to volunteer and coach throughout her undergraduate coursework at UNC Chapel Hill. She has 4 years of aquatic physical therapy experience built with her athletic and orthopedic knowledge. She taught the aquatic exercise class for CPCC PTA students in 2018 and 2019. She also instructs Pilates and volunteers for the Women’s Intercultural Exchange.

Carol Green, PT, COMT, is a physical therapist, Clinical Specialist Level II and certified orthopedic manual therapist at OrthoCarolina Physical Therapy South Park Clinic, Charlotte, NC. She specializes in manual therapy for the spine and extremities and has 33 years of experience. She graduated from The University of Tennessee Center for Health Sciences with a bachelor of science degree in Physical Therapy and The University of North Carolina at Greensboro with a bachelor of science degree in Physical Education and Biology minor. She also serves as chairperson for the Physical Therapy and Occupational Therapy Quality Assurance and Electronic Medical Records Committee and is an APTA-certified clinical instructor and faculty member in the OrthoCarolina orthopedic residency program. Green is a guest lecturer in the Physical Therapy Assistant Program at Central Piedmont Community College, Charlotte, NC. She has special interest in dance, gymnastics injuries, aquatics and ergonomics research, and program development for individuals and companies. For more information, contact PTPEditor@medqor.com

via Leveling Up with Aquatic Therapy – Physical Therapy Products

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[Abstract] The Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria

Abstract

In response to the need to better define the natural history of emerging consciousness after traumatic brain injury (TBI) and to better describe the characteristics of the condition commonly labeled Post-traumatic Amnesia, a case definition and diagnostic criteria for the Post- traumatic Confusional State (PTCS) were developed. This project was completed by the Confusion Workgroup of the American Congress of Rehabilitation Medicine Brain Injury Interdisciplinary Special Interest group. The case definition was informed by an exhaustive literature review and expert opinion of workgroup members from multiple disciplines. The workgroup reviewed 2,466 abstracts and extracted evidence from 44 articles. Consensus was reached through teleconferences, face-to-face meetings, and three rounds of modified Delphi voting. The case definition provides detailed description of PTCS (1) core neurobehavioral features, (2) associated neurobehavioral features, (3) functional implications, (4) exclusion criteria, (5) lower boundary, and (6) criteria for emergence. Core neurobehavioral features include disturbances of attention, orientation, and memory as well as excessive fluctuation. Associated neurobehavioral features include emotional and behavioral disturbances, sleep-wake cycle disturbance, delusions, perceptual disturbances and confabulation. The lower boundary distinguishes PTCS from the minimally conscious state while upper boundary is marked by significant improvement in the four core and five associated features. Key research goals are establishment of cut-offs on assessment instruments and determination of levels of behavioral function that distinguish persons in PTCS from those who have emerged to the period of continued recovery.

via The Post-traumatic Confusional State: A Case Definition and Diagnostic Criteria – Archives of Physical Medicine and Rehabilitation

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[ARTICLE] A Clinical Trial Investigating Telehealth and In-Person Social Communication Skills Training for People With Traumatic Brain Injury: Participant-Reported Communication Outcomes

Abstract

Objective:

To investigate the efficacy of telehealth-based and in-person social communication skills training (TBIconneCT) for people with moderate to severe traumatic brain injury (TBI) based on outcomes reported by the survivor and a close communication partner.

Setting:

Australia. Two telehealth dyads were located outside Australia.

Participants:

Adults (n = 51) at least 6 months after moderate-severe TBI with social communication skills deficits, and their usual communication partners (family members, friends, or paid carers).

Design:

Partially randomized controlled trial, with a telehealth intervention group, in-person intervention group, and a historical control group.

Main Measures:

La Trobe Communication Questionnaire (LCQ) (total score, and number of items with perceived positive change). Both self- and other-reports.

Results:

Trained participants had significantly more items with perceived positive change than did historical controls. A medium effect size in the sample was observed for improvements in total score reported by trained communication partners after treatment. Comparisons between telehealth and in-person groups found medium to large effect sizes in the sample, favoring the telehealth group on some LCQ variables.

Conclusions:

Whether delivered via telehealth or in-person, social communication skills training led to perceived positive change in communication skills. It was unexpected that outcomes for the telehealth group were better than for the in-person group on some variables.

TRAINING COMMUNICATION PARTNERS is best practice in providing intervention for cognitive communication impairments after traumatic brain injury (TBI).1 Providing communication partners with skills to enable effective conversations creates a more positive daily communication environment for people with a TBI. Training focuses on addressing negative patterns that communication partners may use in conversations with people with TBI, such as failing to follow up on the person’s contributions, not giving enough information to support the person’s comprehension, using questions designed to test the person’s memory rather than asking for meaningful information, and querying the person’s accuracy.2 The aim of training is to facilitate collaborative interactions between people with TBI and communication partners.3 The TBI communication partner training program with the highest level of evidence is TBI Express.4 This program has been shown to improve the quality of conversations5,6 and self-reported communication outcomes.7

TBI Express is an intensive program, involving 35 hours of intervention consisting of a combination of group sessions and dyad sessions (attended by both the person with TBI and their communication partner). This makes it difficult to implement TBI Express in full, given limitations on clinician time.8 Availability of families is a further barrier to accessing training, given factors of distance from rehabilitation services9 and competing time demands.10 The TBIconneCT program is a reduced-intensity version of TBI Express involving 15 hours of intervention over 10 sessions with the option for in-person or telehealth delivery. Each session involves the person with TBI and their communication partner attending together. TBIconneCT has shown positive outcomes using telehealth delivery with 2 participants in a single case experimental design study.11 To further investigate the effectiveness of TBIconneCT, a clinical trial was conducted. This trial had 3 arms: in-person TBIconneCT training, telehealth TBIconneCT training, and a historical control group.

The current study reports on a secondary outcome measure from this previously reported trial of TBIconneCT.12 The previous report addressed the primary outcome measure of conversational quality using the Adapted Measure of Support in Conversation (Reveal Competence scale)13 based on ratings from a blinded assessor. The secondary outcome measure reported in the current study evaluated the impact of the training on communication problems from the perspectives of the most important stakeholders: people with TBI and their usual communication partners.14 The La Trobe Communication Questionnaire (LCQ)15 is the secondary measure analyzed in the current article. Although level of insight will affect participants’ reporting, the LCQ has been shown to be a valuable tool that is sensitive to change, and it has been recommended as a supplemental outcome measure in TBI research.16

The research questions for the current study were:

  • (1) Is TBIconneCT training more efficacious than no training in improving LCQ outcomes as rated by people with TBI and their usual communication partners?

For the purposes of this question, the group of trained participants (formed by combining in-person and telehealth participants into a single group) was compared with the group of historical control participants.

  • (2) What is the magnitude of any difference in LCQ outcomes between telehealth and in-person training?

The sample size of this trial was not large enough for a noninferiority design. This question is therefore exploratory in nature.[…]

via A Clinical Trial Investigating Telehealth and In-Person Soci… : The Journal of Head Trauma Rehabilitation

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[BLOG POST] Accessible Sex Toys for People With Disabilities or Chronic Pain

Sex is a basic human need, yet often people with mobility challenges or physical differences are left out of the conversation, from depictions in popular media to the design of sex toys. When considering the latter, most people view sex toys as a naughty bonus. For people with a disability or chronic illness, however, sex toys aren’t “just” for fun — they’re an empowering way to make sex accessible.

“Sex toys can not only give us pleasure but they are assistive technology just like a cane or a shower chair,” Eva Sweeney, sex educator and host of “Cripping Up Sex With Eva,” told The Mighty. “They allow us to explore and enjoy our bodies like everybody else. So many times toys are viewed as novelties or optional when they are necessary for many people with disabilities or chronic illness (and without).”

It’s easy to find enticing sex toys if you’re able-bodied, but it’s more of a challenge to find affordable options that people with mobility challenges or even chronic pain can use comfortably. “Most sex toys are very expensive and as we all know people with disabilities are more likely to live in poverty,” Sweeney said. “That’s the major barrier keeping people with disabilities from getting the toys they need.”

We gathered 15 accessible sex toys, wearables and devices that might just fast-track you to the big “O,” whether you’re looking for solo fun or a partnered encounter. And here’s a little extra advice from Sweeney: “Explore! Try different toys. Everybody is different.”

1. Tongue Star Pleasure Tongue by Hott Products ($5.65)

Tongue Star Pleasure Tongue by Hott Products

This toy lets your tongue do the talking during sexy times with this hands-free vibrator you can wear. It looks a little like a mouth guard, and that’s exactly how you’ll use it. The design reduces the vibrations you feel on your teeth when the vibrator is on. A small vibrator attached to the outside of the mouthpiece, meanwhile, lets you deliver what Hott Products calls “toe-curling thrills” to a partner.

2. Thigh Strap-On by SportSheets ($23.99; $15.36 on Amazon)

Thigh Strap-On by SportSheets

SportSheets’ thigh strap-on lets you give a partner an intimate experience with penetration even if your mobility restricts your pelvic movement. It’s hands-free for you, so while your partner grinds, you get to explore. The strap-on harness is sturdy and comfortable and can be a great solution for accessibility. “Harnesses can be really helpful for keeping toys in place,” Sweeney said. “There are harnesses for every body part and can be custom made,” so let your imagination run wild.

3. Mage Flexible Massager Vibrator by Intimate Melody ($29.95)

Mage Flexible Massager Vibrator by Intimate Melody

“I really like flexible toys because you can mold them in whatever shape you want and they usually stay like that so you don’t have to use your hands as much,” Sweeney told The Mighty. The Mage flexible massager vibrator delivers on this sex toy ideal. Made by Intimate Melody, this vibrator isn’t hands-free, but it’s completely flexible so you can customize the toy to what works best for you. That includes bending, twisting and folding the Mage and exploring its six massage modes at three strength levels.

4. Hollow Strap-On by Adam & Eve ($29.95)

Hollow Strap-On by Adam and Eve

A hollow strap-on can bring new energy into your sexual life if penetration is important to your routine. The hollowed dildo can accommodate an erect or resting penis, and if you live with erectile dysfunction, a hollow strap-on can provide the sensation of giving penetrative sex for you and a partner. The rippled shell will feel great for both parties. It’s a flexible investment because it can be used by any gender thanks to an adjustable, sturdy harness and an easy-to-clean dildo. You can also invest in a vibrating version of this hollow strap-on ($49.95).

5. Sex Stool by Kinkly ($60.99 on Amazon)

Sex Stool by Kinkly

Sometimes, you just need a little extra support. Enter the sex stool, a sturdy metal frame with elastic straps to support your body weight that gives you amazing access to a partner or sex toy mount. With a sex stool, you’ll use less energy and be able to focus more on pleasure and less on strain. It’s easy on the knees, and some users have reported extra tingles thanks to increased compression in your glutes as you use the stool.

6. HelixSyn by Aneros ($69.95)

HelixSyn by Aneros

For those who like to enter through the back door, Aneros’ HelixSyn prostate stimulator is the hands-free option you may be looking for. Advertised as having “velvet touch” silicone, the toy is comfortable for both beginners and advanced users. Its shape fits comfortably inside your body and causes friction in all the right spots as you contract and relax your muscles (a version of anal kegel exercises). HelixSyn’s design pivots as you move, so you’re in good shape no matter what position you choose. Plus, the handle won’t cause any pain and a comfort tab is designed to increase your pleasure.

7. Door Jam Sex Sling by SportSheets ($69.99; $35.11 on Amazon)

Door Jam Sex Sling by SportSheetsTo gain extra support and a lot of flexibility positioning with a partner, give this door jam sex sling by SportSheets a try. The sturdy sling has a seat, hand and foot straps, all of which are adjustable. At least one partner will need to stand. However, the sling can assist in bearing body weight as you try out new sex positions that might not otherwise be possible. Other sling options, like a simple sex sling ($35.99) or the Penetration Station that attaches to the mattress ($44.99), might also be worth checking out.

8. Fin Vibrator by Dame Products ($75)

Fin Vibrator by Dame Products

With Fin, Dame Products has taken the grip challenge out of vibrators. “Fin is a finger vibrator…that’s much easier to hold than most bullets because it has little fins almost that goes between your two fingers,” Dame co-founder, Alexandra Fine, told The Mighty. “It also has a detachable tether that can really tie the product to your hand in a way that a lot of people either with disabilities or arthritis or any challenges gripping something really like….The way it works with your hand, it feels more like a natural extension of your body.” Introduced in 2016 by Fine and Dame co-founder Janet Lieberman, Fin offers dual sensations and three speeds all in the palm of your hand. Also check out Dame Products’ flagship hands-free vibrator you can wear during sex, Eva II ($135).

9. Wearable by Ohnut ($75)

Ohnut Wearable

The first intimate wearable, Ohnut’s creator and founder Emily Sauer wanted to address painful sex for people with a vagina. “I had been experiencing painful sex myself for my entire sexual life and when I had asked doctors for advice they really didn’t want to offer any help,” Sauer told The Mighty. “It finally got to a point where I had felt so isolated by my experience because I was too embarrassed to talk about it and [so I] came up with this crazy idea.”

Ohnut — comprised of four stackable, adjustable linking rings “that allow you to modulate penetration depth” — aims to reduce pain and bring fun back into the bedroom. The squishy, comfortable silicone Ohnut is worn by the penetrating partner or placed on a toy, and you can add or remove rings to personalize penetration depth. Orders placed on Ohnut’s website are scheduled to ship in early November.

10. BonBon Sex Toy Mount by Liberator ($85; $68 on Amazon)

Liberator BonBon Sex Toy MountA variety of pillows can make sex more comfortable and accessible. There are tons of pillow options out there, from wedges to ramps, lifts, sex toy mounts and center stages. From master sex-friendly pillow company Liberator, the BonBon sex toy mount pillow is a versatile investment. You can insert a toy into the mount for solo fun or you can use the BonBon on its own to find a comfortable sex position with a partner. It’s a two-in-one pillow combination for whatever you’re in the mood for.

11. Jive by We-Vibe ($119; $93.92 on Amazon)

Jive by We-Vibe

For a wearable, hands-free vibrator that delivers maximum G-spot sensation, We-Vibe’s Jive has you covered. Easy to manage, the Jive’s design prioritizes user comfort. Once it’s in place, you can deliver 10 modes of self-pleasure. Kick your fun up a notch because the Jive connects to a controllable app via Bluetooth, so you or a partner can control the toy from anywhere, and you can create custom vibes. It’s on the expensive side, and for any toy in a higher price range, Sweeney advised finding a cheaper version for testing before investing in the higher quality version.

12. Pulse III Solo by Hot Octopuss ($119)

Pulse III Solo by Hot Octopuss

Vibrators aren’t just for people with vaginas. The Pulse III Solo by Hot Octopuss brings hands-free vibration to those of you with a penis. It’s expensive, but this “guybrator,” as they call it, delivers oscillating stimulation backed by science to give you an orgasm without lifting a finger. You can adjust the Solo’s speed, and the expandable silicone wings wrap around comfortably for maximum sensation. In addition, Hot Octopuss’ research found that an erection isn’t required to use the Solo: “Tests have shown that used static, Pulse can lead to orgasm even while the user remains flaccid.”

13. Bi-Stronic Fusion by Fun Factory ($220)

Bi-Stronic Fusion by Fun Factory

Check out Fun Factory’s Bi-Stronic Fusion for hands-free penetration. It’s a multidimensional tool, providing thrusting, pulsing and vibrating all in one. Once inserted, it does the work for you. The Fusion is shaped to reach the G-spot and provide clitoral stimulation all at the same time, though some reviewers have said the toy’s larger size makes full insertion (required for the external vibrator to reach the clit) uncomfortable for some people. You can also test-drive the Fusion through 64 pulsation and vibration options.

14. Sex Machine by Humpus ($258)

Humpus Sex MachineHumpus, a U.K.-based company working to revolutionize hands-free pleasure, is nearly ready to release their Humpus sex machine. Made for any gender (or couple), the compact machine is worn around the waist with either a penetrative or sleeve attachment. With the click of a button, Humpus will do the stroking or thrusting, and you have the ability to adjust the speed or the attachment. They’re on the pricey side, and, according to a recent press release, the Humpus won’t be available until the holidays this year at the earliest.

15. Sex Chair by IntimateRider ($329)

IntimateRider Sex ChairDesigned by a person with C6-7 quadriplegia to add more choice to sexual movement, the IntimateRider chair smoothly glides to provide thrusting action. The seat of the chair is short so it doesn’t get in the way of the action, and its design makes it easy to transfer into and find the optimal position. IntimateRider swings into action with movement from your upper torso, or with assistance from your partner. You can also add a RiderMate ($169) or RiderMate Deluxe ($315) for additional positioning and support options for you and a partner.

Looking for some disability-inclusive sex positions? Check out our illustrated list

via Accessible Sex Toys for People With Disabilities or Chronic Pain | The Mighty

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[QUOTATION] “You look sad today”

Relationships Quotes Top 337 Relationship Quotes And Sayings 84

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[Abstract] Machine Learning for Brain Stroke: A Review

Machine Learning (ML) delivers an accurate and quick prediction outcome and it has become a powerful tool in health settings, offering personalized clinical care for stroke patients. An application of ML and Deep Learning in health care is growing however, some research areas do not catch enough attention for scientific investigation though there is real need of research. Therefore, the aim of this work is to classify state-of-arts on ML techniques for brain stroke into 4 categories based on their functionalities or similarity, and then review studies of each category systematically. A total of 39 studies were identified from the results of ScienceDirect web scientific database on ML for brain stroke from the year 2007 to 2019. Support Vector Machine (SVM) is obtained as optimal models in 10 studies for stroke problems. Besides, maximum studies are found in stroke diagnosis although number for stroke treatment is least thus, it identifies a research gap for further investigation. Similarly, CT images are a frequently used dataset in stroke. Finally SVM and Random Forests are efficient techniques used under each category. The present study showcases the contribution of various ML approaches applied to brain stroke.

via Machine Learning for Brain Stroke: A Review – ScienceDirect

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[WEB PAGE] 11 Brain Training Apps to Train Your Mind and Improve Memory – iPhone

Whether at work or at school, people these days are under tremendous pressure to perform, perform and perform! Stress and pressure can have adverse affects on the well-being of a person, and need to be controlled.

Now, this doesn’t mean you make a dash to your nearest therapist. There are a number of wonderful and smart apps that you can use on your phone. These brain training apps have been scientifically designed to target specific areas of the human mind and control harmful emotions such as anxiety, as well as to improve memory and sharpness of the brain.

Here are 11 iPhone apps that you will not only enjoy but also find useful in keeping your mental health balanced at all times.

1. Lumosity

This app consists of games that focus on improving the user’s memory, problem-solving capability, attention span, and thinking. There are three games in each session, and they challenge the brain by changing every time. The user has to complete the games while playing against a clock.

Free of trial. $15 per month for the full version.

Luminosity Mind training apps-Lifehack

2. Fit Brains Trainer

This brain training app has 10 sets of games that work on different areas of the brain and improve memory as well as concentration. A user is required to finish a particular task from each category on a daily basis and the app tracks the progress by a color coded graph.

Free.

Fit Brains Trainer Mind training apps-Lifehack

3. CogniFit Brain Fitness

Developed with the help of neuroscientists, this fun app improves a person’s cognitive abilities, which includes memory and concentration. The progress made by the user over a period of time can be tracked. Users can also play challenge rounds with their friends. The app also modifies the difficulty level to suit the profile of the user and provide recommendations based on the results. Spending 20–30 minutes a few times every week can give measurable improvement in the performance of a user.

First four games free, then $13 a month.

cognifit-Mind Training Apps-Lifehack

4. Brain Fitness Pro

The makers of this app claim that it can improve the IQ of a user, and improve intelligence and memory. The app is fun and is user friendly, and 30 minutes a day can fetch you results in less than three weeks.

Buy for $3.99.

5. Happify

If nothing else makes you happy in life, this app will. Well, this is what the developers claim at least. This app comes loaded with lots of quizzes, polls and gratitude journals, which work on the fundamentals of positive psychology. The app also helps to control stress and emotions to make you feel better.

Free to use.

Happify-Mind Training Apps-Lifehack

6. Clockwork Brain

You will like the little gold robot that comes in every time to explain the next game you are going to play. While the games are not much different to those offered in apps such as Luminosity, the look and feel reminds me of a workshop from old times.

Free.

Clockwork Trsin-Mind Training Apps-Lifehack

7. ReliefLink

Initially created as an app for suicide prevention, it has found its use as a great app for tracking the mood of the user by taking measure of all things relevant to the user’s mental health. In case the user experiences high emotional stress, the app has a coping mechanism that includes voice-recorded mindfulness, exercises and music for relaxation. There is also a map that informs the user of the nearest therapist and medical facilities for mental health treatment.

Relief Link - Mind Training Apps - Lifehack

8. Eidetic

Eidetic is a memory enhancement app and uses a ‘spaced repetition’ technique to help users memorize information such as important phone numbers, words, credit card details or passwords. It also notifies you when it’s time to take a test to see what you remember, so that you retain information in your long-term memory.

Eidetic - Mind Training Apps - Lifehack

9. Braingle

Braingle helps to maintain the sharpness of the brain and improve the reasoning ability of a person through riddles and optical illusions. It is different from other brain training apps that employ memory and reaction based tests. You can also compete with your friends and family members in figuring out the fun riddles.

Free.

Briangle- Mind Training Apps-LIfehack

10. Not The Hole Story

If you have a penchant for solving hard riddles, then this app is a must-have for you. Filled with exclusive riddles along with a simple-to-use interface, the app gives you riddles that you have to solve through a book. You will be given hints along the way, and when you give up, the answers will be revealed. This app will encourage you to broaden your thinking and put your mind to a challenging test.

Free.

Not the hole story - Mind Training Apps - Lifehack

11. Personal Zen

This fun brain training app follows the journey of two animated characters who travel through a field of grass. Personal Zen is a nice app meant for reducing anxiety and trains the brain to focus on the positive aspects. The developer’s advice is to use the app for 10 minutes a day to see the best results.

Free.

personal zen- mind training apps - lifehack

via 11 Brain Training Apps to Train Your Mind and Improve Memory

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[BLOG POST] Hand Rehab after Stroke: The Top 5 Evidenced-Based Methods

After a stroke, it’s challenging enough to navigate the medical system to find what services you need, let alone the right treatment approach for you.

You’ve probably heard a lot of recommendations on how to recover hand function after stroke, and everyone seems to give different advice. That’s why we sifted through the research for you. We’ll explain the top 5 evidence-based methods for hand rehabilitation, why they work, and who they work for.

The top 5 evidence-based treatments for improving hand function after stroke:

  1. Constraint‐induced movement therapy (CIMT)
  2. Mental practice
  3. Mirror therapy
  4. Virtual reality
  5. High dose repetitive task practice

Constraint-Induced Movement Therapy

Unaffected arm wearing oven mitt for at-home constraint therapy.
You can restrict your unaffected side at home by wearing an oven mitt or placing it inside your pants or sweatshirt pocket. This will help remind you to rely on your affected side when completing therapy tasks.

What it is:

Constraint-Induced Movement Therapy (CIMT) is a neuro-rehabilitation method where the non-affected hand is constrained or restricted in order to force the brain to use the affected hand, thereby increasing neuroplasticity.

There are two key components: constraint and shaping.

Constraint refers to the way in which the hand is restricted. Therapists have used casts, splints, and mitts to restrict the use of the non-affected hand. None of them have been shown to be more effective than the other.

Shaping involves repetitive movements or activities at the patient’s ability level which become progressively harder. Therapists use shaping techniques to avoid overwhelming the motor system.

Why it works:

Our brain automatically completes a task in the easiest way possible. Our brain is more interested in completing a task than in how it is accomplished.

After a stroke, it’s easier for our brain to do tasks one-handed. This leads to “learned non-use”.

When we constrain our non-affected hand, suddenly our stronger hand becomes the weaker, less functional hand and we’re forced to use our affected hand. Our affected hand might not have much movement, but to our brain any movement is better than no movement, and the brain is highly motivated to figure out how to accomplish a task.

This is where the “shaping” piece is so important. If you are presented with rehab tasks that overwhelm the motor system or are higher level than your affected hand can functionally do, you’ll be more likely to knock the table over than to participate in picking up pennies from the table.

If you knock the table over with your affected hand, your occupational therapist might actually be excited about it; but in practical life finding that balance of not being too easy and not being so hard that you give up is an important lesson for every human being, not just those after stroke.

Who it’s for:

This approach is used for people who have at least 10 degrees of active wrist and finger extension, as well as 10 degrees of thumb abduction (the ability of the thumb to move out of the palm).

It’s been shown to be effective even years after stroke. Lower intensity CIMT is better than higher intensity in the very early stages after stroke.

Mental Practice

Man in headphones listening to mental practice recordings.
You might listen to an audio recording describing the sequence of throwing a ball, imagining yourself doing it. After listening, actually practice throwing the ball the way you envisioned!

What it is:

Mental practice, sometimes called motor imagery or mental imagery, is a training method for improving your hand and arm function without moving a muscle!

Mental practice is typically done by listening to pre-recorded audio that describes in detail the motor movement of a specific task. The listener imagines their hand and arm moving in a “typical” way, and the instructor provides cues to extend their arm or open their fingers, as well as the entire sensory experience of the task.

While it’s true that you can do mental practice on its own, it’s best combined with physical practice immediately following.

Why it works:

Brain scans show that similar parts of the brain are activated whether movement is actual, observed or imagined.

It’s a separate area of the brain that’s responsible for actually triggering the muscle movement, but it goes to show that there’s a lot more required of the brain to complete a task than just sending a signal to the muscle.

Who it’s for:

Mental practice has been shown to improve arm movement and functional use in patients after stroke of all levels of abilities and as a treatment approach for people months or years after stroke!

Mirror Therapy

Unaffected hand and its mirror image reflected in mirror box.
It is critical to stay focused on the reflected image of your hand during mirror therapy, imagining that it is your affected side performing the target movements.

What it is:

Mirror therapy is another voodoo-seeming approach that has a lot of scientific evidence to back it up. It essentially tricks your brain into thinking your affected hand is moving.

You position a mirror to reflect your non-affected hand, while hiding your affected hand. Any movement of your non-affected hand will be reflected in the mirror and make it seem as though you are actually moving your affected hand.

Why it works:

The approach is centered around mirror neurons, which fire in your brain when you see your arm move. Typically, we think about motor neurons being sent from the brain to the muscle, but we don’t realize that mirror neurons are connected to the motor neurons.

After a stroke you lose the ability to access your motor neurons, but not your mirror neurons. By accessing your mirror neurons through seeing your movement (even if the movement is fake), you are tapping into the network between the neurons.

It’s like trying to reconnect with an old friend on Facebook by finding the friends they’re connected with. It might not be the most direct approach in a real life situation, but in stroke rehab that friend of a friend might be your strongest connection.

Who it’s for:

Mirror therapy can be used for people with no movement of the hand or smaller movements of the hand and shoulder, but not functional movement of the hand.

If you have functional movement of your hand, meaning individual finger movement and wrist movement, you have surpassed the benefit that mirror therapy can provide.

It can be used early after stroke, as well as in the chronic stages of stroke.

Virtual Reality

Neofect Smart Board virtual reality arm exercise system.
The Neofect Smart Board is a non-immersive virtual reality rehabilitation system.

What it is:

Virtual reality uses a computer interface to simulate a real life objects and events. It’s become an increasingly more prevalent rehabilitation technique to provide motivation and engagement in therapy.

There are two types:

  1. Immersive: goggles are placed over the eyes and the patient is visually in a different environment than their actual physical one
  2. Non-immersive: sensors are placed on the body and track the movement of the body and the movements are shown on a screen

Why it works:

Virtual reality works best when paired with traditional therapy. It’s theorized to provide more motivation and engagement for the intensity of therapeutic exercise needed for neuroplasticity. It’s been shown to beneficial in high doses, meaning more than 20 hours.

Another possible factor of why virtual reality works are the same mechanisms that make mirror therapy effective (tapping into the mirror neurons) could be similar.

Virtual reality also creates a biofeedback loop: your brain sends a signal to the muscle, the brain receives a signal back in the form of visual or auditory input. Basically, you get rewarded for your effort.

Who it’s for:

Virtual reality can be used with people who have mild to severe impairments, and from early after stroke to years out.

When deciding what’s right for you, it’s important to look at the adjustability of the device to meet you where you’re at and also to increase in difficulty as you improve.

If you have minimal movements, you’ll want a virtual reality tool specifically for stroke rehabilitation. If you have more movement, it’s possible to use gaming systems not specifically designed for rehab, but make sure you have the support to optimize it for rehab.

High Dose Repetitive Task Practice

Putting coins in a piggy bank during repetitive task practice.
There are many ways to do task-specific training at home. Placing coins into a piggy bank is just one of them!

What it is:

Repetitive Task Practice is when you practice a task or a part of a task over and over. Task-specific training is a type of repetitive task practice, and refers to the task we complete that is relevant to our daily life.

“Reach to grasp, transport and release” is a type of task-specific training because it is one of the common motor requirements for many functional daily tasks.

The keys for repetitive task practice:

  • Task must be meaningful
  • Participant must be an active problem-solver
  • Real life objects are used
  • Difficulty level is not too high and not too low
  • Repetition is key

Why it works:

Repetitive Task Practice is based on motor learning theory. Our brains are driven by function. We’re able to achieve neuroplasticity with development of skills, as our brain processes the demands of the task, which have motor and cognitive components.

It’s often used with other treatments, such as virtual reality, to increase the 15 hour dosage that has been shown to be beneficial.

Who it’s for:

Task-specific practice is generally used and is studied in people who have some functional ability of their hand. It’s been shown to be beneficial throughout the rehabilitation process.

Even though the research has been focused on “functional ability” of the hand by practicing reach, grasp, transport, release; there’s potential for recovery by using the same principles of task-specific practice: real life objects, functional tasks, and problem-solving even without the ability to grasp.

Functionally, we can use our affected upper extremity as a stabilizer, an assist, or for manipulation. There are lots of ways to get that side involved to prevent “learned non-use” and to improve your problem-solving skills.

Now what?

There are two key factors to any hand recovery method: support and meaning.

Neofect aims to support and inspire you to live your best life with virtual reality tools that can be used as part of a constraint-induced movement therapy program or with repetitive task practice.

Our comprehensive recovery and wellness app: Neofect Connect and our YouTube Channel: Find What Works are based on the principles of repetitive task practice and aim to give you the tools to live your best life.

Now the only question is, what are you waiting for?

Pollock  A, Farmer  SE, Brady  MC, Langhorne  P, Mead  GE, Mehrholz  J, van Wijck  F. Interventions for improving upper limb function after stroke. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010820. DOI: 10.1002/14651858.CD010820.pub2.

via Hand Rehab after Stroke: The Top 5 Evidenced-Based Methods

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[BLOG POST] Rehab with Real-World Objects for Improved Hand Use After Stroke

If you’ve been through stroke rehabilitation, chances are that you’re familiar with the phrase, “use it or lose it”. Your therapist likely told you this while explaining the principle of neuroplasticity, the brain’s potential to reorganize after damage to regain lost functions. Hopefully “use it or lose it” has helped you remember to engage your weaker arm throughout the day in order for it to make progress!

Here’s another catchy rehab phrase for your repertoire: “you gain what you train”. Research shows that practicing arm movements related to daily living goals may be more effective at improving arm function than standard, non-goal-directed arm exercise. Basically, if you want to be able to hold eating utensils or write with your affected arm, you’re better served by putting a fork or a pen to use than you are by lifting a dumbbell or pinching putty.

“You gain what you train” seems obvious, right? So, why belabor the point? Because many stroke survivors are not practicing real-world skills with their affected arm on their own time. Learning a new skill requires hours of practice and thousands of repetitions. Stroke survivors must ensure they are dedicating sufficient time at home to addressing their specific arm use goals in order to improve.

Think about your current post-stroke home exercise program. Does it go beyond basic stretching and strengthening? If not, consider incorporating task-specific training into your routine to maximize arm and hand function.

turning-book-pages

Task-specific training overview

What is task-specific training (TST)?

Task-specific training is a therapy technique focusing on improving function of a hemiplegic (weakened) arm through repeated activity practice. Just like how you learned to tie your shoes or ride a bike, TST requires consistent performance of the component steps of a task to help the brain re-learn the big-picture skill.

Task-specific training activities for the post-stroke hemiplegic arm incorporate a real-world object and involve the following four steps:

  • Reaching for the object
  • Grasping the object
  • Moving or manipulating the object
  • Releasing the object

Ideally, a participant will repeat this sequence many times over multiple sessions to show skill improvement. Research studies generally indicate that more repetitions and a greater frequency of training are better.

Who can do TST?

Stroke survivors with sufficient movement to repeatedly reach for an object, hold on to it, and release it using their affected arm are good candidates for TST.

Anyone with activity restrictions on their affected side, or those who experience pain when using their affected side should consult with their medical team before attempting TST.

drinking-from-mug-TST

How to do task-specific training at home:

First, think about what you would like to be able to do better using your affected arm and hand. Ideally, TST goal activities should be centered around a task that has clear and consistent steps and also involves an object. Although that might sound complicated, there are countless TST possibilities available in your home using your everyday belongings! Any of the following ideas make for great TST goals:

  • Using a cup, fork, or spoon
  • Brushing your hair
  • Pulling your pants up
  • Turning a book page
  • Opening a door handle
  • Writing your signature
  • Putting coins into a piggy bank
  • Hammering a nail
  • Putting laundry into a basket

TST skills can also involve your other hand. Consider using your affected hand in the dominant role of a two-handed task, while letting your stronger hand play the role of helper or stabilizer.

  • Fastening buttons or zippers
  • Tying shoelaces
  • Opening containers
  • Pouring liquid from one container into another
  • Putting credit cards into a wallet
  • Wringing out a wet washcloth
  • Putting a stamp on an envelope
  • Folding laundry into halves or quarters

Because TST involves repeating the steps of an activity using your affected arm, we need to think about how to measure performance. Completing a reach/grasp/manipulate/release sequence is considered one repetition of a task. The goal of TST is to complete as many repetitions as possible. View the examples of measuring one repetition from the TST tasks on our list above:

Note: The affected arm starts and ends in the same position relative to the task object/s (e.g. on the tabletop next to the object)
Using a spoon: Pick up the spoon from the tabletop, bring it up to your mouth, put it back on the tabletop, return hand to starting position
Writing your signature: Pick up the pen from the tabletop, bring it to paper to write your full name, put the pen back on the tabletop, return hand to starting position

Note: For a two-handed task, you may choose to repeatedly pick up the stabilized object using your unaffected hand, or hold it throughout the task
Putting credit cards into a wallet: One repetition = pick up credit card from tabletop, insert and remove credit card from wallet (held by unaffected hand), place credit card on tabletop, return hand to starting position

After you have defined your activity and what a repetition looks like, you’re ready to go. You may choose to practice one activity in a TST session, or, for a longer session, you may pick two or three goal areas.

sorting-laundry-TST

How much and how often should I do TST?

Studies show that between one and five repetitions of a task per minute may be ideal to promote improved arm function. Gauge your performance by performing a 15-minute TST test. Have a helper time the number of repetitions you can do during this period. If you have achieved between 15 and 100 repetitions, you’re in the TST sweet spot: continue practicing the skill! If you are over 100 repetitions, it is time to make the task more difficult by add more complex elements (e.g. using heavier objects, attempting the task from standing as opposed to sitting). If that is not possible, try practicing a different, harder skill.

Research has also demonstrated that completing 60 minutes of task-specific training four times per week can produce significant arm function improvements. This is an amount that you may have to build up to. If one hour seems daunting, try to ease into TST practice by attempting increasingly longer intervals (e.g. aim for 5 more minutes of TST each time).

What if I can’t do task-specific training?

Survivors who have some but not all required arm functions to perform TST may choose to perform a modified version incorporating the elements within their capabilities. For instance, TST might consist of repeatedly reaching to tap an object with the hand as opposed to grasping and releasing it.

If you have minimal to no movement in your affected arm, you will not be able to perform TST. However, your affected side can and should still play a role in your daily living tasks. Use your stronger side to place your affected arm within your field of vision during tabletop tasks. If you are doing a two-handed task, use the stronger arm to place the weaker arm to hold or stabilize objects. Even though doing this is not TST, you are still promoting function of your affected side while preventing learned non-use.

Do I have to do task-specific training after stroke?

TST is just one tool in your upper extremity stroke rehab toolbox. There are several other evidence-supported activities that may improve arm and hand function. Some people may not be able to perform TST without the guidance of a therapist, while others may not be motivated by the intervention. If you have questions on how to perform TST at home or whether it is the right option for you, consult with your therapy team.

pulling-tissues-TST

The bottom line: practice means progress

We’ll conclude with one final catchy rehab phrase: “practice means progress”. Needless to say, improving weakened arm function after a stroke can be a long and sometimes frustrating ordeal. However, additional keys to success are right in front of you in the forms of your daily tasks and personal belongings. With practice and repetition, your goals are within reach!

References

French B, Thomas LH, Coupe J, McMahon NE, Connell L, Harrison J, et al.. Repetitive task training for improving functional ability after stroke.Cochrane Database Syst Rev. 2016; 2016:CD006073. doi: 10.1002/14651858.CD006073.pub3.

Hatem SM, Saussez G, Della Faille M, et al. Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Front Hum Neurosci. 2016;10:442. Published 2016 Sep 13. doi:10.3389/fnhum.2016.00442

Lang, Catherine E. PT, PhD; MacDonald, Jillian R.; Gnip, Christopher DPT Counting Repetitions: An Observational Study of Outpatient Therapy for People with Hemiparesis Post-Stroke, Journal of Neurologic Physical Therapy: March 2007 – Volume 31 – Issue 1 – p 3-10 doi: 10.1097/01.NPT.0000260568.31746.34

Waddell, K. J., Strube, M. J., Bailey, R. R., Klaesner, J. W., Birkenmeier, R. L., Dromerick, A. W., & Lang, C. E. (2017). Does Task-Specific Training Improve Upper Limb Performance in Daily Life Poststroke? Neurorehabilitation and Neural Repair, 31(3), 290–300. https://doi.org/10.1177/1545968316680493

Waddell KJ, Birkenmeier RL, Moore JL, Hornby TG, Lang CE. Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis. Am J Occup Ther. 2014;68(4):444-453. doi:10.5014/ajot.2014.011619

via Rehab with Real-World Objects for Improved Hand Use After Stroke

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[Abstract] Neural coordination of bilateral power and precision finger movements

Cover imageAbstract

The dexterity of hands and fingers is related to the strength of control by cortico‐motoneuronal connections which exclusively exist in primates. The cortical command is associated with a task‐specific, rapid proprioceptive adaptation of forces applied by hands and fingers to an object. This neural control differs between “power grip” movements (e.g., reach and grasp of a cup) where hand and fingers act as a unity and “precision grip” movements (e.g., picking up a raspberry) where fingers move independently from the hand.

In motor tasks requiring hands and fingers of both sides a “neural coupling” (reflected in bilateral reflex responses to unilateral stimulations) coordinates power grip movements (e.g., opening a bottle). In contrast, during bilateral precision movements, such as playing piano, the fingers of both hands move independently, due to a direct cortico‐motoneuronal control, while the hands are coupled (e.g., to maintain the rhythm between the two sides).

While most studies on prehension concern unilateral hand movements, many activities of daily life are tackled by bilateral power grips where a neural coupling serves for an automatic movement performance. In primates this mode of motor control is supplemented by a system that enables the uni‐ or bilateral performance of skilled individual finger movements.

via Neural coordination of bilateral power and precision finger movements – Dietz – – European Journal of Neuroscience – Wiley Online Library

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