[Abstract] Motor Recovery Beginning 23 Years After Ischemic Stroke – Journal of Neurophysiology

Abstract

It is widely believed that most stroke recovery occurs within 6 months, with little benefit of physiotherapy or other modalities beyond a year. We report a remarkable case of stroke recovery beginning 23 years after a severe stroke due to embolization from the innominate artery and subclavian artery, resulting from compression of the right subclavian artery by a cervical rib. The patient had a large right fronto-parietal infarction with severe left hemiparesis, and a totally non-functional spastic left hand. He experienced some recovery of hand function that began 23 years after the stroke, a year after he took up regular swimming. As a result, intensive physiotherapy was initiated, with repetetive large muscle movement and a spring-loaded mechanical orthosis that provides resistance to finger flexors and supports finger extensors. Within two years he could pick up coins with the previously useless left hand. Functional MRI studies document widespread distribution of the recovery in both hemispheres. This case provides impetus not only to more intensive and prolonged physiotherapy, but also to treatment with emerging modalities such as stem cell therapy, exosome and micro-RNA therapies.

 

Source: ARTICLES | Journal of Neurophysiology

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[ARTICLE] Agent-based systems for telerehabilitation: strengths, limitations and future challenges (PDF Download Available) – Full Text

Abstract
Telerehabilitation in older adults is most needed in the patient environments, rather than in formal ambulatories or hospitals. Supporting such practices brings significant advantages to patients, their family, formal and informal caregivers, clinicians, and researchers. Several techniques and technologies have been developed aiming at facilitating and enhancing the effectiveness of telerehabilitation. This paper gives a quick overview of the state of the art, investigating video-based, wear-able, robotic, distributed, and gamified telerehabilitation solutions. In particular, agent-based solutions are analyzed and discussed addressing strength, limitations, and future challenges. Elaborating on functional requirements expressed by professional physiotherapists and researchers, the need for extending multi-agent systems (MAS) peculiarities at the sensing level in wearable solutions establishes new research challenges. Employed in cyber-physical scenarios with users-sensors and sensors-sensors interactions, MAS are requested to handle timing constraints, scarcity of resources and new communication means, which are crucial for providing real-time feedback and coaching.
1 Introduction
Healthcare institutions are facing the strain of a significantly larger elderly population [1]. Lengthening life expectancy is met by an increasing demand for medical and technological contributions to extend the ”good-health”, and disability free period.
The major factor catalyzing the elderly’s impairing process is the progres-
sive reduction of mobility, due to the natural aging process, inactivity, dis-
eases such as osteoarthritis, stroke or other neurological conditions, falls with its consequences, such as fear of falls (leading to inactivity), or fractures (needing surgery).Despite the emergence of less-invasive surgical techniques, post-intervention rehabilitation still requires extended periods and tailored therapies, which usually involve complications. Performing traditional rehabilitative practices is leading to a significant increase in public-health costs and, in some cases a lack of resources, thus worsening the services’ quality. Rehabilitation is often a long process and needs to be sustained long after the end of the acute care. Simplifying the access to health services [2] can raise the number of patients, maintaining (or even increasing) the quality of care. For example, patients requiring support, such as continuous or selective monitoring, can benefit from systems that automatically transmit the information gathered in their domestic environment to the health clinics, thus enabling telemonitoring on their health conditions [3].
Although in traditional solutions telemonitoring is a self-contained practice
limited to passively observing the patients, the need for remote sensing is crucially coupled with the need for coaching older adults in their daily living [4,5].
For example, a critical activity such as telerehabilitation cannot be limited
to observing the patients’ behaviors. Indeed, patient adherence and acceptability of rehabilitative practices need to be actively enhanced, overcoming pitfalls due to motor (e.g., endurance), non-motor (e.g., fatigue, pain, dysautonomic symptoms, and motivational), and cognitive deficits. According to Rodriguez et al. [6], telerehabilitation can be formally defined as:
“the application of telecommunication, remote sensing and operation tech-
nologies, and computing technologies to assist with the provision of med-
ical rehabilitation services at a distance.”
Patients, physiotherapists, and health institutes can gain several benefits
from an extensive adoption of telerehabilitation systems [7]. Considering the
economical point of view, Mozaffarian et al. [8] figured out that the total cost
of stroke in the US was estimable to be 34.3 billion dollars in 2008, rising up to 69.1 billion dollars in 2016.
Even though to date they are not precisely quantifiable due to insufficient evidence [9], Mutingi et al. [10] presented as “inevitable advantages”
(i) a substantial cost saving primarily due to the reduction of specialized human resources,
(ii) an enhancement of patient comfort and lifestyle, and (iii) improvements of therapy and decision making processes. Moreover, Morreale et al. [11] mentioned one of the most appreciated benefits: the increase of adherence to rehabilitation protocols.
The multitude of scientific contributions fostering telerehabilitation exploits
new technologies and various architectures to better understand and serve user requirements. However, due to technological or technical limitations, physiotherapists’ needs have not yet been completely satisfied. To fill this gap, a system evolution is required. For example, telerehabilitation systems cannot offer the same behavior to users with diverse conditions. Viceversa, according to the environment condition, they must rather be able to adapt themselves to the user needs [6].
Telerehabilitation is characterized by a very delicate equilibrium between
environment, devices, and users. Thus, the capabilities such as self adaptation, flexibility, and ubiquity are crucial to facilitate and promote the usability and then the actual practices.
Agent-based systems for telerehabilitation: strengths, limitations and future challenges (PDF Download Available). Available from: https://www.researchgate.net/publication/316790326_Agent-based_systems_for_telerehabilitation_strengths_limitations_and_future_challenges [accessed May 26, 2017].

Continue —> Agent-based systems for telerehabilitation: strengths, limitations and future challenges (PDF Download Available)

Fig. 2. Agent-based sensing: future challenge for telerehabilitation MAS. 

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[Abstract] Play seriously: Effectiveness of serious games and their features in motor rehabilitation. A meta-analysis.

Abstract

BACKGROUND:

Evidence for the effectiveness of serious games (SGs) and their various features is inconsistent in the motor rehabilitation field, which makes evidence based development of SGs a rare practice.

OBJECTIVE:

To investigate the effectiveness of SGs in motor rehabilitation for upper limb and movement/balance and to test the potential moderating role of SGs features like feedback, activities, characters and background.

METHODS:

We ran a meta-analysis including 61 studies reporting randomized controlled trials (RCTs), controlled trials (CTs) or case series designs in which at least one intervention for motor rehabilitation included the use of SGs as standalone or in combination.

RESULTS:

There was an overall moderate effect of SGs on motor indices, d = 0.59, [95% CI, 0.48, 0.71], p <  0.001. Regarding the game features, only two out of 17 moderators were statistically different in terms of effect sizes: type of activity (combination of group with individual activities had the highest effects), and realism of the scenario (fantasy scenarios had the highest effects).

CONCLUSIONS:

While we showed that SGs are more effective in improving motor upper limb and movement/balance functions compared to conventional rehabilitation, there were no consistent differences between various game features in their contribution to effects. Further research should systematically investigate SGs features that might have added value in improving effectiveness.

Source: Play seriously: Effectiveness of serious games and their features in motor rehabilitation. A meta-analysis. – PubMed – NCBI

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[Abstract] A motor rehabilitation BCI with multi-modal feedback in chronic stroke patients (P5.300)

ABSTRACT

Objective: Apply BCI technology to improve stroke rehabilitation therapy

Background: Brain-computer interfaces (BCI) measure brain activity to generate control signals for external devices in real-time. BCIs are especially well suited for motor rehabilitation. Motor imagery BCIs can analyze patients’ sensorimotor regions and control conditionally gated feedback devices that allow the patient to regain motor functions.

Design/Methods: Patients with sub-acute stroke were trained for 25 30-minute sessions in which they imagined left or right hand movement. A computer avatar indicated which hand the patient should imagine moving (80 trials left hand; 80 trials right). The BCI system analyzed EEG in real time, deciphered intention for left or right hand movement, and triggered functional electrical stimulation that elicited movement in the corresponding hand and in the computer avatar only when the patient produced the correct corresponding EEG pattern. Motor function improvements were assessed with a 9-hole PEG test.

Results: In a chronic stroke patient the 9-hole PEG test showed an improvement in affected left hand movement from 1 min 30 seconds to 52 sec after 24 training sessions (healthy right hand: 26 sec). BCI accuracy increased from 70% to 98.5 % across sessions. Mean accuracy for the first 3 sessions was 81%; 88% for the last 3. Before training, the patient could not lift his affected arm. After training the patient could reach his mouth to feed himself.

Conclusions: BCI accuracy is an objective marker of a patient’s participation in the task; 50% means that patient doesn’t follow (or cannot follow) the task. This patient’s continued improvement and high final accuracy indicates motivated participation. Most importantly, there was objective improvement in motor function within only 25 training sessions. We attribute these results to the conditionally gated reward from the BCI (inducing Hebbian plasticity), and mirror neuron system activation by the avatar.

Disclosure: Dr. Guger has received personal compensation for activities with g.tec Medical Engineering GmbH as an employee. Dr. Coon has nothing to disclose. Dr. Swift has nothing to disclose.

Source: A motor rehabilitation BCI with multi-modal feedback in chronic stroke patients (P5.300)

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[VIDEO] Brain Injury and Depression – YouTube

Why do people experience depression after brain injury? Learn about the connection between traumatic brain injury and depression in this video. Dr. Frank Lewis, Ph.D., a cognitive psychologist and NeuroRestorative’s Director of Clinical Outcomes, addresses the symptoms and causes of depression following brain injury. He provides advice to family members and treatment options to help individuals cope with depression and continue to heal from their injury.

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[WEB SITE] UC study explores how low risk stress reduction treatments may benefit epilepsy patients

Patients with epilepsy face many challenges, but perhaps the most difficult of all is the unpredictability of seizure occurrence. One of the most commonly reported triggers for seizures is stress.

A recent review article in the European journal Seizure, by researchers at University of Cincinnati Epilepsy Center at the UC Gardner Neuroscience Institute, looks at the stress-seizure relationship and how adopting stress reduction techniques may provide benefit as a low risk form of treatment.

The relationship between stress and seizures has been well documented over the last 50 years. It has been noted that stress can not only increase seizure susceptibility and in rare cases a form of reflex epilepsy, but also increase the risk of the development of epilepsy, especially when stressors are severe, prolonged, or experienced early in life.

“Studies to date have looked at the relationship from many angles,” says Michael Privitera, MD, director of the UC Epilepsy Center and professor in the Department of Neurology and Rehabilitation Medicine at the UC College of Medicine. “The earliest studies from the 1980s were primarily diaries of patients who described experiencing more seizures on ‘high-stress days’ than on ‘low-stress days.'”

Privitera and Heather McKee, MD, an assistant professor in the Department of Neurology and Rehabilitation Medicine, looked at 21 studies from the 1980s to present–from patients who kept diaries of stress levels and correlation of seizure frequency, to tracking seizures after major life events, to fMRI studies that looked at responses to stressful verbal/auditory stimuli.

“Most all [of these studies] show increases in seizure frequency after high-stress events. Studies have also followed populations who have collectively experienced stressful events, such as the effects of war, trauma or natural disaster, or the death of a loved one,” says Privitera. All of which found increased seizure risk during such a time of stress.

For example, a 2002 study evaluated the occurrence of epileptic seizures during the war in Croatia in the early 1990s. Children from war-affected areas had epileptic seizures more often than children not affected by the war. Additionally, the 10-year follow up showed that patients who had their first epileptic seizure during a time of stress were more likely to have controlled epilepsy or even be off medication years later.

“Stress is a subjective and highly individualized state of mental or emotional strain. Although it’s quite clear that stress is an important and common seizure precipitant, it remains difficult to obtain objective conclusions about a direct causal factor for individual epilepsy patients,” says McKee.

Another aspect of the stress-seizure relationship is the finding by UC researchers that there were higher anxiety levels in patients with epilepsy who report stress as a seizure precipitant. The researchers suggest patients who believe stress is a seizure trigger may want to talk with their health care provider about screening for anxiety.

“Any patient reporting stress as a seizure trigger should be screened for a treatable mood disorder, especially considering that mood disorders are so common within this population,” adds McKee.

The researchers report that while some small prospective trials using general stress reduction methods have shown promise in improving outcomes in people with epilepsy, large-scale, randomized, controlled trials are needed to convince both patients and providers that stress reduction methods should be standard adjunctive treatments for people with epilepsy.

“What I think some of these studies point to is that efforts toward stress reduction techniques, though somewhat inconsistent, have shown promise in reducing seizure frequency. We need future research to establish evidence-based treatments and clarify biological mechanisms of the stress-seizure relationship,” says Privitera.

Overall, he says, recommending stress reduction methods to patients with epilepsy “could improve overall quality of life and reduce seizure frequency at little to no risk.”

Some low risk stress reduction techniques may include controlled deep breathing, relaxation or mindfulness therapy, as well as exercise, or establishing routines.

Source: UC study explores how low risk stress reduction treatments may benefit epilepsy patients

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[Abstract] Functional Brain Stimulation in a Chronic Stroke Survivor With Moderate Impairment  

Abstract

OBJECTIVE. To determine the impact of transcranial direct current stimulation (tDCS) combined with repetitive, task-specific training (RTP) on upper-extremity (UE) impairment in a chronic stroke survivor with moderate impairment.

METHOD. The participant was a 54-yr-old woman with chronic, moderate UE hemiparesis after a single stroke that had occurred 10 yr before study enrollment. She participated in 45-min RTP sessions 3 days/wk for 8 wk. tDCS was administered concurrent to the first 20 min of each RTP session.

RESULTS. Immediately after intervention, the participant demonstrated marked score increases on the UE section of the Fugl–Meyer Scale and the Motor Activity Log (on both the Amount of Use and the Quality of Movement subscales).

CONCLUSION. These data support the use of tDCS combined with RTP to decrease impairment and increase UE use in chronic stroke patients with moderate impairment. This finding is crucial, given the paucity of efficacious treatment approaches in this impairment level.

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Source: Functional Brain Stimulation in a Chronic Stroke Survivor With Moderate Impairment | American Journal of Occupational Therapy

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[Abstract] Supporting Stroke Motor Recovery Through a Mobile Application: A Pilot Study

Abstract

Neuroplasticity and motor learning are promoted with repetitive movement, appropriate challenge, and performance feedback. ARMStrokes, a smartphone application, incorporates these qualities to support motor recovery. Engaging exercises are easily accessible for improved compliance. In a multiple-case, mixed-methods pilot study, the potential of this technology for stroke motor recovery was examined. Exercises calibrated to the participant’s skill level targeted forearm, elbow, and shoulder motions for a 6-wk protocol. Visual, auditory, and vibration feedback promoted self-assessment. Pre- and posttest data from 6 chronic stroke survivors who used the app in different ways (i.e., to measure active or passive motion, to track endurance) demonstrated improvements in accuracy of movements, fatigue, range of motion, and performance of daily activities. Statistically significant changes were not obtained with this pilot study. Further study on the efficacy of this technology is supported.

Related Articles

Source: Supporting Stroke Motor Recovery Through a Mobile Application: A Pilot Study | American Journal of Occupational Therapy

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[Abstract] Strength of knee flexors of the paretic limb as an important determinant of functional status in post-stroke rehabilitation

Abstract

Objective

The purpose of the study was to assess the effectiveness of the multi-modal exercise program (MMEP) in patients after stroke, and to identify muscles that are the best predictors of functional performance and changes in functional status in a 3-week rehabilitation program.

Methods

Thirty-one post-stroke patients (60.6 ± 12.7 years) participating in a 3-week MMEP took part in the study. Measurements of extensor and flexor strength of the knee (FextFflex) were done. Functional performance was measured using Timed Up & Go test (TUG), 6-Minute Walk Test (6-MWT) and Tinetti Test.

Results

The rehabilitation program improved all the results of functional tests, as well as the values of strength in the patients. Both baseline and post-rehabilitation functional status was associated with knee flexor and extensor muscle strength of paretic but not of non-paretic limbs. At baseline examination muscle strength difference between both Fflex kg−1and Fext kg−1 had an influence on functional status. After rehabilitation the effect of muscle strength difference on functional status was not evident for Fext kg−1 and, interestingly, even more prominent for Fflex kg−1.

Conclusions

MMEP can effectively increase muscle strength and functional capacity in post-stroke patients. Knee flexor muscle strength of the paretic limb and the knee flexor difference between the limbs is the best predictor of functional performance in stroke survivors

Source: Strength of knee flexors of the paretic limb as an important determinant of functional status in post-stroke rehabilitation

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[BLOG POST] Study Compares Intento Device and Traditional Occupational Therapy  

The Intento device is designed to enable patients to control the functional electronic stimulation that they receive, to help patients regain mobility in arms weakened by a stroke.

The Intento device is designed to enable patients to control the functional electronic stimulation that they receive, to help them regain mobility in arms weakened by a stroke.

A device from Ecole Polytechnique Fédérale de Lausanne startup company Intento is designed to enable stroke patients to self-administer functional electrical stimulation to help regain mobility in their arms weakened by the stroke.

The system consists of electrode patches, a device the patients control using their working hand, and tablet software. The therapist selects one of several programmed movements on the tablet and loads it, with a single click, onto the device. The program shows where the electrodes need to be placed and automatically configures the electrical pulse settings to generate the desired movement. Patients then move their functioning hand to control the electrical stimulation needed.

The ultimate aim is for patients to eventually perform the movements without using the device, explains a media release from Ecole Polytechnique Fédérale.

Results from a study investigating Intento’s device were published recently in Archives of Physical Medicine and Rehabilitation.

In the study, researchers from Lausanne University Hospital (CHUV) compared the device to conventional occupational therapy among 11 patients who were severely paralyzed as the result of a stroke. These patients experienced the stroke more than 6 months prior to the study, and other therapies did not work for them.

Over a period of 10 days, the 11 patients underwent 1.5-hour sessions using the Intento device.

Their mobility results from using the device were then compared to the results following conventional occupational therapy conducted over the same amount of time. The patients’ mobility was measured before and after each type of treatment, according to the release.

The results suggest that 70% of the patients experienced significant improvement in their motor functions, versus only 30% of the patients with the conventional occupational therapy.

“Above and beyond the study’s findings, several of the patients told us a few weeks later that they were already using their arms more than before,” says Andrea Maesani, Intento’s CEO and other cofounder, in the release.

Patients were still making steady progress 6 months after the study was conducted, suggesting that the treatment produces long-term effects, according to the release.

The next step will be a clinical study on a larger group before marketing the device, the founders state in the release.

[Source(s): Ecole Polytechnique Fédérale, EurekAlert]

Source: Study Compares Intento Device and Traditional Occupational Therapy – Rehab Managment

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