Archive for category Cognitive Rehabilitation

[ARTICLE] A comparison of two personalization and adaptive cognitive rehabilitation approaches: a randomized controlled trial with chronic stroke patients – Full Text



Paper-and-pencil tasks are still widely used for cognitive rehabilitation despite the proliferation of new computer-based methods, like VR-based simulations of ADL’s. Studies have established construct validity of VR assessment tools with their paper-and-pencil version by demonstrating significant associations with their traditional construct-driven measures. However, VR rehabilitation intervention tools are mostly developed to include mechanisms such as personalization and adaptation, elements that are disregarded in their paper-and-pencil counterparts, which is a strong limitation of comparison studies. Here we compare the clinical impact of a personalized and adapted paper-and-pencil training and a content equivalent and more ecologically valid VR-based ADL’s simulation.


We have performed a trial with 36 stroke patients comparing Reh@City v2.0 (adaptive cognitive training through everyday tasks VR simulations) with Task Generator (TG: content equivalent and adaptive paper-and-pencil training). The intervention comprised 12 sessions, with a neuropsychological assessment pre, post-intervention and follow-up, having as primary outcomes: general cognitive functioning (assessed by the Montreal Cognitive Assessment – MoCA), attention, memory, executive functions and language specific domains.


A within-group analysis revealed that the Reh@City v2.0 improved general cognitive functioning, attention, visuospatial ability and executive functions. These improvements generalized to verbal memory, processing speed and self-perceived cognitive deficits specific assessments. TG only improved in orientation domain on the MoCA, and specific processing speed and verbal memory outcomes. However, at follow-up, processing speed and verbal memory improvements were maintained, and a new one was revealed in language. A between-groups analysis revealed Reh@City v2.0 superiority in general cognitive functioning, visuospatial ability, and executive functions on the MoCA.


The Reh@City v2.0 intervention with higher ecological validity revealed higher effectiveness with improvements in different cognitive domains and self-perceived cognitive deficits in everyday life, and the TG intervention retained fewer cognitive gains for longer.


Cognitive rehabilitation after stroke

Stroke is a leading cause of long-term acquired disability in adults [1], predisposing patients toward institutionalization and poorer quality of life [2]. Over the coming decades, the incidence of post-stroke disability is expected to increase by 35% due to the rising prevalence of cerebrovascular risk and advances in medicine which are reducing post-stroke mortality rates [3]. Historically, stroke rehabilitation has been focused on motor rehabilitation [45]. However, post-stroke cognitive deficits are pervasive causing disability with major impacts on quality of life and independence on everyday life activities [67]. In the last years, attention to the impact of cognitive deficits has been growing [8] and finding new ways to improve cognition after stroke is considered a priority [9]. Also, more recently, the International Stroke Recovery and Rehabilitation Alliance 2018 working group has identified post-stroke cognitive impairments as a research priority [10].

Regardless of the many new developments in cognitive rehabilitation programs and applications, limited data on the effectiveness of cognitive rehabilitation is available because of the heterogeneity of participants, interventions, and outcome measures [11]. Results from recent reviews corroborate that cognitive rehabilitation has a positive impact on post-stroke cognitive outcomes [1213], although of small magnitude (Hedges’ g = 0.48) [12]. This result is in line with the quantitative [14] and qualitative [15,16,17] findings of previous reviews that have analyzed the effect of cognitive rehabilitation across multiple cognitive domains.

Is cognitive rehabilitation’s impact small or are we missing better cognitive rehabilitation methodologies?

Paper-and-pencil tasks are still the most widely used methods for cognitive rehabilitation because of their accessibility, ease of use, clinical validity and reduced cost [18]. In the last years, computer-based versions of these traditional tasks are also starting to become clinically accepted [1920]. However, there is an absence of specific methodologies that inform health professionals which tasks to apply and under what clinical conditions [21]. Consequently, rehabilitation professionals perform a selection of tasks based on their clinical experience, missing scientific foundations [22]. We have proposed an objective and quantitative framework for the creation of personalized cognitive rehabilitation tasks based on a participatory design strategy with health professionals [23]. In this work, through computational modeling, the authors operationalized 11 paper-and-pencil tasks and developed an Information and Communication Technologies based tool – the Task Generator (TG) – to tailor each of those 11 paper-and-pencil tasks to each patient in the domains of attention, memory, language and executive functions. A clinical evaluation of the TG with twenty stroke patients showed that the TG is able to adapt task parameters and difficulty levels according to patient’s cognitive assessment, and provide a comprehensive cognitive training [24]. However, although it has been shown that rehabilitation strategies based on paper-and-pencil tasks can be personalized and adapted [2425], this approach presents a limited transfer to performance in activities of daily living (ADL) [18].

Over the last years, rehabilitation methodologies based on virtual reality (VR) have been developed as promising solutions to improve cognitive functions [2627]. VR-based tools have shown potential and to be ideal environments to incorporate cognitive tasks within the simulation of ADL’s [28]. A recent trial with a VR-based simulation of everyday life activities (like going to the pharmacy, buying grocery at the supermarket, paying the water bill) suggested that an ecologically valid intervention has more impact than conventional methods (cognitive training using puzzles, calculus, problem resolution and shape sorting) in cognitive rehabilitation of stroke patients [29]. Also, some of these VR-based systems allow the integration of motor training [30] and recent studies have already shown benefits of performing simultaneous motor and cognitive training with stroke patients using VR [3132]. Yet, there is still an insufficient number of rigorous trials to clinically validate VR methods [12] and there are difficulties associated with the limited access which results in a low adoption by health professionals who still prefer mostly use paper-and-pencil interventions [33].

In general, existing ecologically-valid VR-based environments are simulations of cities [2934,35,36,37,38], kitchens [39,40,41,42,43,44,45], streets [46,47,48,49,50,51], supermarkets [52,53,54,55,56], malls and other shopping scenarios [57,58,59,60,61]. Of these, only rare cases take into account training personalization according to patient cognitive profile and session-to-session adaptation [29363841]. Additionally, the results of studies comparing VR cognitive interventions with standard occupational therapy or neuropsychology cognitive paper-and-pencil training are fundamentally subjective as control interventions. OT does not consider cognition as the main training focus, and neuropsychology paper-and-pencil training tasks are too similar to the cognitive assessment scales; additionally, both approaches do not incorporate personalization and dynamic adaptation to performance. Hence, even if rehabilitation sessions last the same, these interventions are not equivalent as they are delivered with uncontrolled difficulty levels and cognitive demands. Personalized rehabilitation is defined as involving an assessment of each patient’s impairments and performing a tailored intervention to his cognitive profile in the different domains. Instead, adaptation deals with the dynamic adjustment of the tasks’ cognitive demands according to the patients’ performance along the intervention sessions, therefore avoiding boredom (tasks that are to easy to solve) or frustration (tasks that are too difficult to solve).

Here we try to address some of the existing limitations in the validation of VR-based cognitive rehabilitation tools. In this study we compared two task content equivalent rehabilitation tools developed under the same personalization and adaptation framework [23]: the TG and the Reh@City v2.0. This framework allows us to make sure that both tools deliver the same controlled adaptation and personalization of difficulty levels, and address the same cognitive demands. Hence, this comparison allows identifying the specific impact of increasing ecological validity of training through VR simulations of ADLs over the same training delivered through clinically accepted paper-and-pencil equivalent tasks. These findings will further inform on the specific benefits of ecologically valid environments delivered though VR and encourage the adoption of these technologies by health professionals.[…]


Fig. 3
Fig. 3 Reh@City v2.0 task examples: a buying food in the supermarket; b making payments at the bank ATM; c playing a cards game at the park and; d setting the table at home

, , , , ,

Leave a comment

[ARTICLE] Psychological and Physiological Responses in Patients with Generalized Anxiety Disorder: The Use of Acute Exercise and Virtual Reality Environment – Full Text


Virtual exercise therapy is considered a useful method by which to encourage patients with generalized anxiety disorder (GAD) to engage in aerobic exercise in order to reduce stress. This study was intended to explore the psychological and physiological responses of patients with GAD after cycling in a virtual environment containing natural images. Seventy-seven participants with GAD were recruited in the present study and randomly assigned to a virtual nature (VN) or a virtual abstract painting (VAP) group. Their electroencephalogram alpha activity, perceived stress, and levels of restorative quality and satisfaction were assessed at baseline and after an acute bout of 20 min of moderate-intensity aerobic exercise. The results showed that both the VN and VAP groups showed significantly higher alpha activity post-exercise as compared to pre-exercise. The VN group relative to the VAP group exhibited higher levels of stress-relief, restorative quality, and personal satisfaction. These findings imply that a virtual exercise environment is an effective way to induce a relaxing effect in patients with GAD. However, they exhibited more positive psychological responses when exercising in such an environment with natural landscapes.

1. Introduction

Generalized anxiety disorder (GAD) is one of the most common mental disorders. It is characterized by persistent, invasive, excessive problems that make daily life difficult [1,2]. Patients with GAD have pre-existing anxiety, nervous reactions (e.g., anxiety, tremors, and headaches) or worry about many events or activities, which will result in their feeling highly stressed and finding it difficult to relax [3,4]. Accordingly, GAD reduces their quality of life and interpersonal relationships owing to the negative effects of stress [5]. If patients with GAD are not properly treated with effective stress-relief strategies, they will succumb to depression or panic disorder in the long run.

Virtual environment (VE) technology has the potential to provide people with a high degree of immersion and presence, which may make individuals with high stress loads feel that they have escaped from the actual surrounding environment [6]. The Cave VE surrounds users by projecting stereoscopic images on a large screen, thereby providing them with a highly immersive experience. In particular, the Cave projection-based VE system allows users to interact with the environment, which in turn allows those who are exercising indoors to feel as if they are exercising in an outdoor environment (e.g., with forest and grass) [7]. Such an isolated environment is thus considered to be a useful tool for promoting indoor and outdoor physical activities (e.g., [7,8]). The characteristics of this virtual reality are important for patients with GAD [9,10] since they are afraid of coming into contact with people. VE can immerse them in a pleasant situation in which to engage in exercise without having to engage with others [11,12].

An important challenge while using Cave VE in improving the quality of life of patients with GAD is to select a suitable virtual scenario, ensure that it has a relaxing effect, and is able to facilitate their engaging in exercise. Stress reduction theory is an important framework explaining why contact with nature might foster stress reduction [13,14] through a relaxing effect on the parasympathetic nervous system [15,16]. This theory argues that stress occurs when individuals encounter events or situations that are perceived to be unfavorable, threatening, or challenging to them [16]. The natural environment has been proposed to facilitate recovery from physiological stress [13,14,17]. Contact with natural places will produce a relatively fast (within minutes) affective reaction at a subconscious level that can be measured through physiological pathways [14,16,18] where exposure to natural settings initiates an innate, rapid, affect-driven process that reduces physiological and psychological stress [16,17]. Thompson et al. (2011) [19] compared the physical and mental health of individuals who participated in physical activities in natural outdoor environments with those engaging in physical activity indoors. They found that exercising in natural environments was associated with more feelings of revitalization and positive engagement, thus lessening tension and depression more than exercising indoors.

Individuals can perform physical activities (e.g., walking, running, riding a bicycle) in simulated landscapes such as forests, parks, woods, and rivers produced by machines, where they can feel immersed in the natural environment through a VE [7,20,21]. Similar to exercising in a natural environment, individuals exercising in simulated virtual natural environments may not only obtain benefits related to their physical health [7], but also may obtain benefits including reducing perceived stress and obtaining restorative effects [22]. Previous studies have reported that cycling in a virtual natural environment can meet individual’s needs for exercise and stress relief, in cases where they are satisfied with exercise in such an environment [16,23]. However, user’s perceptions of value have a critical impact on future behavior [24]. The value perspective argues that providing users with higher value (i.e., reducing stress and perceived recovery) is a key to obtaining higher levels of satisfaction [25,26]. Indeed, provision of a virtual exercise environment is not the only function of such devices; they also provide a sensory experience, with the former referring to the ability to promote engaging in physical activity and the latter referring to the extent to which they feel positive psychological effects during exercise.

At present, many indoor exercisers use a simple static environment, but such a scenario makes users feel bored [27]. The advantages of the virtual environment are that it could create a more attractive indoor exercise environment. Therefore, the present study uses virtual abstract painting (VAP) as an alternative approach to compare the psychological and physiological responses induced by a virtual nature environment. Abstract painting is one of the main categories of visual art. While observing the natural environment can promote relaxation [14,16], observing fine art can also lead to pleasant feelings [28]. The advantage of abstract paintings is that they lack objective visual content, thus allowing participants to interpret the images according to their own preferences [29]. Accordingly, when exercising in this environment, individuals will not exert excessive amounts of attention and can feel good without being bored at the same time.

To understand an individual’s current psychological response state, it is possible to measure changes in the reflex potential produced by the activity of nerve cells in the brain [30]. It is known that alpha waves are related to a relaxed state [30,31]; however, when mental stress or workload is reduced, alpha waves increase [32]. Indeed, Hassan et al. (2018) [31] found that participants observing photos of natural landscapes experiences enhanced brain electrical activity in the form of alpha waves.

To the best of our knowledge, no research has yet been conducted on the potential effects of exercise in a virtual environment with various types of environmental stimuli on psychological and physiological responses in patients with GAD. As virtual reality exercises become more and more popular [20,33] and VE is considered to be a useful tool for promoting exercise and physical health in patients with GAD (e.g., [7]), it is important to understand the psychophysiological responses of patients with GAD (e.g., levels of relaxation, perceived stress, restorative effects, and satisfaction) while exercising in a VE [34,35] since they are important factors related to their subsequent usage [24]. Although a previous study has reported that exercising in a natural environment may benefit physiological and psychological health [22], outdoor exercise and indoor virtual exercise seem to induce different psychological benefits, with greater energy being experienced while exercising outside whereas more relaxation and less tension is felt while exercising inside with virtual reality environment [36]. Valtchanov et al. (2010) [37] also suggested that immersion in virtual nature environments could produce similar beneficial effects on restorative quality and stress relief as exposure to surrogate nature. Importantly, GAD is a psychiatric disorder characterized by fear and avoidance of most social situations and interpersonal relationships owing to the negative effects of stress [5,38]. Therefore, the purpose of this study was to explore the different effects of virtual reality exercises via an indoor Cave VE system comprising natural landscapes and abstract paintings on perceived stress, satisfaction, and levels of restorative effects in patients with GAD. We hypothesized that cycling in a VE would induce positive psychological responses; however, it was posited that more restorative effects and a higher degree of satisfaction could be produced by the natural landscapes compared to abstract paintings. To verify the proposed hypotheses, a randomized controlled trial was conducted.Go to:

2. Methods

2.1. Participants

The participants selected for this study were based on the following inclusion criteria: (a) an initial diagnosis of GAD based on the generalized anxiety disorder 7–item (GAD-7) scale owing to its high sensitivity and specificity to detect GAD [2,39]; (b) aged between 50 and 75 years because exercise leads to several benefits (e.g., reduced mortality rate, delayed cognitive aging, and lowered medical costs) for middle-aged and older adults [40,41,42]; (c) normal body mass index (BMI) (18.5 ≤ BMI <24 kg/m2) as defined by the Taiwan Ministry of Health according to the related morbidity data and mortality risks for Asian populations [43,44]. Exclusion criteria were that the participants had the following: (a) obsessive compulsive disorder or other anxiety disorder; (b) a mini mental state examination (MMSE) score less than 24, representing cognitive impairment; and (c) suffering from claustrophobia since the experiment was performed in a narrow, immersive surround system. Eighty-four participants were contacted, and seven participants were excluded because they were diagnosed with other anxiety disorders by a physician. The study was approved by the Human Research Ethics Committee of the National Cheng Kung University (B-ER-107-150) in Taiwan. Written informed consent was obtained from all participants, in accordance with the Declaration of Helsinki.

A power analysis (G*Power was used to calculate the sample size required for conducting the survey to obtain at least a small-to-medium effect (r = 0.20), using an alpha-level of 0.05 (two-tailed) [45]. Power was set at 0.80 [46]. The results of the G*Power analysis suggested a required sample size of N = 36. Thus, the sample size (n = 77) used in this study was suitable for examining the hypotheses.

2.2. Procedures

This experiment required participants to concentrate for approximately an hour during the experiment. In order to lower potential risk and confounding factors that would interfere with physiological and psychological responses, prior to the experiment the researchers alerted the GAD patients within 24 hours by phone to avoid unwanted behaviors (e.g., staying up late, drinking caffeinated beverages, and taking medications).

Seventy-seven GAD patients diagnosed and referred to by the physician were randomly assigned to the virtual nature (VN, n = 40) or the virtual abstract painting (VAP, n = 37) group. Each participant was asked to arrive at the laboratory at about 8:30–9:30 am to control for circadian influences. When they arrived at the laboratory, the research assistant explained the experimental procedure, and the participant was asked to complete an informed consent form, a demographic questionnaire, the MMSE, the GAD-7, and perceived stress questionnaires. Their height and weight were also measured to calculate their body mass index (BMI). Then, electroencephalogram (EEG) and heart rate (HR) were measured to ascertain that there was no difference between their relaxed and emotional state before the intervention.

Both the VN and VAP groups cycled 20 min in a Cave VE (see Figure 1). The Polar optical HR sensor worn on the participant’s arm was used to monitor their HR during cycling. All participants were asked to exercise at a moderate intensity of 50-60% HRmax. in the VN group, landscapes of forests, parks, woods, and rivers generated by machine simulations were projected in the Cave and moved as the participants stepped onto the bicycle. In the VAP group, a slideshow of abstract paintings was projected in the Cave, with each painting appearing for one minute in random order. These abstract paintings were selected without special meaning for the participants. The paintings present flowing images in common colors (such as green, blue, and yellow). After the exercise intervention, they underwent an EEG exam and completed the questionnaires (see Figure 2).

An external file that holds a picture, illustration, etc.
Object name is ijerph-17-04855-g001.jpg
Figure 1
Experimental images. (a) virtual nature; (b) virtual abstract paintings (Experimental images from evening_tao | Freepik).



, , , , , , ,

Leave a comment

[BLOG POST] How my self-esteem plummeted after a brain injury.

Before my brain injury, and being a realist about my strengths and weaknesses, I was comfortable with them. I was in my early 30’s, and had just got to that point when you really know yourself. Being honest with myself meant I achieved things by playing to my strong points, and asking for support on the things I wasn’t confident in. (Sounds obvious but previously I had been too scared to admit when I was finding something hard.) Life was good, and my self-esteem was in the best place it has ever been.

Enter stage left: Brain injury shakes everything up.

By now you will have heard me talk about how my career ended following my accident. And you might have read how looking for a new job didn’t pan out well for me in Unexpected interviewing disaster for TBI survivor. All of which is bad news for anyone’s self-esteem. But maybe that’s just ego, and I’m over that (sort of).

I have a problem with ME. My consciousness, spirit, soul…. whatever you want to call it. Weirdly, I’m not even sure that I’d noticed. That is until my partner, James, said to me “What’s with all the negative self talk?” This was after days of me listing my perceived faults at any given opportunity. I left like I was just being realistic and acknowledging the facts. But actually this is a change in my “self-concept.”

What is self-concept?

This is the feeling that you’re not the person you were, cognitively or physically, wrapped up in your level of self-esteem. But I’d been through to darkest phase of wondering what was the point of surviving my accident to be left with this inferior version of me. As I knew what that felt like, and how all-consuming it is to question your own existence, I had been brushing under the carpet what I was now feeling.

It appears to me that this can keep coming in waves or cycles. First when you return home and start to see how you can’t go back to life as it was is the first one. But then you adjust and on some level accept what you can achieve. However  I allowed myself to be lulled into a false sense of security. Yes I’ve come a long way, and I do have a place in this world. But as my priorities had changed I’d let go of my vanity. I’d become fat and ugly. (Please don’t feel the need to write in telling me what a ‘beautiful’ woman I am. I realise that this is my inner voice being unreasonably hard on me, and I’m not attention seeking or craving compliments.) I think as my life moves forward my attention and priorities move. Thus I have become more interested again in my appearance and how the world sees me. Basically I am regretting letting myself go.

self-esteem issues following brain injury

The importance of self-care.

I thought to worry about my appearance was self-centered. When you have been faced with your own mortality and continuing health issues it seemed trivial. But that’s really not the case. I know pride is one of the seven deadly sins and as I’m an atheist you might think I’m falling into its trap. But you have to look after yourself in order to have the strength to give to others. I know I said this before in Confess to pressure: being a voice of brain injury, so I’m not going to bang that drum again. Just know that it’s something that you have to keep coming back to and maintain it.

I know that as a natural part of aging everyone has to face changes in their life. Be it our role in society or how our bodies change, no one is immune. Of course each stage means we have to adjust, and sometimes it’ll be harder than others. You don’t need to feel like you’re failing just because it’s hard. After all, it’s the biggest challenges that teach us the most.

Other articles you might like:

Do you struggle with your self-esteem following a brain injury? Have you got an advice you want to give to others?


, , , ,

Leave a comment

[Infographic] Behavioral Broblems of TBI

, ,

Leave a comment

[ARTICLE] Neurocognitive robot-assisted rehabilitation of hand function: a randomized control trial on motor recovery in subacute stroke – Full Text



Hand function is often impaired after stroke, strongly affecting the ability to perform daily activities. Upper limb robotic devices have been developed to complement rehabilitation therapy offered to persons who suffered a stroke, but they rarely focus on the training of hand sensorimotor function. The primary goal of this study was to evaluate whether robot-assisted therapy of hand function following a neurocognitive approach (i.e., combining motor training with somatosensory and cognitive tasks) produces an equivalent decrease in upper limb motor impairment compared to dose-matched conventional neurocognitive therapy, when embedded in the rehabilitation program of inpatients in the subacute stage after stroke.


A parallel-group, randomized controlled trial was conducted on subjects with subacute stroke receiving either conventional or robot-assisted neurocognitive hand therapy using a haptic device. Therapy was provided for 15, 45-min sessions over four weeks, nested within the standard therapy program. Primary outcome was the change from baseline in the upper extremity part of the Fugl-Meyer Assessment (FMA-UE) after the intervention, which was compared between groups using equivalence testing. Secondary outcome measures included upper limb motor, sensory and cognitive assessments, delivered therapy dose, as well as questionnaires on user technology acceptance.


Thirty-three participants with stroke were enrolled. 14 subjects in the robot-assisted and 13 subjects in the conventional therapy group completed the study. At the end of intervention, week 8 and week 32, the robot-assisted/conventional therapy group improved by 7.14/6.85, 7.79/7.31, and 8.64/8.08 points on the FMA-UE, respectively, establishing that motor recovery in the robot-assisted group is non-inferior to that in the control group.


Neurocognitive robot-assisted therapy of hand function allows for a non-inferior motor recovery compared to conventional dose-matched neurocognitive therapy when performed during inpatient rehabilitation in the subacute stage. This allows the early familiarization of subjects with stroke to the use of such technologies, as a first step towards minimal therapist supervision in the clinic, or directly at home after hospital discharge, to help increase the dose of hand therapy for persons with stroke.


Upper-limb robot-assisted therapy has been established as a safe and feasible treatment to complement rehabilitation after neurological injury, such as stroke [1]. Robots can precisely control the interaction with the user (e.g., supporting or resisting in an assist-as-needed manner) and render virtual environments both visually and mechanically, making them ideal tools for sensorimotor training, providing engaging and challenging therapy [23]. Over the past two decades, several robotic devices to train the proximal upper extremity [4] were developed and clinically evaluated, achieving outcomes comparable to dose-matched conventional therapy [1,2,35,6,7,8,9,10].

However, distal arm function is essential for the execution of activities of daily living (e.g., eating, dressing) and is often severely impaired after stroke [11], with low probability of regaining its full functional use [12]. Several studies have shown that functional motor training at the level of the hand with robotic devices can be beneficial and positively translate into recovery of proximal arm function [1314]. Despite recent investigations to develop novel robots to train hand function [91516], only few systems took advantage of the haptic rendering capabilities of robots to support somatosensory training, nor evaluated this in clinical trials. As such, most systems for robot-assisted therapy developed to date focus on movement practice without incorporating an established therapy concept adapted to the capabilities of the respective technology.

In this work, the clinical equivalence of sensorimotor, robot-assisted rehabilitation of hand function is investigated within a four-week randomized controlled trial (RCT) on subacute stroke participants. The neurocognitive rehabilitation method proposed by Perfetti [17] was selected as reference therapy approach. It focuses on the training of sensorimotor functions as well as cognition, which is fundamental during functional interactions between body and environment (e.g., information perception, as well as elaboration, selection and execution of motor plans) [18,19,20]. Because of the relevance of the cognitive processing of sensory inputs, this approach is particularly interesting for hand rehabilitation. Moreover, the integration of multisensory inputs promotes the involvement of associative cortices that play a key role in learning and consequently in neuronal plasticity and recovery [21]. While only a few studies compared neurocognitive therapy to other rehabilitative approaches [1822], some promising work suggested that it can significantly improve upper-limb function, ability to perform activities of daily living and quality of life compared to conventional task-oriented training [22]. Consequently, this approach has recently found increasing interest in the scientific community, applied both in conventional [23,24,25] and in technology-assisted therapy [2627], but has so far not been evaluated in the context of a robot-assisted RCT. The therapy concept inspired by the neurocognitive approach was implemented on a high-fidelity 2 degrees of freedom end-effector haptic device to train hand function (i.e., the ReHapticKnob [28]). The therapy exercises focused on grasping and pronosupination (e.g., tactile discrimination tasks, teach and reproduce tasks, haptic exploration tasks, [29]) and were performed using virtual objects rendered both visually and haptically by the robot, mimicking the physical objects used in conventional therapy. The primary objective of this RCT was to investigate if the implemented robot-assisted hand therapy concept could be integrated into the rehabilitation program of participants with subacute stroke during their inpatient stay (i.e., replace one conventional neurocognitive therapy session on each intervention day) and if, at precisely matched dose, an equivalent reduction in upper limb motor impairment could be achieved. This study design was motivated by the need to establish non-inferiority in terms of rehabilitation outcomes when comparing the proposed intervention to conventional neurocognitive therapy. This is an important first step towards the investigation of more specific robot-assisted protocols that could further take advantage of the abilities of the robotic device, such as increasing dose through semi-supervised therapy. As secondary objectives, we hypothesized that neurocognitive robot-assisted therapy of the hand would lead to improvements in motor, sensory and cognitive functions in participants with subacute stroke.


Trial design

A single center, parallel group, randomized control trial was conducted at the Clinica Hildebrand Centro di Riabilitazione Brissago, Switzerland. Study participants were recruited among inpatients undergoing an intensive interdisciplinary rehabilitation therapy program post-stroke. After screening for eligibility by a medical doctor, participants were randomly assigned (by balanced pre-randomization [1:1]) to a robot-assisted group (RG), receiving robot-assisted neurocognitive therapy with the ReHapticKnob (see Fig. 1) haptic device, or to a control group (CG), receiving dose-matched conventional neurocognitive therapy without the robot. On 15 days distributed over 4 weeks, all subjects received three neurocognitive therapy sessions (i.e., 2 × 45 min and 1 × 30 min) per day focusing on hand function (see Fig. 2). In the RG, one of the 45 min therapy sessions per day was substituted with robot-assisted therapy. Based on ethical grounds, only one session of upper limb therapy per day was replaced to guarantee that all patients could still get access to the standard treatment for subacute inpatients. These sessions were embedded in the weekly therapy plan of each individual participant. The study protocol was reviewed and approved by the local Ethics Committee (EC 2646) and Swissmedic (2013-MD-0002) prior to participant recruitment. Simultaneously, the study was registered on the (non-public) European register EUDAMED and subsequently in

A subject with stroke using the ReHapticKnob. The ReHapticKnob is a haptic device used to train hand opening-closing and forearm pronosupination. The device integrates a set of 7 therapy exercises reproducing typical neurocognitive exercises [29]. In the present exercise, the compliance of different virtual sponges rendered by the device has to be memorized and identified by relying on hand somatosensory inputs during active interaction with the device



, , , , , , ,

Leave a comment

[Infographic] How Trauma Impacts Four Different Types of Memory

, , , , , ,

Leave a comment

[Guide] Apps for managing post-traumatic stress disorder (PTSD) – Full Text PDF


This guide provides a brief overview of some of the assistive technology (AT) mobile health software applications (apps) that may help manage post-traumatic stress disorder (PTSD) symptoms. It describes apps aimed at: re-experiencing symptoms, avoidance symptoms, arousal and reactivity symptoms, and cognition and mood symptoms.

Download article in Full Text 


, , , , , , , ,

1 Comment

[ARTICLE] Vocal music enhances memory and language recovery after stroke: pooled results from two RCTs – Full Text



Previous studies suggest that daily music listening can aid stroke recovery, but little is known about the stimulus‐dependent and neural mechanisms driving this effect. Building on neuroimaging evidence that vocal music engages extensive and bilateral networks in the brain, we sought to determine if it would be more effective for enhancing cognitive and language recovery and neuroplasticity than instrumental music or speech after stroke.


Using data pooled from two single‐blind randomized controlled trials in stroke patients (N = 83), we compared the effects of daily listening to self‐selected vocal music, instrumental music, and audiobooks during the first 3 poststroke months. Outcome measures comprised neuropsychological tests of verbal memory (primary outcome), language, and attention and a mood questionnaire performed at acute, 3‐month, and 6‐month stages and structural and functional MRI at acute and 6‐month stages.


Listening to vocal music enhanced verbal memory recovery more than instrumental music or audiobooks and language recovery more than audiobooks, especially in aphasic patients. Voxel‐based morphometry and resting‐state and task‐based fMRI results showed that vocal music listening selectively increased gray matter volume in left temporal areas and functional connectivity in the default mode network.


Vocal music listening is an effective and easily applicable tool to support cognitive recovery after stroke as well as to enhance early language recovery in aphasia. The rehabilitative effects of vocal music are driven by both structural and functional plasticity changes in temporoparietal networks crucial for emotional processing, language, and memory.


During the last decade, there has been growing interest toward music as a neurorehabilitation tool, especially for stroke.1 This has been fueled by (1) the rapidly increasing prevalence of stroke and its massive socioeconomic burden and growing need for cost‐effective rehabilitation tools2 and (2) advances in music neuroscience, uncovering the wide‐spread cortical and subcortical networks underlying the auditory, motor, cognitive, and emotional processing of music34 and their malleability by musical training.5 In the rehabilitation context, music can be viewed as a form of environmental enrichment (EE) that increases activity‐dependent neuroplasticity in the large‐scale brain network it stimulates.6 In animals, EE is a powerful driver of synaptic plasticity, neurotrophin production, and neurogenesis, improving also cognitive‐motor recovery.7 In stroke patients, EE where patients are provided additional social interaction and stimulating activities (e.g., games) is emerging as a promising way to increase physical, social, and cognitive activity.8

Previously, we explored the long‐term efficacy of musical EE in a three‐arm randomized controlled trial (RCT) comparing daily music listening to a control intervention (audiobook listening) and standard care (SC) in stroke patients. Music listening enhanced the recovery of verbal memory and attention and reduced negative mood9 as well as increased gray matter volume (GMV) in spared prefrontal and limbic areas in left hemisphere‐lesioned patients.10 Corroborating results were recently obtained in another RCT where daily music listening, alone or in combination with mindfulness training, enhanced verbal memory and attention more than audiobooks.11 While these results imply that music listening can be cognitively, emotionally, and neurally effective after stroke, its tailored, more optimized use in stroke rehabilitation requires determining which components of music are specifically driving these effects and which patients benefit most from it.

The vocal (sung) component of music could be one key factor contributing to its rehabilitative efficacy. Singing is one of the oldest forms of human communication, a likely precursor to language evolution.12 Songs represent an important interface between speech and music, binding lyrics and melody into a unified representation and engaging linguistic and vocal‐motor brain processes in addition to the auditory, cognitive, and emotional processing associated with instrumental music. fMRI evidence indicates that listening to sung music activates temporal, frontal, and limbic areas more bilaterally and extensively than listening to speech1314 or instrumental music,1516 also in the early poststroke stage.17 After unilateral stroke, spared brain regions in both ipsi‐ and contralesional hemisphere undergo spontaneous neuroplasticity changes and steer the recovery of behavioral functions, including speech.18 In this regard, the large‐scale bilateral activation induced by vocal music could make it more effective than speech or instrumental music that engage primarily the left or right hemisphere, respectively.19

Vocal music is particularly interesting in the domain of aphasia rehabilitation. In nonfluent aphasia, the ability to retain the ability to produce words through singing is often preserved, and aphasic patients are also able to learn new verbal material when utilizing a sung auditory model.20 Singing‐based speech training interventions, such as melodic intonation therapy (MIT), have been found effective in enhancing the production of trained speech content and the recovery of verbal communication in aphasia, especially when provided at the subacute poststroke stage.2122 Whether regular listening to vocal music could have long‐term positive effects on early language recovery in aphasia is currently unknown.

In the present study, we use data pooled from two RCTs (N = 83), including our previous trial910 (N = 38) and a new, previously unpublished trial (N = 45), to (1) determine the contribution of sung lyrics on the cognitive, linguistic, and emotional efficacy of music by comparing daily listening to vocal music, instrumental music, and audiobooks and (2) uncover the structural neuroplasticity (GMV) and functional connectivity (FC) changes underlying them. We hypothesized that (i) vocal music would be superior to instrumental music and audiobooks in enhancing cognitive and language recovery, (ii) both vocal and instrumental music would enhance mood more than audiobooks, and (iii) the rehabilitative effects of vocal music would be linked to GMV changes in temporal, frontal, and parietal regions associated with the processing of language, music, and memory1317 and commonly induced by musical training5 as well as increased resting‐state functional connectivity (FC), particularly in the default mode network (DMN),23 which has recently been linked to stroke recovery.2425 Moreover, given previous evidence on singing‐based speech rehabilitation in aphasia,2122 we (3) explore whether listening to vocal music can be effective for aphasia recovery.[…]

Continue —->

Figure 3. Pooled voxel‐based morphometry (VBM) results from the Helsinki and Turku studies (N = 75). Panel A: Lesion overlay maps of the three groups. Panels: B‐D: Significant group differences in VBM from acute (T0) to 6‐month (T2) stage in (B) gray matter volume (GMV) across all patients, (C) GMV within aphasic patients, and (D) white matter volume (WMV) within aphasic patients. Data reported in the histograms are mean ± SEM. Correlations to change in language/verbal memory are shown with scatter plots. Results are at P < 0.005 (uncorrected) and only clusters surviving a FWE‐corrected P < 0.05 threshold are shown and labeled. ABG = Audiobook group, IMG = Instrumental music group, T0 = baseline (acute), T1 = 3‐month stage, T2 = 6‐month stage, VMG = Vocal music group. Anatomical abbreviations: CUN = cuneus, ITG = inferior temporal gyrus, LG = lingual gyrus, MOG = middle occipital gyrus, MTG = middle temporal gyrus, STG = superior temporal gyrus.

, , , , ,

Leave a comment

[BLOG POST] How to Improve Short-Term Memory After Brain Injury: 9 Simple Tricks

woman standing in front of purple background with a thinking face to symbolize memory problems after brain injury

Wondering how to improve short-term memory after brain injury? You’ve come to the right place.

In today’s article, we’re showing you 9 unconventional techniques that can help you boost your short-term memory skills. You’ll also learn some healthy habits to cultivate to improve your memory in general.

Let’s get started.

Understanding Short-Term Memory After Brain Injury

One of the most common memory problem after TBI is short-term memory loss. But what is it exactly?

Long-term memory is the type of memory that allows you to store information for an extended period. Short-term memory, on the other hand, refers to a person’s ability to hold information for about 30 seconds.

While 30 seconds might not sound like much time, short-term memory is the reason most people can:

  • Understand sentences, both written and spoken
  • Recall small sequences of numbers, like telephone numbers
  • Remember what’s on their grocery list

Essentially, short-term memory allows you to learn new things and interact with the world. This can explain why behavior changes after TBI are quite common.

For example, TBI patients with short-term memory loss might forget important details of a conversation, lose track of time and feel unsure of what day it is, or be unable to retrace a route they took earlier that day.

A person with severe short-term memory problems also could not follow a conversation, because they would forget what the person speaking to them just said.

Causes of Short-Term Memory Loss After Brain Injury

Several brain regions help process and encode memories, and damage to any of these areas can cause short-term memory loss. Some of the main areas of the brain involved in memory include the:

Even if a brain injury does not directly damage these areas, research has shown that prolonged levels of stress can shrink the hippocampus. This helps explain why even mild traumatic brain injury survivors can experience memory loss.

It’s also important to note that short-term memory loss is different from confabulation, a condition where a person creates false or inaccurate memories without the intent to deceive. If you’re concerned about the possibility of confabulation in a loved one the suffered a brain injury, talk to their doctor for a diagnosis.

Cognitive Tricks to Improve Short-Term Memory After Brain Injury

Now that you understand what short-term memory is and how brain injury can affect it, it’s time to learn how to improve your memory.

The following are some unconventional ways to stimulate your brain and boost your short-term memory after TBI:

1. Use Association

One of the best ways to improve your short-term memory after brain injury is to use association.

In fact, that’s the way most people learn things. For example, if you ever took piano lessons, you can probably still remember the notes of the musical scale by remembering the phrase “Every Good Boy Does Fine.”

You might already know this as a mnemonic, and it works by using the first letter of a word to remind you of a different word.

Therefore, next time you want to remember something important, try linking it to something else, like a word that rhymes.

While that may sound too simple, making odd connections like that is actually the natural way your brain remembers things.

2. Use Vivid Images

brain injury patient sitting in a chair surrounded by colorful paint to symbolize vivid imagery

Not all association has to be mnemonic. Those aren’t always very helpful when you want to remember things like appointments.

But according to researchers on memory, association can still help you if you connect a fact with something concrete and vivid.

For example, if you need to remember that your doctor’s appointment is at 4 P.M, here are some tricks you can use:

  • Remember that the car you will drive to the doctor’s office has four wheels, which is what time you need to be there.
  • Shorten doctor to the word “doc” which rhymes with dog, which has four legs, etc…
  • Imagine your dog is driving your car, which has four wheels.

These examples are absurd, but that’s the point. The crazier the image, the easier it will be for your brain to remember it.

These kinds of associations can be hard to do at first, but as you practice, they will become second nature.

3. Space Your Repetition

Repetition is the secret to learning almost anything. However, you can’t simply repeat something a few times and expect to remember it.

Instead, you must space out your repetition so you can reinforce what you want to remember right when you’re about to forget.

One way to do this is to create some flashcards with whatever information you’re trying to learn. If you remember the info, wait ten minutes, and then quiz yourself. If you get it right again, wait 40 minutes, then 60 etc…

The point is to keep challenging yourself.

This is similar to regaining the ability to walk after brain injury. Repeating the movement reinforces neural pathways in the brain until the action is fully encoded.

This means the more you rehearse a memory, the easier it will be to recall.

4. Listen to Music

tbi patient wearing headphones and listening to music to improve short-term memory after tbi

Music therapy has many cognitive benefits for brain injury patients, but perhaps the most powerful benefit is how listening to music boosts memory.

Not only does music help brain injury patients recover old memories, it even helps people retain new information.

So, if you want to remember something important, try singing it to the tune of your favorite song. You’ll be surprised how much more you’ll be able to memorize.

5. Write it Down

Writing down things you want to remember is usually used as a compensatory practice. You look at what you wrote to make sure you don’t forget it.

But it turns out that the act of writing something on paper also forces your brain to focus more, which in turn improves memory.

That’s why writing notes is more effective for learning than typing on a laptop.

Healthy Habits to Improve Memory After Brain Injury

If you want to permanently improve short-term memory after brain injury, you must do more than use a few mental tricks.

You’ll also need to cultivate healthy habits that promote good memory.

Here are just a few lifestyle changes you can make to improve your short-term memory.

6. Rest

woman sleeping in bed with eye mask on for deep rest

Most memory problems after brain injury are caused by an overstressed brain. If the brain gets too tired, it can’t devote any energy to paying attention, which means it won’t be able to store any memories.

That’s why rest is so important after a brain injury. Rest gives your brain the energy to retain information.

Studies have also shown that sleep is the time when your brain consolidates memories. In other words, during sleep, short-term memories stick and become long-term memories, according to researchers at Beth Israel Deaconess Medical Center.

Therefore, make sure you get enough rest throughout the day. If you have trouble staying asleep at night, talk to your doctor about taking melatonin supplements.

7. Try Meditation

Meditation can reduce stress on your brain, which will help it hold on to more memories.

In fact, research shows that mindfulness meditation practice improves executive function, working memory, and attention skills.

Since attention and concentration are key to memorization, this means meditation can improve your memory abilities.

Meditating is hard work at first, but after enough practice, you’ll find it much easier to pay attention for longer periods, and you’ll start seeing improvements in your memory.

8. Exercise

woman walking through the park during autumn

Regular, non-strenuous exercise is one of the best activities you can do to improve short-term memory after brain injury.

According to several studies, aerobic exercise actually stimulates the growth of new brain cells and improves memory and cognition. It also increases cerebral blood flow, which brings more oxygen to the brain structures in charge of memory.

That’s why it’s so important to stay active every day, if possible. If you can’t visit your physical therapist more than once or twice a week, you can still take part in recreational therapy activities.

There are even home therapy devices such as FitMi that help keep you moving every day, even if you have severe physical limitations.

9. Eat Memory-Boosting Foods

Finally, to improve short-term memory, you must give your brain the fuel it needs to function. This means improving your brain injury recovery diet.

Start by focusing on what not to eat. Specifically, try to avoid eating foods high in trans fats and processed sugar, since these foods cause the liver to produce fats that are damaging to the brain.

Instead, try to consume foods that are known to help with TBI recovery. Specifically, focus on consuming foods high in antioxidants and omega-3s. These foods have been linked to better overall brain function, including memory.

Improving Memory After Brain Injury is Possible

How the brain stores memory is a fascinating process. Hopefully, these tricks have shown you how to make the most of this process.

You might also want to try some cognitive training apps to help boost your memory. These can give you the practice you need to restore your memory.

With enough practice and with healthy living habits, you should begin to see an improvement in your short-term memory. Good luck!


, , , , , ,

Leave a comment

[Absttract + References] Psychiatric Disorders After Traumatic Brain Injury: A Nationwide Population-Based Cohort Study and the Effects of Rehabilitation Therapies – Archives of PMR



To investigate the risk of psychiatric disorders after traumatic brain injury (TBI), and to clarify whether the post-TBI rehabilitation was associated with a lower risk of developing psychiatric disorders.


A register-based, retrospective cohort design.


Using data from the National Health Insurance Research Database of Taiwan, we established an exposed cohort with TBI and a nonexposed group without TBI matched by age and year of diagnosis between 2000 and 2015.


This study included 231,894 patients with TBI and 695,682 patients without TBI (N=927,576).


Rehabilitation therapies in TBI patients.

Main Outcome Measures

A multivariable Cox proportional hazards regression model was used to compare the risk of developing psychiatric disorders.


The incidence rate of psychiatric disorders was higher in the TBI group than the control group. Compared with the control group, the risk of psychiatric disorders in the TBI group was twofold (hazard ratio [HR]=2.072; 95% confidence interval [95% CI], 1.955-2.189; P<.001). Among the participants with TBI, 49,270 (21.25%) had received rehabilitation therapy and had a lower risk of psychiatric disorders (HR=0.691; 95% CI, 0.679-0.703; P<.001). In the subgroup analysis, the medium- to high-level intensity rehabilitation therapy was associated with lower risks of psychiatric disorder (HR=0.712 and 0.568, respectively), but there was no significant finding in the low-intensity group.


We found that TBI was associated with a high risk for developing psychiatric disorders, and that the post-TBI rehabilitation significantly reduced the risk of psychiatric disorders in a dose-dependent manner.


    • Lee Y.K.
    • Hou S.W.
    • Lee C.C.
    • Hsu C.Y.
    • Huang Y.S.
    • Su Y.C.
    Increased risk of dementia in patients with mild traumatic brain injury: a nationwide cohort study.PLoS One. 2013; 8 (e62422)View in Article 
    • Fann J.R.
    • Ribe A.R.
    • Pedersen H.S.
    • et al.
    Long-term risk of dementia among people with traumatic brain injury in Denmark: a population-based observational cohort study.Lancet Psychiatry. 2018; 5: 424-431View in Article 
    • Wang H.K.
    • Lin S.H.
    • Sung P.S.
    • et al.
    Population based study on patients with traumatic brain injury suggests increased risk of dementia.J Neurol Neurosurg Psychiatry. 2012; 83: 1080-1085View in Article 
    • Ho C.H.
    • Hsieh K.Y.
    • Liang F.W.
    • et al.
    Pre-existing hyperlipidaemia increased the risk of new-onset anxiety disorders after traumatic brain injury: a 14-year population-based study.BMJ Open. 2014; 4e005269View in Article 
    • Tsai M.C.
    • Tsai K.J.
    • Wang H.K.
    • et al.
    Mood disorders after traumatic brain injury in adolescents and young adults: a nationwide population-based cohort study.J Pediatr. 2014; 164: 136-141View in Article 
    • Seel R.T.
    • Kreutzer J.S.
    • Rosenthal M.
    • Hammond F.M.
    • Corrigan J.D.
    • Black K.
    Depression after traumatic brain injury: a National Institute on Disability and Rehabilitation Research Model Systems multicenter investigation.Arch Phys Med Rehabil. 2003; 84: 177-184View in Article 
    • Osborn A.J.
    • Mathias J.L.
    • Fairweather-Schmidt A.K.
    • Anstey K.J.
    Traumatic brain injury and depression in a community-based sample: a cohort study across the adult life span.J Head Trauma Rehabil. 2018; 33: 62-72View in Article 
    • Huang M.F.
    • Su C.H.
    • Tu H.P.
    • et al.
    Association between bipolar disorder and subsequent traumatic brain injury in patients who received inpatient treatment.Psychiatry Res. 2018; 261: 517-521View in Article 
    • Bayley P.J.
    • Kong J.Y.
    • Helmer D.A.
    • et al.
    • MIND Study Group
    Challenges to be overcome using population-based sampling methods to recruit veterans for a study of post-traumatic stress disorder and traumatic brain injury.BMC Med Res Methodol. 2014; 14: 48View in Article 
    • Molloy C.
    • Conroy R.M.
    • Cotter D.R.
    • Cannon M.
    Is traumatic brain injury a risk factor for schizophrenia? A meta-analysis of case-controlled population-based studies.Schizophr Bull. 2011; 37: 1104-1110View in Article 
    • Mainio A.
    • Kyllonen T.
    • Viilo K.
    • Hakko H.
    • Sarkioja T.
    • Rasanen P.
    Traumatic brain injury, psychiatric disorders and suicide: a population-based study of suicide victims during the years 1988-2004 in Northern Finland.Brain Inj. 2007; 21: 851-855View in Article 
    • Roozenbeek B.
    • Maas A.I.
    • Menon D.K.
    Changing patterns in the epidemiology of traumatic brain injury.Nat Rev Neurol. 2013; 9: 231-236View in Article 
    • Hoofien D.
    • Gilboa A.
    • Vakil E.
    • Donovick P.J.
    Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning.Brain Inj. 2001; 15: 189-209View in Article 
    • Dijkers M.P.
    Quality of life after traumatic brain injury: a review of research approaches and findings.Arch Phys Med Rehabil. 2004; 85: 21-35View in Article 
    • Bayen E.
    • Pradat-Diehl P.
    • Jourdan C.
    • et al.
    Steering Committee of the PariS-TBI study. Predictors of informal care burden 1 year after a severe traumatic brain injury: results from the PariS-TBI study.J Head Trauma Rehabil. 2013; 28: 408-418View in Article 
    • Mills A.L.
    • Kreutzer J.S.
    Theoretical applications of positive psychology to vocational rehabilitation after traumatic brain injury.J Occup Rehabil. 2016; 26: 20-31View in Article 
    • Kanchan A.
    • Singh A.R.
    • Khan N.A.
    • Jahan M.
    • Raman R.
    • Rao T.S.
    Impact of neuropsychological rehabilitation on activities of daily living and community reintegration of patients with traumatic brain injury.Indian J Psychiatry. 2018; 60: 38-48View in Article 
    • Bombardier C.H.
    • Fann J.R.
    • Ludman E.J.
    • et al.
    The relations of cognitive, behavioral, and physical activity variables to depression severity in traumatic brain injury: reanalysis of data from a randomized controlled trial.J Head Trauma Rehabil. 2017; 32: 343-353View in Article 
    • Ho Chan W.
    Taiwan’s healthcare report 2010.EPMA J. 2010; 1: 563-585View in Article 
    • National Health Insurance Research Database
    (Available at:) accessed: November 1, 2019View in Article 
    • Chien W.C.
    • Chung C.H.
    • Lin F.H.
    • et al.
    The risk of injury in adults with attention-deficit hyperactivity disorder: a nationwide, matched-cohort, population-based study in Taiwan.Res. Dev Disabil. 2017; 65: 57-73View in Article 
    • Chien W.C.
    • Chung C.H.
    • Lai C.H.
    • Chou C.H.
    A retrospective population-based study of injury types among elderly in Taiwan.Int J Inj Contr Saf Promot. 2014; 21: 3-8View in Article 
    • Chang S.Y.
    • Chien W.C.
    • Chung C.H.
    • et al.
    Risk of dementia after charcoal-burning suicide attempts: a nationwide cohort study in Taiwan.J Investig Med. 2018; 66: 1070-1082View in Article 
    • Chu C.W.
    • Chien W.C.
    • Chung C.H.
    • et al.
    Electroconvulsive therapy and risk of dementia-a nationwide cohort study in Taiwan.Front Psychiatry. 2018; 9: 397View in Article 
    • Tzeng N.S.
    • Chung C.H.
    • Lin F.H.
    • et al.
    Anti-herpetic medications and reduced risk of dementia in patients with herpes simplex virus infections-a nationwide, population-based cohort study in Taiwan.Neurotherapeutics. 2018; 15: 417-429View in Article 
    • Tzeng N.S.
    • Chung C.H.
    • Lin F.H.
    • et al.
    Risk of dementia in adults with ADHD: a nationwide, population-based cohort study in Taiwan.J Atten Disord. 2019; 23: 995-1006View in Article 
    • Hsieh C.Y.
    • Su C.C.
    • Shao S.C.
    • et al.
    Taiwan’s National Health Insurance Research Database: past and future.Clin Epidemiol. 2019; 11: 349-358View in Article 
    • Cheng C.L.
    • Kao Y.H.
    • Lin S.J.
    • Lee C.H.
    • Lai M.L.
    Validation of the National Health Insurance Research Database with ischemic stroke cases in Taiwan.Pharmacoepidemiol Drug Saf. 2011; 20: 236-242View in Article 
    • Liang J.A.
    • Sun L.M.
    • Muo C.H.
    • Sung F.C.
    • Chang S.N.
    • Kao C.H.
    The analysis of depression and subsequent cancer risk in Taiwan.Cancer Epidemiol Biomarkers Prev. 2011; 20: 473-475View in Article 
    • Baker S.P.
    • O’Neill B.
    • Haddon Jr., W.
    • Long W.B.
    The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care.J Trauma. 1974; 14: 187-196View in Article 
    • Stoner H.B.
    • Heath D.F.
    • Yates D.W.
    • Frayn K.N.
    Measuring the severity of injury.J R Soc Med. 1980; 73: 19-22View in Article 
    • Chang C.Y.
    • Chen W.L.
    • Liou Y.F.
    • et al.
    Increased risk of major depression in the three years following a femoral neck fracture–a national population-based follow-up study.PLoS One. 2014; 9e89867View in Article 
    • Needham D.M.
    • Scales D.C.
    • Laupacis A.
    • Pronovost P.J.
    A systematic review of the Charlson comorbidity index using Canadian administrative databases: a perspective on risk adjustment in critical care research.J Crit Care. 2005; 20: 12-19View in Article 
    • Fine J.P.
    • Gray R.J.
    A proportional hazards model for the subdistribution of a competing risk.J Am Stat Assoc. 1999; 94: 496-509View in Article 
    • Tzeng N.S.
    • Chung C.H.
    • Lin F.H.
    • et al.
    Headaches and risk of dementia.Am J Med Sci. 2017; 353: 197-206View in Article 
    • IBM SPSS Predictive Analytics
    IBM SPSS predictive analytics gallery.(Available at:) accessed: November 1, 2019View in Article 
    • Perry D.C.
    • Sturm V.E.
    • Peterson M.J.
    • et al.
    Association of traumatic brain injury with subsequent neurological and psychiatric disease: a meta-analysis.J Neurosurg. 2016; 124: 511-526View in Article 
    • McMillan T.M.
    • Teasdale G.M.
    • Stewart E.
    Disability in young people and adults after head injury: 12-14 year follow-up of a prospective cohort.J Neurol Neurosurg Psychiatry. 2012; 83: 1086-1091View in Article 
    • Harrison-Felix C.
    • Kolakowsky-Hayner S.A.
    • Hammond F.M.
    • et al.
    Mortality after surviving traumatic brain injury: risks based on age groups.J Head Trauma Rehabil. 2012; 27: E45-E56View in Article 
    • Bigler E.D.
    • Maxwell W.L.
    Neuropathology of mild traumatic brain injury: relationship to neuroimaging findings.Brain Imaging Behav. 2012; 6: 108-136View in Article 
    • Shiel A.
    • Burn J.P.
    • Henry D.
    • Clark J.
    • Wilson B.A.
    • Burnett M.E.
    • McLellan D.L.
    The effects of increased rehabilitation therapy after brain injury: results of a prospective controlled trial.Clin Rehabil. 2001; 15: 501-514View in Article 
    • Skandsen T.
    • Finnanger T.G.
    • Andersson S.
    • Lydersen S.
    • Brunner J.F.
    • Vik A.
    Cognitive impairment 3 months after moderate and severe traumatic brain injury: a prospective follow-up study.Arch Phys Med Rehabil. 2010; 91: 1904-1913View in Article 
    • Meares S.
    • Shores E.A.
    • Taylor A.J.
    • et al.
    Mild traumatic brain injury does not predict acute postconcussion syndrome.J Neurol Neurosurg Psychiatry. 2008; 79: 300-306View in Article 
    • Bangirana P.
    • Giordani B.
    • Kobusingye O.
    • et al.
    Patterns of traumatic brain injury and six-month neuropsychological outcomes in Uganda.BMC Neurol. 2019; 19: 18View in Article 
    • Thompson J.N.
    • Majumdar J.
    • Sheldrick R.
    • Morcos F.
    Acute neurorehabilitation versus treatment as usual.Br J Neurosurg. 2013; 27: 24-29View in Article 
    • Lee S.Y.
    • Amatya B.
    • Judson R.
    • et al.
    Clinical practice guidelines for rehabilitation in traumatic brain injury: a critical appraisal.Brain Inj. 2019; 33: 1263-1271View in Article 
    • Zhu X.
    • Poon W.
    • Chan C.C.
    • Chan S.S.
    Does intensive rehabilitation improve the functional outcome of patients with traumatic brain injury (TBI)? A randomized controlled trial.Brain Inj. 2007; 21: 681-690View in Article 
    • Sarajuuri J.M.
    • Kaipio M.-L.
    • Koskinen S.K.
    • Niemelä M.R.
    • Servo A.R.
    • Vilkki J.S.
    Outcome of a comprehensive neurorehabilitation program for patients with traumatic brain injury.Arch Phys Med Rehabil. 2005; 86: 2296-2302View in Article 
    • Königs M.
    • Beurskens E.A.
    • Snoep L.
    • Scherder E.J.
    • Oosterlaan J.
    Effects of timing and intensity of neurorehabilitation on functional outcome after traumatic brain injury: a systematic review and meta-analysis.Arch Phys Med Rehabil. 2018; 99: 1149-1159View in Article 
    • Turner-Stokes L.
    • Pick A.
    • Nair A.
    • Disler P.B.
    • Wade D.T.
    Multi-disciplinary rehabilitation for acquired brain injury in adults of working age.Cochrane Database Syst Rev. 2015; 12: CD004170View in Article 
    • Griesbach G.S.
    • Hovda D.A.
    • Molteni R.
    • Wu A.
    • Gomez-Pinilla F.
    Voluntary exercise following traumatic brain injury: brain-derived neurotrophic factor upregulation and recovery of function.Neuroscience. 2004; 125: 129-139View in Article 
    • Piao C.S.
    • Stoica B.A.
    • Wu J.
    • et al.
    Late exercise reduces neuroinflammation and cognitive dysfunction after traumatic brain injury.Neurobiol Dis. 2013; 54: 252-263View in Article 
    • Wheeler S.
    • Acord-Vira A.
    • Davis D.
    Effectiveness of interventions to improve occupational performance for people with psychosocial, behavioral, and emotional impairments after brain injury: a systematic review.Am J Occup Ther. 2016; 70: 1-9View in Article 
    • Draper K.
    • Ponsford J.
    • Schönberger M.
    Psychosocial and emotional outcomes 10 years following traumatic brain injury.J Head Trauma Rehabil. 2007; 22: 278-287View in Article 
    • Whelan-Goodinson R.
    • Ponsford J.
    • Schonberger M.
    Association between psychiatric state and outcome following traumatic brain injury.J Rehabil Med. 2008; 40: 850-857View in Article 
    • Akerlund E.
    • Esbjornsson E.
    • Sunnerhagen K.S.
    • Bjorkdahl A.
    Can computerized working memory training improve impaired working memory, cognition and psychological health?.Brain Inj. 2013; 27: 1649-1657View in Article 
    • Foreman B.P.
    • Caesar R.R.
    • Parks J.
    • et al.
    Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury.J. Trauma. 2007; 62: 946-950View in Article 


, ,

Leave a comment

%d bloggers like this: