Archive for category REHABILITATION

[TED Talk] David Casarett: A doctor’s case for medical marijuana

Subtitles and Transcript

0:12 I would like to tell you about the most embarrassing thing that has ever happened to me in my years of working as a palliative care physician. This happened a couple of years ago. I was asked as a consultant to see a woman in her 70s — retired English professor who had pancreatic cancer. I was asked to see her because she had pain, nausea, vomiting … When I went to see her, we talked about those symptoms and in the course of that consultation, she asked me whether I thought that medical marijuana might help her. I thought back to everything that I had learned in medical school about medical marijuana, which didn’t take very long because I had learned absolutely nothing. And so I told her that as far as I knew, medical marijuana had no benefits whatsoever. And she smiled and nodded and reached into the handbag next to the bed, and pulled out a stack of about a dozen randomized controlled trials showing that medical marijuana has benefits for symptoms like nausea and pain and anxiety. She handed me those articles and said, “Maybe you should read these before offering an opinion … doctor.”

1:29 (Laughter)

1:30 So I did. That night I read all of those articles and found a bunch more. When I came to see her the next morning, I had to admit that it looks like there is some evidence that marijuana can offer medical benefits and I suggested that if she really was interested, she should try it. You know what she said? This 73-year-old, retired English professor? She said, “I did try it about six months ago. It was amazing. I’ve been using it every day since. It’s the best drug I’ve discovered. I don’t know why it took me 73 years to discover this stuff. It’s amazing.”

2:10 (Laughter)

2:11 That was the moment at which I realized I needed to learn something about medical marijuana because what I was prepared for in medical school bore no relationship to reality.

2:22 So I started reading more articles, I started talking to researchers, I started talking to doctors, and most importantly, I started listening to patients. I ended up writing a book based on those conversations, and that book really revolved around three surprises — surprises to me, anyway. One I already alluded to — that there really are some benefits to medical marijuana. Those benefits may not be as huge or as stunning as some of the most avid proponents of medical marijuana would have us believe, but they are real. Surprise number two: medical marijuana does have some risks. Those risks may not be as huge and as scary as some of the opponents of medical marijuana would have us believe, but they are real risks, nonetheless. But it was the third surprise that was most … surprising. And that is that a lot of the patients I talked with who’ve turned to medical marijuana for help, weren’t turning to medical marijuana because of its benefits or the balance of risks and benefits, or because they thought it was a wonder drug, but because it gave them control over their illness. It let them manage their health in a way that was productive and efficient and effective and comfortable for them.

3:37 To show you what I mean, let me tell you about another patient. Robin was in her early 40s when I met her. She looked though like she was in her late 60s. She had suffered from rheumatoid arthritis for the last 20 years, her hands were gnarled by arthritis, her spine was crooked, she had to rely on a wheelchair to get around. She looked weak and frail, and I guess physically she probably was, but emotionally, cognitively, psychologically, she was among the toughest people I’ve ever met. And when I sat down next to her in a medical marijuana dispensary in Northern California to ask her about why she turned to medical marijuana, what it did for her and how it helped her, she started out by telling me things that I had heard from many patients before. It helped with her anxiety; it helped with her pain; when her pain was better, she slept better. And I’d heard all that before. But then she said something that I’d never heard before, and that is that it gave her control over her life and over her health. She could use it when she wanted, in the way that she wanted, at the dose and frequency that worked for her. And if it didn’t work for her, then she could make changes. Everything was up to her. The most important thing she said was she didn’t need anybody else’s permission — not a clinic appointment, not a doctor’s prescription, not a pharmacist’s order. It was all up to her. She was in control.

5:00 And if that seems like a little thing for somebody with chronic illness, it’s not — not at all. When we face a chronic serious illness, whether it’s rheumatoid arthritis or lupus or cancer or diabetes, or cirrhosis, we lose control. And note what I said: “when,” not “if.” All of us at some point in our lives will face a chronic serious illness that causes us to lose control. We’ll see our function decline, some of us will see our cognition decline, we’ll be no longer able to care for ourselves, to do the things that we want to do. Our bodies will betray us, and in that process, we’ll lose control. And that’s scary. Not just scary — that’s frightening, it’s terrifying. When I talk to my patients, my palliative care patients, many of whom are facing illnesses that will end their lives, they have a lot of be frightened of — pain, nausea, vomiting, constipation, fatigue, their impending mortality. But what scares them more than anything else is this possibility that at some point, tomorrow or a month from now, they’re going to lose control of their health, of their lives, of their healthcare, and they’re going to become dependent on others, and that’s terrifying.

6:17 So it’s no wonder really that patients like Robin, who I just told you about, who I met in that clinic, turn to medical marijuana to try to claw back some semblance of control. How do they do it though? How do these medical marijuana dispensaries — like the one where I met Robin — how do they give patients like Robin back the sort of control that they need? And how do they do it in a way that mainstream medical hospitals and clinics, at least for Robin, weren’t able to? What’s their secret? So I decided to find out.

6:54 I went to a seedy clinic in Venice Beach in California and got a recommendation that would allow me to be a medical marijuana patient. I got a letter of recommendation that would let me buy medical marijuana. I got that recommendation illegally, because I’m not a resident of California — I should note that. I should also note, for the record, that I never used that letter of recommendation to make a purchase, and to all of you DEA agents out there —

7:21 (Laughter)

7:22 love the work that you’re doing, keep it up.

7:25 (Laughter)

7:26 Even though it didn’t let me make a purchase though, that letter was priceless because it let me be a patient. It let me experience what patients like Robin experience when they go to a medical marijuana dispensary. And what I experienced — what they experience every day, hundreds of thousands of people like Robin — was really amazing. I walked into the clinic, and from the moment that I entered many of these clinics and dispensaries, I felt like that dispensary, that clinic, was there for me. There were questions at the outset about who I am, what kind of work I do, what my goals are in looking for a medical marijuana prescription, or product, what my goals are, what my preferences are, what my hopes are, how do I think, how do I hope this might help me, what am I afraid of. These are the sorts of questions that patients like Robin get asked all the time. These are the sorts of questions that make me confident that the person I’m talking with really has my best interests at heart and wants to get to know me.

8:33 The second thing I learned in those clinics is the availability of education. Education from the folks behind the counter, but also education from folks in the waiting room. People I met were more than happy, as I was sitting next to them — people like Robin — to tell me about who they are, why they use medical marijuana, what helps them, how it helps them, and to give me advice and suggestions. Those waiting rooms really are a hive of interaction, advice and support.

9:03 And third, the folks behind the counter. I was amazed at how willing those people were to spend sometimes an hour or more talking me through the nuances of this strain versus that strain, smoking versus vaporizing, edibles versus tinctures — all, remember, without me making any purchase whatsoever. Think about the last time you went to any hospital or clinic and the last time anybody spent an hour explaining those sorts of things to you. The fact that patients like Robin are going to these clinics, are going to these dispensaries and getting that sort of personalized attention and education and service, really should be a wake-up call to the healthcare system. People like Robin are turning away from mainstream medicine, turning to medical marijuana dispensaries because those dispensaries are giving them what they need.

9:57 If that’s a wake-up call to the medical establishment, it’s a wake-up call that many of my colleagues are either not hearing or not wanting to hear. When I talk to my colleagues, physicians in particular, about medical marijuana, they say, “Oh, we need more evidence. We need more research into benefits, we need more evidence about risks.” And you know what? They’re right. They’re absolutely right. We do need much more evidence about the benefits of medical marijuana. We also need to ask the federal government to reschedule marijuana to Schedule II, or to deschedule it entirely to make that research possible. We also need more research into medical marijuana’s risks. Medical marijuana’s risks — we know a lot about the risks of recreational use, we know next to nothing about the risks of medical marijuana. So we absolutely do need research, but to say that we need research and not that we need to make any changes now is to miss the point entirely. People like Robin aren’t seeking out medical marijuana because they think it’s a wonder drug, or because they think it’s entirely risk-free. They seek it out because the context in which it’s delivered and administered and used, gives them the sort of control they need over their lives. And that’s a wake-up call we really need to pay attention to.

11:16 The good news though is that there are lessons we can learn today from those medical marijuana dispensaries. And those are lessons we really should learn. These are often small, mom-and-pop operations run by people with no medical training. And while it’s embarrassing to think that many of these clinics and dispensaries are providing services and support and meeting patients’ needs in ways that billion-dollar healthcare systems aren’t — we should be embarrassed by that — but we can also learn from that. And there are probably three lessons at least that we can learn from those small dispensaries.

11:51 One: we need to find ways to give patients more control in small but important ways. How to interact with healthcare providers, when to interact with healthcare providers, how to use medications in ways that work for them. In my own practice, I’ve gotten much more creative and flexible in supporting my patients in using drugs safely to manage their symptoms — with the emphasis on safely. Many of the drugs I prescribe are drugs like opioids or benzodiazepines which can be dangerous if overused. But here’s the point. They can be dangerous if they’re overused, but they can also be ineffective if they’re not used in a way that’s consistent with what patients want and need. So that flexibility, if it’s delivered safely, can be extraordinarily valuable for patients and their families. That’s number one.

12:39 Number two: education. Huge opportunities to learn from some of the tricks of those medical marijuana dispensaries to provide more education that doesn’t require a lot of physician time necessarily, or any physician time, but opportunities to learn about what medications we’re using and why, prognoses, trajectories of illness, and most importantly, opportunities for patients to learn from each other. How can we replicate what goes on in those clinic and medical dispensary waiting rooms? How patients learn from each other, how people share with each other.

13:13 And last but not least, putting patients first the way those medical marijuana dispensaries do, making patients feel legitimately like what they want, what they need, is why, as healthcare providers, we’re here. Asking patients about their hopes, their fears, their goals and preferences. As a palliative care provider, I ask all my patients what they’re hoping for and what they’re afraid of. But here’s the thing. Patients shouldn’t have to wait until they’re chronically seriously ill, often near the end of life, they shouldn’t have to wait until they’re seeing a physician like me before somebody asks them, “What are you hoping for?” “What are you afraid of?” That should be baked into the way that healthcare is delivered.

13:58 We can do this — we really can. Medical marijuana dispensaries and clinics all across the country are figuring this out. They’re figuring this out in ways that larger, more mainstream health systems are years behind. But we can learn from them, and we have to learn from them. All we have to do is swallow our pride — put aside the thought for a minute that because we have lots of letters after our name, because we’re experts, because we’re chief medical officers of a large healthcare system, we know all there is to know about how to meet patients’ needs.

14:31 We need to swallow our pride. We need to go visit a few medical marijuana dispensaries. We need to figure out what they’re doing. We need to figure out why so many patients like Robin are leaving our mainstream medical clinics and going to these medical marijuana dispensaries instead. We need to figure out what their tricks are, what their tools are, and we need to learn from them. If we do, and I think we can, and I absolutely think we have to, we can guarantee all of our patients will have a much better experience.

15:00 Thank you.

15:01 (Applause)

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[WEB SITE] Gaming helps personalized therapy level up – Penn State University

UNIVERSITY PARK, Pa. — Using game features in non-game contexts, computers can learn to build personalized mental- and physical-therapy programs that enhance individual motivation, according to Penn State engineers.

“We want to understand the human and team behaviors that motivate learning to ultimately develop personalized methods of learning instead of the one-size-fits-all approach that is often taken,” said Conrad Tucker, assistant professor of engineering design and industrial engineering.

They seek to use machine learning to train computers to develop personalized mental or physical therapy regimens — for example, to overcome anxiety or recover from a shoulder injury — so many individuals can each use a tailor-made program.

“Using people to individually evaluate others is not efficient or sustainable in time or human resources and does not scale up well to large numbers of people,” said Tucker. “We need to train computers to read individual people. Gamification explores the idea that different people are motivated by different things.”

To begin creating computer models for therapy programs, the researchers tested how to most effectively make the completion of a physical task into a gamified application by incorporating game features like scoring, avatars, challenges and competition.

“We’re exploring here how gamification could be applied to health and wellness by focusing on physically interactive gamified applications,” said Christian Lopez, graduate student in industrial engineering, who helped conduct the tests using a virtual-reality game environment.

Screen from game designed to test features for gamification use in physical and mental therapy. Image: Kimberly Cartier / Penn State

In the virtual-reality tests, researchers asked participants to physically avoid obstacles as they moved through a virtual environment. The game system recorded their actual body positions using motion sensors and then mirrored their movements with an avatar in virtual reality.

Participants had to bend, crouch, raise their arms, and jump to avoid obstacles. The participant successfully avoided a virtual obstacle if no part of their avatar touched the obstacle. If they made contact, the researchers rated the severity of the mistake by how much of the avatar touched the obstacle.

In one of the application designs, participants could earn more points by moving to collect virtual coins, which sometimes made them hit an obstacle.

“As task complexity increases, participants need more motivation to achieve the same level of results,” said Lopez. “No matter how engaging a particular feature is, it needs to move the participant towards completing the objective rather than backtracking or wasting time on a tangential task. Adding more features doesn’t necessarily enhance performance.”

Tucker and Lopez created a predictive algorithm — a mathematical formula to forecast the outcome of an event — that rates the potential usefulness of a game feature. They then tested how well each game feature motivated participants when completing the virtual-reality tasks. They compared their test results to the algorithm’s predictions as a proof of concept and found that the formula correctly anticipated which game features best motivated people in the physically interactive tasks.

The researchers found that gamified applications with a scoring system, the ability to select an avatar, and in-game rewards led to significantly fewer mistakes and higher performance than those with a win-or-lose system, randomized gaming backgrounds and performance-based awards.

Sixty-eight participants tested two designs that differed only by the features used to complete the same set of tasks. Tucker and Lopez published their results in Computers in Human Behavior.

The researchers chose the tested game features from the top-ranked games in the Google Play app store, taking advantage of the features that make the games binge-worthy and re-playable, and then narrowed the selection based on available technology.

Their algorithm next ranked game features by how easily designers could implement them, the physical complexity of using the feature, and the impact of the feature on participant motivation and ability to complete the task. If a game feature is too technologically difficult to incorporate into the game, too physically complex, does not offer enough incentive for added effort or works against the end goal of the game, then the feature has low potential usefulness.

The researchers would also like to use these results to boost workplace performance and personalize virtual-reality classrooms for online education.

“Game culture has already explored and mastered the psychological aspects of games that make them engaging and motivating,” said Tucker. “We want to leverage that knowledge towards the goal of individualized optimization of workplace performance.”

To do this, Tucker and Lopez next want to connect performance with mental state during these gamified physical tasks. Heart rate, electroencephalogram signals and facial expressions will be used as proxies for mood and mental state while completing tasks to connect mood with game features that affect motivation.

The National Science Foundation funded this research.

Source: Gaming helps personalized therapy level up | Penn State University

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[ARTICLE] The impact of large structural brain changes in chronic stroke patients on the electric field caused by transcranial brain stimulation – Full Text

Abstract

Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (TDCS) are two types of non-invasive transcranial brain stimulation (TBS). They are useful tools for stroke research and may be potential adjunct therapies for functional recovery. However, stroke often causes large cerebral lesions, which are commonly accompanied by a secondary enlargement of the ventricles and atrophy. These structural alterations substantially change the conductivity distribution inside the head, which may have potentially important consequences for both brain stimulation methods. We therefore aimed to characterize the impact of these changes on the spatial distribution of the electric field generated by both TBS methods. In addition to confirming the safety of TBS in the presence of large stroke-related structural changes, our aim was to clarify whether targeted stimulation is still possible. Realistic head models containing large cortical and subcortical stroke lesions in the right parietal cortex were created using MR images of two patients. For TMS, the electric field of a double coil was simulated using the finite-element method. Systematic variations of the coil position relative to the lesion were tested. For TDCS, the finite-element method was used to simulate a standard approach with two electrode pads, and the position of one electrode was systematically varied. For both TMS and TDCS, the lesion caused electric field “hot spots” in the cortex. However, these maxima were not substantially stronger than those seen in a healthy control. The electric field pattern induced by TMS was not substantially changed by the lesions. However, the average field strength generated by TDCS was substantially decreased. This effect occurred for both head models and even when both electrodes were distant to the lesion, caused by increased current shunting through the lesion and enlarged ventricles. Judging from the similar peak field strengths compared to the healthy control, both TBS methods are safe in patients with large brain lesions (in practice, however, additional factors such as potentially lowered thresholds for seizure-induction have to be considered). Focused stimulation by TMS seems to be possible, but standard tDCS protocols appear to be less efficient than they are in healthy subjects, strongly suggesting that tDCS studies in this population might benefit from individualized treatment planning based on realistic field calculations.

1. Introduction

Transcranial brain stimulation (TBS) methods are useful tools to induce and to quantify neural plasticity, and as such are increasingly being used in stroke research and as potential adjunct therapies in stroke rehabilitation. The cerebral lesions caused by stroke result in persisting physical or cognitive impairments in around 50% of all survivors (Di Carlo, 2008Leys et al., 2005 ;  Young and Forster, 2007), meaning that new therapies are urgently needed. Transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (TDCS) are two TBS approaches which are being increasingly utilised in stroke research. Single-pulse TMS combined with electromyography (EMG) or electroencephalography (EEG) can be used to assess cortical excitability, for example to index the functional state of the perilesional tissue. The neuromodulatory effects of repetitive TMS protocols (rTMS) may, in association with neuro-rehabilitative treatments, enhance motor recovery (Liew et al., 2014). Similar results have been demonstrated for TDCS. For example, anodal TDCS of the hand area in the primary motor cortex has been shown to improve motor performance of the affected hand (Allman et al., 2016Hummel et al., 2005 ;  Stagg et al., 2012) and anodal TDCS applied over the left frontal cortex enhanced naming accuracy in patients with aphasia (Baker et al., 2010). However, not all studies report a clear-cut positive impact of TBS on the stroke symptoms. Rather, the observed effects are often weak and not consistent across patients, demonstrating the need for a better understanding of the underlying biophysical and physiological mechanisms.

Compared with healthy subjects, several factors might contribute to a change in the neuroplastic response to TBS protocols in stroke patients, including changes in the neural responsiveness to the applied electric fields, as well as differences in the underlying physiology and metabolism (Blicher et al., 2009Blicher et al., 2015 ;  O’Shea et al., 2014). When the lesions are large, they may also substantially alter the generated electric field pattern, meaning that the assumptions on spatial targeting as derived from biophysical modelling and physiological experiments in healthy subjects might no longer be valid. Stroke lesions are often accompanied by secondary macrostructural changes such as cortical atrophy and enlargement of the ventricles (e.g., Skriver et al., 1990), which may further contribute to changes in the field pattern. In addition, the safety of TBS in patients with large lesions needs to be further clarified, as it is possible that the lesions might cause stimulation “hot spots”. In chronic patients, the stroke cavity becomes filled with corticospinal fluid (CSF), which might cause shunting of current, funnelling the generated currents towards the surrounding brain tissue and potentially causing localized areas of dangerously high field strengths.

Here, using finite-element calculations and individual head models derived from structural MR images, we focused on the impact of a large cortical lesion in chronic stroke on the electric field pattern generated in the brain by TMS and TDCS, respectively. Firstly, we assessed the safety of the stimulation by comparing the achieved field strengths with those estimated for a healthy control. Secondly, we tested how reliably we can accurately target the perilesional tissue, often the desired target for TBS, as reorganisation here is thought to underpin functional recovery (Kwakkel et al., 2004). Finally, we were also interested to see whether any observed changes in the field pattern were specific to a patient with a cortical lesion (which is connected to the CSF layer underneath the skull), or whether similar effects might occur in case of large chronic subcortical lesion. We therefore additionally tested the field distribution in a head model of a patient with a subcortical lesion occurring at a similar position as the cortical lesion.

2. Materials and methods

2.1. Selection of patients

The aim of this study was to characterize the effect of a large chronic cortical stroke lesion on the electric field distribution generated by TBS, and to compare the effects of this lesion to that caused by a large chronic subcortical lesion. MR images of several patients were visually inspected to select two datasets, which had a cortical [P01] and subcortical lesion [P02], respectively, within the same gross anatomical regions.

Patient P01 was a 36 year old female with episodic migraine; she was admitted with left hemiparalysis, fascial palsy and a total NIHSS score of 16 due to a right ICI/MCI occlusion. She was treated with IV thrombolysis and thrombectomy and recanalization was achieved 5 h after symptom onset. One year post-stroke she still suffered from motor impairment (Wolf Motor Function Test [WMFT] score of 30) and was scanned as part of a clinical study investigating the effect of combining Constraint-Induced Movement Therapy and tDCS (Figlewski et al., 2017; Clinical trials NCT01983319, Regional Ethics approval: 1-10-72-268-13). The structural scans showed a cortical lesion in the right parietal lobe (Fig. 1A). The lesion volume, delineated manually with reference to T1- and T2-weighted imaging, was 26,415 mm3.

Fig. 1:Fig. 1.

A) Coronal view of patient P01 with a cortical lesion in the right hemisphere. The top shows the T1-weighted MR image and the bottom the reconstructed head mesh. The view was chosen to include the lesion centre. The lesion is marked by red dashed circles. B) Corresponding view of patient P02 with a large subcortical lesion at a similar location in the right hemisphere. C) Corresponding view of the data set of the healthy control. D) The coil and electrode positions were systematically moved along two directions that were approximately perpendicular to each other. Five positions were manually placed every 2 cm in posterior – anterior direction symmetrically around the centre of the cortical lesion. The same was repeated along the lateral – medial direction. Both lines share the same centre position above the lesion, resulting in 9 positions in total. E) At each position, two coil orientations were tested which resulted in a current flow underneath the coil centre from anterior to posterior (top) and from lateral to medial, respectively (bottom). F) For each position of the yellow “stimulating” electrode, two positions of the blue return electrode were tested. First, the contralateral equivalent of the electrode position above the centre of the cortical lesion was used (top). In addition, a position on the contralateral forehead was tested (bottom).

Patient P02 was a 44 year old female. She woke up with a left hemiparesis and an acute CT scan showed no bleeding. No IV thrombolysis was given due to uncertain timing of symptom onset. An embolic stroke was suspect due to a patent foramen ovale, which was subsequently closed. She was scanned with MRI 9 months post stroke showing a right subcortical infarct, at which time she had a WMFT score of 8. The lesion volume, delineated as for P01, was 56,010 mm3. She was scanned as part of a clinical study investigating the effect of combining tDCS with daily motor training (Allman et al., 2016; Regional Ethics approval: Oxfordshire REC A; 10/H0604/98)….

Continue —> The impact of large structural brain changes in chronic stroke patients on the electric field caused by transcranial brain stimulation

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[Abstract] The treatment of fatigue by non-invasive brain stimulation

Summary

The use of non-invasive brain neurostimulation (NIBS) techniques to treat neurological or psychiatric diseases is currently under development. Fatigue is a commonly observed symptom in the field of potentially treatable pathologies by NIBS, yet very little data has been published regarding its treatment. We conducted a review of the literature until the end of February 2017 to analyze all the studies that reported a clinical assessment of the effects of NIBS techniques on fatigue. We have limited our analysis to repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). We found only 15 studies on this subject, including 8 tDCS studies and 7 rTMS studies. Of the tDCS studies, 6 concerned patients with multiple sclerosis while 6 rTMS studies concerned fibromyalgia or chronic fatigue syndrome. The remaining 3 studies included patients with post-polio syndrome, Parkinson’s disease and amyotrophic lateral sclerosis. Three cortical regions were targeted: the primary sensorimotor cortex, the dorsolateral prefrontal cortex and the posterior parietal cortex. In all cases, tDCS protocols were performed according to a bipolar montage with the anode over the cortical target. On the other hand, rTMS protocols consisted of either high-frequency phasic stimulation or low-frequency tonic stimulation. The results available to date are still too few, partial and heterogeneous as to the methods applied, the clinical profile of the patients and the variables studied (different fatigue scores) in order to draw any conclusion. However, the effects obtained, especially in multiple sclerosis and fibromyalgia, are really carriers of therapeutic hope.

Source: The treatment of fatigue by non-invasive brain stimulation

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[Abstract] A soft supernumerary robotic finger and mobile arm support for grasping compensation and hemiparetic upper limb rehabilitation

Abstract

In this paper, we present the combination of our soft supernumerary robotic finger i.e. Soft-SixthFinger with a commercially available zero gravity arm support, the SaeboMAS. The overall proposed system can provide the needed assistance during paretic upper limb rehabilitation involving both grasping and arm mobility to solve task-oriented activities. The Soft-SixthFinger is a wearable robotic supernumerary finger designed to be used as an active assistive device by post stroke patients to compensate the paretic hand grasp. The device works jointly with the paretic hand/arm to grasp an object similarly to the two parts of a robotic gripper. The SaeboMAS is a commercially available mobile arm support to neutralize gravity effects on the paretic arm specifically designed to facilitate and challenge the weakened shoulder muscles during functional tasks. The proposed system has been designed to be used during the rehabilitation phase when the arm is potentially able to recover its functionality, but the hand is still not able to perform a grasp due to the lack of an efficient thumb opposition. The overall system also act as a motivation tool for the patients to perform task-oriented rehabilitation activities.

With the aid of proposed system, the patient can closely simulate the desired motion with the non-functional arm for rehabilitation purposes, while performing a grasp with the help of the Soft-SixthFinger. As a pilot study we tested the proposed system with a chronic stroke patient to evaluate how the mobile arm support in conjunction with a robotic supernumerary finger can help in performing the tasks requiring the manipulation of grasped object through the paretic arm. In particular, we performed the Frenchay Arm Test (FAT) and Box and Block Test (BBT). The proposed system successfully enabled the patient to complete tasks which were previously impossible to perform.

Source: A soft supernumerary robotic finger and mobile arm support for grasping compensation and hemiparetic upper limb rehabilitation

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[ARTICLE] Transcranial Direct Current Stimulation Does Not Affect Lower Extremity Muscle Strength Training in Healthy Individuals: A Triple-Blind, Sham-Controlled Study – Full Text

The present study investigated the effects of anodal transcranial direct current stimulation (tDCS) on lower extremity muscle strength training in 24 healthy participants. In this triple-blind, sham-controlled study, participants were randomly allocated to the anodal tDCS plus muscle strength training (anodal tDCS) group or sham tDCS plus muscle strength training (sham tDCS) group. Anodal tDCS (2 mA) was applied to the primary motor cortex of the lower extremity during muscle strength training of the knee extensors and flexors. Training was conducted once every 3 days for 3 weeks (7 sessions). Knee extensor and flexor peak torques were evaluated before and after the 3 weeks of training. After the 3-week intervention, peak torques of knee extension and flexion changed from 155.9 to 191.1 Nm and from 81.5 to 93.1 Nm in the anodal tDCS group. Peak torques changed from 164.1 to 194.8 Nm on extension and from 78.0 to 85.6 Nm on flexion in the sham tDCS group. In both groups, peak torques of knee extension and flexion significantly increased after the intervention, with no significant difference between the anodal tDCS and sham tDCS groups. In conclusion, although the administration of eccentric training increased knee extensor and flexor peak torques, anodal tDCS did not enhance the effects of lower extremity muscle strength training in healthy individuals. The present null results have crucial implications for selecting optimal stimulation parameters for clinical trials.

Introduction

Transcranial direct current stimulation (tDCS) is a non-invasive cortical stimulation procedure in which weak direct currents polarize target brain regions (Nitsche and Paulus, 2000). The application of anodal tDCS to the primary motor cortex of the lower extremity transiently increases corticospinal excitability in healthy individuals (Jeffery et al., 2007Tatemoto et al., 2013) and improves motor function in healthy individuals and patients with stroke (Tanaka et al., 20092011Madhavan et al., 2011Sriraman et al., 2014Chang et al., 2015Montenegro et al., 20152016Angius et al., 2016Washabaugh et al., 2016). Thus, anodal tDCS has a potential to become a new adjunct therapeutic strategy for the rehabilitation of leg motor function and locomotion following a stroke.

Lower leg muscle strength is an important motor function required for patients who have had a stroke to regain activities of daily living (ADL). Lower leg muscle strength correlates with performance in activities, including sit-to-stand, gait, and stair ascent (Bohannon, 2007). Furthermore, lower leg muscle strength training increases muscle strength and improves ADL in patients with stroke (Ada et al., 2006). Therefore, lower leg muscle strength training is one of the important activities rehabilitating patients with stroke to regain their independence in ADL.

Several studies have examined the effect of a single session of tDCS on lower leg muscle strength, although the evidence is inconsistent (Tanaka et al., 20092011Montenegro et al., 20152016Angius et al., 2016Washabaugh et al., 2016). Its effects seem dependent on tDCS protocols, training tasks, muscle groups, and subject populations. Although, most tDCS studies on lower leg muscle strength have focused on the acute effects of a single tDCS application, to the best of our knowledge, no study has examined how lower extremity strength training combined with repeated sessions of tDCS affects lower leg muscle strength. This type of investigation has strong clinical implications for the application of tDCS in rehabilitation for patients with lower leg muscle weakness.

Thus, to examine whether anodal tDCS can enhance the effects of lower extremity muscle strength training, the present study simultaneously applied anodal tDCS and lower extremity muscle strength training to healthy individuals and evaluated their effects on lower extremity muscle strength.

Continue —> Frontiers | Transcranial Direct Current Stimulation Does Not Affect Lower Extremity Muscle Strength Training in Healthy Individuals: A Triple-Blind, Sham-Controlled Study | Perception Science

Figure 1. Experimental setup of the muscle strength training and torque assessment.

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[Conference paper] Upper-Limb Kinematics During Feeding and Drinking – Abstract+References

Abstract

Feeding and drinking are Activities of Daily Living which can be used to assess the motor control and functional ability of the upper limb. This paper presents the upper-limb kinematics during the execution of feeding and drinking activities, such analysis consisted in the measurement of angles of flexion for trunk and arm. Eight healthy subjects performed these activities in a simulated-environment while they were video recorded. Markers on anatomical landmarks were used to analyze the kinematics of the upper limb in the sagittal plane. Additionally an electro-hydraulic sensor was attached to each upper limb to assess the vertical position of the wrist relative to the shoulder. Results showed a difference on the angles of the elbow and trunk. The electro-hydraulic sensor showed to be an efficient way to record the vertical position of wrist.

References

Source: Upper-Limb Kinematics During Feeding and Drinking | SpringerLink

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[Conference paper] Usage of VR Headsets for Rehabilitation Exergames – Abstract+References

Abstract

The work presented here is part of a large project aimed at finding new ways to tackle exergames used for physical rehabilitation. The preferred user group consists of physically impaired who normally cannot use commercially available games; our approach wants to fill a niche and allow them to get the same playing experience like healthy. Four exercises were implemented with the Blender Game engine and connected to a motion capture device (Kinect) via a modular middleware. The games incorporate special features that enhance weak user movements, such that the avatar reacts in the same way as for persons without physical restrictions. Additionally, virtual reality glasses have been integrated to achieve a more immersive feeling during play. In this work, we compare the results of preliminary user tests, performed with and without VR glasses. Test outcomes are good for motion amplification in some of the games but do not present generally better results when using the VR glasses.

Source: Usage of VR Headsets for Rehabilitation Exergames | SpringerLink

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[Abstract] Motor compensation and its effects on neural reorganization after stroke

Abstract

Stroke instigates a dynamic process of repair and remodelling of remaining neural circuits, and this process is shaped by behavioural experiences. The onset of motor disability simultaneously creates a powerful incentive to develop new, compensatory ways of performing daily activities. Compensatory movement strategies that are developed in response to motor impairments can be a dominant force in shaping post-stroke neural remodelling responses and can have mixed effects on functional outcome. The possibility of selectively harnessing the effects of compensatory behaviour on neural reorganization is still an insufficiently explored route for optimizing functional outcome after stroke.

Source: Motor compensation and its effects on neural reorganization after stroke : Nature Reviews Neuroscience : Nature Research

Figure 1: The motor cortex and its descending projection pathways are often affected by strokes that result in upper-extremity impairments.

The motor cortex and its descending projection pathways are often affected by strokes that result in upper-extremity impairments.

a | Simplified illustrations of motor cortical regions of a human (left), and of motor cortical regions of a naive rat, derived using intracortical microstimulation (right), are shown. The colours show the cortical territories that are…

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[WEB SITE] The Rehabilitation Gaming System

slideshow 1RGS is a highly innovative Virtual Reality (VR) tool for the rehabilitation of deficits that occur after brain lesions and has been successfully used for the rehabilitation of the upper extremities after stroke.
The RGS is based on the neurobiological considerations that plasticity of the brain remains  throughout life and therefore can be utilized to achieve functional reorganization of the brain areas affected by stroke. This can be realized by means of activation of secondary motor areas such as the so called mirror neurons system.

RGS deploys a deficit oriented training approach. Specifically, while training with RGS the patient is playing individualized games where movement execution is combined with the observation of correlated actions performed by a virtual body. The system optimizes the user’s training by analyzing the qualitative and quantitative aspects of the user’s performance. This warranties a detailed assessment of the deficits of the patient and their recovery dynamics.

Key articles and Recent publications

also see specs.upf.edu

Source: The Rehabilitation Gaming System | Rehabilitation Gaming System

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