[Abstract] Provider perceptions of the assessment and rehabilitation of sexual functioning after traumatic brain injury – CNS
OBJECTIVE: To explore how health care professionals who work with individuals with TBI address issues related to the assessment and treatment of sexuality after TBI.
METHODS: A survey composed of 53 questions was developed to evaluate professional training, assessment of sexuality in individuals with TBI and attitudes towards sexuality. The sample consisted of 324 self-identified TBI health care professionals.
RESULTS: Ninety seven per cent of participants believed that sexuality should be discussed during rehabilitation; however, 36% reported talking about it. Seventy nine per cent reported that their patients have asked about sexuality after TBI, with 60% feeling calm and competent addressing the topic. The main reason for not discussing the topic was that patients do not ask for information (42%). Assessment (87%) and treatment of sexuality (82%) in individuals with TBI are considered a part of their professional responsibility.
CONCLUSION: Despite recognition of the importance of addressing the topic and the belief of it being their professional responsibility, many professionals reported lack of training. Working to increase comfort with the topic and providing comprehensive education on treating sexuality may be beneficial.
[Abstract] Quantification method of motor function recovery of fingers by using the device for home rehabilitation – IEEE Conference Publication
[Abstract] The Combined Effects of Adaptive Control and Virtual Reality on Robot-Assisted Fine Hand Motion Rehabilitation in Chronic Stroke Patients: A Case Study
Robot-assisted therapy is regarded as an effective and reliable method for the delivery of highly repetitive training that is needed to trigger neuroplasticity following a stroke. However, the lack of fully adaptive assist-as-needed control of the robotic devices and an inadequate immersive virtual environment that can promote active participation during training are obstacles hindering the achievement of better training results with fewer training sessions required. This study thus focuses on these research gaps by combining these 2 key components into a rehabilitation system, with special attention on the rehabilitation of fine hand motion skills. The effectiveness of the proposed system is tested by conducting clinical trials on a chronic stroke patient and verified through clinical evaluation methods by measuring the key kinematic features such as active range of motion (ROM), finger strength, and velocity. By comparing the pretraining and post-training results, the study demonstrates that the proposed method can further enhance the effectiveness of fine hand motion rehabilitation training by improving finger ROM, strength, and coordination.
Physical and cognitive rehabilitation is usually a challenging activity as people with any kind of deficit has to carry out tasks difficult due to their abilities damaged. Moreover, such difficulties become even harder while they have to work at home in an isolated manner. Therefore, the development of collaborative rehabilitation systems emerges as one of the best alternatives to mitigate such isolation and turn a difficult task into a challenging and stimulating one. As any other collaborative system, the need of being aware of other participants (their actions, locations, status, etc.) is paramount to achieve a proper collaborative experience. This awareness should be provided by using those feedback stimuli more appropriate according to the physical and cognitive abilities of the patients. This has led us to define an awareness interpretation for collaborative cognitive and physical systems. This has been defined by extending an existing proposal that has been already applied to the collaborative games field. Furthermore, in order to put this interpretation into practice, a case study based on an association image-writing rehabilitation pattern is presented illustrating how this cognitive rehabilitation task has been extended with collaborative features and enriched
with awareness information
This is a call to survivors of stroke and/or traumatic brain injury to consider demonstrating our newest ‘games’ innovations. We at 3DPreMotorSkill Technologies, LLC research and develop special video game-like technology for survivors.
We have completed two clinical trials with 47 survivors. No survivor was harmed in any way and we do not sell or charge anything for participating in our research.
Our ‘games’ benefit from a natural ability we all have: motor imagery. Motor imagery implies visualizing body movements. If you can ‘think’ of your impaired limb making movements, our ‘games’ present virtual, controllable limbs you can use to act out your ‘thinking.’
Our first clinical trial was published in the Journal of Rehabilitation Research and Development, JRRD Volume 51, Number 3, 2014 Pages 377–390: “Pilot study: Computer-based virtual anatomical interactivity for rehabilitation of individuals with chronic acquired brain injury.”
Our second clinical trial was reported at a conference in The Netherlands (poster sections below). Our full report is under peer review by the journal Frontiers in Human Neuroscience.
Our mission is to help survivors to help themselves by ‘playing’ our self-movement-management ‘games’, called Pre-Action Games & Exercises (PAGEs).
PAGEs are easy and fun to play. First, you see a realistic virtual limb on a computer screen. The virtual limb represents your impaired limb. You control it to make realistic physical movements. A standard computer mouse is used to point the cursor to all or part of the virtual limb and click and drag it to simulate unimpaired movements.
While controlling the virtual limb a signal is automatically sent to a wearable hand movement device (WHMD). The WHMD physically and mildly manipulates your impaired left hand. The result is mental and physical feedback to you.
A limited number of survivors (approximately five) of stroke and/or traumatic brain injury will be selected to play PAGEs games. All games are free to volunteers and will take about 30 minutes to complete, here in Tallahassee.
- be 21 years of age or older
- have a moderate to mildly impaired (hemiparetic) left hand
- have consulted your physician, therapist and family and be in sub-acute or less intense therapy
- be responsible for their own consent and transportation to and from a location within Tallahassee
- be willing to try-out for selection (approximately 15 minutes).
- All we need for the selection try-out is you and an aide, if you like. Please email interest to firstname.lastname@example.org and be sure to add “WHMD” to the “Subject:” line, so that your response is read. Send any details you wish, such as left hand impairment and date of brain injury.
Imagine being in pain, but happily distracted from your suffering by being totally immersed in floating lazily down a river or tossing fish to hungry otters that pop up out of nowhere. Such scenarios of a 360-degree world are possible via virtual reality (VR), whereby a patient sits in a chair wearing a head visor connected to a computer and holds a small wireless device in his or her hand to change direction.
“Although [VR] is very early in its inception for treating painful conditions, we are hopeful that VR will interest other research and payors,” said James Choo, MD, owner and medical director of Pain Consultants of East Tennessee, in Knoxville, which conducted two clinical studies of VR. “I think there is a lot of potential for VR, especially if you marry VR to other pain treatments that are not widely available but that we know work, such as cognitive-behavioral therapy and mindfulness meditation for lower back pain.”
However, he added that few pain psychologists are practicing in the United States, and cognitive-behavioral therapy is time-consuming. “We have never had scalable treatments that work and that can be highly disseminated,” Dr. Choo said. “With VR, if you have the right software, there is an enormous potential to disseminate that type of care to millions of people rather than just a handful of patients who have access to the one pain psychologist that might be in their region.”
Similarly, mindfulness-based instruction through VR may be plausible.
“The effects of the type of VR program that we used derive from a game,” Dr. Choo said. “It is not just a passive immersive experience of looking around at the scene. You are actually playing a game—interacting with the environment itself. Besides distracting pain, VR is fun, like playing a video game.”
Dr. Choo said the immersive experience of being in a virtual environment and simply being distracted from pain are helpful. In addition, “perhaps even the immersive experience has its own analgesic effect,” he said. “But we do not understand quite yet the neuropathways that are being affected that cause the analgesic effect. Once we do, then we will be able to better target the type of VR programs that best suit the patient and their particular pain needs.”
Ted Jones, PhD, a clinical psychologist at Pain Consultants of East Tennessee, heard a conference speaker last year refer to VR as a syringe, meaning its effect “depends on the content.” He added, “Historically, since the late 1980s, VR has been used for procedural pain—basically for burn pain and injections in an inpatient setting or a burn unit. However, the majority of pain [treated by clinicians] is outpatient pain. So we are taking what has been used for inpatient procedural pain and using it for outpatient pain.”
To date, VR treatments at the clinic have been isolated to two completed studies, using software called Cool! developed by Firsthand Technology.
“What we have found is that if you give someone doses of VR, it cuts their pain dramatically,” said Dr. Jones, who was principal investigator of both trials. “However, there is no [long-term] effect. A week later, the patient is right back where he or she started, both painwise and depression-wise and stresswise. It is similar to a person coming to a pain clinic, giving them a dose of medicine and sending them home.”
The first study, conducted in 2015 and published last year in PLOS ONE (2016;11:e0167523), consisted of 30 patients with chronic pain. Participants were asked about their pain before and after a single, five-minute session of VR conducted at the clinic.
“The study decreased pain by 55% to 60%,” Dr. Jones said. “VR is like distractionon steroids, because when your brain is in a virtual world, it is like you are there. In comparison, morphine reduces pain by only one-third.”
The second study, performed last year at the clinic, involved 10 patients with neuropathic pain. The protocol was three sessions of VR, each lasting 20 minutes and spaced one week apart.
“Pain was cut by roughly 70%, due to the longer exposure sessions and multiple treatments,” Dr. Jones said. “There was also a lingering effect. Most patients reported that their pain continued to be less for about one day on average after each session.”
‘Still Out of Reach’
However, depression, anxiety, beliefs about pain and how to cope with pain did not change over time. “In other words, VR did not provide patients any emotional or cognitive benefit,” Dr. Jones said.
Dr. Jones said a single VR unit costs between $3,000 and $4,000. Although it’s a dramatic drop from the previous $8,000 cost, “it is still out of reach for most patients,” he said. “Further, many of the units currently available have a lot of wires and require a high-end machine. You cannot take it home with you—physically or financially.”
To address these shortcomings, Pain Consultants of East Tennessee and the University of Tennessee plan on conducting a pilot study of 10 to 20 patients this fall with the portable Samsung Gear VR, which has an easy-to-use headset and some pain and relaxation applications, along with a Fitbit fitness mobile device to detect activity level and record pain.
“We will determine if daily VR home use is effective, which should be the case, based on our two previous studies,” Dr. Jones said. “Using VR at home several times a day is like being prescribed a pain reliever to be taken two or three times daily. VR has the chance to replace as-needed pain medicine at home.”
The occupational therapy department at the pain clinic is also scheduled to incorporate VR into therapy for conditions such as phantom limb pain and stroke pain. “For this application, VR acts like a mirror, so patients can see and restore movement,” Dr. Jones said.
Despite enthusiasm about VR for pain, there are several hurdles and challenges to make the modality effective in the clinical space. Besides no payors yet, “we need more in-depth studies to show its efficacy for [specific] conditions,” Dr. Choo said.
Apart from employing VR as simply a game, VR may be used as a substitute therapist in certain cases, or for biometric functioning and rehabilitation. “These are completely different programs,” Dr. Choo said. “Therefore, we have to be very specific on the types of software programs we use and the way they deliver care.”
For instance, VR could be used to help patients meditate or provide biofeedback.
“One of the key [goals] is for VR to become a scalable model,” Dr. Choo said. “The unit we are using is not portable. But in the future, we envision all VR units being extremely portable, easy to use and accessible.”
Dr. Jones added, “VR has a lot of potential. We just need to match it to the right patient at the correct setting and the right cost.”
Summary: By capturing a cell by cell view of seizures propagating through a mouse brain, researchers discovered neurons fire in a sequential pattern, regardless of how quickly the seizure occurs. The findings confirm seizures are not a result of neurons going haywire.
Source: Columbia University.
Of the 50 million people who suffer from epilepsy worldwide, a third fail to respond to medication. As the search for better drugs continues, researchers are still trying to make sense of how seizures start and spread.
In a new study in Cell Reports, researchers at Columbia University come a step closer by showing that the neurons of mice undergoing seizures fire off in a sequential pattern no matter how quickly the seizure propagates — a finding that confirms seizures are not the result of neurons randomly going haywire.
“This is good news,” said the study’s senior author, Dr. Rafael Yuste, a neuroscientist at Columbia. “It means that local neuronal circuits matter, and that targeting the right cells may stop or even prevent some types of brain seizure.”
To induce the seizures, researchers injected a tiny area of cortex in awake mice with two types of drugs–one that increases neuronal firing and another that blocks the inhibitory interneurons that control information flow between cells. Recording the seizures as they rippled outward, researchers found that cells in the mouse’s brain systematically fired one after the other. Under both models, the seizure spread across the top layer of cortex in a wave-like pattern before descending into its lower layers.
Unexpectedly, they found that whether the seizure lasted 10 seconds or 30 seconds, it followed the same route, like a commuter stuck in traffic. The concept of neurons firing in a reliable pattern no matter how fast the seizure is traveling is illustrated on the cover of Cell Reports, drawn by the study’s lead author, Dr. Michael Wenzel.
“The basic pattern of a string stretched between two hands stays the same whether the hands move closer together or farther away,” he says. “Just as neurons maintain their relative firing patterns regardless of how slowly or quickly the seizure unfolds.”
Researchers were able to get a cell-by-cell view of a seizure propagating through a mouse’s brain using high-speed calcium imaging that allowed them to zoom in 100 times closer than electrode techniques used on the human brain.
It may be the first time that researchers have watched a seizure unfold at this level of detail, and their findings suggest that inhibitory neurons may be a promising area of future research, said Dr. Catherine Schevon, a neurology professor at Columbia University Medical Center who was not involved in the research.
“The role of inhibitory restraint in seizure development is an area that few have studied at micrometer scale,” she said. “This could be a useful treatment target for future drug development or stem cell interneuron implants.”
Happily in improving your brain’s ability to function, it is not necessary to pay for expensive online games, that ultimately add nothing to the quality of your life. These nine training tips are free to engage in, will improve your brain’s function, and entice you to live life to its fullest!
How We Can Increase Brain Function As We Age
A study of randomly chosen individuals age 57-71 showed improved brain function after just 12 hours of strategic brain training exercises. Using MRIs of the participants brains both before and after, researchers saw upwards of an 8% improvement in blood flow and other indices that indicate improved brain function.
Improved brain function included improved ability to strategize, remember and draw big-picture conclusions from lengthy texts of information.
Remarkably, in a follow up study using MRIs again on the participants, researchers found that the benefits derived from the single training session were still in place one year later. Enhanced synaptic plasticity means that we can think faster, listen better, respond to situations faster and concentrate with greater focus. Creativity is enhanced as well.
MRI of the Brain
[ARTICLE] A randomised controlled cross-over double-blind pilot study protocol on THC:CBD oromucosal spray efficacy as an add-on therapy for post-stroke spasticity – Full Text
Introduction Stroke is the most disabling neurological disorder and often causes spasticity. Transmucosal cannabinoids (tetrahydrocannabinol and cannabidiol (THC:CBD), Sativex) is currently available to treat spasticity-associated symptoms in patients with multiple sclerosis. Cannabinoids are being considered useful also in the treatment of pain, nausea and epilepsy, but may bear and increased risk for cardiovascular events. Spasticity is often assessed with subjective and clinical rating scales, which are unable to measure the increased excitability of the monosynaptic reflex, considered the hallmark of spasticity. The neurophysiological assessment of the stretch reflex provides a precise and objective method to measure spasticity. We propose a novel study to understand if Sativex could be useful in reducing spasticity in stroke survivors and investigating tolerability and safety by accurate cardiovascular monitoring.
Methods and analysis We will recruit 50 patients with spasticity following stroke to take THC:CBD in a double-blind placebo-controlled cross-over study. Spasticity will be assessed with a numeric rating scale for spasticity, the modified Ashworth scale and with the electromyographical recording of the stretch reflex. The cardiovascular risk will be assessed prior to inclusion. Blood pressure, heart rate, number of daily spasms, bladder function, sleep disruption and adverse events will be monitored throughout the study. A mixed-model analysis of variance will be used to compare the stretch reflex amplitude between the time points; semiquantitative measures will be compared using the Mann-Whitney test (THC:CBD vs placebo) and Wilcoxon test (baseline vs treatment).
Stroke is one of the most disabling neurological disease and frequently determines important chronic consequences such as spasticity. Prevalence of poststroke spasticity ranges from 4% to 42.6%, with the prevalence of disabling spasticity ranging from 2% to 13%.1 Treatment of poststroke spasticity is based on rehabilitation, local injection of botulinum toxin (BoNT) in the affected muscles for focal spasticity and/or use of classic oral drugs such as tizanidine, baclofen, thiocolchicoside and benzodiazepines, which are not always effective and have a good number of possible side effects.
The transmucosal administration of delta-9-tetrahydrocannabinol and cannabidiol (THC and CBD at 1:1 ratio oromucosal spray, Sativex) is able to reduce spasticity acting on endocannabinoid receptors CB1and CB2. This novel drug has been licensed after an extensive clinical trial programme2–4 in adult patients with multiple sclerosis who have shown no significant benefit from other antispasmodic drugs. More than 45 000 patient/years of exposure since its approval in more than 15 EU countries support their antispasticity effectiveness and safety profile in this indication.5 Besides improving spasticity, cannabinoids can be beneficial in reducing pain, chemotherapy-induced nausea and vomiting; moreover, they contribute to reducing seizures and to lowering eye pressure in glaucoma.6Cannabinoids can also exert psychological effects by lowering anxiety levels and inducing sedation or euphoria. Marijuana, which is the main source of cannabinoids, is declared illegal in many countries mostly because of the risk of abuse, dependence and withdrawal syndrome, related to the effect of its high amounts of THC. Several reports support an increased ischaemic stroke risk related to relevant abuse of smoked marijuana7–17 as well as synthetic cannabinoids.18–20 Ischaemic stroke following cannabis involves more frequently basal ganglia and cerebellum where CB1 and CB2 receptors show a higher expression.13
The ‘French Association of the Regional Abuse and Dependence Monitoring Centres Working Group on Cannabis Complications’ warns about the increased cardiovascular risk related to the use of herbal cannabis, mostly consisting of acute coronary syndromes and peripheral arteriopathies, potentially leading to life-threatening conditions.21 The detrimental consequences of cannabinoids could be attributed to the increase in heart rate22 as well as arterial spasms also in the context of a reversible cerebral vasoconstriction syndrome,23 but also vasculitis, postural hypotension and cardioembolism.24
On the other side, some studies support a beneficial effect on stroke evolution of cannabinoid receptors stimulation. In fact, cannabinoid-mediated activation of CB1 and CB2 receptors reduces inflammation and neuronal injury in acute ischaemic stroke.25 Activation of CB2 receptors shows protective effects after ischaemic injury26 and inhibits atherosclerotic plaque progression.27 28
To our knowledge, no correlations have been reported between haemorrhagic stroke and cannabinoids intake. In our opinion, the modification of blood pressure is the most important cannabinoid effect that should be taken into account in patients with a previous haemorrhagic stroke or predisposed to intracranial bleeding. Cannabinoids are indeed capable of inducing blood pressure fluctuations in a specific triphasic pattern (low-high-low) potentially harmful if the patient is with bleeding risk.29Ischaemic disease is not included among THC:CBD oromucosal spray contraindications. However, considering that, to our knowledge, no study has been performed with THC:CBD oromucosal spray on post-stroke spasticity, we believe that a particular caution should be used in stroke patients.
The decision of which method of measure is considered as end point is a major issue in studies involving spasticity. The definition of spasticity provided by Lance is one of the most precise and reliable, focusing on the stretch reflex as the neurophysiological equivalent of spasticity.30 Probably because of technical complexity and required expertise, neurophysiological approaches are rarely adopted. Clinical rating scales such as the modified Ashworth scale (MAS)31 or subjective scores such as the numeric rating scale (NRS) for spasticity are being widely used.32 33 Recent evidence supports the idea that MAS and NRS are indeed useful to quickly rate spasticity in a clinical setting, however NRS provide a very variable and imprecise assessment of many symptoms related to spasticity, but where spasticity itself is probably only a common factor.34 The adoption of stretch reflex as the most appropriate neurophysiological measure of spasticity increases the specificity and reduces the variability of the end point and is particularly suitable for clinical trials.
Our proposal is therefore to assess the efficacy of THC:CBD oromucosal spray in patients with spasticity following stroke as add-on to first-line antispasticity medications with an experimental pilot randomised placebo-controlled cross-over clinical trial using the stretch reflex as primary outcome measure. Prior to inclusion in the study, we propose strict selection criteria in order to reduce the risk of relevant side effects. […]
Feeling tired is a normal part of life. Whether you didn’t get a good night of sleep or wore yourself out with a busy day or an exerting activity, your body can only handle so much before you start to feel the physical effects of being tired. In cases like these, all you need to do is rest in order to feel re-charged and rejuvenated. But for individuals who have suffered from a stroke, it’s not that easy.
Fatigue after a stroke is common, and it’s different from simply feeling tired. Post-stroke fatigue can make somebody feel like they completely lack energy or strength, with a persistent feeling of being tired or weary. Unlike typical tiredness, a nap or sleeping longer at night won’t solve things. If you are experiencing post-stroke fatigue, it is important to consult with your doctor so you can take the proper steps to start feeling better and more energized.
What is Post-Stroke Fatigue?
Post-stroke fatigue can occur after a mild or severe stroke, and roughly 40 to 70 percent of stroke patients experience this “invisible symptom.” It’s a particularly frustrating side effect of a stroke because it can make you feel completely exhausted and off your game, which in turn makes recovering from the stroke seem even more difficult.
Those who experience post-stroke fatigue can feel like they are not in control of their recovery, as it’s hard for them to muster the energy to participate in their rehab activities or normal day-to-day functions. Many individuals with post-stroke fatigue initially confuse it with “being tired,” but post-stroke fatigue is not the same thing as just being tired. It can come out of nowhere, without warning, and rest isn’t always the solution.
Post-stroke fatigue is draining both physically and emotionally/mentally, and the severity of the stroke does not seem to correlate to the severity of the fatigue. Even a mild stroke can result in extreme post-stroke fatigue, and even if you suffered a stroke some time ago and feel as if you’ve made a full recovery, post-stroke fatigue can still impact you.
What Causes Post-Stroke Fatigue?
Experts aren’t entirely sure what causes post-stroke fatigue because there has been limited research on the subject.Medical conditions like diabetes and heart disease can play a role, as can any pre-existing fatigue issues an individual had before suffering from a stroke. In addition to fatigue, sleep apnea is another issue reported by stroke survivors, so it’s possible there is some sort of link between the two, though nothing has been proven.
Survivors often feel stressed or depressed about the stroke afterwards, from worrying about the recovery process to being concerned with their symptoms. Stress and the mental demands that come with it can lead to fatigue. There are a lot of unknowns about the cause of post-stress fatigue, but one thing is certain: a stroke takes a big toll on a person’s body, and many stroke survivors feel severe fatigue as a result.
How Do You Tell if You Have Post-Stroke Fatigue?
Remember that there’s a difference between feeling tired and having post-stroke fatigue. The latter will give you afeeling of complete exhaustion; you will lack all energy and feel extremely weary. You will probably feel like you have to rest every day, or even multiple times a day. This can make it difficult to accomplish things, whether it’s something as simple as spending time with family, running errands, or even attending your post-stroke therapy sessions.
Until you feel the type of exhaustion that comes with post-stroke fatigue it’s difficult to explain, so don’t feel frustrated if your friends and family don’t understand why you’re struggling. If you think you have post-stroke fatigue, don’t hesitate to consult with your doctor.
Tips to Increase Your Energy
The first step in combating post-stroke fatigue is to discuss it with your doctor. Let them know what you’ve been feeling. Your doctor will probably start the process by making sure you’ve had an up-to-date physical. With that information, your doctor can rule out other potential causes for your fatigue or determine if your fatigue might stem from your medication.
It goes without saying, but try to take naps if time allows. Naps won’t cure you of your fatigue long term, but resting when you feel run down can help you feel more refreshed, even if only for a short while.
Do your best to relax. Don’t let your post-stroke fatigue, or any other side effects of your stroke, get you down. Stay positive! Being stressed or tense will only sap you of more energy. A positive attitude goes a long way in feeling upbeat and energetic. Try to get back into the swing of things by returning to your pre-stroke routines. Simple things like staying active and involved with friends and family can yield big benefits.
Yes, it will seem overwhelming at times. Suffering from a stroke, dealing with the aftermath, and having no energy on top of it can be tough, but celebrate your successes. Take baby steps, and be proud of the progress you’ve made. Focus on what you’ve accomplished during your recovery so far, rather than dread what’s left to be done.
Tired of Being Tired
Post-stroke fatigue is a daunting condition, and many people who are recovering from a stroke might not even realize they have it, instead thinking they are simply tired. If you’ve had a stroke and find yourself feeling sapped of your energy on a consistent basis, talk to your doctor. There’s a chance you have post-stroke fatigue. You’re not alone; 40 to 70 percent of stroke survivors experience this kind of exhaustion.
By speaking with the proper medical professionals, making it a point to rest as often as possible, and having a positive mindset, you can combat the constant drowsiness and work on returning to your pre-stroke energy levels.