Posts Tagged aphasia

[WEB SITE] Telehealth resources in response to COVID-19 for stroke care and rehabilitation professionals

The resources on this page have been collected for use by stroke care and rehabilitation professionals to provide telehealth services due to COVID-19 isolation or social distancing.

Please note

  • This web page contains links to information and materials and other content that might assist health professionals work and consult remotely with people with stroke, and with people with stroke who may have been discharged prior to completing their full rehabilitation programs.
  • The linked information, materials and other content on this web page has not been created, produced or endorsed by the Stroke Foundation.
  • The linked information, materials and other content on this web page is not intended to replace a health professional’s own professional judgement and decision-making.
  • The Stroke Foundation shall not bear any liability for reliance by any user on the linked information, materials and other content on this web page.

Medicare item numbers

COVID-19 Telehealth MBS items can now be claimed. See the list at the bottom of the linked news item, or the Australian Government’s fact sheet on Temporary Telehealth Bulk-Billed Items for COVID-19. The government has confirmed that existing face-to-face attendance items under the MBS can be used to deliver telehealth consultations by the following allied health professionals:

  • Aboriginal and Torres Strait Islander health workers and health practitioners
  • psychologists
  • dietitians
  • occupational therapists
  • audiologists
  • optometrists
  • orthoptists
  • physiotherapists
  • social workers.

For more information, see the government’s Frequently asked questions (PDF).

Synapse Medical has a free blog that answers questions about COVID-19 numbers. FAQs are also available, and questions can be posted.

Communication tools for people with aphasia

Accessible healthcare communication materials and resources may be needed by people with aphasia and/or cognitive difficulties. The Centre for Research Excellence in Aphasia Rehabilitation and Recovery have put together a repository of materials, including in languages other than English, and they will continue to update it. Open either the PDF or the Excel document to find all the links. Key information includes:

  • General public health information about COVID-19
  • Pictographics relating to COVID-19, to support communication
  • Supported communication training for health professionals, to enhance their communication with people with aphasia
  • Wellbeing, peer support and social connection
  • Adapting aphasia assessments
  • Technology and telerehabilitation, with aphasia-friendly resources for using web-based platforms.

As healthcare professionals transition to telerehabilitation, it may seem too challenging to include people with aphasia. However, it is absolutely possible and should be promoted.

General telehealth guides and tips

Guide to using telehealth for clinicians during COVID-19 (PDF), a 4-page guide document with instructions on how to set up and run a successful telerehab session, with links to guidelines and tips on effective communication.

Centre of Research Excellence (CRE) in Telehealth, based at the University of Queensland. Highlights include:

  • What is Telehealth, with a series of videos describing what it is and gives examples of how it is done
  • Policy Digest, which covers a myriad of policy documents from guidelines to codes to conduct to standards to resource packages. It really is comprehensive and worth a look.

NSW Agency for Clinical Innovation’s telehealth website, updated daily with useful resources including:

NeoRehab telerehabilitation platform eHAB, designed specifically for allied health telerehab services. It contains tools for measurement, data capture, interactive media capabilities, and can do multi-point calls – all of which are often necessary for rehabilitation services. The platform has the necessary security features that health services demand. Training in how to use eHAB is available. The designer of this system, Prof. Trevor Russell, is happy to support teams to get set up with the system. Contact t.russell@uq.edu.au

Video consultation guide for GP practices, a blog post that includes tips for high quality consultations, but is mostly COVID-19 diagnosis related. There is also a PDF document you can scroll through without having to download, which gives references for telehealth effectiveness.

Australian Physiotherapy Association’s webinar series on telehealth is freely available, with a Q&A about how to make a rapid transition. Additionally, the Australian Physiotherapy Neurology Group has a Facebook group you can request to join, where lots of members are sharing ideas and resources. You do not need to be an APA member, but you do need to be a physio and it may take a day or two for the moderator to get you linked in.

Australian Physiotherapy Association’s guidelines on the use of telehealth in response to COVID-19 (PDF, 33 pages) have also been released. These guidelines include practical tips and considerations around privacy, safety and ethics.

Register for free UTS telepractice webinars for rapid transition during COVID-19. SPROUTS Clinic (Speech Pathology Reaching Out at UTS) is not just reaching out to speech pathologists during COVID-19 – they’re reaching out to all disciplines, health professionals, schools and health services caught up in the disruption to allied health services. The webinar is held fortnightly through April/May 2020 depending on demand, to support services Australia-wide in their rapid transition to implementing telehealth-related telepractice. Clinicians in other countries are welcome to attend, but time zones are made to suit UTS staff living in Sydney and NSW, Australia. The examples provided relate to speech pathology but can be easily applied to learning across any health discipline. Webinars will not be recorded. The main benefit in attending is the active learning model enabling engagement and interaction between the participants and with the teachers.

For novice clinicians, the Stroke Training and Awareness Resources (STARS) website includes 19 e-learning resources to support key competencies in stroke care.

Online panel discussion: COVID19 & digital technology: the roles, relevance & risks of using telehealth in a crisis (90 min). Dr Norman Swan talks to Prof Trish Greenhalgh, Dr Amandeep Hansra, Dr Neale Fong, Karrie Long and Dr Daniel Stefanski about their experience of using telehealth.

Free webinar: The role of Telehealth in curbing the COVID-19 Epidemic. Five expert panellists will share practical strategies for health professionals, including lessons from their own journeys and insights to how COVID-19 might change the way we use technology to deliver healthcare in the long-term. Register now for the webinar on Thursday 23 April 2020, 12–1 pm AEST.

Virtual conference 24 April 2020 – From the Frontlines: A Covid-19 Special Event (CPD points apply). The Australian Institute of Digital Health has brought together local and international professionals to discuss the critical role of technology innovation, data innovation, telehealth and virtual care. Attend live on Friday 24 April, or register and get access to watch the conference later, as well as get a month’s access to Digital Health TV – a collection of hundreds of videos and presentations about telehealth and digital healthcare innovation.

Bridges Self Management team have collated some of their evidence-based resources for self management. As they say, “if there was ever a time for good self-management support, it is now.”

Stroke Tele-Etiquette by Victorian Stroke Telemedicine (VST) Service, a short (2 min 15 sec) video on the most important concepts to consider when using telemedicine for clinical consultations: Environment; Technology; Appearance and Communication (ETAC).

Assessment tools

iWalkAssess app from the University of Toronto provides instructions and tools to facilitate measuring walking speed and a 6-minute walk test. It includes automatic comparison to normative data and functions for goal setting. It is not designed for use via telehealth, but could possibly be adapted and may be a useful tool for novice clinicians.

How to administer the Montreal Cognitive Assessment (MoCA), via phone or telehealth. Score sheets can be downloaded from www.mocatest.org

Remote Administration Guidelines for the NIH Toolbox®: Response to COVID-19. From the United States National Institutes of Health (NIH), the Toolbox is a comprehensive set of neuro-behavioral measurements that quickly assess cognitive, emotional, sensory, and motor functions from the convenience of an iPad.

Swallowing examinations

Telepractice Dysphagia Assessment Service is an e-learning program for establishing and conducting adult clinical swallowing evaluations via telepractice. it has separate packages for Speech Pathology Managers implementing telepractice services, and for training clinical speech pathologists and healthcare support workers. The model of care described in this program was developed, tested and validated through research conducted by the Centre for Research in Telerehabilitation at The University of Queensland, and the Speech Pathology & Audiology Department at The Royal Brisbane & Women’s Hospital.

To access the Telepractice Dysphagia Assessment Service as a non-QHealth clinican, you first need to register for the iLearn website following the instructions in iLearn user help for external (PDF). Once your registration is processed, log into iLearn, go to the Course Catalogue, and search for “Telepractice”. Click on the link for the course (AHPOQ-R) Telepractice Dysphagia Assessment Service.

If you have any queries or issues with accessing this resource, please contact clare.burns@health.qld.gov.au or nicky.graham@health.qld.gov.au

Therapy tools and resources

In addition to other resources below, physiotherapyexercises.com has a range of exercises on file that can be prescribed using a mobile option – and it’s free. There is a link to a 9-min video “how to guide” for the mobile version – look for “New Mobile Functionality” on the home page. It is also available in several different languages.

Mobility training

Setting up safe and effective home exercises (PDF), a 3-page guide including photos.

REPS Recovery Exercises app consists of video-guided, post-stroke exercise programs, including TASK. The aim of TASK is to help people after stroke to exercise at home, on an ongoing basis. People can practice everyday tasks, such as sitting, standing, stepping and standing up. It was designed to improve and/or maintain strength and mobility, as well as encourage people after stroke to be more physically active. TASK is also available as a web-based program.

Clock Yourself app is for balance training. It contains five stages that introduce progressively complex activities to train balance – very good for high-level balance exercises and dual tasking. Cost $1.99

AMOUNT trial patient instructions (PDF). This trial used readily available technology (e.g. Wii Fit, Xbox Kinect) and rehab technology (e.g. fysiogaming, Stepping tiles). The 14-page patient instructions are clear and aphasia-friendly, with clear instructions on using iPads as well as the trial-specific apps and FitBits. The AMOUNT trial protocol (DOCX) includes instructions and clinical decision-making guides.

Balance exercise ideas for home programs (PDF), a useful 5-page list from StrokeEd.

Tracking physical activity using devices (PDF), a 9-page document with instructions for using a range of common apps and devices, such as FitBit, Garmin, MapMyWalk and others.

Recovery of upper limb function and Walking learning modules on InformMe were created and reviewed by stroke, occupational therapy and physiotherapy experts. They contain practical advice for therapists when assessing and planning treatment for upper limb recovery and walking after stroke.

Clinician’s guide to task training for stroke survivors – the aim of this program is to help you review rehabilitation techniques with a focus on task-specific training.

HEALTH HUB LIVE is hosted daily at 12.30 pm on Facebook by the team at St Vincent’s Private Hospital Sydney. These sessions guide people through daily prehabilitation exercises that can be done at home, as well as important health and wellness information to support people through COVID-19.

Arm function

ViaTherapy app is designed as a decision tree for prescribing evidence-based arm exercises for people after stroke. It could be particularly useful for novice clinicians, or those with less experience in stroke. Easy to use on a mobile or PC interface.

GRASP program, with therapist Instructor manuals, participant manuals, and exercise log sheet and the target board are all available to download for free once you have registered at the website. GRASP is graded in three levels, dependent on the level of arm movement the person has. The program is available in both hospital and at home versions.

PUSH arm exercise program was originally designed and implemented at Bankstown-Lidcombe Hospital, Stroke Unit. The program is based on evidence regarding arm training and dosage. There is currently no specific evidence validating the PUSH program. PUSH is suitable for stroke survivors with limited movement in their affected arm.

Communication training

See the Accessible healthcare communication materials and resources from the CRE in Aphasia Rehabilitation and Recovery linked above. The full contents are described at the top of this page, but they include information on adapting aphasia assessments, and aphasia-friendly resources for using web-based platforms.

Speech Pathology Australia has a telepractice web page, which is accessible to their members only. The telepractice FAQ page has additional information which may help speech pathology clinicians to set up telepractice services (e.g., videos on practicalities of telepractice), and information on funding streams. These web pages will be updated regularly as new resources become available.

Psychological support

thiswayup.org.au has online courses available for chronic pain and a range of mental health conditions. All courses are free until 30 April 2020.

Vision and perception

Read-Right program for hemianopic alexia: This online program, developed by the team at UCL Queen Square Institute of Neurology, is a practice-based therapy that aims to improve reading speeds in people with hemianopic alexia, a reading disorder related to a visual impairment (hemianopia) usually caused by a stroke or brain injury. The main part of the therapy involves reading scrolling text. The program includes in-built tests of visual fields, reading speed and visual search. Program participants are able to select from a wide range of reading materials including classic novels, current newspapers and popular novels (such as Harry Potter). The program is free for the first 7 days then at a cost of 5 GBP per month (approx $10 AUD).

Eye Search program for visual scanning: Free online therapy for patients with visual search problems (hemianopia or visual neglect) caused by stroke or brain injury, developed by the team at UCL Queen Square Institute of Neurology. It is behavioural therapy designed to improve patients’ speed and accuracy when finding objects through an online game that focuses on visual scanning and the training of the parts of the brain that control eye movements. Each level of the game then becomes increasingly difficult.

Wellness

PAVING the Path to Wellness™: Emergency Response Edition, a free, 6-week virtual program for patients who are recovering from brain injury and stroke and don’t have the funds to pay for this rehabilitation. The program includes a wellness toolkit for building a healthy mindset through lifestyle changes such as creating a wholesome diet and exercise plan, learning how to enjoy regular sleep patterns, identifying important goals, finding meaning and purpose, and forming powerful personal connections. With funding from brain injury charity SameYou, Spaulding Rehabilitation Hospital will accommodate 150 free places on their program, on a first come, first served basis. See eligibility requirements and registration guidelines in the link.

Fitness training

TIME (Together In Movement through Exercise) Program information (PDF). There are exercise and wellness videos for people with mobility challenges and lots of seated options.

Lessons learnt from the ExDose Trial (DOCX 41 KB). Some helpful tips from Margaret Galloway that emerged during a study of a telehealth-delivered exercise program aimed at increasing cardiorespiratory fitness for people after stroke.

ESSA (Exercise and Sports Science Australia) video webinars from exercise physiologists about ‘taking your clinic online’, ‘telehealth in practice’ and ‘how to deliver telehealth: a case study”. (See the “Resources section” at bottom of page). Note: these examples are not stroke specific.

Hacks for exercising after stroke, a 13 min presentation by Dr Sarah Valkenborghs aimed at inspiring stroke survivors, but which includes useful tips for exercising for people with significant mobility issues.

Aerobic exercise after stroke (PDF), from the Canadian Partnership For Stroke Recovery. This guide for stroke survivors addresses the benefits of aerobic exercise, who should participate, why they should participate, how to get started and what’s involved. It also includes a sample program and tips on how to monitor exercise intensity. The accompanying Clinician’s guide (PDF) includes key messages, elements and considerations of an aerobic program, addressing barriers and outcome measures.

EnableMe podcast with physiotherapist Dr Natalie Fini (18 min) to help stroke survivors learn about physical activity and exercise following stroke.

Clock Yourself app is a training tool for patients developed by physiotherapist Meg Lowry. It progressively increases tasks for people and works on improving balance and reaction times.

Free “Senior Strong” workouts from the Body Project. This is a commercial company, but the workouts are freely available on YouTube and via the links below. The workouts were designed in conjunction with a nursing professor from the UK. They include older adults demonstrating as well as the fitness instructor. Instructors are engaging, with lots of talking but clear visual demonstrations. Some use dumbbell weights, which can be substituted with cans of beans or other household items. All (apart from the standing balance one) demonstrate sitting and standing options.

Relevant research papers

Safety and feasibility of telehealth delivered exercise (fitness) training. For full text contact Margaret Galloway, Margaret.Galloway@newcastle.edu.au

Hassett L, van den Berg M, Lindley RI, Crotty M, McCluskey A, van der Ploeg HP, Smith ST, Schurr K, Howard K, Hackett ML, Killington M, Bongers B, Togher L, Treacy D, Dorsch S, Wong S, Scrivener K, Chagpar S, Weber H, Pinheiro M, Heritier S, Sherrington C (2020). Digitally enabled aged care and neurological rehabilitation to enhance outcomes with Activity and MObility UsiNg Technology (AMOUNT) in Australia: A randomised controlled trialPLoS Med. 2020 Feb 18;17(2):e1003029. doi: 10.1371/journal.pmed.1003029. eCollection 2020 Feb.

Laver KE, Adey-Wakeling Z, Crotty M, Lannin NA, George S, Sherrington C (2020). Telerehabilitation services for stroke. Cochrane Database Syst Rev. 2020 Jan 31;1:CD010255. doi: 10.1002/14651858.CD010255.pub3.

Bagot K, Moloczij N, Arthurson L, Hair C, Hancock S, Bladin CF, Cadilhac DA (2020). Nurses’ role in implementing and sustaining acute telemedicine: a mixed-methods, pre-post design using an extended technology acceptance modelJ Nurs Scholarsh. 2020 Jan;52(1):34-46. doi: 10.1111/jnu.12509. Epub 2019 Sep 11.

Bagot KL, Moloczij N, Barclay-Moss K, Vu M, Bladin CF, Cadilhac DA (2020). Sustainable implementation of innovative, technology-based health care practices: A qualitative case study from stroke telemedicineJ Telemed Telecare. 2020 Jan-Feb;26(1-2):79-91. doi: 10.1177/1357633X18792380. Epub 2018 Sep 7.

Galloway M, Marsden D, Callister R, Erikson K, Nilsson M, English C (2019). The feasibility of a telehealth exercise program aimed at increasing cardiorespiratory fitness for people after strokeInternational Journal of Telerehabilitation 11(2); 9-28. doi:10.5195/ijt.2019.6290

Caughlin S, Mehta S, Corriveau H, Eng JJ, Eskes G, Kairy D, Meltzer J, Sakakibara BM, Teasell R (2019). Implementing telerehabilitation after stroke: lessons learned from Canadian trialsTelemed J E Health. 2019 Sep 9. doi: 10.1089/tmj.2019.0097.

Maddison R, Rawstorn JC, Stewart RAH, Benatar J, Whittaker R, Rolleston A, Jiang Y, Gao L, Moodie M, Warren I, Meads A, Gant N (2018). Effects and costs of real-time cardiac telerehabilitation: randomised controlled non-inferiority trialHeart. 2019 Jan;105(2):122-129. doi: 10.1136/heartjnl-2018-313189. Epub 2018 Aug 27.

Hamilton C, McCluskey A, Hassett L, Killington M, Lovarini M (2018). Patient and therapist experiences of using affordable feedback-based technology in rehabilitation: a qualitative study nested in a randomized controlled trialClin Rehabil. 2018 Sep;32(9):1258-1270. doi: 10.1177/0269215518771820. Epub 2018 Apr 26.

Bagot KL, Cadilhac DA, Kim J, Vu M, Savage M, Bolitho L, Howlett G, Rabl J, Dewey HM, Hand PJ, Denisenko S, Donnan GA, Bladin CF; Victorian Stroke Telemedicine Programme Consortium (2017). Transitioning from a single-site pilot project to a state-wide regional telehealth service: The experience from the Victorian Stroke Telemedicine programmeJ Telemed Telecare. 2017 Dec;23(10):850-855. doi: 10.1177/1357633X17734004.

Bagot KL, Cadilhac DA, Bladin CF et al (2017). Integrating acute stroke telemedicine consultations into specialists’ usual practice: a qualitative analysis comparing the experience of Australia and the United KingdomBMC Health Serv Res 17, 751 (2017). https://doi.org/10.1186/s12913-017-2694-1

Laver KE1, Lange B, George S, Deutsch JE, Saposnik G, Crotty M (2017). Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD008349. DOI: 10.1002/14651858.CD008349.pub4.

Bagot KL, Bladin CF, Vu M, Kim J, Hand PJ, Campbell B, Walker A, Donnan GA, Dewey HM, Cadilhac DA; VST collaborators (2016). Exploring the benefits of a stroke telemedicine programme: An organisational and societal perspectiveJ Telemed Telecare. 2016 Dec;22(8):489-494.

Chen J, Jin W, Zhang XX, Xu W, Liu XN, Ren CC (2015). Telerehabilitation approaches for stroke patients: systematic review and meta-analysis of randomized controlled trialsJ Stroke Cerebrovasc Dis. 2015 Dec;24(12):2660-8. doi: 10.1016/j.jstrokecerebrovasdis.2015.09.014. Epub 2015 Oct 23.

Clark RA, Conway A, Poulsen V, Keech W, Tirimacco R, Tideman P (2015). Alternative models of cardiac rehabilitation: a systematic reviewEur J Prev Cardiol. 2015 Jan;22(1):35-74. doi: 10.1177/2047487313501093. Epub 2013 Aug 13.

Crotty M, Killington M, van den Berg M, Morris C, Taylor A, Carati C (2014). Telerehabilitation for older people using off-the-shelf applications: acceptability and feasibilityJ Telemed Telecare. 2014 Oct;20(7):370-6. doi: 10.1177/1357633X14552382.

PubMed search for systematic reviews on telerehab for stroke (free to access). On 26/3/20 there were 14 hits.

Evidence to guide telehealth physiotherapy. The Physiotherapy Evidence Database (PEDro) has compiled a list of systematic reviews of tele-physiotherapy published in the last 5 years.

via InformMe – Telehealth resources in response to COVID-19

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[WEB SITE] What Disabilities Can Result From a TBI? – BrainLine

What Disabilities Can Result From a TBI?

National Institute of Neurological Disorders and Stroke
¿Qué discapacidades pueden resultar de un traumatismo cerebral?

 

Disabilities resulting from a TBI depend upon the severity of the injury, the location of the injury, and the age and general health of the patient. Some common disabilities include problems with cognition (thinking, memory, and reasoning), sensory processing (sight, hearing, touch, taste, and smell), communication (expression and understanding), and behavior or mental health (depression, anxiety, personality changes, aggression, acting out, and social inappropriateness).

Within days to weeks of the head injury approximately 40 percent of TBI patients develop a host of troubling symptoms collectively called postconcussion syndrome (PCS). A patient need not have suffered a concussion or loss of consciousness to develop the syndrome and many patients with mild TBI suffer from PCS. Symptoms include headache, dizziness, vertigo (a sensation of spinning around or of objects spinning around the patient), memory problems, trouble concentrating, sleeping problems, restlessness, irritability, apathy, depression, and anxiety. These symptoms may last for a few weeks after the head injury. The syndrome is more prevalent in patients who had psychiatric symptoms, such as depression or anxiety, before the injury. Treatment for PCS may include medicines for pain and psychiatric conditions, and psychotherapy and occupational therapy todevelop coping skills.

Cognition is a term used to describe the processes of thinking, reasoning, problem solving, information processing, and memory. Most patients with severe TBI, if they recover consciousness, suffer from cognitive disabilities, including the loss of many higher level mental skills. The most common cognitive impairment among severely head-injured patients is memory loss, characterized by some loss of specific memories and the partial inability to form or store new ones. Some of these patients may experience post-traumatic amnesia (PTA), either anterograde or retrograde. Anterograde PTA is impaired memory of events that happened after the TBI, while retrograde PTA is impaired memory of events that happened before the TBI.

Many patients with mild to moderate head injuries who experience cognitive deficits become easily confused or distracted and have problems with concentration and attention. They also have problems with higher level, so-called executive functions, such as planning, organizing, abstract reasoning, problem solving, and making judgments, which may make it difficult to resume pre-injury work-related activities. Recovery from cognitive deficits is greatest within the first 6 months after the injury and more gradual after that.

Patients with moderate to severe TBI have more problems with cognitive deficits than patients with mild TBI, but a history of several mild TBIs may have an additive effect, causing cognitive deficits equal to a moderate or severe injury.

Many TBI patients have sensory problems, especially problems with vision. Patients may not be able to register what they are seeing or may be slow to recognize objects. Also, TBI patients often have difficulty with hand-eye coordination. Because of this, TBI patients may be prone to bumping into or dropping objects, or may seem generally unsteady. TBI patients may have difficulty driving a car, working complex machinery, or playing sports. Other sensory deficits may include problems with hearing, smell, taste, or touch. Some TBI patients develop tinnitus, a ringing or roaring in the ears. A person with damage to the part of the brain that processes taste or smell may develop a persistent bitter taste in the mouth or perceive a persistent noxious smell. Damage to the part of the brain that controls the sense of touch may cause a TBI patient to develop persistent skin tingling, itching, or pain. Although rare, these conditions are hard to treat.

Language and communication problems are common disabilities in TBI patients. Some may experience aphasia, defined as difficulty with understanding and producing spoken and written language; others may have difficulty with the more subtle aspects of communication, such as body language and emotional, non-verbal signals.

In non-fluent aphasia, also called Broca’s aphasia or motor aphasia, TBI patients often have trouble recalling words and speaking in complete sentences. They may speak in broken phrases and pause frequently. Most patients are aware of these deficits and may become extremely frustrated. Patients with fluent aphasia, also called Wernicke’s aphasia or sensory aphasia, display little meaning in their speech, even though they speak in complete sentences and use correct grammar. Instead, they speak in flowing gibberish, drawing out their sentences with non-essential and invented words. Many patients with fluent aphasia are unaware that they make little sense and become angry with others for not understanding them. Patients with global aphasia have extensive damage to the portions of the brain responsible for language and often suffer severe communication disabilities.

TBI patients may have problems with spoken language if the part of the brain that controls speech muscles is damaged. In this disorder, called dysarthria, the patient can think of the appropriate language, but cannot easily speak the words because they are unable to use the muscles needed to form the words and produce the sounds. Speech is often slow, slurred, and garbled. Some may have problems with intonation or inflection, called prosodic dysfunction. An important aspect of speech, inflection conveys emotional meaning and is necessary for certain aspects of language, such as irony. These language deficits can lead to miscommunication, confusion, and frustration for the patient as well as those interacting with him or her.

Most TBI patients have emotional or behavioral problems that fit under the broad category of psychiatric health. Family members of TBI patients often find that personality changes and behavioral problems are the most difficult disabilities to handle. Psychiatric problems that may surface include depression, apathy, anxiety, irritability, anger, paranoia, confusion, frustration, agitation, insomnia or other sleep problems, and mood swings. Problem behaviors may include aggression and violence, impulsivity, disinhibition, acting out, noncompliance, social inappropriateness, emotional outbursts, childish behavior, impaired self-control, impaired self awareness, inability to take responsibility or accept criticism, egocentrism, inappropriate sexual activity, and alcohol or drug abuse/addiction. Some patients’ personality problems may be so severe that they are diagnosed with borderline personality disorder, a psychiatric condition characterized by many of the problems mentioned above. Sometimes TBI patients suffer from developmental stagnation, meaning that they fail to mature emotionally, socially, or psychologically after the trauma. This is a serious problem for children and young adults who suffer from a TBI. Attitudes and behaviors that are appropriate for a child or teenager become inappropriate in adulthood. Many TBI patients who show psychiatric or behavioral problems can be helped with medication and psychotherapy.

 

via What Disabilities Can Result From a TBI? | BrainLine

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[VIDEO] Aphasia – Imagine life without words – YouTube

Aphasia – Imagine life without words – it could happen to you.

All comments are welcome on our Facebook page at http://www.facebook.com/Understanding…

Aphasia (or dysphasia) is a communication difficulty caused by brain damage. Most people who have aphasia have had a stroke, but it can also occur from tumours, infection and progressive diseases like motor neuron disease (ALS).

There are different types of aphasia like Wernicke’s, Broca’s. Conduction, Anomic and Global Aphasia which relates to the part of the brain that’s damaged. The term is also a descriptor of whether you lose your capacity to understand speech, talk, read and/or write. There are also different severity types, Global being the most severe as it affects all modes of written and verbal communication. However there is one commonality, the person with aphasia’s frustration at not being able to communicate in the way they used to.

This video on “Aphasia – life without words” was made by a Speech Pathologist and aims to take you into the world of a person with aphasia – a young mother who struggles to do everyday things. How does she shop? Eat at a café? Spend time with friends? This video also shows real life examples of supports and treatment options anyone can put in place, once they have been shown how.

Millions of people suffer from this condition, its time they had a voice, it is time people understood aphasia.

Please share this link with friends, family and colleagues and help raise awareness.

Aphasia: FIND the opportunity, MAKE the difference

via Aphasia – Imagine life without words – YouTube

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[Fact Sheet] Post-Stroke Rehabilitation Fact Sheet – National Institute of Neurological Disorders and Stroke

Post-Stroke Rehabilitation Fact Sheet

In the United States more than 700,000 people suffer a stroke each year, and approximately two-thirds of these individuals survive and require rehabilitation. The goals of rehabilitation are to help survivors become as independent as possible and to attain the best possible quality of life. Even though rehabilitation does not “cure” the effects of stroke in that it does not reverse brain damage, rehabilitation can substantially help people achieve the best possible long-term outcome.

What is post-stroke rehabilitation?

Rehabilitation helps stroke survivors relearn skills that are lost when part of the brain is damaged. For example, these skills can include coordinating leg movements in order to walk or carrying out the steps involved in any complex activity. Rehabilitation also teaches survivors new ways of performing tasks to circumvent or compensate for any residual disabilities. Individuals may need to learn how to bathe and dress using only one hand, or how to communicate effectively when their ability to use language has been compromised. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully directed,well-focused, repetitive practice—the same kind of practice used by all people when they learn a new skill, such as playing the piano or pitching a baseball.

Rehabilitative therapy begins in the acute-care hospital after the person’s overall condition has been stabilized, often within 24 to 48 hours after the stroke. The first steps involve promoting independent movement because many individuals are paralyzed or seriously weakened. Patients are prompted to change positions frequently while lying in bed and to engage in passive or active range of motion exercises to strengthen their stroke-impaired limbs. (“Passive” range-of-motion exercises are those in which the therapist actively helps the patient move a limb repeatedly, whereas “active” exercises are performed by the patient with no physical assistance from the therapist.) Depending on many factors—including the extent of the initial injury—patients may progress from sitting up and being moved between the bed and a chair to standing, bearing their own weight, and walking, with or without assistance. Rehabilitation nurses and therapists help patients who are able to perform progressively more complex and demanding tasks, such as bathing, dressing, and using a toilet, and they encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. Beginning to reacquire the ability to carry out these basic activities of daily living represents the first stage in a stroke survivor’s return to independence.

For some stroke survivors, rehabilitation will be an ongoing process to maintain and refine skills and could involve working with specialists for months or years after the stroke.

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What disabilities can result from a stroke?

The types and degrees of disability that follow a stroke depend upon which area of the brain is damaged. Generally, stroke can cause five types of disabilities: paralysis or problems controlling movement; sensory disturbances including pain; problems using or understanding language; problems with thinking and memory; and emotional disturbances.

Paralysis or problems controlling movement (motor control)

Paralysis is one of the most common disabilities resulting from stroke. The paralysis is usually on the side of the body opposite the side of the brain damaged by stroke, and may affect the face, an arm, a leg, or the entire side of the body. This one-sided paralysis is called hemiplegia (one-sided weakness is called hemiparesis). Stroke patients with hemiparesis or hemiplegia may have difficulty with everyday activities such as walking or grasping objects. Some stroke patients have problems with swallowing, called dysphagia, due to damage to the part of the brain that controls the muscles for swallowing. Damage to a lower part of the brain, the cerebellum, can affect the body’s ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance.

Sensory disturbances including pain

Stroke patients may lose the ability to feel touch, pain, temperature, or position. Sensory deficits also may hinder the ability to recognize objects that patients are holding and can even be severe enough to cause loss of recognition of one’s own limb. Some stroke patients experience pain, numbness or odd sensations of tingling or prickling in paralyzed or weakened limbs, a symptom known as paresthesias.

The loss of urinary continence is fairly common immediately after a stroke and often results from a combination of sensory and motor deficits. Stroke survivors may lose the ability to sense the need to urinate or the ability to control bladder muscles. Some may lack enough mobility to reach a toilet in time. Loss of bowel control or constipation also may occur. Permanent incontinence after a stroke is uncommon, but even a temporary loss of bowel or bladder control can be emotionally difficult for stroke survivors.

Stroke survivors frequently have a variety of chronic pain syndromes resulting from stroke-induced damage to the nervous system (neuropathic pain). In some stroke patients, pathways for sensation in the brain are damaged, causing the transmission of false signals that result in the sensation of pain in a limb or side of the body that has the sensory deficit. The most common of these pain syndromes is called “thalamic pain syndrome” (caused by a stroke to the thalamus, which processes sensory information from the body to the brain), which can be difficult to treat even with medications. Finally, some pain that occurs after stroke is not due to nervous system damage, but rather to mechanical problems caused by the weakness from the stroke.  Patients who have a seriously weakened or paralyzed arm commonly experience moderate to severe pain that radiates outward from the shoulder. Most often, the pain results from lack of movement in a joint that has been immobilized for a prolonged period of time (such as having your arm or shoulder in a cast for weeks) and the tendons and ligaments around the joint become fixed in one position. This is commonly called a “frozen” joint; “passive” movement (the joint is gently moved or flexed by a therapist or caregiver rather than by the individual) at the joint in a paralyzed limb is essential to prevent painful “freezing” and to allow easy movement if and when voluntary motor strength returns.

Problems using or understanding language (aphasia)

At least one-fourth of all stroke survivors experience language impairments, involving the ability to speak, write, and understand spoken and written language. A stroke-induced injury to any of the brain’s language-control centers can severely impair verbal communication. The dominant centers for language are in the left side of the brain for right-handed individuals and many left-handers as well. Damage to a language center located on the dominant side of the brain, known as Broca’s area, causes expressive aphasia. People with this type of aphasia have difficulty conveying their thoughts through words or writing. They lose the ability to speak the words they are thinking and to put words together in coherent, grammatically correct sentences. In contrast, damage to a language center located in a rear portion of the brain, called Wernicke’s area, results in receptive aphasia. People with this condition have difficulty understanding spoken or written language and often have incoherent speech. Although they can form grammatically correct sentences, their utterances are often devoid of meaning. The most severe form of aphasia, global aphasia, is caused by extensive damage to several areas of the brain involved in language function. People with global aphasia lose nearly all their linguistic abilities; they cannot understand language or use it to convey thought.

Problems with thinking and memory

Stroke can cause damage to parts of the brain responsible for memory, learning, and awareness. Stroke survivors may have dramatically shortened attention spans or may experience deficits in short-term memory. Individuals also may lose their ability to make plans, comprehend meaning, learn new tasks, or engage in other complex mental activities. Two fairly common deficits resulting from stroke are anosognosia, an inability to acknowledge the reality of the physical impairments resulting from stroke, and neglect, the loss of the ability to respond to objects or sensory stimuli located on the stroke-impaired side. Stroke survivors who develop apraxia (loss of ability to carry out a learned purposeful movement) cannot plan the steps involved in a complex task and act on them in the proper sequence. Stroke survivors with apraxia also may have problems following a set of instructions. Apraxia appears to be caused by a disruption of the subtle connections that exist between thought and action.

Emotional disturbances

Many people who survive a stroke feel fear, anxiety, frustration, anger, sadness, and a sense of grief for their physical and mental losses. These feelings are a natural response to the psychological trauma of stroke. Some emotional disturbances and personality changes are caused by the physical effects of brain damage. Clinical depression, which is a sense of hopelessness that disrupts an individual’s ability to function, appears to be the emotional disorder most commonly experienced by stroke survivors. Signs of clinical depression include sleep disturbances, a radical change in eating patterns that may lead to sudden weight loss or gain, lethargy, social withdrawal, irritability, fatigue, self-loathing, and suicidal thoughts. Post-stroke depression can be treated with antidepressant medications and psychological counseling.

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What medical professionals specialize in post-stroke rehabilitation?

Post-stroke rehabilitation involves physicians; rehabilitation nurses; physical, occupational, recreational, speech-language, and vocational therapists; and mental health professionals.

Physicians

Physicians have the primary responsibility for managing and coordinating the long-term care of stroke survivors, including recommending which rehabilitation programs will best address individual needs. Physicians also are responsible for caring for the stroke survivor’s general health and providing guidance aimed at preventing a second stroke, such as controlling high blood pressure or diabetes and eliminating risk factors such as cigarette smoking, excessive weight, a high-cholesterol diet, and high alcohol consumption.

Neurologists usually lead acute-care stroke teams and direct patient care during hospitalization. They sometimes participate on the long-term rehabilitation team. Other subspecialists often lead the rehabilitation stage of care, especially physiatrists, who specialize in physical medicine and rehabilitation.

Rehabilitation nurses

Nurses specializing in rehabilitation help survivors relearn how to carry out the basic activities of daily living. They also educate survivors about routine health care, such as how to follow a medication schedule, how to care for the skin, how to move out of a bed and into a wheelchair, and special needs for people with diabetes. Rehabilitation nurses also work with survivors to reduce risk factors that may lead to a second stroke, and provide training for caregivers.

Nurses are closely involved in helping stroke survivors manage personal care issues, such as bathing and controlling incontinence. Most stroke survivors regain their ability to maintain continence, often with the help of strategies learned during rehabilitation. These strategies include strengthening pelvic muscles through special exercises and following a timed voiding schedule. If problems with incontinence continue, nurses can help caregivers learn to insert and manage catheters and to take special hygienic measures to prevent other incontinence-related health problems from developing.

Physical therapists

Physical therapists specialize in treating disabilities related to motor and sensory impairments. They are trained in all aspects of anatomy and physiology related to normal function, with an emphasis on movement. They assess the stroke survivor’s strength, endurance, range of motion, gait abnormalities, and sensory deficits to design individualized rehabilitation programs aimed at regaining control over motor functions.

Physical therapists help survivors regain the use of stroke-impaired limbs, teach compensatory strategies to reduce the effect of remaining deficits, and establish ongoing exercise programs to help people retain their newly learned skills. Disabled people tend to avoid using impaired limbs, a behavior called learned non-use. However, the repetitive use of impaired limbs encourages brain plasticity and helps reduce disabilities.

Strategies used by physical therapists to encourage the use of impaired limbs include selective sensory stimulation such as tapping or stroking, active and passive range-of-motion exercises, and temporary restraint of healthy limbs while practicing motor tasks.

In general, physical therapy emphasizes practicing isolated movements, repeatedly changing from one kind of movement to another, and rehearsing complex movements that require a great deal of coordination and balance, such as walking up or down stairs or moving safely between obstacles. People too weak to bear their own weight can still practice repetitive movements during hydrotherapy (in which water provides sensory stimulation as well as weight support) or while being partially supported by a harness. A recent trend in physical therapy emphasizes the effectiveness of engaging in goal-directed activities, such as playing games, to promote coordination. Physical therapists frequently employ selective sensory stimulation to encourage use of impaired limbs and to help survivors with neglect regain awareness of stimuli on the neglected side of the body.

Occupational and recreational therapists

Like physical therapists, occupational therapists are concerned with improving motor and sensory abilities, and ensuring patient safety in the post-stroke period. They help survivors relearn skills needed for performing self-directed activities (also called occupations) such as personal grooming, preparing meals, and housecleaning. Therapists can teach some survivors how to adapt to driving and provide on-road training. They often teach people to divide a complex activity into its component parts, practice each part, and then perform the whole sequence of actions. This strategy can improve coordination and may help people with apraxia relearn how to carry out planned actions.

Occupational therapists also teach people how to develop compensatory strategies and change elements of their environment that limit activities of daily living. For example, people with the use of only one hand can substitute hook and loop fasteners (such as Velcro) for buttons on clothing. Occupational therapists also help people make changes in their homes to increase safety, remove barriers, and facilitate physical functioning, such as installing grab bars in bathrooms.

Recreational therapists help people with a variety of disabilities to develop and use their leisure time to enhance their health, independence, and quality of life.

Speech-language pathologists

Speech-language pathologists help stroke survivors with aphasia relearn how to use language or develop alternative means of communication. They also help people improve their ability to swallow, and they work with patients to develop problem-solving and social skills needed to cope with the after-effects of a stroke.

Many specialized therapeutic techniques have been developed to assist people with aphasia. Some forms of short-term therapy can improve comprehension rapidly. Intensive exercises such as repeating the therapist’s words, practicing following directions, and doing reading or writing exercises form the cornerstone of language rehabilitation. Conversational coaching and rehearsal, as well as the development of prompts or cues to help people remember specific words, are sometimes beneficial. Speech-language pathologists also help stroke survivors develop strategies for circumventing language disabilities. These strategies can include the use of symbol boards or sign language. Recent advances in computer technology have spurred the development of new types of equipment to enhance communication.

Speech-language pathologists use special types of imaging techniques to study swallowing patterns of stroke survivors and identify the exact source of their impairment. Difficulties with swallowing have many possible causes, including a delayed swallowing reflex, an inability to manipulate food with the tongue, or an inability to detect food remaining lodged in the cheeks after swallowing. When the cause has been pinpointed, speech-language pathologists work with the individual to devise strategies to overcome or minimize the deficit. Sometimes, simply changing body position and improving posture during eating can bring about improvement. The texture of foods can be modified to make swallowing easier; for example, thin liquids, which often cause choking, can be thickened. Changing eating habits by taking small bites and chewing slowly can also help alleviate dysphagia.

Vocational therapists

Approximately one-fourth of all strokes occur in people between the ages of 45 and 65. For most people in this age group, returning to work is a major concern. Vocational therapists perform many of the same functions that ordinary career counselors do. They can help people with residual disabilities identify vocational strengths and develop résumés that highlight those strengths. They also can help identify potential employers, assist in specific job searches, and provide referrals to stroke vocational rehabilitation agencies.

Most important, vocational therapists educate disabled individuals about their rights and protections as defined by the Americans with Disabilities Act of 1990. This law requires employers to make “reasonable accommodations” for disabled employees. Vocational therapists frequently act as mediators between employers and employees to negotiate the provision of reasonable accommodations in the workplace.

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When can a stroke patient begin rehabilitation?

Rehabilitation should begin as soon as a stroke patient is stable, sometimes within 24 to 48 hours after a stroke. This first stage of rehabilitation can occur within an acute-care hospital; however, it is very dependent on the unique circumstances of the individual patient.

Recently, in the largest stroke rehabilitation study in the United States, researchers compared two common techniques to help stroke patients improve their walking.  Both methods—training on a body-weight supported treadmill or working on strength and balance exercises at home with a physical therapist—resulted in equal improvements in the individual’s ability to walk by the end of one year. Researchers found that functional improvements could be seen as late as one year after the stroke, which goes against the conventional wisdom that most recovery is complete by 6 months. The trial showed that 52 percent of the participants made significant improvements in walking, everyday function and quality of life, regardless of how severe their impairment was, or whether they started the training at 2 or 6 months after the stroke.

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Where can a stroke patient get rehabilitation?

At the time of discharge from the hospital, the stroke patient and family coordinate with hospital social workers to locate a suitable living arrangement. Many stroke survivors return home, but some move into some type of medical facility.

Inpatient rehabilitation units

Inpatient facilities may be freestanding or part of larger hospital complexes. Patients stay in the facility, usually for 2 to 3 weeks, and engage in a coordinated, intensive program of rehabilitation. Such programs often involve at least 3 hours of active therapy a day, 5 or 6 days a week. Inpatient facilities offer a comprehensive range of medical services, including full-time physician supervision and access to the full range of therapists specializing in post-stroke rehabilitation.

Outpatient units

Outpatient facilities are often part of a larger hospital complex and provide access to physicians and the full range of therapists specializing in stroke rehabilitation. Patients typically spend several hours, often 3 days each week, at the facility taking part in coordinated therapy sessions and return home at night. Comprehensive outpatient facilities frequently offer treatment programs as intense as those of inpatient facilities, but they also can offer less demanding regimens, depending on the patient’s physical capacity.

Nursing facilities

Rehabilitative services available at nursing facilities are more variable than are those at inpatient and outpatient units. Skilled nursing facilities usually place a greater emphasis on rehabilitation, whereas traditional nursing homes emphasize residential care. In addition, fewer hours of therapy are offered compared to outpatient and inpatient rehabilitation units.

Home-based rehabilitation programs

Home rehabilitation allows for great flexibility so that patients can tailor their program of rehabilitation and follow individual schedules. Stroke survivors may participate in an intensive level of therapy several hours per week or follow a less demanding regimen. These arrangements are often best suited for people who require treatment by only one type of rehabilitation therapist. Patients dependent on Medicare coverage for their rehabilitation must meet Medicare’s “homebound” requirements to qualify for such services; at this time lack of transportation is not a valid reason for home therapy. The major disadvantage of home-based rehabilitation programs is the lack of specialized equipment. However, undergoing treatment at home gives people the advantage of practicing skills and developing compensatory strategies in the context of their own living environment. In the recent stroke rehabilitation trial, intensive balance and strength rehabilitation in the home was equivalent to treadmill training at a rehabilitation facility in improving walking.

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What research is being done?

The National Institute of Neurological Disorders and Stroke (NINDS), a component of the U.S. National Institutes of Health (NIH), has primary responsibility for sponsoring research on disorders of the brain and nervous system, including the acute phase of stroke and the restoration of function after stroke.  The NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development, through its National Center for Medical Rehabilitation Research, funds work on mechanisms of restoration and repair after stroke, as well as development of new approaches to rehabilitation and evaluation of outcomes.  Most of the NIH-funded work on diagnosis and treatment of dysphagia is through the National Institute on Deafness and Other Communication Disorders.  The National Institute of Biomedical Imaging and Bioengineering collaborates with NINDS and NICHD in developing new instrumentation for stroke treatment and rehabilitation.  The National Eye Institute funds work directed at restoration of vision and rehabilitation for individuals with impaired or low vision that may be due to vascular disease or stroke.

The NINDS supports research on ways to enhance repair and regeneration of the central nervous system. Scientists funded by the NINDS are studying how the brain responds to experience or adapts to injury by reorganizing its functions (plasticity)—using noninvasive imaging technologies to map patterns of biological activity inside the brain. Other NINDS-sponsored scientists are looking at brain reorganization after stroke and determining whether specific rehabilitative techniques, such as constraint-induced movement therapy and transcranial magnetic stimulation, can stimulate brain plasticity, thereby improving motor function and decreasing disability. Other scientists are experimenting with implantation of neural stem cells, to see if these cells may be able to replace the cells that died as a result of a stroke.

*An ischemic stroke or “brain attack” occurs when brain cells die because of inadequate blood flow. When blood flow is interrupted, brain cells are robbed of vital supplies of oxygen and nutrients. About 80 percent of strokes are caused by the blockage of an artery in the neck or brain. A hemorrhagic stroke is caused by a burst blood vessel in the brain that causes bleeding into or around the brain.

**Functions compromised when a specific region of the brain is damaged by stroke can sometimes be taken over by other parts of the brain. This ability to adapt and change is known as neuroplasticity.

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Where can I get more information?

For more information on neurological disorders or research programs funded by the National Institute of Neurological Disorders and Stroke, contact the Institute’s Brain Resources and Information Network (BRAIN) at:

BRAIN
P.O. Box 5801
Bethesda, MD 20824
800-352-9424
http://www.ninds.nih.gov

Information also is available from the following organizations:

American Stroke Association: A Division of American Heart Association
7272 Greenville Avenue

Dallas, TX 75231-4596

Tel: 888-4STROKE (478-7653)
Brain Aneurysm Foundation
269 Hanover Street, Building 3

Hanover, MA 02339

Tel: 781-826-5556; 888-BRAIN02 (272-4602)
Brain Attack Coalition
31 Center Drive
Room 8A07

Bethesda, MD 20892-2540

Tel: 301-496-5751
Children’s Hemiplegia and Stroke Assocn. (CHASA)
4101 West Green Oaks Blvd., Ste. 305
PMB 149

Arlington, TX 76016

Tel: 817-492-4325
Fibromuscular Dysplasia Society of America (FMDSA)
20325 Center Ridge Road Suite 620

Rocky River, OH 44116

Tel: 216-834-2410; 888-709-7089
Hazel K. Goddess Fund for Stroke Research in Women
785 Park Road, #3E

New York, NY 10021

Heart Rhythm Society
1325 G Street, N.W.
Suite 400

Washington, DC 20005

Tel: 202-464-3454
Joe Niekro Foundation
PO Box 2876

Scottsdale, AZ 85252

Tel: 602-318-1013
National Aphasia Association
P.O. Box 87

Scarsdale, NY 10583

Tel: 212-267-2814; 800-922-4NAA (4622)
National Stroke Association
9707 East Easter Lane
Suite B

Centennial, CO 80112-3747

Tel: 303-649-9299; 800-STROKES (787-6537)
YoungStroke, Inc.
P.O. Box 692

Conway, SC 29528

Tel: 843-248-9019; 843-655-2835

“Post-Stroke Fact Sheet”, NINDS, Publication date September 2014.

NIH Publication No. 14-1846

Stroke fact sheet available in multiple languages through MedlinePlus

Back to Stroke Information

See a list of all NINDS disorders


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Prepared by:
Office of Communications and Public Liaison
National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
NINDS health-related material is provided for information purposes only and does not necessarily represent endorsement by or an official position of the National Institute of Neurological Disorders and Stroke or any other Federal agency. Advice on the treatment or care of an individual patient should be obtained through consultation with a physician who has examined that patient or is familiar with that patient’s medical history.

All NINDS-prepared information is in the public domain and may be freely copied. Credit to the NINDS or the NIH is appreciated.

 

via Post-Stroke Rehabilitation Fact Sheet | National Institute of Neurological Disorders and Stroke

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[REVIEW] Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls – Full Text

Acute brain ischemia causes changes in several neural networks and related cortico-subcortical excitability, both in the affected area and in the apparently spared contralateral hemisphere. The modulation of these processes through modern techniques of noninvasive brain stimulation, namely repetitive transcranial magnetic stimulation (rTMS), has been proposed as a viable intervention that could promote post-stroke clinical recovery and functional independence. This review provides a comprehensive summary of the current evidence from the literature on the efficacy of rTMS applied to different clinical and rehabilitative aspects of stroke patients. A total of 32 meta-analyses published until July 2019 were selected, focusing on the effects on motor function, manual dexterity, walking and balance, spasticity, dysphagia, aphasia, unilateral neglect, depression, and cognitive function after a stroke. Only conventional rTMS protocols were considered in this review, and meta-analyses focusing on theta burst stimulation only were excluded. Overall, both HF-rTMS and LF-rTMS have been shown to be safe and well-tolerated. In addition, the current literature converges on the positive effect of rTMS in the rehabilitation of all clinical manifestations of stroke, except for spasticity and cognitive impairment, where definitive evidence of efficacy cannot be drawn. However, routine use of a specific paradigm of stimulation cannot be recommended yet due to a significant level of heterogeneity of the studies in terms of protocols to be set and outcome measures that have to be used. Future studies need to preliminarily evaluate the most promising protocols before going on to multicenter studies with large cohorts of patients in order to achieve a definitive translation into daily clinical practice.

Background

Stroke is a common acute neurovascular disorder that causes disabling long-term limitations to daily living activities. The most common consequence of a stroke is motor deficit of variable degree,1 although nonmotor symptoms are also relevant and often equally disabling.2 To date, to the best of the authors’ knowledge, there is no validated treatment that is able to restore the impaired functions by a complete recovery of the damaged tissue. Indeed, stroke management basically consists of reducing the initial ischemia in the penumbra, preventing future complications, and promoting a functional recovery using physiotherapy, speech therapy, occupational therapy, and other conventional treatments.3,4

Ischemic damage is associated with significant metabolic and electrophysiological changes in cells and neural networks involved in the affected area. From a pure electrophysiological perspective, however, beyond the affected area, there is a local shift in the balance between the inhibition and excitation of both the affected and contralateral hemisphere, consisting of increased excitability and disinhibition (reduced activity of the inhibitory circuits).3,5 In addition, subcortical areas and spinal regions may be altered.3,5 In particular, the role of the uninjured hemisphere seems to be of utmost significance in post-stroke clinical and functional recovery.

Different theoretical models have been proposed to explain the adaptive response of the brain to acute vascular damage. According to the vicariation model, the activity of the unaffected hemisphere contributes to the functional recovery after a stroke through the replacement of the lost functions of the affected areas. The interhemispheric competition model considers the presence of mutual inhibition between the hemispheres, and the damage caused by a stroke disrupts this balance, thus producing a reduced inhibition of the unaffected hemisphere by the affected side. This results in increased inhibition of the affected hemisphere by the unaffected side. More recently, a new model, called bimodal balance recovery, has been proposed.3,5 It introduces the concept of a structural reserve, which describes the extent to which the nondamaged neural pathways contribute to the clinical recovery. The structural reserve determines the prevalence of the interhemispheric imbalance over vicariation. When the structural reserve is high, the interhemispheric competition model can predict the recovery better than the vicariation model, and vice versa.3

Repetitive transcranial magnetic stimulation

One of the proposed interventions to improve stroke recovery, by the induction of neuromodulation phenomena, is based on methods of noninvasive brain stimulation. Among them, transcranial magnetic stimulation (TMS) is a feasible and painless neurophysiological technique widely used for diagnostic, prognostic, research, and, when applied repetitively, therapeutic purposes.69 By electromagnetic induction, TMS generates sub or suprathreshold currents in the human cortex in vivo and in real time.10,11

The most common stimulation site is the primary motor cortex (M1), that generates motor evoked potentials (MEPs) recorded from the contralateral muscles through surface electromyography electrodes.11 The intensity of TMS, measured as a percentage of the maximal output of the stimulator, is tailored to each patient based on the motor threshold (MT) of excitability. Resting MT (rMT) is found when the target muscle is at rest, it is defined as the minimal intensity of M1 stimulation required to elicit an electromyography response with a peak-to-peak amplitude > 50 µV in at least 5 out of 10 consecutive trials.11 Alternatively TMS MTAT 2.0 software (http://www.clinicalresearcher.org/software.htm) is a free tool for TMS researchers and practitioners. It provides four adaptive methods based on threshold-tracking algorithms with the parameter estimation by sequential testing, using the maximum-likelihood strategy for estimating MTs. Active MT (aMT) is obtained during a tonic contraction of the target muscle at approximately 20% of the maximal muscular strength.11

The rMT is considered a basic parameter in providing the global excitation state of a central core of M1 neurons.11 Accordingly, rMT is increased by drugs blocking the voltage-gated sodium channels, where the same drugs may not have an effect on the gamma-aminobutyric acid (GABA)-ergic functions. In contrast, rMT is reduced by drugs increasing glutamatergic transmission not mediated by the N-methyl-D-aspartate (NMDA) receptors, suggesting that rMT reflects both neuronal membrane excitability and non-NMDA receptor glutamatergic neurotransmission.12 Finally, the MT increases, being often undetectable, when a substantial portion of M1 or the cortico-spinal tract is damaged (i.e. by stroke or motor neuron disease), and decreases when the motor pathway is hyperexcitable (such as epilepsy).13

Repetitive (rTMS) is a specific stimulation paradigm characterized by the administration of a sequence of consecutive stimuli on the same cortical region, at different frequencies and inter sequence intervals. As known, rTMS can transiently modulate the excitability of the stimulated cortex, with both local and remote effects outlasting the stimulation period. Conventional rTMS modalities include high-frequency (HF-rTMS) stimulation (>1 Hz) and low-frequency (LF-rTMS) stimulation (⩽1 Hz).11 High-frequency stimulation typically increases motor cortex excitability of the stimulated area, whereas low-frequency stimulation usually produces a decrease in excitability.14 The mechanisms by which rTMS modulates the brain are rather complex, although they seem to be related to the phenomena of long-term potentiation (LTP) and long-term depression (LTD).15

When applied after a stroke, rTMS should ideally be able to suppress the so called ‘maladaptive plasticity’16,17 or to enhance the adaptive plasticity during rehabilitation. These goals can be achieved by modulating the local cortical excitability or modifying connectivity within the neuronal networks.10

rTMS in stroke rehabilitation: an overview

According to the latest International Federation of Clinical Neurophysiology (IFCN) guidelines on the therapeutic use of rTMS,10 there is a possible effect of LF-rTMS of the contralesional motor cortex in post-acute motor stroke, and a probable effect in chronic motor stroke. An effect of HF-rTMS on the ipsilesional motor cortex in post-acute and chronic motor stroke is also possible.

The potential role of rTMS in gross motor function recovery after a stroke has been assessed in a recent comprehensive systematic review of 70 studies by Dionisio and colleagues.18 The majority of the publications reviewed report a role of rTMS in improving motor function, although some randomized controlled trials (RCTs) were not able to confirm this result,1923 as shown by a recent large randomized, sham-controlled, clinical trial of navigated LF-rTMS.24 It has also been suggested that rTMS can specifically improve manual dexterity,10 which is defined as the ability to coordinate the fingers and efficiently manipulate objects, and is of crucial importance for daily living activities.25 Notably, most of the studies focused on motor impairment in the upper limbs, whereas limited data is available on the lower limbs.18 Walking and balance are frequently impaired in stroke patients and significantly affect the quality of life (QoL),26,27 and rTMS might represent a valid aid in the recovery of these functions.28,29 Spasticity is another common complication after a stroke, consisting of a velocity-dependent increase of muscular tone,30 and for which rTMS has been proposed as a rehabilitation tool.31

Dysphagia is highly common in stroke patients, it impairs the global clinical recovery, and predisposes to complications.32 It has been pointed out that rTMS targeting the M1 area representing the muscles involved in swallowing may contribute to the treatment of post-stroke dysphagia.33

Nonmotor deficit is also a relevant post-stroke disability that negatively impacts the QoL. Aphasia is a very common consequence of stroke, affecting approximately 30% of stroke survivors and significantly limiting rehabilitation.34 According to the IFCN guidelines, to date, there is no recommendation for LF-rTMS of the contralesional right inferior frontal gyrus (IFG). Similarly, no recommendation for HF-rTMS or intermittent theta burst stimulation (TBS) of the ipsilesional left IFG or dorsolateral prefrontal cortex (DLPFC) in Broca’s aphasia has been currently approved.10 The same is true for LF-rTMS of the right superior temporal gyrus in Wernicke’s aphasia.10

Neglect is the incapacity to respond to tactile or visual contralateral stimuli that are not caused by a sensory-motor deficit.35 Although hard to treat, rTMS has been proposed as a tool for neglect rehabilitation.36 However, the IFCN guidelines state that currently there is no recommendation for LF-rTMS of the contralesional left posterior parietal cortex, or for HF-rTMS of the ipsilesional right posterior parietal cortex.10 In a recent systematic review, most of the included studies supported the use of TMS for the rehabilitation of aphasia, dysphagia, and neglect, although the heterogeneity of stimulation protocols did not allow definitive conclusions to be drawn.37

Post-stroke depression is a relevant complication of cerebrovascular diseases.38 The role of rTMS in the management of major depressive disorders is well documented,39,40 and currently, rTMS is internationally approved and indicated for the treatment of major depression in adults with antidepressant medication resistance, and in those with a recurrent course of illness, or in cases of moderate-to-severe disease severity.39 In major depression disorders, according to the IFCN guidelines, there is a clear antidepressant effect of HF-rTMS over the left DLPFC, a probable antidepressant effect of LF-rTMS on the right DLPFC, and probably no differential antidepressant effect between right LF-rTMS and left HF-rTMS. Moreover, there is currently no recommendation for bilateral stimulation combining HF-rTMS of the left DLPFC and LF-rTMS of the right DLPFC. The mentioned guidelines also state that the antidepressant effect when stimulating DLPFC is probably additive, and possibly potentiating, to the efficacy of antidepressant drugs.10 However, no specific recommendation currently addresses the use of rTMS in post-stroke depression. Recently, rTMS has been proposed as a treatment option for the late-life depression associated with chronic subcortical ischemic vascular disease, the so called ‘vascular depression’.4144 Three studies tested rTMS efficacy in vascular depression (one was a follow-up study with citalopram). Although presenting positive findings, further trials should refine clinical and diagnostic criteria to assess its impact on antidepressant efficacy.45

Approximately 25–30% of stroke patients develop an immediate or delayed cognitive impairment or an overt picture of vascular dementia.46 There is evidence of an overall positive effect on cognitive function for both LF-rTMS47 and HF-rTMS,48 supported by studies on experimental models of vascular dementia.4952 Nonetheless, the few trials examining the effect on stroke-related cognitive deficit produced mixed results.5356 In particular, two studies found no effect on cognition when stimulating the left DLPFC at 1 Hz and 10 Hz,53,54 whereas a pilot study found a positive effect on the Stroop interference test with HF-rTMS over the left DLPFC in patients with vascular cognitive impairment without dementia.55 However, this finding was not replicated in a follow-up study.56 To summarize, rTMS can induce beneficial effects on specific cognitive domains, although data are limited and their clinical significance needs to be further validated. Major challenges exist in terms of appropriate patient selection and optimization of the stimulation protocols.57

Central post-stroke pain (CPSP) is the pain resulting from an ischemic lesion of the central nervous system.58 It represents a relatively common complication after a stroke, although it is often under-recognized and, therefore, undertreated.59 According to the IFCN guidelines for the use of rTMS in the treatment of neuropathic pain, there is a definite analgesic effect of HF-rTMS of contralateral M1 to the pain side, and LF-rTMS of contralateral M1 to the pain side is probably ineffective. In addition, there is currently no recommendation for cortical targets other than contralateral M1 to the pain side.10 Notably, rTMS might be effective in drug-resistant CPSP patients.58 A recent systematic review that included nine HF-rTMS studies suggested an effect on CPSP relief, but also underlined the insufficient quality of the studies considered.60

Study objective

In this article, we aim to provide an up-to-date overview of the most recent evidence on the efficacy of rTMS in the rehabilitation of stroke patients. Although several studies have been published, a conclusive statement supporting a systematic use of rTMS in the multifaceted clinical aspects of stroke rehabilitation is still lacking.

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Continue —> Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls – Francesco Fisicaro, Giuseppe Lanza, Alfio Antonio Grasso, Giovanni Pennisi, Rita Bella, Walter Paulus, Manuela Pennisi, 2019

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[WEB SITE] Communication problems after brain injury

Communication problems after brain injury are very common. Although most of us take it for granted, the ability to communicate requires extremely complex skills and many different parts of the brain are involved.

There are four main categories of the effects of brain injury. Any of these can cause communication problems:

  • Physical – affecting how the body works
  • Cognitive – affecting how the person thinks, learns and remembers
  • Emotional – affecting how the person feels
  • Behavioural – affecting how a person acts

Many people will experience more than one form of communication problem after brain injury, depending on the areas of the brain affected and the severity of the injury. It is also important to recognise that such problems may occur alongside other changes in physical, cognitive, emotional and behavioural functions.

The diagram below shows the cerebral cortex. The cortex is the outer part of the brain, which is responsible for our more sophisticated thinking skills. Many of the functions listed are important for communication and injury to any of these areas can impair communication skills.

This section explains some of the ways brain injury can affect communication.

  • Language impairment – aphasia (often called dysphasia)
    Covers problems with understanding language and expressing thoughts through language. Also covers problems with reading and writing.
  • Speech difficulties
    Discusses disorders of speech that can occur after brain injury.
  • Cognitive communication difficulties
    Covers some of the problems with communication caused by cognitive difficulties, such as memory impairment, attention difficulties, poor social skills and fatigue.

Our booklet Coping with communication problems after brain injury provides more in-depth information about the issues covered here, and you can contact the Headway helpline if you have any further questions.

via Communication problems | Headway

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[NEWS] New Study Suggests Benefits of Digital Therapy for Stroke Patients – Rehab Managment

Published on 

ConstantTherapy

A large scale retrospective study of post-stroke rehabilitation practices compares outcomes among patients using tablet-based therapy at home and those who complete the same therapy in a clinic.

The study, published in Frontiers in Neurology, analyzed data from 3,686 Constant Therapy users—patients with post-stroke aphasia—over a 4-year period (2013-2017).

In the study, home users and clinic users completed cognitive and language tasks such as Functional Math, Name Pictures, Map Reading, and Auditory Commands that are featured in the Constant Therapy app. Home users worked independently while clinic users worked under the guidance of a clinician. The study compared improvement rates for both groups, who were initially struggling with a task (less than 60% accuracy) but eventually mastered it (more than 90% accuracy), explains a media release from The Learning Corp.

Key findings include:

  • Home users took less time to master tasks than users who only practiced in the clinic. While both home and clinic users required roughly the same amount of practice to master cognitive and language tasks, users who had on-demand access to therapy on their tablet mastered tasks in a median of six days, while those with only in-clinic access mastered tasks in a median of 12 days.
  • Home users practiced therapy more frequently than clinic users. Users who had access to digital therapy on their own terms took advantage of practicing at home at least every two days, while clinic users practiced in the clinic just once every five days.
  • Improvements are possible long after a stroke has occurred. Thousands of people in the study, regardless of where they practiced, showed significant gains in language and cognitive skills even though their stroke occurred long ago (on average two years ago for home users and average of 1.6 years ago for clinic users).
  • Improvements aren’t just for the young. While the average age of home users was 60 years old and the average age of clinic users was 64 years old, nearly one third (29%) of users were 71 years old or more, and the oldest user was 97 years old.

Veera Anantha, president and CTO of The Learning Corp, suggests that the study’s findings show that home users who practice often can also progress quickly, which may mean they are ready to work on more challenging tasks in their next home or clinic session.

“These insights from real world patient experience could help update existing guidelines and highlight areas for future study to uncover how improvements in specific tasks can help people living post-stroke regain the skills they cherish, such as reading a newspaper, having a complete conversation, or ordering from a menu at a restaurant,” Anantha states.

A previous study published in Frontiers in Human Neuroscience examined the effectiveness of Constant Therapy among a group of 51 patients. It provided preliminary evidence for the usefulness of a tablet-based platform to deliver tailored language and cognitive therapy to individuals with aphasia, per the release.

[Source(s): The Learning Corp, Business Wire]

 

via New Study Suggests Benefits of Digital Therapy for Stroke Patients – Rehab Managment

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[WEB SITE] Recovering From A Left Side Stroke – Saebo

Have you ever heard someone describe themselves as “right-brained” or “left-brained”? This concept is based on the brain having two hemispheres that perform different, specialized functions. Creative types have a dominant right brain, while analytical people favor the left. It is necessary to understand the functions of both hemispheres when assessing consequences of neurological damage. This knowledge helps anticipate problems that might occur and customize strategies for recovery.

Although the brain is divided into two hemispheres, they work in tandem to absorb information and process details. For instance, visual signals are sent to the right hemisphere first, but the left hemisphere uses context from past experiences to comprehend what the right brain has “seen”.

A left-brain stroke comes with a particular set of symptoms, changes, and challenges. An understanding of these consequences may ease the frustrations of stroke survivors and their families during the recovery process.

What Does The Left Brain Control?

The left hemisphere is responsible for controlling the logic of information processing. Common functions of the left hemisphere include the following:

  • Language
  • Critical thinking and analysis
  • Judgment and reasoning
  • Decision-making
  • Mathematics and sequencing

In a way, the left hemisphere processes information in words and numbers, as opposed to images, as the right hemisphere does. This lends to the common belief that “right-brain thinkers” are often more “creative” types, while left-brain thinkers are more analytical and mathematical.

Possible Effects Of A Left-Brain Stroke

Motor Impairment

On a physical level, the left hemisphere controls the right side of the body, and vice versa. Most physical impairments and paralysis after a stroke stem from issues in the brain, not in the impaired limb itself. Right-sided limbs are likely to suffer complications after a left-brain stroke, possibly resulting in hemiplegia—the paralysis of one side of the body.

Those recovering from a stroke may experience paralysis in certain limbs, and/or less severe symptoms including motor function impairment, muscle weakness, and spasticity. A combination of impairments can make daily life more challenging, both physically and psychologically.

Aphasia

Since the left hemisphere bears most of the responsibility for receiving and deciphering language, a left-brain stroke can often impair both speech production and the interpretation of word-based information. These impairments are collectively known as aphasia, and the consequences for everyday life depend on the type of aphasia experienced.

There are two main types of aphasia:

  1. Receptive aphasia complicates the brain’s reception and interpretation of words from speech or text. An individual with receptive aphasia may experience a range of confusion, from missing a word here or there to needing things repeated several times before they are comprehended. Left-brain stroke survivors may respond best to simpler words and direct, one-on-one conversations. Excessive distractions or multiple people speaking at once may inhibit comprehension. A survivor may find it easier to read short sentences, while complicated sentences and large paragraphs may cause frustration.
  2. Expressive aphasia complicates the spoken or written expression of thoughts. The exact manifestation will vary from person to person. At times, an individual with expressive aphasia may leave words out of long sentences, use words they don’t intend to say, or even use incomprehensible sounds instead of words. Changes in pace and inflection are also indicative of this.

The effects of aphasia become particularly complex when stroke survivors try to express their needs, especially during the initial stages of recovery. Someone may intend to ask for water but end up asking for something else entirely because they cannot find the right words. Depending on where the neurological damage occurred, stroke survivors may experience a combination of both types of aphasia.

Intellectual Impairment

Since analytical tasks default to the left hemisphere, a left-brain stroke may impair the management of common household and daily activities. Paying bills, handling money, or taking care of other analytical tasks may become more difficult. The stroke survivor may become dependent on family or a caretaker to complete important organizational tasks.

Behavioral Changes

It is common for those with left-brain injuries to process information more slowly and therefore move with more caution. Rushing may cause confusion or even injury. The inability to move quickly may lead to frustration and even periods of anger or depression.

Visual Impairment

Vision issues are particularly common in the right eye after a left-brain stroke. Potential problems include drooping of the eyelid and impaired blood flow to the retina. The stroke survivor may experience hemianopia, or blindness in half of the visual field.

Agnosia—the inability to recognize and name items—may also occur for the same reasons that produce aphasia. An injury to brain regions that manage naming and recognition may prevent the survivor from identifying common items, adding a sensation of foreignness and confusion to daily life.

Recovering From A Left-Brain Stroke

Though changes after a left-brain stroke are often abrupt and severe, the brain has an incredible ability to adjust and even reconnect neurological pathways. This ability is called neuroplasticity and occurs before you’re even born. Throughout childhood and adulthood, new pathways form as new information is absorbed by the brain. After an injury, the brain’s neuroplasticity can be sparked to form new neurons and connections through the repetition of targeted rehabilitation exercises. It is only through this constant repetition that the brain rewires and brings to life the lost connections.

Exercises that focus on the right side of the body and reinforce analytical reasoning are the most effective methods to support the regrowth of neurological pathways in the left hemisphere. After all, the body and mind are forever learning. This is true even if portions of the brain are no longer fully functional. Neural functions can adjust and change, for the better, through the support of ongoing rehabilitation.

All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.

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[Review] Current evidence on transcranial magnetic stimulation and its potential usefulness in post-stroke neurorehabilitation: Opening new doors to the treatment of cerebrovascular disease – Full Text

Abstract

Introduction

Repetitive transcranial magnetic stimulation (rTMS) is a therapeutic reality in post-stroke rehabilitation. It has a neuroprotective effect on the modulation of neuroplasticity, improving the brain’s capacity to retrain neural circuits and promoting restoration and acquisition of new compensatory skills.

Development

We conducted a literature search on PubMed and also gathered the latest books, clinical practice guidelines, and recommendations published by the most prominent scientific societies concerning the therapeutic use of rTMS in the rehabilitation of stroke patients. The criteria of the International Federation of Clinical Neurophysiology (2014) were followed regarding the inclusion of all evidence and recommendations.

Conclusions

Identifying stroke patients who are eligible for rTMS is essential to accelerate their recovery. rTMS has proven to be safe and effective for treating stroke complications. Functional brain activity can be optimised by applying excitatory or inhibitory electromagnetic pulses to the hemisphere ipsilateral or contralateral to the lesion, respectively, as well as at the level of the transcallosal pathway to regulate interhemispheric communication. Different studies of rTMS in these patients have resulted in improvements in motor disorders, aphasia, dysarthria, oropharyngeal dysphagia, depression, and perceptual-cognitive deficits. However, further well-designed randomised controlled clinical trials with larger sample size are needed to recommend with a higher level of evidence, proper implementation of rTMS use in stroke subjects on a widespread basis.

Introduction

Stroke patients should receive early neurorehabilitation after convalescence. For many years, researchers have aimed to identify new therapeutic targets to hasten recovery from stroke. However, we continue to lack a universally accepted, approved pharmacological therapy for these patients.1234 ;  5 After stroke, organisational changes in brain interneuronal activity in the affected area and the surrounding healthy tissue may on occasion promote functional recovery. Neurorehabilitation may help achieve this aim. Unfortunately, there are also occasions when neural reorganisation is suboptimal; in these cases, the problem persists and becomes chronic. In this context, transcranial magnetic stimulation (TMS) emerged as a tool for studying the brain and has been used since the mid-1980s to treat certain neuropsychiatric disorders. Neurorehabilitation is based on the idea that the brain is a dynamic entity able to adapt to internal and external homeostatic changes. This adaptive capacity, called neuroplasticity, is also present in patients with acquired brain injuries. The degree of recovery and the functional prognosis of these patients depend on the extent of neuroplastic changes.12345 ;  6 When performed by experienced physicians, TMS is a safe, non-invasive technique which enables the organisation of these neural changes (Fig. 1). The technique’s applications are expanding rapidly.12345678 ;  9

Modern TMS device.

Figure 1.

Modern TMS device.

We present the results of a literature review of the most relevant articles, manuals, and clinical practice guidelines addressing TMS (background information, diagnostic and therapeutic uses, and especially its usefulness for stroke neurorehabilitation) and published between 1985 (when the technique was first used) and 2015.

 

Development

The organisation of language in the brain

The left hemisphere of the brain is the anatomo-functional seat of language in 96% of right-handed and 70% of left-handed individuals. Language processing in the left hemisphere involves certain anatomical pathways for language comprehension, repetition, and production (Fig. 2). Positron emission tomography and functional magnetic resonance imaging (fMRI) studies conducted during multiple language tasks have shown brain activation not only in the main language centres (lesions to these areas may cause Broca aphasia, Wernicke aphasia, etc.) (Fig. 3) but also in many other locations, such as the thalamus (alertness), the basal ganglia (motor modulation), and the limbic system (affect and memory). Language is the perfect model for understanding how the central nervous system works as a whole.10 ;  11

Figure 2. The functional pathways involved in comprehension, repetition, and production of written, gesture, and spoken language, according to the Wernicke-Geschwind model. Within the left hemisphere, language organisation follows certain anatomical pathways for language comprehension, repetition, and production. Sounds are processed by the bilateral auditory cortex, in the superior temporal gyrus (primary auditory area), and decoded in the posterior area of the left temporal cortex (Wernicke area); the latter is connected to other cortical areas or networks which assign meaning to words. During reading, output from the primary visual area (bilaterally) travels to other parieto-occipital association areas for word and phrase recognition (especially the left fusiform gyrus, located in the inferior surface of the temporal lobe, where there is a key word recognition centre) and reaches the angular gyrus, which processes language-related visual and auditory information. In spontaneous language repetition and production, auditory information must travel through the arcuate fasciculus towards the left inferior frontal region (Broca area), which is responsible for language production; this area is also known to be involved in such other functions as action comprehension (mirror neurons). To produce written or spoken language, output from the Wernicke area, the Broca area, and nearby association areas must reach the primary motor cortex.10 ;  11
Adapted with permission from Bear et al.10

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Continue —> Current evidence on transcranial magnetic stimulation and its potential usefulness in post-stroke neurorehabilitation: Opening new doors to the treatment of cerebrovascular disease

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[Abstract] Low-frequency rTMS of the unaffected hemisphere in stroke patients: A systematic review

Abstract

The aim of this review was to summarize the evidence for the effectiveness of low-frequency (LF) repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere in promoting functional recovery after stroke. We performed a systematic search of the studies using LF-rTMS over the contralesional hemisphere in stroke patients and reviewed the 67 identified articles. The studies have been gathered together according to the time interval that had elapsed between the stroke onset and the beginning of the rTMS treatment. Inhibitory rTMS of the contralesional hemisphere can induce beneficial effects on stroke patients with motor impairment, spasticity, aphasia, hemispatial neglect and dysphagia, but the therapeutic clinical significance is unclear. We observed considerable heterogeneity across studies in the stimulation protocols. The use of different patient populations, regardless of lesion site and stroke aetiology, different stimulation parameters and outcome measures means that the studies are not readily comparable, and estimating real effectiveness or reproducibility is very difficult. It seems that careful experimental design is needed and it should consider patient selection aspects, rTMS parameters and clinical assessment tools. Consecutive sessions of rTMS, as well as the combination with conventional rehabilitation therapy, may increase the magnitude and duration of the beneficial effects. In an increasing number of studies, the patients have been enrolled early after stroke. The prolonged follow-up in these patients suggests that the effects of contralesional LF-rTMS can be long-lasting. However, physiological evidence indicating increased synaptic plasticity, and thus, a more favourable outcome, in the early enrolled patients, is still lacking. Carefully designed clinical trials designed are required to address this question. LF rTMS over unaffected hemisphere may have therapeutic utility, but the evidence is still preliminary and the findings need to be confirmed in further randomized controlled trials.

Source: Low-frequency rTMS of the unaffected hemisphere in stroke patients: A systematic review – Sebastianelli – 2017 – Acta Neurologica Scandinavica – Wiley Online Library

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