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The Book: Neuroscience-Based Rehabilitation for Stroke Patients | InTechOpen, Published on: 2017-05-10. Authors: Takayuki Kodama and Hideki Nakano
Chapter 9: Neuroscience-Based Rehabilitation for Stroke Patients
Hitherto, physical therapy for rehabilitating patients with cerebral dysfunction has focused on acquiring and improving compensatory strategies by using the remaining functions; it has been presumed that once neural functions have been lost, they cannot be restored. However, neuroscience-based animal research and neuroimaging research since the 1980s have demonstrated that recovery arises from plastic changes in the central nervous system and reconstruction of neural networks; this research is ushering in a new age of neuroscience-based rehabilitation as a treatment for cerebral dysfunction (such as stroke). In this paper, in regard to mental practices using motor imagery and kinaesthetic illusion, we summarize basic discoveries and theories relating to motor function therapy based on neuroscientific theory; in particular, we outline a novel rehabilitation method using kinaesthetic illusion induced by vibrational stimulus, which the authors are currently attempting in stroke patients.
Conventional physical therapy (PT) for the rehabilitation of patients with brain dysfunction focuses on the acquisition of function through alternative means by using and improving the patients’ existing functions, and it is based on the assumption that once a neutral function is lost, it can never be recovered . However, animal neuroscience studies [2–4] that were conducted after the 1980s and neuroimaging studies [5, 6] have shown that recovery can occur as a result of plastic changes in the nervous system or reorganization of the neural network, and rehabilitation (neuroscience-based rehabilitation, NBR) after cerebral dysfunction (e.g. stroke) has reached a new era in treatment. These observations suggest that the plasticity that is observed in patients is related to the characteristic that the more the patient receives therapy in specific parts of their body, the more that the brain areas that control these parts will be functionally as well as anatomically extended.
Functional recovery originally referred to a patient’s recovery from limitations in their behavior, movements, and/or activity . Therefore, the purpose of NBR is not only to induce the reorganization of brain functions through neural plasticity mechanisms but also recover comprehensive bodily motor functions and brain functions for autonomous and active social behavior. What type of treatment strategy is required so that patients feel positively engaged by it, gradually understand its effects, and work toward a goal? Previous studies have revealed important factors in the effects of NBR treatment, such as the amount of therapy [8, 9], rehabilitation implementation environment , and performance of neurocognitive rehabilitation  through mental practice techniques, such as motor imagery (MI) . Among these factors, treatments involving MI are strongly recommended because MI contributes to the reorganization of neural functions. MI, which is an approach that is based on neuroscientific data and the motor learning theory, is defined as the capacity to internally mimic physical movements without any associated motor output . The cognitive process that occurs during the imagination of movements involves various components, such as mutual understandings between oneself and others (environment), observations of movements, mental manipulations of objects, and psychological time and movement planning. Instead of repeating simple physical movements to receive feedback on outcome in the actual therapy, the practice of voluntary and skill-requiring movements that are geared toward task completion induces the functional recovery . Thus, an important element of the patients’ engagement in the therapy is that it occurs in an active and top-down fashion through the use of MI. However, because MI has a task-specific nature, cognitive functions and memories of motor experiences that equip the patients to perform the task are required. Patients with neurofunctional states that make motor execution (ME) difficulty may suffer not only from impairments in motor-related brain areas but also from modifications in their intracerebral body representations (e.g. somatoparaphrenia) [15, 16]. In such cases, the exploitation of kinaesthetic illusions [17–20], which can be induced in the brain by extraneous stimuli, such as vibratory stimulations, becomes important for inputting appropriate motor-sensory information into the brain in a passive and bottom-up fashion. Therefore, the implementation of a mental practice to determine the criteria for adequate treatment according to the states of the patient’s cognitive functions and motor functions is important in order to select and implement the best therapy. Thus, this paper summarizes the basic understanding and theories of mental practices that use MI or kinaesthetic illusion and discusses, in particular, research results concerning kinaesthetic illusions that are induced by vibratory stimulations, which we are currently attempting on stroke patients.
2. What is neuroscience-based rehabilitation?
NBR involves a series of processes that are selected for the intervention according to the current brain function theories that have been revealed by neuroscience and other similar studies and verification of its outcomes. For example, the selection of a NBR strategy for a stroke patient requires a combination of deep clinical reasoning, the experience of the therapist, and a vast understanding of the evidence obtained by studies from wide-ranging academic fields on the factors that support recovery mechanisms and produce particular outcomes. First, the neural basis of brain cell reorganization will be presented.
2.1. Neural basis of brain cell reorganization
The current understanding of neural reorganization after dysfunction is not that the neurons themselves recover after their axons are damaged but rather that damaged functional networks recover due to several processes that induce the recovery of motor and cognitive functions. Cajal , who was a proponent of neuron theory, stated that the central nervous system (brain and spinal cord) of adult mammals would not recover once it is damaged. However, studies that have been conducted since the 1980s and that have shown that alterations in the peripheral nervous system, such as denervation and amputation, change somatic sensations and the representations of body parts while they are in motion have revealed that the brain has plasticity. In 1998, Eriksson et al.  reported the new formation of neurons in the central nervous system of human beings. These findings raised the question of whether the plastic changes and functional reorganization that occur in subjects with cranial nerve disorders originate from an ischemic state, such as a cerebrovascular disturbance. The underlying mechanisms of the plasticity that occurs after a cortical deficit are thought to involve (i) the redundancy of neuronal connections in the central nervous system, (ii) morphological changes in the neurons, and (iii) changes in synaptic information transmission . If neurons are damaged, astrocytes begin to divide due to the activity of microglia. These glial cells then reinforce the areas that have been damaged by brain lesions and release neurotrophic factors, such as nerve growth factor, to promote neuronal sprouting (it takes around two weeks for synapses to grow after nerve damage ). The sprouted neurons are then connected to an existing neural network, which forms a new network. In other words, if neurons are damaged, new neurons begin to reorganize themselves in order to compensate for it. Adequate NBR stimulates the neural network with the neurofunction that is most similar to the predamaged functional state of the neural network, even though the new network is not located in the damaged region. If strong inputs enter the network multiple times, the synaptic connections will be reinforced. However, plasticity will not be induced in synapses with little information (input specificity), and the synapses will be excluded from the network formation [24, 25].
These findings have been confirmed by several famous studies. Nudo et al.  caused artificial cerebral infarcts in monkeys in the region of the primary motor cortex (M1) that corresponds to fingers and then forced the monkeys to use fingers with motor deficits. Thus, they reported that the brain region that previously controlled the shoulders and elbows prior to the therapy then controlled the fingers and more distal body parts (Figure 1). Merzenich et al.  surgically sutured the fingers of monkeys and then compared the pre- and post-surgical somatotopies of Brodmann area (BA) 3b, which corresponds to the sensorimotor area (SMA). Microelectrodes were used to record the responses in BA3b to finger stimuli. The third and fourth fingers were then surgically sutured, and the responses were recorded again a month later. Thus, the boundary between the third and fourth fingers became unclear. In addition, the results of a study that was conducted in human beings suggested that the plasticity of brain cells depends on sensory input. The results of a magnetoencephalography study that compared the somatotopies of the first and fifth fingers of string players to normal controls showed that a broader cerebral cortical area was activated for string players compared to the controls .
These findings suggest that the size of the intracerebral somatotopic representation, which is vital to ME, is determined by the degree of use of the region. If you try to induce plasticity in specific parts of the bodies of stroke patients, as mentioned above, the induction of neural plasticity in a pathway that allows highly efficient information processing by repeating movements in a pattern like the normal pattern should be possible, provided the patient has retained their motor functions to a certain degree. However, if a patient has the functional level of almost not able to perform movement or is only able to perform the movement in an abnormal pattern, the stimulation of the plasticity for the formation of a neural network that is required to be able to regain normal motor function may not be possible. Ward et al.  chronologically examined the relationships between motor function recovery scores and task-related brain activities for approximately 12 months after the onset of stroke with functional magnetic resonance imaging. They found a negative correlation between motor function recovery scores and a decline in the hyperactivity of brain areas in the damaged and undamaged hemispheres (M1, premotor cortex; PMC, supplementary motor cortex; SMC, cerebellum). These findings suggest that a better recovery of motor function is associated with better connectivity between the functional systems of multiple brain regions and that a continuous and long-term approach is required to study the changes in the morphologies and networks of neurons. Thus, a qualitative and continuous approach  is required in studies of the recovery of the entire neural system (e.g. transcortical network, M1-PMC neural network ) in order to be able to perform movement rather than merely establishing quantitative interventions of movement. Thus, next, we will discuss the current understanding of what is required in interventions for stroke patients.[…]
As technology becomes an ever more prevalent part of everyday life and population-based physical activity programmes seek new ways to increase lifelong engagement with physical activity, so the two have become increasingly linked. This book offers a thorough, critical examination of emerging technologies in physical activity and health, considering technological interventions within the dominant theoretical frameworks, exploring the challenges of integrating technology into physical activity promotion and offering solutions for its implementation.
Technology in Physical Activity and Health Promotion occupies a broadly positive stance toward interactive technology initiatives and, while discussing some negative implications of an increased use of technology, offers practical recommendations for promoting physical activity through a range of media, including:
- social media
- mobile apps
- global positioning and geographic information systems
- active videogames (exergaming)
- virtual reality settings.
Offering a logical and clear critique of technology in physical activity and health promotion, this book will serve as an essential reference for upper-level undergraduates, postgraduate students and scholars working in public health, physical activity and health and kinesiology, and healthcare professionals.
Hemianopia leads to severe impairment of spatial orientation and mobility. In cases without macular sparing an additional reading disorder occurs. Persistent visual deficits require rehabilitation. The goal is to compensate for the deficits to regain independence and to maintain the patient’s quality of life. Spontaneous adaptive mechanisms, such as shifting the field defect towards the hemianopic side by eye movements or eccentric fixation, are beneficial, but often insufficient. They can be enhanced by training, e.g., saccadic training to utilize the full field of gaze in order to improve mobility and by special training methods to improve reading performance. At present only compensatory interventions are evidence-based.
Source: PHYSIOTHERAPY BOOKS
The coupling of several areas of the medical field with recent advances in robotic systems has seen a paradigm shift in our approach to selected sectors of medical care, especially over the last decade. Rehabilitation medicine is one such area. The development of advanced robotic systems has ushered with it an exponential number of trials and experiments aimed at optimising restoration of quality of life to those who are physically debilitated. Despite these developments, there remains a paucity in the presentation of these advances in the form of a comprehensive tool. This book was written to present the most recent advances in rehabilitation robotics known to date from the perspective of some of the leading experts in the field and presents an interesting array of developments put into 33 comprehensive chapters. The chapters are presented in a way that the reader will get a seamless impression of the current concepts of optimal modes of both experimental and ap- plicable roles of robotic devices.
- Chapter 1 Robotic Solutions in Pediatric Rehabilitation
- Chapter 2 Biomechanical Constraints in the Design of Robotic Systems for Tremor Suppression
- Chapter 3 Robotics and Virtual Reality Applications in Mobility Rehabilitation
- Chapter 4 Designing Safety-Critical Rehabilitation Robots
- Chapter 5 Work Assistive Mobile Robot for the Disabled in a Real Work Environment
- Chapter 6 The Evolution and Ergonomics of Robotic-Assisted Surgical Systems
- Chapter 7 Design and Implementation of a Control Architecture for Rehabilitation Robotic Systems
- Chapter 8 A 3-D Rehabilitation System for Upper Limbs “EMUL”, and a 6-DOF Rehabilitation System “Robotherapist” and Other Rehabilitation Systems with High Safety
- Chapter 9 The Rehabilitation Robots FRIEND-I & II: Daily Life Independency through Semi-Autonomous Task-Execution
- Chapter 10 Functional Rehabilitation: Coordination of Artificial and Natural Controllers
- Chapter 11 Passive-type Intelligent Walker Controlled Based on Caster-like Dynamics
- Chapter 12 Powered Human Gait Assistance
- Chapter 13 Task-oriented and Purposeful Robot-Assisted Therapy
- Chapter 14 Applications of Robotics to Assessment and Physical Therapy of Upper Limbs of Stroke Patients
- Chapter 15 Applications of a Fluidic Artificial Hand in the Field of Rehabilitation
- Chapter 16 Upper-Limb Exoskeletons for Physically Weak Persons
- Chapter 17 Cyberthosis: Rehabilitation Robotics With Controlled Electrical Muscle Stimulation
- Chapter 18 Haptic Device System For Upper Limb Motor Impairment Patients: Developing And Handling In Healthy Subjects
- Chapter 19 Rehabilitation of the Paralyzed Lower Limbs Using Functional Electrical Stimulation: Robust Closed Loop Control
- Chapter 20 Risk Evaluation of Human-Care Robots
- Chapter 21 Robotic Exoskeletons for Upper Extremity Rehabilitation
- Chapter 22 Upper Limb Rehabilitation System for Self-Supervised Therapy: Computer-Aided Daily Performance Evaluation for the Trauma and Disorder in the Spinal Cord and Peripheral Nerves
- Chapter 23 PLEIA: A Reconfigurable Platform for Evaluation of HCI Acting
- Chapter 24 Facial Automaton for Conveying Emotions as a Social Rehabilitation Tool for People with Autism
- Chapter 25 Upper-Limb Robotic Rehabilitation Exoskeleton: Tremor Suppression
- Chapter 26 Lower-Limb Wearable Exoskeleton
- Chapter 27 Exoskeleton-Based Exercisers for the Disabilities of the Upper Arm and Hand
- Chapter 28 Stair Gait Classification from Kinematic Sensors
- Chapter 29 The ALLADIN Diagnostic Device: An Innovative Platform for Assessing Post-Stroke Functional Recovery
- Chapter 30 Synthesis of Prosthesis Architectures and Design of Prosthetic Devices for Upper Limb Amputees
- Chapter 31 An Embedded Control Platform of a Continuous Passive Motion Machine for Injured Fingers
- Chapter 32 A Portable Robot for Tele-Rehabilitation: Remote Therapy and Outcome Evaluation
- Chapter 33 Bio-Inspired Interaction Control of Robotic Machines for Motor Therapy
Informatics For Health Professionals Is An Excellent Resource To Provide Healthcare Students And Professionals With The Foundational Knowledge To Integrate Informatics Principles Into Practice. The Theoretical Underpinning Of This Text Is The Foundation Of Knowledge Model, Which Explains How Informatics Relates To Knowledge Acquisition, Knowledge Processing, Knowledge Generation, Knowledge Dissemination, And Feedback. Once Readers Understand Informatics And The Way In Which It Supports Practice, Education, Administration, And Research, They Can Apply These Principles To Improve Patient Care At All Levels. Key Content Focuses On Current Informatics Research And Practice Including But Not Limited To: •Technology Trends •Information Security Advances •Health Information Exchanges •Care Coordination •Transition Technologies •Ethical And Legislative Aspects •Social Media Use •Mobile Health •Bioinformatics •Knowledge Management •Data Mining, And More Helpful Learning Tools Include: Case Studies, Provoking Discussion Questions, Research Briefs, And Call Outs On Cutting-Edge Innovations, Meaningful Use, And Patient Safety. INSTRUCTOR RESOURCES: Instructor’S Manual, Slides In Powerpoint Format, And A Test Bank. STUDENT RESOURCES: Each New Print Copy Includes Navigate 2 Advantage Access That Unlocks An Interactive Ebook, Student Practice Activities And Assessments, And A Dashboard That Reports Actionable Data. Some Ebook And Electronic Versions Do Not Include Navigate 2 Advantage Access.
Neuroplasticity – or brain plasticity – is the ability of the brain to modify its connections or re-wire itself. Without this ability, any brain, not just the human brain, would be unable to develop from infancy through to adulthood or recover from brain injury.
What makes the brain special is that, unlike a computer, it processes sensory and motor signals in parallel. It has many neural pathways that can replicate another’s function so that small errors in development or temporary loss of function through damage can be easily corrected by rerouting signals along a different pathway.
The problem becomes severe when errors in development are large, such as the effects of the Zika virus on brain development in the womb, or as a result of damage from a blow to the head or following a stroke. Yet, even in these examples, given the right conditions the brain can overcome adversity so that some function is recovered.
The brain’s anatomy ensures that certain areas of the brain have certain functions. This is something that is predetermined by your genes. For example, there is an area of the brain that is devoted to movement of the right arm. Damage to this part of the brain will impair movement of the right arm. But since a different part of the brain processes sensation from the arm, you can feel the arm but can’t move it. This “modular” arrangement means that a region of the brain unrelated to sensation or motor function is not able to take on a new role. In other words, neuroplasticity is not synonymous with the brain being infinitely malleable.
Part of the body’s ability to recover following damage to the brain can be explained by the damaged area of the brain getting better, but most is the result of neuroplasticity – forming new neural connections. In a study ofCaenorhabditis elegans, a type of nematode used as a model organism in research, it was found that losing the sense of touch enhanced the sense of smell. This suggests that losing one sense rewires others. It is well known that, in humans, losing one’s sight early in life can heighten other senses, especially hearing.
As in the developing infant, the key to developing new connections is environmental enrichment that relies on sensory (visual, auditory, tactile, smell) and motor stimuli. The more sensory and motor stimulation a person receives, the more likely they will be to recover from brain trauma. For example, some of the types of sensory stimulation used to treat stroke patients includes training in virtual environments, music therapy and mentally practising physical movements.
The basic structure of the brain is established before birth by your genes. But its continued development relies heavily on a process called developmental plasticity, where developmental processes change neurons and synaptic connections. In the immature brain this includes making or losing synapses, the migration of neurons through the developing brain or by the rerouting and sprouting of neurons.
There are very few places in the mature brain where new neurons are formed. The exceptions are the dentate gyrus of the hippocampus (an area involved in memory and emotions) and the sub-ventricular zone of the lateral ventricle, where new neurons are generated and then migrate through to the olfactory bulb (an area involved in processing the sense of smell). Although the formation of new neurons in this way is not considered to be an example of neuroplasticity it might contribute to the way the brain recovers from damage. …
Visit Web Site —> What Is Brain Plasticity and Why Is It So Important? | SciTech Connect
For acute, subacute, or chronic stroke, and neurotrauma, a range of rehabilitation strategies will be essential to optimize possible benefits of molecular, cellular, and novel pharmacological restorative approaches. The neurorehabilitation strategies must be chosen to engage the targeted networks of these novel approaches, drawing upon studies of motor and cognitive learning-related neural adaptations that accompany progressive practice. Regulatory agencies and the pharma/biotech industry will need to keep an open mind about the likely synergy that will come from interleaving repair strategies and rehabilitation interventions.
For clinical trials aimed at motor restoration, outcome measurement tools should be relevant to the anticipated targets of repair-enhanced rehabilitation. Most outcomes to date have been drawn from disease-specific and rehabilitation toolboxes. In studies that include participants who are more than a few weeks beyond acquiring profound impairments and disabilities, outcome measures will likely have to go beyond off-the-shelf tools that were not designed to detect modest clinical evidence of sensorimotor system repair. This chapter describes specific rehabilitation strategies and outcome assessments in the context of interfacing them with neurorestoration approaches.