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[ARTICLE] Leap Motion-based virtual reality training for improving motor functional recovery of upper limbs and neural reorganization in subacute stroke patients – Full Text

 

Abstract

Virtual reality is nowadays used to facilitate motor recovery in stroke patients. Most virtual reality studies have involved chronic stroke patients; however, brain plasticity remains good in acute and subacute patients. Most virtual reality systems are only applicable to the proximal upper limbs (arms) because of the limitations of their capture systems. Nevertheless, the functional recovery of an affected hand is most difficult in the case of hemiparesis rehabilitation after a stroke. The recently developed Leap Motion controller can track the fine movements of both hands and fingers. Therefore, the present study explored the effects of a Leap Motion-based virtual reality system on subacute stroke. Twenty-six subacute stroke patients were assigned to an experimental group that received virtual reality training along with conventional occupational rehabilitation, and a control group that only received conventional rehabilitation. The Wolf motor function test (WMFT) was used to assess the motor function of the affected upper limb; functional magnetic resonance imaging was used to measure the cortical activation. After four weeks of treatment, the motor functions of the affected upper limbs were significantly improved in all the patients, with the improvement in the experimental group being significantly better than in the control group. The action performance time in the WMFT significantly decreased in the experimental group. Furthermore, the activation intensity and the laterality index of the contralateral primary sensorimotor cortex increased in both the experimental and control groups. These results confirmed that Leap Motion-based virtual reality training was a promising and feasible supplementary rehabilitation intervention, could facilitate the recovery of motor functions in subacute stroke patients. The study has been registered in the Chinese Clinical Trial Registry (registration number: ChiCTR-OCH-12002238).

Introduction

Chronic conditions such as stroke are becoming more prevalent as the world’s population ages (Christensen et al., 2009). Although the number of fatalities caused by stroke has fallen in most countries, stroke is still a leading cause of acquired adult hemiparesis (Langhorne et al., 2009; Liu and Duan, 2017). Up to 85% of patients who survive a stroke experience hemiparesis, resulting in impaired movement of an arm and hand (Nakayama et al., 1994). Among them, a large proportion (46% to 95%) remain symptomatic six months after experiencing an ischemic stroke (Kong et al., 2011). The loss of upper limb function adversely affects the quality of life and impedes the normal use of other body parts. The motor function recovery of the upper limbs is more difficult than that of the lower extremities (Kwakkel et al., 1996; Nichols-Larsen et al., 2005; Día and Gutiérrez, 2013). Functional motor recovery in the affected upper extremities in patients with hemiparesis is the primary goal of physical therapists (Page et al., 2001). Evidence suggests that repetitive, task-oriented training of the paretic upper extremity is beneficial (Barreca et al., 2003; Wolf et al., 2006). Rehabilitation intervention is a critical part of the recovery and studies have reported that intensive repeated practice is likely necessary to modify the neural organization and favor the recovery of the functional upper limb motor skills of stroke survivors (Brunnstrom, 1966; Kopp et al., 1999; Taub et al., 1999; Wolf et al., 2006; Nudo, 2011). Meta-analyses of clinical trials have indicated that longer sessions of practice promote better outcomes in the case of impairments, thus improving the daily activities of people after a stroke (Nudo, 2011; Veerbeek et al., 2014; Sehatzadeh, 2015; French et al., 2016). However, the execution of these conventional rehabilitation techniques is tedious, resource-intensive, and often requires the transportation of patients to specialized facilities (Jutai and Teasell, 2003; Teasell et al., 2009).

Virtual reality training is becoming a promising technology that can promote motor recovery by providing high-intensity, repetitive, and task-orientated training with computer programs simulating three-dimensional situations in which patients play by moving their body parts (Saposnik et al., 2010, 2011; Kim et al., 2011; Laver et al., 2015; Tsoupikova et al., 2015). The gaming industry has developed a variety of virtual reality systems for both home and clinical applications (Saposnik et al., 2010; Bao et al., 2013; Orihuela-Espina et al., 2013; Gatica-Rojas and Méndez-Rebolledo, 2014). The most difficult task related to hemiparesis rehabilitation after a stroke is the functional recovery of the affected hand (Carey et al., 2002). To facilitate the functional recovery of a paretic hand along with that of the proximal upper extremity, an ideal virtual reality system should be able to track hand position and motion, which is not a feature of most existing virtual reality systems (Jang et al., 2005; Merians et al., 2009). The leap motion controller developed by Leap Motion (https://www.leapmotion.com) provides a means of capturing and tracking the fine movements of the hand and fingers, while controlling a virtual environment requiring hand-arm coordination as part of the practicing of virtual tasks (Iosa et al., 2015; Smeragliuolo et al., 2016).

Most virtual reality studies have often only involved patients who have experienced chronic stroke (Piron et al., 2003; Yavuzer et al., 2008; Saposnik et al., 2010; da Silva Cameirao et al., 2011). For patients in the chronic stage, who had missed the window of opportunity present at the acute and subacute stages (in which the brain plasticity peaks), rehabilitation-therapy-induced neuroplasticity can only be effective within a relatively narrow range (Chen et al., 2002). No motor function recovery of the hands, six months after the onset of a stroke, indicates a poor prognosis for hand function (Duncan et al., 1992).

We hypothesized that Leap Motion-based virtual reality training would facilitate motor functional recovery of the affected upper limb, as well as neural reorganization in subacute stroke patients. Functional magnetic resonance imaging (fMRI), also called blood oxygenation level-dependent fMRI (BOLD-fMRI), is widely used as a non-invasive, convenient, and economical method to examine cerebral function (Ogawa et al., 1990; Iosa et al., 2015; Yu et al., 2016). In the present study, we evaluated the brain function reorganization by fMRI, as well as the motor function recovery of the affected upper limb in patients with subacute stroke using Leap Motion-based virtual reality training.[…]

Continue —>  Leap Motion-based virtual reality training for improving motor functional recovery of upper limbs and neural reorganization in subacute stroke patients Wang Zr, Wang P, Xing L, Mei Lp, Zhao J, Zhang T – Neural Regen Res

Figure 1: Leap Motion-based virtual reality system and training games.
(A, B) Leap Motion-based virtual reality system; (C) petal-picking game; (D) piano-playing game; (E) robot-assembling game; (F) object-catching with balance board game; (G) firefly game; (H) bee-batting game.

 

 

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[Abstract] Improving Cognitive Function in Patients with Stroke: Can Computerized Training Be the Future?

Background

Cognitive impairment after stroke is common and can cause disability with a high impact on quality of life and independence. Cognitive rehabilitation is a therapeutic approach designed to improve cognitive functioning after central nervous system’s injuries. Computerized cognitive rehabilitation (CCR) uses multimedia and informatics resources to optimize cognitive compromised performances. The aim of this study is to evaluate the effects of pc cognitive training with Erica software in patients with stroke.

Methods

We studied 35 subjects (randomly divided into 2 groups), affected by either ischemic or hemorrhagic stroke, having attended from January 2013 to May 2015 the Laboratory of Robotic and Cognitive Rehabilitation of Istituto di Ricerca e Cura a Carattere Scientifico Neurolesi in Messina. Cognitive dysfunctions were investigated through a complete neuropsychological battery, administered before (T0) and after (T1) each different training.

Results

At T0, all the patients showed language and cognitive deficits, especially in attention process and memory abilities, with mood alterations. After the rehabilitation program (T1), we noted a global cognitive improvement in both groups, but a more significant increase in the scores of the different clinical scales we administered was found after CCR.

Conclusions

Our data suggest that cognitive pc training by using the Erica software may be a useful methodology to increase the post-stroke cognitive recovery.

 

via Improving Cognitive Function in Patients with Stroke: Can Computerized Training Be the Future?

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[BOOK Chapter] Biomechanics of the Upper Limb – Google Books

The BOOK —> Atlas of Orthoses and Assistive Devices E-Book – Joseph Webster, Douglas Murphy – Google Books

 Go to Chapter 11: Biomechanics of the Upper Limb

 

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[BOOK] Seidel’s Physical Examination Handbook – E-Book: An Interprofessional Approach – Google Books

Front CoverSeidel’s Physical Examination Handbook – E-BookAn Interprofessional Approach

Elsevier Health SciencesNov 30, 2017 – Medical – 336 pages

 

 

via Seidel’s Physical Examination Handbook – E-Book: An Interprofessional Approach – Jane W. Ball, Joyce E. Dains, John A. Flynn, Barry S. Solomon, Rosalyn W. Stewart – Google Books

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[ARTICLE] Dramatic Weight Loss with Levetiracetam – Full Text

Summary

Background: Levetiracetam is considered a “weight-neutral” drug. We report 19 cases of significant weight loss associated with levetiracetam at a dose ranging from 500 to 2000 mg/day.

Methods: The population was divided into two groups. Group 1 includes patients in whom levetiracetam was the only possible cause of weight loss and Group 2 those in whom other factors may have played a role. Similar cases reported by the French national drug safety center were added (Group 3).

Results: Group 1 included 9 females and 3 males (weight loss ranging from 8.1% to 28.6%). Three patients had levetiracetam in monotherapy. Prior levetiracetam only three were overweight. One patient was hospitalized for a thorough assessment of weight loss. Seven patients reported reduced caloric intake due to decreased pleasure with food. The other five did not report any changes in feeding behavior. Group 2 included seven females with a weight loss ranging from 10% to 26.6%. One patient was on topiramate since two years prior to levetiracetam. Weight loss started with the introduction of levetiracetam. In 4 patients, there was a decreased dosage or cessation of a previous drug known to produce weight gain in some cases simultaneously to the introduction of levetiracetam, but in two of these patients these drugs had not produced any weight gain. Group 3 included only two patients (weight loss: 7 and 20 kg).

Conclusions: This study provides evidence that levetiracetam can cause significant weight loss. Women are at higher risk while initial weight is not a factor.

Levetiracetam (LEV) is an antiepileptic drug with a broad clinical spectrum effective in focal epilepsy as well as in idiopathic generalized epilepsy (Grunewald, 2005Di Bonaventura et al., 2005). The majority of adverse effects are of mild to moderate severity, the most commonly reported being asthenia, somnolence, headache, and dizziness (Genton et al., 2006). Less frequent events that may also occur are anorexia, nausea, dry mouth (Biton, 2002) and behavioral and psychiatric events (Dinkelacker et al., 2003Genton et al., 2006).

LEV is considered “weight-neutral” (Gidal et al., 2003Briggs and French, 2004). However, weight loss is listed in a study comparing LEV in adult vs ageing patients (Cramer et al., 2003) and four cases of considerable weight loss have been published with LEV used in cotherapy at a dose ranging from 2000 to 3000 mg/day (Hadjikoutis et al., 2003). In the light of our recent clinical experience, we report 19 cases of weight loss associated with LEV but at lower doses and in monotherapy in three patients. These 19 patients were divided in two soubgroups, with LEV as the likely contributing factor vs cases with confounding variables.[…]

 

Continue —> Dramatic Weight Loss with Levetiracetam – Gelisse – 2007 – Epilepsia – Wiley Online Library

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[WEB SITE] 31 Strategies for Living with Traumatic Brain Injury – BrainLine

by Melissa Johnson, Bringing the Battle Home
31 Strategies for Living with Traumatic Brain Injury
Caregiver blogger, Melissa Johnson, shares 31 tips and strategies she uses to help her husband cope with his TBI in a more effective manner.

1. Use a Mobile Calendar App

I created a calendar for Sean in my iPhone and shared it with him (see brief instructions below or click here). Now I can add his appointments, meetings, and trips on my phone and he is able to access them through the app on his iPhone and iPad. In addition to time and date, I can add the location or notes for the event. The app allows me set alerts which come across both our mobile devices as notifications. I normally set alerts a day in advance and an hour in advance to allow  me time to remind him and avoid last-minute surprise. Using the calendar also helps me track his events that aren’t on my personal schedule (such as VFW meetings). I check the calendar each night and remind Sean of the next day’s schedule. It’s handy because i can manage it for him, see any items he adds himself, and view my own calendar at the same time.

Open the iPhone’s calendar app and click on “Calendars”:

Open the iPhone's calendar app and click on Calendars

Select “Edit” under iCloud Calendars:

Select Edit under iCloud Calendars

Select “Add Calendar” and follow instructions for naming calendar:

Select Add Calendar and follow instructions for naming calendar

Select “Add Person” to share the calendar:

Select Add Person to share the calendar

2. Sign up for Cozi

Visit cozi.com and sign up for their shared online calendar (I use the free version). Cozi offers shared calendars and lists that can be accessed by any family members with login information on their computers or mobile devices. You can opt to text individual mobile devices with appointments and notes automatically. I use Cozi to send Sean text messages each day reminding him to take medications and when to eat meals. I have the texts sent to my phone as well so I can verbally remind him (in case I lose track of time). There is room to add notes to each event, so messages sent can be as detailed as needed.

3. Develop a White Board Schedule

We started with a very detailed daily schedule to help Sean remember the progression of each day’s tasks. It worked well for a time, then reached a point where it overwhelmed him visually and cognitively. We now use a simpler version and combine it with text reminders for medications, meals etc. and verbal reminders.

Develop a White Board Schedule

Develop a White Board Schedule

4. Hold Daily Meetings

Choose a time of day that is structured (not over dinner, while doing homework with the kids, or while distracted with other activities) and is a typically a good time of day for focus. Sean and I chose to have our meetings each morning. This time was set aside to review the day’s activities, discuss needs, and address any military or VA issues or answer questions he had (to avoid fixating on these issues all day long—which had become a huge problem). We recorded a few notes in a notebook so he could look back at the discussion if he had questions later in the day, or needed a reminder of what we decided. Gradually, we have moved away from structured meetings since we don’t deal with the same volume of VA and military issues at the moment, and instead do a brief check in each morning to cover his schedule. I also check the calendar on Sunday night and alert him to upcoming activities and appointments for the week ahead.

5. Use a Timer

Time can be difficult to track for a person with a TBI. Setting a timer can help add structure to the day, aid in staying on task, and improve efficiency and independence. Try setting a timer to:

  • Break tasks into smaller steps
  • Allow for scheduled breaks
  • Set start or end times for activities
  • Allow transition time

6. Use Labels

TBI can make it difficult to remember where items are stored, and looking through multiple cupboards and drawers can add frustration. We use a system of labels around the house to locate key items.  After our home remodel a couple years ago, Sean found the increased number of light switches especially confusing, so I labeled those as well. You may want to label drawers, cupboard doors, bathroom cabinets, nightstand drawers, storage in the garage, etc. to fit the needs in your home.

Use Labels

It can also be confusing, and even frightening, to operate appliances or equipment. Sean struggled for months to operate the new microwave since the buttons were different. Our new flat-top stove was a particular concern as the burners have options for different sized pans, and the surface stays hot long after the burner is turned off. I printed brief instructions for each appliance, mounted on a magnetic sheet, and covered with laminating film so they can be wiped clean, if needed. We also used orange bump dots to mark the buttons he may  need to use most to make them more visible.

Laminate labels so they can be wiped clean.

Laminte labels so they can be wiped clean.

It’s easy to forget the items you need when you leave the house. I hang notes on doors (try colored Post It notes), and set necessary items on a chair next to the back door where they will be visible on the way out. I also made magnetic notes for items Sean needs each time he leaves the house.

Magnetic notes for items Sean needs each time he leaves the house.

7. Keep Things in the Same Location

When our daughter was home last summer she helped put groceries away and moved the yogurt to the opposite side of the refrigerator shelf. Sean thought we were out of yogurt for days when in fact we had plenty–just in the wrong spot. The same happens if I wash a bag of carrots and put them in a Tupperware bowl to preserve freshness. I now label that container so he knows what’s inside (the same for fresh cut fruit or vegetables) with reusable wipe-off labels.

Staying organized is a matter of establishing a habit for most of us. Many times I can’t find my wallet, keys, or phone if I put them in new locations. We have a shelf by the door for Sean’s keys and wallet. His medications for the day go on the same counter each morning. His chargers stay plugged in next to his nightstand. His hearing aids stay on top of the dresser. He has a small set of stacking drawers on his dresser for extra keys, cords, and eyeglasses. This routine aids with memory when he can’t locate an item.

8. Simplify Household Chores

Keep chores simple. We have learned that multi-step instructions or long lists of tasks overwhelm Sean’s brain and result in nothing being accomplished. To enable him to be helpful and avoid nagging we’ve come up with our own system.

Sean has a few tasks that he is in charge of completing. I can remind him with a note on the counter, but then allow plenty of time for him to complete the job independently. He is in charge of taking out the trash, feeding the dogs in the afternoon, keeping his area in the basement clean and organized, and putting away leftovers after each meal. In order to ensure he is completing chores independently, I do not step in to take over or redo what he has done. This means the trash might sit in the porch for a couple days until he remembers to pick it up and take it outside (though I remind him more frequently if it has food waste or it’s hot outside).

Sean still enjoys maintaining our home and yard, although he’s not able to do many tasks independently. He is no longer able to safely mow the lawn or shovel the snow. Since I have no desire to do either, our solution was to locate dependable people who offer those services and make it Sean’s job to call them when needed. At times it takes a day or two for him to remember to make the call, but the responsibility for doing so is solely his. He also calls to schedule car maintenance or home repair and I help him identify the person to call when necessary.

It’s important to note that changes in our routine (illness, pain, travel, company) will disrupt his routine and we will need to start over getting him back on track.

9. Create a Safe Space

Sensory overload and stress can lead to fatigue, anxiety, and anger. Having a safe space to retreat and decompress is an easy way to take time away and calm down or rest. Choose a quiet place that can be dedicated to relaxing activities. Equip this space with whatever you find comforting: TV, headphones, computer, comfortable chair, puzzles, books, etc. It is helpful to have items dedicated only to this space, with spares for other areas of the house, so this area is always prepared and ready.

When spending time at the home of relatives or friends, try to identify a safe space ahead of time. Talk to the host about the purpose of this space and ask them to help you select a location. Bring portable headphones, laptop, iPad, books, etc. in a back pack as a “mobile safe space.” Prepare ahead of time by discussing the plan and visit the safe area when you arrive.

Be aware of clues. For example, if Sean disappears with no notice I know he is taking down time and doesn’t need my support, but if he is seeking my attention, he needs me to direct him to the safe area and help him get settled in. He may need pain meds or extra support.

It may also be helpful to choose a safe word or code word that can be used during times of distress.

10. Using Tools to Aid Memory

Highlighters and Post-It notes or sticky tabs are great for marking important information in books, binders, and manuals. They are also handy if you print emails, memos, or meeting notes.

Digital recorders can be used to record meetings or classes, but can also be used to keep audio notes or reminders throughout the day. Most smart devices have digital recorders built in, so there is no need to purchase a separate device.

Lists can serve a variety of purposes. Sean is currently using a small whiteboard to track his to-do items for bike camp along with his weekly schedule. He keeps a Post-It note on the counter where he can jot down things he needs me to know (which can range from grocery items to appointments or tasks) and I can add to the calendar or to my own list. We also keep a list of his goals on the bulletin board along with a list of upcoming travel dates. The key is keeping all these lists in one location so he knows where to find them.

11. Track Health and Activity

It is important to document health changes and symptoms to identify patterns and track changes over time. Many times when doctors ask Sean how has been feeling, his answer is based on how he is feeling at the moment because he can’t recall how his mood or pain has been over the past few weeks or months since he last saw the doctor.

I make brief notes each day on Sean’s level and type of pain, if he uses additional medications, his sleep quality, nightmares, periods of confusion, etc. along with his activity levels such as riding his bike, walking his dog, or attending events and meetings. This enables us to give his providers the most accurate picture of his overall health and activity.

12. Manage Medications

Medication errors can be harmful or even fatal. Be sure to keep all medications in a safe place (we use a small safe) out of reach of children. Store medications in their original containers with pharmacy labels intact. Double check dates on labels for expiration and refill information.

Since Sean takes many daily pills, we use a pill sorter designed to hold a week’s worth of medication and divided into slots for AM, noon, and PM medications (the Velcro at the top of each box is to help him identify the AM container due to diminished vision). Occasionally, Sean gets confused and takes pills from the wrong slot at the wrong time of day, so we use a small jar with a lid to avoid confusion.

We keep an up-to-date printed list of medications in the safe, my purse, Sean’s wallet, and with emergency information.

If you receive prescriptions from the VA, you can use My HealtheVet to manage prescriptions and refills.

For more information, read this article about VA prescriptions from Family Of a Vet.

13. Find a Hobby

Keeping the mind and body active is an effective tool against depression, anxiety, and even pain. After an injury, it can be difficult to stay active and enjoy the same activities as before. Finding a hobby is one way to stay connected with others and constructively deal with stress and tension.

Exploring different hobbies can open your mind to new and creative endeavors. Engage local friends and family members to increase your amount of social interaction. Check your local area for hobby groups that have clubs or meetings. Take a class to learn something new.

Take time to explore alternatives and get connected with groups that offer adaptive sporting programs like Challenge Aspen Military OpportunitiesLakeshore Foundation’s Lima Foxtrot programUSABA, and Higher Ground (a few of many available to veterans). Building new skills is an excellent strategy for coping with changes in your life.

Volunteer activities can also offer a fantastic outlet and can become a hobby of sorts, too. The focus is on finding new activities to keep you active and healthy.

14. Allow More Time to Complete Activities

Cognitive deficits due to TBI can cause a variety of processing and attention difficulties. The following are key areas that can impact success when completing tasks and activities:

  • Difficulty sustaining concentration for a period of time
  • Inability to filter or combine information
  • Losing track of time
  • Fixating on one aspect of the task, unable to move forward
  • Inability to make decisions, or making quick decisions which are not thought out
  • Memory and confusion issues
  • Slower processing time

It is important to allow time to think and respond, and provide prompting as necessary. Good ways to assist include:

  • Be generous with wait time.
  • Limit the number of steps.
  • Use note cards or prompts.
  • Remember building toward independence is a process.

15. Use Photo Albums to Aid in Memory

Several years ago Sean and my dad went on a fly fishing trip to Sun Valley Idaho. A few weeks later a friend asked Sean about the trip. Sean gave a blank stare and said he hadn’t been on a fishing trip. Several other times Sean has had difficulty remembering the events of trips, and the people he has met. I have put together small albums from each trip to help Sean recall these events. I have used labels to help him identify people. We look at the photos together and talk about what he did that he enjoyed. Slowly, people he has met multiple times have stuck in his memory. It’s handy when he asks questions about a trip, or about someone he’s met, to have the photos close at hand.

16. Use a Script

That might sound funny at first, but it’s incredibly helpful. I have found over the years that having scripts for the children when they are assisting Sean can make for a much smoother visit. I have included a few examples. Be sure to make note of what works in your individual situation.

Our daughter was staying with Sean and he was requesting to eat out every night. She had purchased groceries and was getting frustrated with his wanting to change her plans every night. I explained that he was probably getting hungry and making suggestions simply as a way to solve his hunger problem. I told her that as it neared dinner time she should tell him, “I’m making ____ for dinner tonight. It will be ready around 6:00.” The simple act of making him aware of what was coming next was enough to put him at ease.

When he gets anxious in public we practice using calming words such as, “We will be finished shortly.” “I understand your frustration, let’s finish up and get out of here.” “If you need to leave, just let me know.” Hearing the phrases he is used to helps him remain calm, and helps whoever is assisting him know what to do in tense situations.

When Sean is having a migraine the pain is normally compounded by confusion. He repeatedly gets out of bed, or asks what he should be doing. It is helpful to say, “You need to lay down (take a pill, use an ice pack, stay still) until you are feeling better. That’s your only job right now.” I may need to repeat it a few times, but it works much more effectively than trying to answer each question or concern he raises.

17. Manage Stress

Stress is a normal physical response to events that make you feel threatened or upset your balance in some way.  Stress can also impair cognition, processing, and memory, and prolonged stress can wreak havoc on the entire body.  It’s important to take time to restore the balance in your body and brain on a regular basis. Here are a few ways you can recover from and reduce the stress in your life.

  • Get regular exercise.
  • Eat a healthy diet.
  • Practice good sleep habits.
  • Reduce caffeine and sugar intake.
  • Avoid alcohol, cigarettes, and other drugs.
  • Take regular breaks.
  • Learn to say no.
  • Take time to connect with others.
  • Find activities that replenish your soul.

18. Stick to a Routine

Individuals with brain injury may have difficulty planning and organizing their daily tasks. It is helpful to plan out a consistent routine at home that is predictable. Get up at the same time each day. Perform hygiene tasks in the same order. Eat scheduled meals. Use checklists where necessary to help stay on track. Predictability can reduce anxiety about the unknown and consistency will increase the level of independence in the home.

19. Travel Wisely

Travel can be stressful even under the best of circumstances. Being prepared can ensure your travel plans go as smoothly as possible.

Use a specific packing list. Sean often means to pack an item, or thinks he has it when he doesn’t. Having a list to check off allows him to pack independently and be confident he has all he needs.

Bring enough medications (prescription and over-the-counter as needed). Include an extra day or two to allow a buffer should travel plans change. Be sure to include extra pain medications. Always keep medications and any critical care items in your carry-on baggage should flights be canceled or delayed

Pack a variety of comfort items and activities such as a travel pillow and blanket, books or audio books, portable electronic device loaded with music or games, headphones, and snacks. Sean packs the items he needs in his backpack whether we are flying or driving so he has them close at hand.

If you have a service dog, be sure to include treats and comfort items along with necessary care tools and plenty of food. Keep the dog’s critical items in your carry-on baggage. It’s helpful to have ADA guidelines available along with service animal guidelines from the Air Carrier Access Act (see Seat Assignments page 6) should you encounter any questions or concerns about your service animal.

If driving, be prepared to make stops along the way and allow break time.

When flying, allow enough time to comfortably get through security and to gates on time. TSA offers a service for disabled veterans that will provide assistance at the airport. Contact the TSA Cares Helpline for more information.

When you arrive at your destination, allow time to settle in before starting activities.

If you are staying in a hotel, locate nearby restaurants or choose a hotel with a restaurant onsite. Dine at off-peak hours to avoid crowds.

If using public transportation, study the routes and fares ahead of time. Have taxi fare and reliable cab company numbers on hand. If driving, know the best routes around town and the locations of your destinations.

Have a clear (but flexible) itinerary with planned breaks and meal times.

Remember that when you return home extra recovery time will be needed before starting your normal routine.

20. Prepare Simple Meals

One of Sean’s goals is to help plan and prepare meals a couple times a week. Sean received training in safe cooking techniques during his blind rehab programs and is interested in becoming more independent in the kitchen.

  • Plan the menu and shopping list. Choose meals with fewer steps to follow.
  • Store all items in one spot with a label in the cupboard and/or refrigerator.
  • Use a tray to gather ingredients at preparation time. Gather needed cooking utensils in the same fashion. Have a timer available.
  • Use recipe cards with clear steps. Follow all steps in order and use the timer to signal when it’s time for the next step.
  • Practice kitchen safety.
  • Include clean up as part of meal prep.

Store all items in one spot with a label in the cupboard and/or refrigerator.Store all items in one spot with a label in the cupboard and/or refrigerator.

You might also try make-ahead freezer meals that can be reheated by following instructions taped to the container. Convenience meals such as microwave meals, frozen dinners, or sandwiches are another easy way to share in the cooking responsibilities.

21. Prepare for Absence or Illness

Preparing to be away from home (or, gasp! sick) can be incredibly stressful. By planning ahead of time (when possible) you can make your absence easier for all parties. Pre-planning is especially valuable when absences come as a surprise.

Identify how the care recipient will:

  • get to and from appointments, meetings, and outings
  • get meals or groceries (and/or remember to prepare and eat meals)
    • stock up on microwaveable meals, canned goods, frozen foods, juices
  • remember to take medications
  • care for pets
  • stay on a sleep schedule
  • clean up

Identify people who can assist with daily tasks, or who can stop by during the day to check in.

Have a list of emergency number on hand.

Have copies of medication lists, doctors, insurance information in a central location.

Help your loved one identify what he/she can do to help you. Being helpful and providing care for you is an easy way to put anxieties to rest.

22. Emergency Information

Always carry emergency information in your wallet or purse. This information should include medical conditions, doctors’ information, current medications, and insurance information along with any emergency contact numbers.

As an added measure, you might consider a free AVBI Medical Alert Tag and ID Cardthrough American Veterans with Brain Injuries.

A new option available for purchase is My ID band which allows medical professionals to electronically access your emergency information.

Smart phone users can download an app such as ICE (In Case of Emergency) which displays emergency information on the lock screen in case you are in an accident.

23. Create an Emergency Binder

I know what to do in an emergency involving Sean. I carry his critical medical information and know his history. But what if an accident occurred and I was not the person on the scene? What if something happened to me, would he know what to do? Creating an Emergency Binder could literally save a life.

Things to include:

  • Personal Information (for each family member): name, SSN, DOB, height, weight
  • Copies of insurance cards, VA ID card, military ID
  • Allergy information
  • Names of doctors with specialties and contact information
  • Brief medical history, including any mental health conditions
  • Current medications and dosages with prescriber and pharmacy information
  • Emergency contact numbers for family members
  • Copies of legal documents such as a Durable Power of Attorney for Health Care, Living Will, and Advance Directives

If you are interested in a free, ready-made packet you can print and fill in, email me at melissa@familyofavet.com and I will send to you.

Also, be sure to post emergency numbers in a visible location and include suicide hotline numbers.

24. Use Apps

Check out these Life-Changing Mobile Apps for People with Brain Injury.

From this list Sean uses Audible, Cozi, ICE, Lumosity, PTSD Coach, Dragon Dictation, Breathe2Relax, and T2 Mood Tracker. Check them out and see what might work for your situation.

Sean also uses Brain Fit and Brain Trainer apps occasionally. He has the MyLocation app which allows a user to find their location and share with others. Sean’s is set up to send me his location if he is confused or lost.

25. Educate Family and Friends

It can be incredibly difficult for family members and friends to understand the changes that happen after injury. This is especially true when dealing with an invisible injury like TBI. It’s important to have a support system that includes loved ones, which means you may need to take an active role as educator to help them understand how the injury has impacted the immediate family, as well as the care recipient, and how they can best be of assistance.

Be prepared to have difficult conversations. Whether discussing care concerns or expressing a need for space and privacy, conversations with family members can be touchy post injury.

Have realistic expectations. Every member of the team has different abilities, skills, comfort levels, and limitations.

Be clear about who is in charge of making care decisions, and what medical information will be shared.

Share strategies that work. Encourage others to get involved in positive ways by following the model that works for you.

Make necessary adaptations for holidays and events. Discuss strategies for success in advance.

Most importantly, be sure all members are educated about the nature of the disability and expected outcomes. Share information on TBI that you find helpful. You can find tons of helpful articles and videos at BrainlineBrainline Military, and Family Of a Vet. Also check out Brain Injury Association of America and American Veterans with Brain Injuries. Visit your local county extension office, or do a quick google search, for local brain injury agencies or support groups.

26. Keep a Journal

Journaling has been shown to help reduce symptoms of anxiety and depression and improve overall feelings of self-worth. Taking time each day to jot down notes about the events of the day and how you felt throughout the day is an excellent tool to help get in touch with emotions and process feelings. By reading through previous journal entries you can identify common stressors or triggers and develop a plan for positive coping strategies when those triggers arise. Depending on your preference, a personal journal can be shared with doctors or counselors for more insight.

For those with TBI, a journal can also serve as a reference book to record events and memories. It’s easy to look back and see when something happened, or browse through entries to refresh your memory.

If paper and pencil isn’t your thing, or you’re on the go, try using a digital voice recorder to dictate your journal entries

27. Keep it Simple

Eliminate what you can. Think you can’t? Start by reviewing activities for each family member. Evaluate your choices. Why are you involved with each activity? Is this activity meaningful and necessary? Does this activity enrich our lives in long-term ways? If not, consider eliminating it. Keep in mind that the goal is to streamline your home life and relieve stress and tension from your family.

Consider your options. You won’t be the world’s worst parent if you don’t attend every single game. Talk to other parents about carpooling to activities. There are usually other parents who would be relieved by a rotating schedule. If a season-long program doesn’t fit into your schedule, check into local day camps or classes your child could attend. Choose activities where your child is adequately supervised and time is structured to gain time for yourself. Use this time to run errands, or, bring a good book and enjoy a little down time.

Don’t do things simply because you’re feeling pressured. While it may be easier to say “yes” in the moment, think about how you will feel once you are obligated. If it’s not the right choice for you say “no” and stick to it.

What can you outsource? Do you have a neighbor who can share carpooling duties to and from school? Is there a friend or family member who can take the kids off-site for playdates? Can you afford to have someone come in to clean or have groceries delivered? Check with your local VA facilities, veterans’ organizations, or churches for additional resources and services.

Be honest about your needs and limitations. Many times people want to help but don’t know how.

Utilize available services such as Occupational Therapy, Speech Therapy, Physical Therapy, or Recreation Therapy along with services through any available caregiver programs. These trained professionals have a wealth of information and resources.

Forgive yourself. No one is prepared for major life changes. It’s ok to not have all the answers or to not have your sh*t together all the time. We all struggle to get through the day at times and find it takes much longer to recover after setbacks or when new issues arise.

28. Get Plenty of Sleep

Sleep is essential to good physical and mental health. When you don’t get enough sleep memory, concentration, coordination, and mood are negatively impacted. Lack of sleep over a period of time causes your physical health to decline and can lead to increased depression and anxiety. Sean’s nightmares, night sweats, insomnia, fatigue, restless leg syndrome, sleep apnea, and chronic pain all have a negative impact on his quality and quantity of sleep (and mine!). Sleep medications help with some of the symptoms, but don’t solve the problem.

To combat sleep deprivation and allow your body as much rest as possible, establish a sleep schedule by going to be and waking at set times each day.  Take naps, if needed, early in the day. Avoid if napping disrupts nighttime sleep.

Turn off electronics. Keep the room dark and cool. Make the bedroom a quiet space, or use a white noise machine to create an audibly peaceful environment. Invest in a comfortable mattress, pillows, and bedding.

Avoid caffeine and sugar after dinner, and don’t eat large meals late in the day. Alcohol and nicotine can also be factors in quality of sleep.

Take time to unwind before bedtime. Read, meditate, or practice deep breathing exercises. Take a warm bath. Listen to soothing music. Dim the lights. This can help your body and brain get into sleep mode.

29. Encourage Independence

Independence is a critical component of recovery after TBI. While your loved one may not be able to do all their former activities to the same extent as before the injury, implementing support and modifications can maximize independence.

  • Set realistic goals and start small.
  • Create an environment for success. Have needed materials on hand in areas where they are easy to access.
  • Use checklists or verbal prompts where possible.
  • Practice safety and good judgement.
  • Give immediate, constructive feedback. Use praise and encouragement.
  • Accept that mistakes will happen and make modifications when necessary.
  • Connect with others who will encourage independence in or out of the home.

30. Use Praise and Positive Affirmations

A little praise can go a long way toward boosting a person’s mood and creating a positive pattern of behavior and interaction.

  • Remember to say, “Thank you.” Even for the small things like taking out the trash (even if it takes several days to get it done) or wiping off the table.
  • Leave little notes of appreciation around the house.
  • Share your pride in their accomplishments.
  • Keep a gratitude journal.

31. Resources

Looking for additional information on traumatic brain injury? Check out these websites:

Additional resources and reading material available on tabs at the top of this page.

Posted on BrainLine October 25, 2016

About the Author

Melissa and Sean JohnsonMelissa Johnson and her husband, Sean, were married in 1995 and raised their three children in Aberdeen, SD. Melissa taught for 15 years in Special Education and First Grade. Sean served in the US Army and was deployed three times in his 24-year career in the military. Sean was injured by a mortar blast on March 25, 2006, in Balad, Iraq. The blast resulted in a traumatic brain injury. Sean is also legally blind and struggles with post-traumatic stress disorder.

When Sean returned home in 2007, the family struggled to adjust to this “new” man in their house. Melissa eventually left her teaching job to become a full-time caregiver to her husband. She is now a certified caregiver through the VA’s Caregiver Program.

Both Melissa and Sean have been active with the Blinded Veterans Association since 2009. Sean serves as Commander of his local VFW chapter and is also the Junior Vice of the local Disabled American Veterans chapter. Melissa currently works with the Military and Veteran Caregiver Network as the Education and Training Coordinator. She serves with the Elizabeth Dole Foundation as a Caregiver Fellow. She is honored to work alongside other caregivers from across the nation to raise awareness of the issues facing our nation’s caregivers and families.

Read more from Melissa on her blog: Bringing the Battle Home

via 31 Strategies for Living with Traumatic Brain Injury | BrainLine

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[Abstract+References] The Face Tracking System for Rehabilitation Robotics Applications – Conference paper

Abstract

The paper presents the working model of the face tracking system. The proposed solution may be used as one of the parts of the rehabilitation or assistive robotic system and serve as the robotic vision subsystem or as the module controlling robotic arm. It is a low-cost design, it is based on open source hardware and software components. As a hardware base the Raspberry Pi computer was used. The machine vision software is based on Python programming language and OpenCV computer vision library.

Preview

References

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via The Face Tracking System for Rehabilitation Robotics Applications | SpringerLink

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[Abstract] Cognitive behavior therapy to treat sleep disturbance and fatigue after traumatic brain injury – CNS

OBJECTIVE: To evaluate the efficacy of adapted cognitive behavioral therapy (CBT)
for sleep disturbance and fatigue in individuals with traumatic brain injury
(TBI).
DESIGN: Parallel 2-group randomized controlled trial.
SETTING: Outpatient therapy.
PARTICIPANTS: Adults (N=24) with history of TBI and clinically significant sleep
and/or fatigue complaints were randomly allocated to an 8-session adapted CBT
intervention or a treatment as usual (TAU) condition.
INTERVENTIONS: Cognitive behavior therapy.
MAIN OUTCOME MEASURES: The primary outcome was the Pittsburgh Sleep Quality Index
(PSQI) posttreatment and at 2-month follow-up. Secondary measures included the
Insomnia Severity Index, Fatigue Severity Scale, Brief Fatigue Inventory (BFI),
Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale.
RESULTS: At follow-up, CBT recipients reported better sleep quality than those
receiving TAU (PSQI mean difference, 4.85; 95% confidence interval [CI],
2.56-7.14). Daily fatigue levels were significantly reduced in the CBT group (BFI
difference, 1.54; 95% CI, 0.66-2.42). Secondary improvements were significant for
depression. Large within-group effect sizes were evident across measures (Hedges
g=1.14-1.93), with maintenance of gains 2 months after therapy cessation.
CONCLUSIONS: Adapted CBT produced greater and sustained improvements in sleep,
daily fatigue levels, and depression compared with TAU. These pilot findings
suggest that CBT is a promising treatment for sleep disturbance and fatigue after
TBI.

via Traumatic Brain Injury Resource Guide – Research Reports – Cognitive behavior therapy to treat sleep disturbance and fatigue after traumatic brain injury

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[Abstract+References] A pilot randomized controlled trial of on-line interventions to improve sleep quality in adults after mild or moderate traumatic brain injury.

To explore feasibility and potential efficacy of on-line interventions for sleep quality following a traumatic brain injury (TBI).

A two parallel-group, randomized controlled pilot study.

Community-based.

In all, 24 participants (mean age: 35.9 ± 11.8 years) who reported experiencing sleep difficulties between 3 and 36 months after a mild or moderate TBI.

Participants were randomized to receive either a cognitive behaviour therapy or an education intervention on-line. Both interventions were self-completed for 20–30 minutes per week over a six-week period.

The Pittsburgh Sleep Quality Index assessed self-reported sleep quality with actigraphy used as an objective measure of sleep quality. The CNS Vital Signs on-line neuropsychological test assessed cognitive functioning and the Rivermead Post-concussion Symptoms and Quality of Life after Brain Injury questionnaires were completed pre and post intervention.

Both programmes demonstrated feasibility for use post TBI, with 83.3% of participants completing the interventions. The cognitive behaviour therapy group experienced significant reductions (F = 5.47, p = 0.04) in sleep disturbance (mean individual change = −4.00) in comparison to controls post intervention (mean individual change = −1.50) with a moderate effect size of 1.17. There were no significant group differences on objective sleep quality, cognitive functioning, post-concussion symptoms or quality of life.

On-line programmes designed to improve sleep are feasible for use for adults following mild-to-moderate TBI. Based on the effect size identified in this pilot study, 128 people (64 per group) would be needed to determine clinical effectiveness.

 

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via A pilot randomized controlled trial of on-line interventions to improve sleep quality in adults after mild or moderate traumatic brain injuryClinical Rehabilitation – Alice Theadom, Suzanne Barker-Collo, Kelly Jones, Margaret Dudley, Norah Vincent, Valery Feigin, 2017

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[ARTICLE] Increasing upper limb training intensity in chronic stroke using embodied virtual reality: a pilot study – Full Text

Abstract

Background

Technology-mediated neurorehabilitation is suggested to enhance training intensity and therefore functional gains. Here, we used a novel virtual reality (VR) system for task-specific upper extremity training after stroke. The system offers interactive exercises integrating motor priming techniques and embodied visuomotor feedback. In this pilot study, we examined (i) rehabilitation dose and training intensity, (ii) functional improvements, and (iii) safety and tolerance when exposed to intensive VR rehabilitation.

Methods

Ten outpatient stroke survivors with chronic (>6 months) upper extremity paresis participated in a ten-session VR-based upper limb rehabilitation program (2 sessions/week).

Results

All participants completed all sessions of the treatment. In total, they received a median of 403 min of upper limb therapy, with 290 min of effective training. Within that time, participants performed a median of 4713 goal-directed movements. Importantly, training intensity increased progressively across sessions from 13.2 to 17.3 movements per minute. Clinical measures show that despite being in the chronic phase, where recovery potential is thought to be limited, participants showed a median improvement rate of 5.3% in motor function (Fugl-Meyer Assessment for Upper Extremity; FMA-UE) post intervention compared to baseline, and of 15.4% at one-month follow-up. For three of them, this improvement was clinically significant. A significant improvement in shoulder active range of motion (AROM) was also observed at follow-up. Participants reported very low levels of pain, stress and fatigue following each session of training, indicating that the intensive VR intervention was well tolerated. No severe adverse events were reported. All participants expressed their interest in continuing the intervention at the hospital or even at home, suggesting high levels of adherence and motivation for the provided intervention.

Conclusions

This pilot study showed how a dedicated VR system could deliver high rehabilitation doses and, importantly, intensive training in chronic stroke survivors. FMA-UE and AROM results suggest that task-specific VR training may be beneficial for further functional recovery both in the chronic stage of stroke. Longitudinal studies with higher doses and sample sizes are required to confirm the therapy effectiveness.

Background

Stroke affects about 17 million people per year worldwide, with an increasing rate every year [1]. Stroke survivors often suffer from physical and mental disabilities, heavily impacting their quality of life. Five years after the first stroke, nearly 66% of patients exhibit different degrees of disability and only 34% are functionally independent in their activities of daily living [2].

Motor rehabilitation after stroke

Motor dysfunction is the most prevalent impairment, with 9 out of 10 stroke survivors suffering from some form of upper limb motor disability [3], and it is a strong predictor of poor functional recovery [4]. Thus, there is a strong need for rehabilitative approaches enhancing motor recovery for stroke patients [5]. To maximize neural, motor and functional recovery, training needs to be long-lasting, challenging, repetitive, task-specific, motivating, salient, and intensive [6]. Standard motor rehabilitation after stroke typically includes neurofacilitation techniques, task-specific training and task-oriented training [7]. Further approaches include strength training, trunk restraint, somatosensory training, constraint-induced movement therapy, bilateral arm training, coordination of reach to grasp, mirror training, action observation and neuromuscular electrical stimulation [8].

Time scheduled for therapy and its frequency are determinant factors for the outcome of motor rehabilitation [9], with a recommended initial amount of at least 45 min for a minimum of 5 days per week [10]. However, the frequency of the delivered therapy usually decreases with time, with therapy being discontinued between 3 and 6 months after the vascular accident [7]. Under these rehabilitation conditions, recovery of motor function has been observed to be strongest during the first month after stroke and to slow down during subsequent months, reaching a “plateau” by 3–6 months post stroke [1112]. Clinical evidence for motor improvement in chronic stroke [13] suggests that the “plateau” may depend not only on neurobiological factors, but may also be caused by other factors such as reduction in rehabilitation services [14].

Thus, increasing therapy dose, also in the chronic phase of the disease, might be a critical factor to achieve a positive outcome. Although several guidelines for upper limb rehabilitation have been recently issued [510], the relationship between training intensity and recovery patterns is not yet fully established. Indeed, it is not fully clear how to quantify the dose increase leading to a positive outcome. Training volume, understood as the number of repetitions, seems to be a more relevant parameter of dose than just the total time allocated for therapy [9]. An important issue is how to quantify and capture this concept in a measurable parameter. Intensity of training, understood as the number of repetitions divided by the number of minutes of active therapy, might be a fundamental factor (together with amount and frequency of therapy) to quantify training efficiency. This knowledge becomes critical in order to evaluate cost-effectiveness of new technology-mediated interventions and to select the most valuable therapy procedures at the different stages of the continuum of care for stroke survivors.

Virtual reality for motor rehabilitation

Different complementary solutions have been proposed during the last decades to help increase and maintain the rehabilitation dose in the long term, mainly through continued therapy. Virtual reality (VR) based motor rehabilitation is a relatively recent approach, showing evidence of moderate effectiveness in improving upper limb and ADL function when compared to conventional therapy [15].

Many VR setups, and often generic (i.e. not developed for rehabilitation purposes) commercial off-the-shelf computer games, are used to perform a series of exercises, where patients move in front of a console and receive mostly visual feedback about their movements [161718]. This represents a limited approach, whereby the level of immersion and potential feedback is restricted to a single sensorimotor action-perception loop: the patient moves and receives only abstract visual feedback from the screen. A rather different approach implies embodied sensorimotor feedback, where movements of the patient in the real world are reproduced as movements of an anthropomorphic avatar in the virtual environment. Under such conditions, VR allows for more elaborated sensorimotor activation, which may impact the recovery process. In particular, through sensorimotor resonance mechanisms, embodied sensorimotor feedback allows the integration of motor priming techniques and cognitive principles related to body perception and action, including mirror therapy [19] and action observation [2021], which have been shown to improve functional recovery and increase cortical activation of the ipsilesional side after stroke. This embodied technology can be achieved by using motion capture technology that interprets the patient’s movements and provides multisensory (vision, audio, touch) feedback to the user about the movement performance. Such enriched VR experiences have been demonstrated to increase patients’ motivation [22] and facilitate functional recovery by engaging appropriate neural circuits in the motor system [23].

One of the VR advantages is that it enables simulated practice of functional tasks at a higher dosage than traditional therapies [15]. Lohse and colleagues recently reviewed the duration, time and frequency scheduled for different VR and computer games interventions, but training intensity (as defined above) was no reported [24]. In general, authors reported an overall median of 570 min of VR (or computer games) therapy delivered, with duration ranging from 20 to 60 min per session, and 8 to 36 sessions [24]. Otherwise, intensity of training is rarely reported for VR training (see [25] for an exception). However, this is a critical factor to estimate cost-effectiveness of VR-based interventions.

Objectives of the study

The present study aims at investigating the feasibility of admninistering intensive training in chronic stroke patients using a dedicated VR-based system that embeds real-time 3D motion capture and embodied visual feedback to deliver functional exercises designed to train impaired motor skills of the upper limb. Our primary goal was to assess (i) rehabilitation dose and training intensity in chronic patients. Additionally, we asked (ii) whether chronic stroke survivors improve functional outcomes of the upper limb when exposed to intensive VR-based therapy, and we measured (iii) safety and tolerance to such a technology-mediated intervention. We hypothesize that intensive VR-based rehabilitation may lead to high rehabilitation doses and functional improvement in chronic stroke survivors.[…]

Fig. 1a Participant performing an upper limb exercise (Grasping) with the MindMotion ™ PRO technology; b Participant doing the Reaching exercise; c Participant doing a Fruitchamp exercise

 

Continue —>  Increasing upper limb training intensity in chronic stroke using embodied virtual reality: a pilot study | Journal of NeuroEngineering and Rehabilitation | Full Text

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