Archive for category Books

[ΒΟΟΚ] Navigated Transcranial Magnetic Stimulation in Neurosurgery – Βιβλία Google

Εξώφυλλο
Sandro Krieg
Springer, 13 Ιουλ 2017295 σελίδες
This book is the first comprehensive work summarizing the advances that have been made in the neurosurgical use of navigated transcranial magnetic stimulation (nTMS) over the past ten years. Having increasingly gained acceptance as a presurgical mapping modality in neurosurgery, today it is widely used for preoperative mapping of cortical motor and language function, risk stratification and improving the accuracy of subcortical fiber bundle visualization. 

This unique work will provide neurosurgeons and neuroscientists who are starting their nTMS program essential and detailed information on the technique and protocols, as well as the current clinical evidence on and limitations of the various applications of nTMS. At the same time, more experienced nTMS users looking for deeper insights into nTMS mapping and treatment in neurosurgery will find clearly structured, accessible information. The book was prepared by an international mix of authors, each of which was chosen for their status as a respected expert on the respective subtopic, as evinced by their landmark publications on nTMS.

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Source: Navigated Transcranial Magnetic Stimulation in Neurosurgery – Βιβλία Google

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[BOOK] The Integrated Nervous System: A Systematic Diagnostic Case-Based Approach – Google Books

Front CoverThis innovative textbook is modelled on problem-based learning. It bridges the gap between academic neuroanatomy and clinical neurology and effectively takes the reader from the classroom to the clinic, so that learning can be applied in practice.

This second edition has been updated and expanded to include many more clinical cases within both the book and the accompanying Wweb site. Significant additions include

  • abbreviated presentation of the history and neurologic examination of all the cases on the web site (now numbering over 50) within the text at the end of each of the clinical chapters.
  • new ‘maps’ — visual representations of the clinical motor, sensory and reflex findings.
  • the web site further expands the cases – presenting them in detail, and providing an ‘expert’ commentary to discuss the reasoning for the localization and etiological diagnosis.

This book and the associated Web site will be of practical value to all the professionals who deal with people who have neurological conditions, as well as being invaluable to medical students and residents. This includes physiatrists (rehabilitation medicine specialists), physiotherapists, occupational therapists and speech therapists, and nurses who specialize in the care of neurological patients. We think that this text will also be of value for family physicians and specialists in internal medicine and pediatrics, all of whom must differentiate between organic pathology of the nervous system and other conditions.

Source: The Integrated Nervous System: A Systematic Diagnostic Case-Based Approach … – Walter J. Hendelman, Peter Humphreys, Christopher R. Skinner – Google Books

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[BOOK] Neuropsychological Rehabilitation: The International Handbook – Google Books

ΕξώφυλλοThis outstanding new handbook offers unique coverage of all aspects of neuropsychological rehabilitation. Compiled by the world’s leading clinician-researchers, and written by an exceptional team of international contributors, the book is vast in scope, including chapters on the many and varied components of neuropsychological rehabilitation across the life span within one volume. Divided into sections, the first part looks at general issues in neuropsychological rehabilitation including theories and models, assessment and goal setting. The book goes on to examine the different populations referred for neuropsychological rehabilitation and then focuses on the rehabilitation of first cognitive and then psychosocial disorders. New and emerging approaches such as brain training and social robotics are also considered, alongside an extensive section on rehabilitation around the world, particularly in under-resourced settings. The final section offers some general conclusions and an evaluation of the key issues in this important field. This is a landmark publication for neuropsychological rehabilitation. It is the standalone reference text for the field as well as essential reading for all researchers, students and practitioners in clinical neuropsychology, clinical psychology, occupational therapy, and speech and language therapy. It will also be of great value to those in related professions such as neurologists, rehabilitation physicians, rehabilitation psychologists and medics.

Source: Neuropsychological Rehabilitation: The International Handbook – Βιβλία Google

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[BOOK] “Occupational Therapy – Occupation Focused Holistic Practice in Rehabilitation” – Chapter 9: Virtual Reality and Occupational Therapy

Abstract

Virtual reality is three dimensional, interactive and fun way in rehabilitation. Its first known use in rehabilitation published by Max North named as “Virtual Environments and Psychological Disorders” (1994). Virtual reality uses special programmed computers, visual devices and artificial environments for the clients’ rehabilitation. Throughout technological improvements, virtual reality devices changed from therapeutic gloves to augmented reality environments. Virtual reality was being used in different rehabilitation professions such as occupational therapy, physical therapy, psychology and so on. In spite of common virtual reality approach of different professions, each profession aims different outcomes in rehabilitation. Virtual reality in occupational therapy generally focuses on hand and upper extremity functioning, cognitive rehabilitation, mental disorders, etc. Positive effects of virtual reality were mentioned in different studies, which are higher motivation than non‐simulated environments, active participation of the participants, supporting motor learning, fun environment and risk‐free environment. Additionally, virtual reality was told to be used as assessment. This chapter will focus on usage of virtual reality in occupational therapy, history and recent developments, types of virtual reality technologic equipment, pros and cons, usage for pediatric, adult and geriatric people and recent research and articles.

1. Introduction

Enhancement of functional ability and the realization of greater participation in community life are the two major goals of rehabilitation science. Improving sensory, motor, cognitive functions and practice in everyday activities and occupations to increase participation with intensive rehabilitation may define these predefined goals [1, 2]. Intervention is based primarily on the different types of purposeful activities and occupations with active participation [35]. For many injuries and disabilities, the rehabilitation process is long, and clinicians face the challenge of identifying a variety of appealing, meaningful and motivating intervention tasks that may be adapted and graded to facilitate this process [5].

Occupational therapy (OT), which is one of the rehabilitation professions, is a client‐centered profession that helps people who are suffering participation and occupational performance limitations. OT offers a wide range of rehabilitation strategies in different medical and social diagnosis [2]. The common point of all these strategies in rehabilitation is that OT assesses and supports enhancing functional ability and participation throughout participating in meaningful activities in a person’s lifespan. To enhance participation, OT, like the rest of the health professions, uses World Health Organization’s International Classification of Functioning, Disability and Health (ICF) to understand function in a biopsychosocial manner. In ICF framework, function is defined as the interactions between an individual, their health conditions and the social and personal situations in which they thrive. The complex interactions between these variables define function and disability [1].

ICF classifies health and health‐related fields in two groups. These groups are “body functions” and “body structures” and “activity and participation.” Sub heading of these groups is considered as body function and structures (physical, physiological etc), activities (daily tasks) and participation (life roles) [1]. When these groups taken into account in rehabilitation, occupational therapists focus on all areas to enhance a client’s activity participation, social participation, etc. However, in current literature, there are various rehabilitation approaches that are being used for this aim. Advancements in technology in the twenty‐first century create great opportunities for people working in different areas. In particular, in health practices like rehabilitation, technology supports therapists’ to rehabilitate their clients in too many different ways like robotics, stimulation devices, assessment tools and virtual reality [610].

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[BOOK] Living Beyond Brain Injury: A Resource Manual – Vicky Hall – Google Books

Front CoverA brain injury can have a dramatic effect on all areas of a person’s life. This manual is designed to provide an understanding of some of the effects of a brain injury and how to manage them. It focuses on how brain injury may affect thinking skills (e.g. memory), emotions and other related areas (e.g. sleep, work and driving). This manual provides techniques based on psychological approaches, which have been shown to be effective with people who have experienced a brain injury. As well as being an important resource for mental health professionals, it will also be useful for families who wish to help a person with a brain injury. It has two clear functions: a resource manual for clinicians and carers / families to work through with brain injury survivors; and a self-help resource for clients with a brain injury.

Source: Living Beyond Brain Injury: A Resource Manual – Vicky Hall – Google Books

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[BOOK] Chapter 9: Neuroscience-Based Rehabilitation for Stroke Patients

The Book: Neuroscience-Based Rehabilitation for Stroke Patients | InTechOpen, Published on: 2017-05-10. Authors: Takayuki Kodama and Hideki Nakano

Chapter 9: Neuroscience-Based Rehabilitation for Stroke Patients

Abstract

Hitherto, physical therapy for rehabilitating patients with cerebral dysfunction has focused on acquiring and improving compensatory strategies by using the remaining functions; it has been presumed that once neural functions have been lost, they cannot be restored. However, neuroscience-based animal research and neuroimaging research since the 1980s have demonstrated that recovery arises from plastic changes in the central nervous system and reconstruction of neural networks; this research is ushering in a new age of neuroscience-based rehabilitation as a treatment for cerebral dysfunction (such as stroke). In this paper, in regard to mental practices using motor imagery and kinaesthetic illusion, we summarize basic discoveries and theories relating to motor function therapy based on neuroscientific theory; in particular, we outline a novel rehabilitation method using kinaesthetic illusion induced by vibrational stimulus, which the authors are currently attempting in stroke patients.

1. Introduction

Conventional physical therapy (PT) for the rehabilitation of patients with brain dysfunction focuses on the acquisition of function through alternative means by using and improving the patients’ existing functions, and it is based on the assumption that once a neutral function is lost, it can never be recovered [1]. However, animal neuroscience studies [24] that were conducted after the 1980s and neuroimaging studies [5, 6] have shown that recovery can occur as a result of plastic changes in the nervous system or reorganization of the neural network, and rehabilitation (neuroscience-based rehabilitation, NBR) after cerebral dysfunction (e.g. stroke) has reached a new era in treatment. These observations suggest that the plasticity that is observed in patients is related to the characteristic that the more the patient receives therapy in specific parts of their body, the more that the brain areas that control these parts will be functionally as well as anatomically extended.

Functional recovery originally referred to a patient’s recovery from limitations in their behavior, movements, and/or activity [7]. Therefore, the purpose of NBR is not only to induce the reorganization of brain functions through neural plasticity mechanisms but also recover comprehensive bodily motor functions and brain functions for autonomous and active social behavior. What type of treatment strategy is required so that patients feel positively engaged by it, gradually understand its effects, and work toward a goal? Previous studies have revealed important factors in the effects of NBR treatment, such as the amount of therapy [8, 9], rehabilitation implementation environment [10], and performance of neurocognitive rehabilitation [11] through mental practice techniques, such as motor imagery (MI) [12]. Among these factors, treatments involving MI are strongly recommended because MI contributes to the reorganization of neural functions. MI, which is an approach that is based on neuroscientific data and the motor learning theory, is defined as the capacity to internally mimic physical movements without any associated motor output [13]. The cognitive process that occurs during the imagination of movements involves various components, such as mutual understandings between oneself and others (environment), observations of movements, mental manipulations of objects, and psychological time and movement planning. Instead of repeating simple physical movements to receive feedback on outcome in the actual therapy, the practice of voluntary and skill-requiring movements that are geared toward task completion induces the functional recovery [14]. Thus, an important element of the patients’ engagement in the therapy is that it occurs in an active and top-down fashion through the use of MI. However, because MI has a task-specific nature, cognitive functions and memories of motor experiences that equip the patients to perform the task are required. Patients with neurofunctional states that make motor execution (ME) difficulty may suffer not only from impairments in motor-related brain areas but also from modifications in their intracerebral body representations (e.g. somatoparaphrenia) [15, 16]. In such cases, the exploitation of kinaesthetic illusions [1720], which can be induced in the brain by extraneous stimuli, such as vibratory stimulations, becomes important for inputting appropriate motor-sensory information into the brain in a passive and bottom-up fashion. Therefore, the implementation of a mental practice to determine the criteria for adequate treatment according to the states of the patient’s cognitive functions and motor functions is important in order to select and implement the best therapy. Thus, this paper summarizes the basic understanding and theories of mental practices that use MI or kinaesthetic illusion and discusses, in particular, research results concerning kinaesthetic illusions that are induced by vibratory stimulations, which we are currently attempting on stroke patients.

2. What is neuroscience-based rehabilitation?

NBR involves a series of processes that are selected for the intervention according to the current brain function theories that have been revealed by neuroscience and other similar studies and verification of its outcomes. For example, the selection of a NBR strategy for a stroke patient requires a combination of deep clinical reasoning, the experience of the therapist, and a vast understanding of the evidence obtained by studies from wide-ranging academic fields on the factors that support recovery mechanisms and produce particular outcomes. First, the neural basis of brain cell reorganization will be presented.

2.1. Neural basis of brain cell reorganization

The current understanding of neural reorganization after dysfunction is not that the neurons themselves recover after their axons are damaged but rather that damaged functional networks recover due to several processes that induce the recovery of motor and cognitive functions. Cajal [1], who was a proponent of neuron theory, stated that the central nervous system (brain and spinal cord) of adult mammals would not recover once it is damaged. However, studies that have been conducted since the 1980s and that have shown that alterations in the peripheral nervous system, such as denervation and amputation, change somatic sensations and the representations of body parts while they are in motion have revealed that the brain has plasticity. In 1998, Eriksson et al. [21] reported the new formation of neurons in the central nervous system of human beings. These findings raised the question of whether the plastic changes and functional reorganization that occur in subjects with cranial nerve disorders originate from an ischemic state, such as a cerebrovascular disturbance. The underlying mechanisms of the plasticity that occurs after a cortical deficit are thought to involve (i) the redundancy of neuronal connections in the central nervous system, (ii) morphological changes in the neurons, and (iii) changes in synaptic information transmission [22]. If neurons are damaged, astrocytes begin to divide due to the activity of microglia. These glial cells then reinforce the areas that have been damaged by brain lesions and release neurotrophic factors, such as nerve growth factor, to promote neuronal sprouting (it takes around two weeks for synapses to grow after nerve damage [23]). The sprouted neurons are then connected to an existing neural network, which forms a new network. In other words, if neurons are damaged, new neurons begin to reorganize themselves in order to compensate for it. Adequate NBR stimulates the neural network with the neurofunction that is most similar to the predamaged functional state of the neural network, even though the new network is not located in the damaged region. If strong inputs enter the network multiple times, the synaptic connections will be reinforced. However, plasticity will not be induced in synapses with little information (input specificity), and the synapses will be excluded from the network formation [24, 25].

These findings have been confirmed by several famous studies. Nudo et al. [8] caused artificial cerebral infarcts in monkeys in the region of the primary motor cortex (M1) that corresponds to fingers and then forced the monkeys to use fingers with motor deficits. Thus, they reported that the brain region that previously controlled the shoulders and elbows prior to the therapy then controlled the fingers and more distal body parts (Figure 1). Merzenich et al. [26] surgically sutured the fingers of monkeys and then compared the pre- and post-surgical somatotopies of Brodmann area (BA) 3b, which corresponds to the sensorimotor area (SMA). Microelectrodes were used to record the responses in BA3b to finger stimuli. The third and fourth fingers were then surgically sutured, and the responses were recorded again a month later. Thus, the boundary between the third and fourth fingers became unclear. In addition, the results of a study that was conducted in human beings suggested that the plasticity of brain cells depends on sensory input. The results of a magnetoencephalography study that compared the somatotopies of the first and fifth fingers of string players to normal controls showed that a broader cerebral cortical area was activated for string players compared to the controls [6].

media/F1.png

Figure 1. Representation of the distal forelimb in cortical area 4 derived from pre- and post-training mapping procedures [8].

These findings suggest that the size of the intracerebral somatotopic representation, which is vital to ME, is determined by the degree of use of the region. If you try to induce plasticity in specific parts of the bodies of stroke patients, as mentioned above, the induction of neural plasticity in a pathway that allows highly efficient information processing by repeating movements in a pattern like the normal pattern should be possible, provided the patient has retained their motor functions to a certain degree. However, if a patient has the functional level of almost not able to perform movement or is only able to perform the movement in an abnormal pattern, the stimulation of the plasticity for the formation of a neural network that is required to be able to regain normal motor function may not be possible. Ward et al. [27] chronologically examined the relationships between motor function recovery scores and task-related brain activities for approximately 12 months after the onset of stroke with functional magnetic resonance imaging. They found a negative correlation between motor function recovery scores and a decline in the hyperactivity of brain areas in the damaged and undamaged hemispheres (M1, premotor cortex; PMC, supplementary motor cortex; SMC, cerebellum). These findings suggest that a better recovery of motor function is associated with better connectivity between the functional systems of multiple brain regions and that a continuous and long-term approach is required to study the changes in the morphologies and networks of neurons. Thus, a qualitative and continuous approach [28] is required in studies of the recovery of the entire neural system (e.g. transcortical network, M1-PMC neural network [29]) in order to be able to perform movement rather than merely establishing quantitative interventions of movement. Thus, next, we will discuss the current understanding of what is required in interventions for stroke patients.[…]

Continue —> Neuroscience-Based Rehabilitation for Stroke Patients | InTechOpen

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[BOOK] Chapter 7: After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation – Full Text

 

 “Physical Disabilities – Therapeutic Implications”, book edited by Uner Tan, ISBN 978-953-51-3248-6, Print ISBN 978-953-51-3247-9, Published: June 14, 2017 under CC BY 3.0 license. © The Author(s)

Chapter 7: After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation

Abstract

This chapter presents a review of the rehabilitation technologies for people who have suffered a stroke, comparing and analyzing the impact that these technologies have on their recovery in the short and long term. The problematic is presented, and motor impairments for upper and lower limbs are characterized. The goal of this chapter is to show novel trends and research for the assistance and treatment of motor impairment caused by strokes.

1. Introduction

Stroke is the most common acquired neurological disease in the adult population worldwide (15 million every year [1]). Based on recently published studies, incidence of stroke in Europe at the beginning of the twenty-first century ranged from 95 to 290/100,000 per year [37]. Between 2000 and 2010, the relative rate of stroke deaths dropped by 35.8% in the United States and other countries. However, each year stroke affects nearly 800,000 individuals, becoming the first cause of chronic disability and the third cause of death. It is a global public health problem worldwide that generates a significant burden of illness for healthy life years lost due to disability and premature death.

One-third of stroke survivors achieve only a poor functional outcome 5 years after the onset of stroke. Although there is great progress in the management of acute stroke, most of the care to reduce dependence on post-stroke patients depends on rehabilitation. Optimal functional recovery is the ultimate goal of neurorehabilitation after acute brain injury, mainly by optimizing sensorimotor performance in functional actions. New brain imaging techniques are making it clear that the neurological system is continually remodeling throughout life and after damage through experience and learning in response to activity and behavior.

Rehabilitation in stroke patients seeks to minimize the neurological deficit and its complications, encourage family, and facilitate social reintegration of the individual to ultimately improve their quality of life. Stroke rehabilitation is divided into three phases. The acute phase usually extends for the 1st weeks, where patients get treated and stabilized in a hospital and get stabilized. Subacute phase (1–6 months) is the phase where the rehabilitation process is more effective for recovering functions. In chronic phase (after 6 months), rehabilitation is meant to treat and decrease motor sequels.

The potential ability of the brain to readapt after injury is known as neuroplasticity, which is the basic mechanism underlying improvement in functional outcome after stroke. Therefore, one important goal of rehabilitation of stroke patients is the effective use of neuroplasticity for functional recovery [38].

As mentioned before, neural plasticity is the ability of nervous system to reorganize its structure, function, and connections in response to training. The type and extent of neural plasticity is task—specific, highly time-sensitive and strongly influenced by environmental factors as well as motivation and attention.

Current understanding of mechanisms underlying neural plasticity changes after stroke stems from experimental models as well as clinical studies and provides the foundation for evidence-based neurorehabilitation. Evidence accumulated during the past 2 decades together with recent advances in the field of stroke recovery clearly shows that the effects of neurorehabilitation can be enhanced by behavioral manipulations in combination with adjuvant therapies that stimulate the endogenous neural plasticity.

Nowadays, a large toolbox of training-oriented rehabilitation techniques has been developed, which allows the increase of independence and quality of life of the patients and their families [39]. The recovery of function has been shown to depend on the intensity of therapy, repetition of specified-skilled movements directed toward the motor deficits and rewarded with performance-dependent feedback.

The use of technological devices not only helps to increase these aspects but also facilitates the work of therapists in order to enhance the abilities of patients and a higher level of functional recovery. They create environments with a greater amount of sensorimotor stimuli that enhance the neuroplasticity of patients, translating into a successful functional recovery. The use of technological devices can transfer the effects of rehabilitation to the different environments where patients spend their daily life allowing a favorable social reintegration. In this chapter, a review of technologies for rehabilitation of mobility in upper and lower extremity is presented.[…]

Continue —>  After Stroke Movement Impairments: A Review of Current Technologies for Rehabilitation | InTechOpen

Figure 1. Mechanical treatment devices. (a) Armeo Spring and (b) Saebo ReJoyce.

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[BOOK] Chapter 5: Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study – Full Text

THE BOOK:  “Physical Disabilities – Therapeutic Implications”, book edited by Uner Tan, ISBN 978-953-51-3248-6, Print ISBN 978-953-51-3247-9, Published: June 14, 2017 under CC BY 3.0 license. © The Author(s).

CHAPTER 5: By Marta Rodríguez-Hernández, Carmen Fernández-Panadero, Olga López-Martín and Begoña Polonio-López

 

Abstract

Purpose: The aim is to present an overview of existing tools for hand rehabilitation after brain injury and a pilot study to test HandTutor® in patients with chronic brain damage (CBD).

Method: Eighteen patients with CBD have been selected to test perception on effectiveness, usability and acceptance of the device. This group is a sample of people belonging to a wider study consisting in a randomized clinical trial (RCT) that compares: (1) experimental group that received a treatment that combines the use of HandTutor® with conventional occupational therapy (COT) and (2) control group that receives only COT.

Results: Although no statistical significance has been analysed, patients report acceptance and satisfaction with the treatment, decrease of muscle tone, increase of mobility and better performance in activities of daily life. Subjective perceptions have been contrasted with objective measures of the range of motion before and after the session. Although no side effects have been observed after intervention, there has been some usability problems during setup related with putting on gloves in patients with spasticity.

Conclusions: This chapter is a step further of evaluating the acceptance of technological devices in chronic patients with CBD, but more research is needed to validate this preliminary results.

1. Introduction

According to the World Health Organization [1], cerebrovascular accidents (stroke) are the second leading cause of death and the third leading cause of disability. The last update of the global Burden of Ischemic and Haemorrhagic Stroke [2] indicates that although age-standardized rates of stroke mortality have decreased worldwide in the past two decades, the absolute numbers of people who have a stroke every year are increasing. In 2013, there were 10.3 million of new strokes, 6.5 million deaths from stroke, almost 25.7 million stroke survivors and 113 million of people with disability-adjusted life years (DALYs) due to stroke.

One of the most frequent problems after stroke is upper limb (UL) impairments such as muscle weakness, contractures, changes in muscle tone, and other problems related to coordination of arms, hands or fingers [3, 4]. These impairments induce disabilities in common movements such as reaching, picking up or holding objects and difficult activities of daily living (ADLs) such as washing, eating or dressing, their participation in society, and their professional activities [5]. Most of people experiencing this upper limb impairment will still have problems chronically several years after the stroke. Impairment in the upper limbs is one of the most prevalent consequences of stroke. For this reason making rehabilitation is an essential step towards clinical recovery, patient empowerment and improvement of their quality of life. [6, 7].

Traditionally, therapies are usually provided to patients during their period of hospitalization by physical and occupational therapists and consist in mechanical exercises conducted by the therapists. However, in the last decades, many changes have been introduced in the rehabilitation of post-stroke patients. On the one hand, increasingly, treatments extend in time beyond the period of hospitalization and extend in the space, beyond the hospital to the patient’s home [8]. On the other hand, new agents are involved in treatments, health professionals (doctors, nurses) and non-health professionals (engineers, exercise professionals, carers and family). Most of these changes have been made possible thanks to the development of technology [9].

2. Technological devices for upper limb rehabilitation

In the last 10 years, there has been increasing interest in the use of different technological devices for upper limb (UL) rehabilitation generally [5, 9], and particularly hand rehabilitation for stroke patients [10]. These studies have approached the problem from different points of view: (1) on the one hand, by analysing the physiological and psychophysical characteristics of different devices [11], (2) on the other analysing the key aspects of design and usability [12] and (3) finally studying its effectiveness in therapy [13, 14]. According to Kuchinke [12], these technical devices can be organized into two big groups: (1) on the one hand, devices based on virtual reality (VR) and (2) on the other robotic glove-like devices (GDs).

One of the main advantage of VRs and serious games [15] is to promote task-oriented and repetitive movement training of motor skill while using a variety of stimulating environments and facilitates adherence to treatment in the long term [16]. These devices can be used at home and in most cases do not require special investment in therapeutic hardware because they can use game consumables existing at home such as Nintendo(R) Wii1 [17, 18], Leapmotion2 [19, 20] or Kinect sensor3 [21, 22]. Although first systematic studies based in VRs indicate that there is insufficient evidence to determine its effectiveness compared to conventional therapies [8], more recent studies [13, 14, 23] offer moderate evidence on the benefits of VR for UL motor improvement. Most researchers agree that VRs work well as coadjuvant to complement more conventional therapies; however, further studies with larger samples are needed to identify most suitable type of VR systems, to determine if VR results are sustained in the long term and to define the most appropriate treatment frequency and intensity using VR systems in post-stroke patients.

On the other hand, robotic systems and glove-like devices that provide extrinsic feedback like kinaesthetic and/or tactile stimulation have stronger evidence in the literature that improve motion ability of post-stroke patients [10, 24, 25]. Most of the evidences about effectiveness of GDs are based in pilot studies with non-commercial prototypes [2630], but nowadays, there are also several commercial glove-like devices that support hand rehabilitation therapies for these patients such as HandTutor® [31, 32], Music Glove [3335], Rapael Smart Glove [36] or CyberTouch [16, 37]. The main disadvantages of GDs are price, availability, because they are not yet widespread, and in some case the difficulty of setup handling and ergonomics.

As far as we know, there is little evidence in the literature supporting commercial glove-like devices for hand rehabilitation. This chapter presents a randomized clinical study (RCS) to test HandTutor® System in patients with chronic brain damage (CBD). There are some promising studies that show positive results by applying the HandTutor® in different groups of patients with stroke and traumatic brain injury (TBI) [31, 32], but samples include only people who are in the acute or subacute disease or injury but do not include chronic patients. This may be due to the added difficulty of obtaining positive results in interventions aimed at this group, in addition to the characteristics of adaptability and usability of the device that it is also harder for this kind of patients. The present work focuses on hand rehabilitation for chronic post-stroke patients.

3. Experimental design

We have conducted a pilot study (PS) to test acceptance, usability and adaptability of HandTutor® device in patients with chronic brain damage (CBD). This work describes setup, study protocol and preliminary results.

3.1. Participants description

Eligible participants met the following inclusion criteria: (1) At least 18-year age, (2) diagnosed with acquired brain injury: stroke or traumatic brain injury (TBI) and (3) chronic brain damage (more than 24 months from injury). In the final sample, 18 participants aged between 30 and 75 years old, 28% of subjects included in the pilot study are diagnosed with TBI and the remaining 72% of stroke; of these, more than half (56%) have left hemiplegia. The time from injury time exceeds 24 months, reaching 61% of cases 5 years of evolution. All the subjects included in the study attend regularly to a direct care acquired brain injury centre.

3.2. Device description

HandTutor® is a task-oriented device consistent on an ergonomic wearable glove and a laptop with rehabilitation software to enable functional training of hand, wrist and fingers. There are different models to fit both hands (left and right) and different sizes. The system allows the realization of an intensive and repetitive training but, at the same time, is flexible and adaptable to different motor abilities of patients after suffering a neurological, traumatological or rheumatological injury. The software allows the therapist to obtain different types of measures and to customize treatments for different patients, adapting the exercises to their physical and cognitive impairments. The HandTutor® provides augmented feedback and allows the participation of the user in different games that require practising their motor skills to achieve the game objective. Game objectives are highly challenging for patients and promote the improvement of deteriorated skills.

3.3. Study protocol

A randomized clinical trial (RCT) has been conducted with an experimental group and a control group. Participants in the experimental group have been treated with HandTutor® technological device, combined with conventional occupational therapy (set of functional tasks aimed at the mobility of the upper limb in ADLs). The control group only received conventional occupational therapy. All participants in the experimental group attend two weekly sessions with HandTutor®. Both groups received a weekly session of conventional therapy. It is a longitudinal study with pre-post intervention assessment, in which each subject is his control.

This chapter describes the first phase of the RCT, consisting of a pilot study (PS) to test the acceptance, usability and adaptability of the device by patients. For the PS, 18 patients of the global group were selected. Each subject completed four sessions using HandTutor® in both hands and a weekly session of COT. Each session includes quantitative and qualitative evaluation. The former one includes pre-intervention, and post-intervention assessment evaluating passive and active joint range of fingers and wrist, the latter include patients’ interviews and therapist’s observations. During the session, participants receive immediate visual and sensory feedback about their performance during exercises.

Each session includes a pre-intervention assessment and a back, wrist and hand. At the beginning of the session, the therapist evaluated the passive and active joint range of all fingers and wrist (flexion and extension). After the session, patient and therapist reviewed the increased joint range achieved during therapy on the joints involved. The software allows analysing and comparing the minimum and maximum levels in each of the movements required by the exercise. Each session lasts 45 minutes and consists of two exercises that focus their activity in flexion and extension of wrist and fingers independently, reaction speed and accuracy of the selected motion to move some elements included in the exercise.

First exercise of the session consisted in score as many balls as possible in the basket situated at the left of the patient. Every ball came to the patient from his right side. The goal of the second exercise of the session was destroying cylindrical rocks that were going from the right side to a planet situated in the left side. In both exercises, none of the elements appeared at the same height. That is why the patient had to adjust the degrees of flexion and extension of wrist, fingers or both. The occupational therapist could modify the speed, number of balls and minimum and maximum of degrees to achieve the accomplishment.

In addition to the quantitative variables described above, the therapist evaluated with qualitative methodology through interviews and observation, the condition of the skin (redness in the contact area with the glove), increased muscle tone, pain, motivation and difficulty understanding the instructions, level of usability, applicability and functionality of the patient. During the intervention, the therapist verbally corrected offsets trunk and lower limbs, annotating associated reactions in the facial muscles.

4. Results and discussion

All the participants of the experimental group completed the pilot study (n = 18). Table 1 shows the passive and active range of motion (ROM) of the preseason evaluation in fingers and wrist, divided by diagnostic (stroke vs. traumatic brain injury). Every data about ROM is shown in millimetres (average score). In the evaluation, it is noted that the hand of the participants with traumatic brain injury showed lower passive and active joints in all of the fingers (active: V: 9, IV: 10, III: 9, II: 8 and I: 10; passive: V and IV: 14, III: 11, II: 17 and I: 16), except in the wrist (stroke: active 8; passive 23 vs. traumatic brain injury: active 18; passive 20).

Stroke (average in mm) Traumatic brain injury (average in mm)
Range of motion (flexo-extension)
Wrist
Little
Ring
Middle
Index
Thumb
Active

8
11
14.3
11
10
8.3
Passive

23
20.3
22.6
22.6
22.6
20.6
Active

18
9
10
9
8
10
Passive

20
14
14
11
17
16
Active flexion deficit
Wrist
Little
Ring
Middle
Index
Thumb

9
5.6
5
4.3
5.6
9

2
0
0
2
0
1
Active extension deficit
Wrist
Little
Ring
Middle
Index
Thumb

6
3.3
3.3
8.4
7
3.3

0
5
4
0
9
5
Treatments sessions log
Reaction speed
Accuracy
Time in seconds (half)
Number of objects
Primary ranger

10
Full
240
1
Full

10
Full
240
1
Full

Table 1.

Hand ROM evaluation pre-session and treatments sessions log.

Participants with stroke show higher deficits in the flexion active of the first, second and fifth fingers (9, 5.6 and 5.6, respectively), while the extension appears more weakened in the second and third fingers (7 and 8.4, respectively). However, the participants with traumatic brain injury show higher deficit of flexion in the third finger and the extension in the second, fourth and fifth fingers.

In every session, exercises were configured with the same reaction speed and the same number of objects, to allow the participants to achieve the maximum number of hits. Some of them showed deficit of attention, which means that the speed and the increase of stimulations could decrease the final scores and the motivation of the intervention. In the case of the participants who show spasticity, this speed allows them to autorelax and control the hand between the stimulations. The length of exercises were modified according to the muscular and attentional fatigue of the participant, starting with 5 minutes and decreasing, in some cases, up to 3 minutes. All the participants reached the accuracy of movement calculated by the system, according to the preseason ROM evaluation. Also, all of them were allowed to work all of the primary movement range calculated in the evaluation.

At the beginning of the session, the occupational therapist explained the exercise to the participant and conducted a 1-minute test to check understanding. Only was necessary to provide additional verbal instruction to improve comprehension in the 11% of the cases.

Figures 1 and 2 show the ROM evaluation of the hand. In Figure 1, the active evaluation of flexion of wrist and extension of fingers is observed. Figure 2 includes the graphic representation of the millimetres of active movements (in red colour) versus the passive ones (in blue colour) of two hands with left hemiplegia (1 and 2) and two hands of participants with traumatic brain injury (tetraparesis and predominance of affectation in the right hemibody).

media/F1.png

Figure 1.

Hand ROM evaluation (active).

media/F2.png

Figure 2.

Hand ROM evaluation HandTutor® (passive and active).

Figures 3 and 4 display the functioning of the HandTutor® during the intervention. Figure 3 shows the glove with the hand in flexo-extension, while Figure 4 shows the assisted movement of the occupational therapist to obtain the higher ranges of flexion in a participant who shows rigidity and attentional issues. Besides, in the contralateral hand, it can be seen the associated reactions in the top member, which is not forming a part of the intervention. The hand replicates the movement that the occupational therapist is trying to get in the most affected member.

media/F3.png

Figure 3.

Flexo-extension hand with HandTutor®.

media/F4.png

Figure 4.

Example of assisted movement with HandTutor®.

Figures 5 and 6 show maximum and minimum scores for diagnostic. In them, it can be observed the heterogeneity of the flexion and extension movement of the participants in the study. Regarding the wrist, it is not observed huge differences by diagnostic, except in the minimum flexo-extension of the stroke group, especially in the extension. Nevertheless, the articular ranges of the fingers differ until they reach a difference of 20 millimetres in the third finger in the case of the group diagnosed with stroke, coinciding with the group diagnosed with traumatic brain injury.

media/F5.png

Figure 5.

Flexo-extension maximum and minimum of fingers in treatments sessions log.

media/F6.png

Figure 6.

Flexo-extension maximum and minimum of wrist in treatments session logs.

Participants referred increasing satisfaction with this new therapy. During the intervention, the software provided quantitative measures and immediate feedback of variations in patient mobility showing that HandTutor® sensors are highly sensitive to small variations in patient movement. In post-intervention interviews, patients reported that the glove decreases muscle tone of the hand and wrist, allowing ending the session with increased mobility.

All sessions evaluated qualitatively, through an interview, the following parameters: skin condition, motivation, difficulty in the understanding of instructions, level of HandTutor® utility, clinic applicability and satisfaction.

During the sessions, no side effects were observed related to the skin or post-intervention pain related with the hand use. Every participant ended the sessions without any visible injury in the skin (absence of redness, marks or changes in the coloration) and without any kind of pain. This was evaluated both at the end of the session and at the beginning of the next. To be able to contrast the information in relation with the skin condition and the pain, the data were triangulated by asking the participant and his/her primary caregiver the following day of every intervention. In both cases, they confirmed our data.

All participants referred high level of motivation and satisfaction at the end of the intervention due to the perceived higher performance of limb segments and joins involved in the exercises in their activities of daily life (ADLs). The subjective perception of the patient was checked by comparing the ROM (active vs. passive) pre-post measurement session. All participants showed and transmitted a great motivation and satisfaction with the HandTutor® intervention, except for one user. This one presents acoustic, visual and tactile hypersensitivity. After the pilot study, this participant transmitted that the glove, the sound and the images of the system induced in him/her nervousness and rejection. This information was contrasted with caregivers and professionals of the centre.

Some difficulties were found at the following of the exercise instructions, the motivation and interest maintenance during the 11% of the cases, as a consequence of the presence of attention and/or memory impairments.

All participants shared the sensation of decreasing the muscular tone, immediately at the end of every session and transmitted that this feeling stayed all day long, allowing them a higher mobility and independence at the ADLs.

During the study, some problems were observed associated with the difficulty in putting on the HandTutor® glove, especially in hands with high degrees of spasticity, mainly in diagnosed cases of traumatic brain injury (27.8%; Figure 7). Participants with lower ROM valued positively that the exercise was adapted to their possibilities, so they can reach and move objects even with their limited mobility. The 20% of the users valued negatively the weight of the system placed in the forearm, especially those with weak musculature. The occupational therapists reduced the gravity effect including a cradle to facility the placement of the forearm.

media/F7.png

Figure 7.

Spastic hand with HandTutor®.

In those patients that showed sweating, there were placed vinyl or latex gloves on their hands to avoid direct contact with the glove.

Therefore, it seems that the HandTutor® is a device with high degrees of acceptance and usability among patients with CBD.

5. Conclusions

This chapter is a step further of evaluating the acceptance of technological devices in chronic patients with CBD. On one hand, in the theoretical part of the study, we have found in the literature strong evidence confirming the effectiveness of glove-like devices in hand rehabilitation after brain injury, but no so solid evidence of VRs effectiveness over traditional treatment. On the other hand, the practical pilot study to test HandTutor points in the expected direction confirming participants’ satisfaction about effectiveness and ergonomics of glove-like devices, but according to Ref. [12], there are still some issues to be solved in the usability of these devices for patients with spasticity.

The grade of usability of the HandTutor® device with chronic patients with CBD is high; we only find difficulties in those who show attention disorders and/or memory issues or sensorial hypersensibility. The degree of spasticity should also be taken into account in the design of the experience, because difficulties may arise in the placement of the device when the degree of spasticity is high or there is rigidity or other associated reactions.

Most of the studies performed with active gloves similar to HandTutor® device have been performed in patients in the acute or subacute phase of brain damage. It is important to emphasize that in this study, unlike the previous ones, the rehabilitation has been done with patients with more than 24 months of evolution since the diagnosis of the damage and therefore with a very high degree of chronicity in the neurological sequelae. This is one of the main contributions of the presented work since the more time has passed since the diagnosis of brain damage; the more difficult it is to achieve significant improvements with rehabilitation.

In our study, the HandTutor® device has performed effectively for the spasticity treatment in patients with CBD, producing improvements in the performance of the ADLs and elevating the motivation and satisfaction grades with his use in rehabilitation processes. However, this trial does not provide significant statistical evidence about HandTutor® effectiveness, and it would be recommendable to replicate the study with more participants to confirm our findings.

6. Acknowledgements

Work partially funded by SYMBHYO-ITC [MCINN PTQ-15-0705], RESET [MCINN TIN2014-53199-C3-1-R], eMadrid [CAM S2013/ICE-2715] and PhyMEL [UC3M 2015/00402/001] projects. Authors would like to thank Maria Pulido for their feedback in VR devices, and we also want to express our gratitude to the patients involved in the pilot study.

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Source: Hand Rehabilitation after Chronic Brain Damage: Effectiveness, Usability and Acceptance of Technological Devices: A Pilot Study | InTechOpen

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[BOOK] Technology in Physical Activity and Health Promotion – Google Books

Front CoverAs technology becomes an ever more prevalent part of everyday life and population-based physical activity programmes seek new ways to increase lifelong engagement with physical activity, so the two have become increasingly linked. This book offers a thorough, critical examination of emerging technologies in physical activity and health, considering technological interventions within the dominant theoretical frameworks, exploring the challenges of integrating technology into physical activity promotion and offering solutions for its implementation.

Technology in Physical Activity and Health Promotion occupies a broadly positive stance toward interactive technology initiatives and, while discussing some negative implications of an increased use of technology, offers practical recommendations for promoting physical activity through a range of media, including:

  • social media
  • mobile apps
  • global positioning and geographic information systems
  • wearables
  • active videogames (exergaming)
  • virtual reality settings.

Offering a logical and clear critique of technology in physical activity and health promotion, this book will serve as an essential reference for upper-level undergraduates, postgraduate students and scholars working in public health, physical activity and health and kinesiology, and healthcare professionals.

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Source: Technology in Physical Activity and Health Promotion – Google Books

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[BOOK + References] Adaptation and Rehabilitation in Patients with Homonymous Visual Field Defects

Abstract

Hemianopia leads to severe impairment of spatial orientation and mobility. In cases without macular sparing an additional reading disorder occurs. Persistent visual deficits require rehabilitation. The goal is to compensate for the deficits to regain independence and to maintain the patient’s quality of life. Spontaneous adaptive mechanisms, such as shifting the field defect towards the hemianopic side by eye movements or eccentric fixation, are beneficial, but often insufficient. They can be enhanced by training, e.g., saccadic training to utilize the full field of gaze in order to improve mobility and by special training methods to improve reading performance. At present only compensatory interventions are evidence-based.

References (71)

Source: Adaptation and Rehabilitation in Patients with Homonymous Visual Field Defects – Springer

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