Posts Tagged chronic

[ARTICLE] A comparison of two personalization and adaptive cognitive rehabilitation approaches: a randomized controlled trial with chronic stroke patients – Full Text



Paper-and-pencil tasks are still widely used for cognitive rehabilitation despite the proliferation of new computer-based methods, like VR-based simulations of ADL’s. Studies have established construct validity of VR assessment tools with their paper-and-pencil version by demonstrating significant associations with their traditional construct-driven measures. However, VR rehabilitation intervention tools are mostly developed to include mechanisms such as personalization and adaptation, elements that are disregarded in their paper-and-pencil counterparts, which is a strong limitation of comparison studies. Here we compare the clinical impact of a personalized and adapted paper-and-pencil training and a content equivalent and more ecologically valid VR-based ADL’s simulation.


We have performed a trial with 36 stroke patients comparing Reh@City v2.0 (adaptive cognitive training through everyday tasks VR simulations) with Task Generator (TG: content equivalent and adaptive paper-and-pencil training). The intervention comprised 12 sessions, with a neuropsychological assessment pre, post-intervention and follow-up, having as primary outcomes: general cognitive functioning (assessed by the Montreal Cognitive Assessment – MoCA), attention, memory, executive functions and language specific domains.


A within-group analysis revealed that the Reh@City v2.0 improved general cognitive functioning, attention, visuospatial ability and executive functions. These improvements generalized to verbal memory, processing speed and self-perceived cognitive deficits specific assessments. TG only improved in orientation domain on the MoCA, and specific processing speed and verbal memory outcomes. However, at follow-up, processing speed and verbal memory improvements were maintained, and a new one was revealed in language. A between-groups analysis revealed Reh@City v2.0 superiority in general cognitive functioning, visuospatial ability, and executive functions on the MoCA.


The Reh@City v2.0 intervention with higher ecological validity revealed higher effectiveness with improvements in different cognitive domains and self-perceived cognitive deficits in everyday life, and the TG intervention retained fewer cognitive gains for longer.


Cognitive rehabilitation after stroke

Stroke is a leading cause of long-term acquired disability in adults [1], predisposing patients toward institutionalization and poorer quality of life [2]. Over the coming decades, the incidence of post-stroke disability is expected to increase by 35% due to the rising prevalence of cerebrovascular risk and advances in medicine which are reducing post-stroke mortality rates [3]. Historically, stroke rehabilitation has been focused on motor rehabilitation [45]. However, post-stroke cognitive deficits are pervasive causing disability with major impacts on quality of life and independence on everyday life activities [67]. In the last years, attention to the impact of cognitive deficits has been growing [8] and finding new ways to improve cognition after stroke is considered a priority [9]. Also, more recently, the International Stroke Recovery and Rehabilitation Alliance 2018 working group has identified post-stroke cognitive impairments as a research priority [10].

Regardless of the many new developments in cognitive rehabilitation programs and applications, limited data on the effectiveness of cognitive rehabilitation is available because of the heterogeneity of participants, interventions, and outcome measures [11]. Results from recent reviews corroborate that cognitive rehabilitation has a positive impact on post-stroke cognitive outcomes [1213], although of small magnitude (Hedges’ g = 0.48) [12]. This result is in line with the quantitative [14] and qualitative [15,16,17] findings of previous reviews that have analyzed the effect of cognitive rehabilitation across multiple cognitive domains.

Is cognitive rehabilitation’s impact small or are we missing better cognitive rehabilitation methodologies?

Paper-and-pencil tasks are still the most widely used methods for cognitive rehabilitation because of their accessibility, ease of use, clinical validity and reduced cost [18]. In the last years, computer-based versions of these traditional tasks are also starting to become clinically accepted [1920]. However, there is an absence of specific methodologies that inform health professionals which tasks to apply and under what clinical conditions [21]. Consequently, rehabilitation professionals perform a selection of tasks based on their clinical experience, missing scientific foundations [22]. We have proposed an objective and quantitative framework for the creation of personalized cognitive rehabilitation tasks based on a participatory design strategy with health professionals [23]. In this work, through computational modeling, the authors operationalized 11 paper-and-pencil tasks and developed an Information and Communication Technologies based tool – the Task Generator (TG) – to tailor each of those 11 paper-and-pencil tasks to each patient in the domains of attention, memory, language and executive functions. A clinical evaluation of the TG with twenty stroke patients showed that the TG is able to adapt task parameters and difficulty levels according to patient’s cognitive assessment, and provide a comprehensive cognitive training [24]. However, although it has been shown that rehabilitation strategies based on paper-and-pencil tasks can be personalized and adapted [2425], this approach presents a limited transfer to performance in activities of daily living (ADL) [18].

Over the last years, rehabilitation methodologies based on virtual reality (VR) have been developed as promising solutions to improve cognitive functions [2627]. VR-based tools have shown potential and to be ideal environments to incorporate cognitive tasks within the simulation of ADL’s [28]. A recent trial with a VR-based simulation of everyday life activities (like going to the pharmacy, buying grocery at the supermarket, paying the water bill) suggested that an ecologically valid intervention has more impact than conventional methods (cognitive training using puzzles, calculus, problem resolution and shape sorting) in cognitive rehabilitation of stroke patients [29]. Also, some of these VR-based systems allow the integration of motor training [30] and recent studies have already shown benefits of performing simultaneous motor and cognitive training with stroke patients using VR [3132]. Yet, there is still an insufficient number of rigorous trials to clinically validate VR methods [12] and there are difficulties associated with the limited access which results in a low adoption by health professionals who still prefer mostly use paper-and-pencil interventions [33].

In general, existing ecologically-valid VR-based environments are simulations of cities [2934,35,36,37,38], kitchens [39,40,41,42,43,44,45], streets [46,47,48,49,50,51], supermarkets [52,53,54,55,56], malls and other shopping scenarios [57,58,59,60,61]. Of these, only rare cases take into account training personalization according to patient cognitive profile and session-to-session adaptation [29363841]. Additionally, the results of studies comparing VR cognitive interventions with standard occupational therapy or neuropsychology cognitive paper-and-pencil training are fundamentally subjective as control interventions. OT does not consider cognition as the main training focus, and neuropsychology paper-and-pencil training tasks are too similar to the cognitive assessment scales; additionally, both approaches do not incorporate personalization and dynamic adaptation to performance. Hence, even if rehabilitation sessions last the same, these interventions are not equivalent as they are delivered with uncontrolled difficulty levels and cognitive demands. Personalized rehabilitation is defined as involving an assessment of each patient’s impairments and performing a tailored intervention to his cognitive profile in the different domains. Instead, adaptation deals with the dynamic adjustment of the tasks’ cognitive demands according to the patients’ performance along the intervention sessions, therefore avoiding boredom (tasks that are to easy to solve) or frustration (tasks that are too difficult to solve).

Here we try to address some of the existing limitations in the validation of VR-based cognitive rehabilitation tools. In this study we compared two task content equivalent rehabilitation tools developed under the same personalization and adaptation framework [23]: the TG and the Reh@City v2.0. This framework allows us to make sure that both tools deliver the same controlled adaptation and personalization of difficulty levels, and address the same cognitive demands. Hence, this comparison allows identifying the specific impact of increasing ecological validity of training through VR simulations of ADLs over the same training delivered through clinically accepted paper-and-pencil equivalent tasks. These findings will further inform on the specific benefits of ecologically valid environments delivered though VR and encourage the adoption of these technologies by health professionals.[…]


Fig. 3
Fig. 3 Reh@City v2.0 task examples: a buying food in the supermarket; b making payments at the bank ATM; c playing a cards game at the park and; d setting the table at home

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[BLOG POST] Traumatic Brain Injury and Hyperbaric Oxygen Treatment

In 2015, the Will Smith film Concussion, which depicts Dr. Bennet Omalu’s struggle to uncover the truth about brain damage to football players, brought international attention to Traumatic Brain Injury (TBI) and its long-term complications.

According to the Center for Disease Control (CDC), there were 2.87 million TBI-related emergency room visits in 2014 — and an estimated 817,000 children were treated for TBI-related head injuries.

While the brain sits inside the hard, bony case of the skull, it is soft, almost like a banana. This makes it vulnerable to rapid acceleration and deceleration injuries known as concussions, which occurs when the brain impacts the skull with sufficient force that it causes bruising. At each point of injury, local swelling, bleeding, and even neuronal death can occur.

Over the following hours and days, inflammation develops around the bruised area, just like injuries do elsewhere in the body. Since the skull is inflexible, the swelling pushes inward on the brain, reducing blood flow and extending the damage further across the brain adjacent to the injury and causing impairments over a much larger area; moreover, neurons in this expanded area may be damaged and unable to carry out their function. They may not die, but they will persist in an inactive or stunned state, basically not functioning for an indefinite period of time.

The immediate injury may cause loss of consciousness, or people may just feel stunned and lose track of what is happening around them. They also may have an initial headache and some confusion, which typically improves over the next several hours.

Long-term Consequences of TBI

Let’s now look at how TBI symptoms often develop after a concussion. As inflammation develops, more serious symptoms can increase, peaking over the next one to two weeks. These include headache; a confusion often described as “brain fog”; nausea; irritability, emotional lability; being overwhelmed easily; sensitivity to light and sound; impaired concentration, memory, and problems solving; difficulty multitasking; struggle with visual stimulation, such as processing information from computer or TV screens; and severe fatigue. These symptoms typically plateau and slowly improve over several months.

When brain scans reveal no gross destruction of brain matter, this type of injury is typically referred to as “mild” TBI. However, functional scans (PET, SPECT) will demonstrate impairment in blood flow and metabolism in the affected areas. These impairments in blood flow and neuronal activity may persist for years, resulting in chronic impairments of brain function with the associated symptoms described above.

These persistent symptoms can lead to further life problems, such as loss of job, relationship problems, loss of self-esteem or confidence, financial problems, mood dysregulation, and other mental health problems.

Common causes of TBI include anything that causes concussions, such as: falls — 48% of all head injuries are due to falls; being struck by or against an object — 17%, the second-most common cause; followed by motor-vehicle accidents. Other causes include bike accidents, sports injuries, and combat injuries, such being near concussive bomb blasts.

Hyperbaric Oxygen Treatment

Recently, hyperbaric oxygen treatment (HBOT) has been demonstrated to provide marked improvement in people suffering with TBI, even years after their injuries occurred. HBOT is the use of oxygen at higher-than-atmospheric concentrations and pressures for the treatment of disease. HBOT was first used in the 1930s to treat decompression sickness in divers (commonly known as “the bends”) and currently has 13 FDA-approved uses, including: gas gangrene, air embolism, osteomyelitis, radiation necrosis, diabetic ulcers, and the aforementioned decompression sickness.

Current scientific evidence suggests that HBOT can permanently and dramatically improve symptoms of chronic TBI years after the initial head injury. Understanding the physiologic effects of HBOT gives insight as to its therapeutic benefits.

Breathing room air (21% oxygen or O2) at atmospheric pressure at sea level (1 atmosphere or 1ATM), about 97 percent of the total oxygen in the blood is bound to hemoglobin and 3 percent dissolved into the blood serum. By the time the oxygen diffuses through the tissues, into the cells, and reaches the mitochondria (energy producing organelles inside the cells), only trace amounts are available. HBOT’s main function is to temporarily super-saturate body tissues with oxygen. HBOT delivering 100-percent oxygen at 1.3 ATM increases dissolved oxygen in the serum by seven-fold. HBOT delivering 100-percent oxygen at 3.00 ATM increases dissolved oxygen in the serum by more than a factor of 15. Body tissues outside the circulation will thereby experience a commensurate increase in oxygen concentration.

A warning: If a hyper-oxygenated state is maintained for long periods, it will cause significant oxidative damage to the body tissues, undermining any health benefits. Long periods of HBOT are harmful. But short, 1-hour pulses of HBOT triggers a variety of healing processes without overwhelming the body’s antioxidant systems. Current known health-inducing responses from HBOT include stimulating powerful anti-inflammatory effect, reduction of edema, increased blood perfusion, new blood vessel growth, improved immune response, enhancement of the body’s antioxidant system, improved stem-cell activity from bone marrow, improved growth of neuronal axons, and modulation of thousands of genes involved in bodily healing.

Just as with any medicinal dosing, while the right dose can heal, too much medicine can harm. With TBI, too big a dose of HBOT will worsen the condition. Dose is determined by the pressure in the chamber and the time spent in the chamber. The higher-pressure treatment of 2.0 ATM is best for infections but will worsen TBI. After several decades of research, it has been determined that TBI is best treated with lower pressures and session time limits.

The recommended HBOT protocol for TBI is currently one or more blocks of 40, 1-hour sessions delivered at 1.3 or 1.5 ATM. Case reports of individuals who have suffered with post-TBI symptoms for decades, and who prior to treatment had SPECT scans showing decreased perfusion in multiple brain regions, found not only marked improvement in function, but SPECT scans after HBOT were normal.

After treatment, patients report improvement in concentration, emotional stability, ability to multitask, and memory.

HBOT is not FDA-approved for TBI treatment. This is due to the fact that it is not possible to develop a sham treatment for it and, thus, no placebo-controlled trials have been done to demonstrate its effectiveness over a placebo. Because HBOT is not FDA approved, insurance companies will typically not pay for it.

However, if you or someone you love has suffered with TBI and struggled with functional impairments, I recommend you speak with your healthcare provider about a trial of HBOT.


  1. Goderez, B., Treatment of Traumatic Brain Injury with Hyperbaric Oxygen Therapy, Psychiatric Times, Vol. 36, Iss. 5, May, 28, 2019.
  2. Harch PG, Andrews SR, Fogarty EF, A phase I study of low-pressure hyperbaric oxygen therapy for blast-induced post-concussion syndrome and post-traumatic stress disorder. J Neurotrauma. 2012;29:168-185.
  3. Efrati S, Ben-Jacob E. How and why hyperbaric oxygen therapy can bring new hope for children suffering from cerebral palsy: an editorial perspective. Undersea Hyperbaric Med. 2014;41:71-74.
  4. Harch, P. Hyperbaric oxygen in chronic traumatic brain injury: oxygen, pressure, and gene therapy. Med Gas Res. 2015;5:9.
  5. Harch P, Mccullough V. The Oxygen Revolution. Hobart, NY: Hatherleigh Press; 2010.
  6. Mukherjee A, Raison M, Sahni T, Intensive rehabilitation combined with HBO2 therapy in children with cerebral palsy: a controlled longitudinal study. Undersea Hyperbaric Med. 2014;41:77-85.
  7. Harch PG, Fogarty EF. Hyperbaric oxygen therapy for Alzheimer’s dementia with positron emission tomography imaging: a case report. Med Gas Res. 2018:8:181-184.
  8. Jain KK. Textbook of Hyperbaric Medicine. New York, NY: Springer International Publishing AG; 2017: 345-348.


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[Abstract] Improvement of active movement and function in adults with chronic spastic paresis following repeated treatment with abobotulinumtoxinA (Dysport®)


There are limited data on improvements of active limb movement and function following treatment with botulinum toxin in chronic spastic paresis. We report the effect of repeated injections of abobotulinumtoxinA (aboBoNT-A) on these parameters from two Phase III multicenter open-label (OL) trials in adults with spasticity post-stroke/traumatic brain injury; one trial in upper limb spasticity, the other in lower limb spasticity. These are extensions to respective double-blind studies (DB) in which adults received a single aboBoNT-A injection (Gracies et al. Lancet Neurol 2015; Esquenazi et al. AAPM&R 2016).

Material/Patients and methods

Subjects (18–78 years) received aboBoNT-A (500 to 1500U) over a year (injections ≥ 12 weeks apart) in their affected limb. Active movement was assessed by active range of motion (XA) against elbow, wrist and finger flexors or active ankle dorsiflexion. Active function was assessed by Modified Frenchay Scale (MFS) (upper limb) or the 10-meter walking speed test (lower limb). Results for cycle 4 week 4 of the OL phase are presented.


Eighty-one subjects received 5 injections in their UL and 139 subjects in their LL. XA improved in the upper limb across injection cycles, with active finger extension (most frequently injected muscle group) increasing by a mean (SD) of +38.0 (53.4)°. The overall increase in MFS was +0.40 (0.75), an improvement that was more pronounced with 1500U (500U in shoulder muscles): +0.62 (0.48) vs. +0.30 (0.83) for 1000U. Active ankle dorsiflexion improved by +6.5(10.9)° with knee extended. Comfortable walking speed improved by +0.088 (0.144) (mean increase of 25% from baseline of DB phase).


Improvement in active movement and function in subjects with chronic upper or lower limb spasticity was observed following repeat injections of aboBoNT-A over a year. A more pronounced efficacy with 1500U versus 1000U aboBoNT-A for active function in the upper limb may suggest the importance of shoulder muscle injections.


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[Abstract] Does overground robotic gait training improve non-motor outcomes in patients with chronic stroke? Findings from a pilot study


• Patients with stroke present long term non motor symptoms, including constipation.

• Robotics has proven effective in improving functional recovery in patients with stroke.

• Ekso may be a useful tool in improving post-stroke non motor symptoms.


Stroke is the leading cause of disability among the elderly in the industrialized world. No more than 40% of stroke survivors walk independently, and only after receiving appropriate rehabilitation treatment; many stroke patients have also non-motor symptoms. The aim of this pilot study is to evaluate the effects of Ekso-training on non-motor outcomes, including gastrointestinal function and psychological well-being, in post stroke patients. We enrolled 30 post-stroke subjects, which were randomized into two groups in order of recruitment: 15 patients were trained with the overground exoskeleton Ekso-GT (experimental group, EG), whereas 15 patients were submitted to a standard gait training (control group, CG). Both the groups underwent the same amount of physiotherapy. At the end of the training, only in the EG we observed a significant improvement in constipation, mood, and coping strategies, with regard to social support, as well as in the perception of quality of life (as per SF-12). According to these preliminary data, overground robotic gait training can be considered a valuable tool in improving non-motor symptoms, including constipation and behavioral disorders in patients with chronic stroke.


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[ARTICLE] Exploring the relationship between effort perception and post-stroke fatigue – Full Text PDF


Objective: To test the hypothesis – post-stroke fatigue, a chronic, pathological fatigue condition, is driven by altered effort perception.

Participants: Fifty-eight non-depressed, mildly impaired stroke survivors with varying severity of fatigue completed the study.

Main outcome measures: Self-reported fatigue (trait and state), perceived effort – PE (explicit and implicit) and motor performance was measured in a handgrip task. Trait fatigue was measured using Fatigue Severity Scale-7 and Neurological Fatigue Index. State fatigue was measured using a visual analogue scale (VAS). Length of hold at target force, overshoot above target force and force variability in handgrip task were measures of motor performance. PE was measured using a VAS (explicit PE) and line length estimation, a novel implicit measure of PE.

Results: Regression analysis showed 11.6% of variance in trait fatigue was explained by implicit PE (R=0.34; P=0.012). Greater fatigue related to longer length of hold at target force (R=0.421; P<0.001). A backward regression showed length of hold explained explicit PE in the 20% force condition (R=0.306; P=0.021) and length of hold and overshoot above target force, explained explicit PE in the 40% (R=0.399; P=0.014 & 0.004) force condition. In the 60% force condition, greater explicit PE was explained by higher force variability (R=0.315; P=0.017). None of the correlations were significant for state fatigue.

Conclusion: Trait fatigue, but not state fatigue, correlating with measures of perceived effort and motor performance may suggest that altered perception may lead to high fatigue mediated by changes in motor performance. This novel finding furthers our mechanistic understanding of post-stroke fatigue.[…]

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[ARTICLE] Ankle and Foot Spasticity Patterns in Chronic Stroke Survivors with Abnormal Gait – Full Text


Chronic stroke survivors with spastic hemiplegia have various clinical presentations of ankle and foot muscle spasticity patterns. They are mechanical consequences of interactions between spasticity and weakness of surrounding muscles during walking. Four common ankle and foot spasticity patterns are described and discussed through sample cases. The patterns discussed are equinus, varus, equinovarus, and striatal toe deformities. Spasticity of the primary muscle(s) for each deformity is identified. However, it is emphasized that clinical presentation depends on the severity of spasticity and weakness of these muscles and their interactions. Careful and thorough clinical assessment of the ankle and foot deformities is needed to determine the primary cause of each deformity. An understanding of common ankle and foot spasticity patterns can help guide clinical assessment and selection of target spastic muscles for botulinum toxin injection or nerve block.

1. Introduction

About 80% of chronic stroke survivors have varying degrees of abnormal gait and impaired locomotion capability [1]. Spasticity in the ankle and foot muscles is very common, and often results in various ankle and foot deformities, including equinus, varus, equinovarus, and striatal toe deformities. The spastic equinovarus deformity is the most common deformity seen [2,3,4]. An ankle and foot joint abnormality could have subsequent effects on the knee, hip, and trunk position and control in post-stroke hemiplegic gait through a kinetic chain effect. For example, an equinovarus deformity shifts the ground reaction force anterior to the knee joint, and thus facilitates knee (hyper)extension during the stance phase. Stroke survivors are often forced to increase hip extension to compensate for knee (hyper)extension to keep the center of gravity within the forefoot. During the swing phase, increased knee and hip flexion is required to clear the equinovarus foot from the floor. However, they are often unable to do so due to weak hip and knee flexors, and, instead, present with hip hiking and leg circumduction. Additionally, stroke survivors have a smaller base of support due to the equinovarus deformity. The stance phase is shortened to minimize the risk of fall. Therefore, the ankle and foot deformity is often associated with kinetic and kinematic gait abnormalities, such as gait asymmetry, slow speed, genu recurvatum, etc [3,5].Joint abnormalities in the hip, knee, ankle, and foot joints observed in post-stroke hemiplegic gait are mechanical consequences of the interactions among muscle spasticity, weakness, and disordered motor control during locomotion [6]. Depending on the severity of spasticity and weakness of muscles surrounding a joint, various joint abnormalities can develop. The complex ankle and foot anatomy contribute directly to observed deformities. As shown in Figure 1, four groups of muscles (invertors, evertors, dorsiflexors, and plantarflexors) act on the ankle–foot complex. Any isolated ankle movement is a net result of the combined activation of a group of target muscles, e.g., inversion occurs when dorsiflexors (primarily the tibialis anterior muscle) and plantarflexors (primarily the tibialis posterior muscle) co-activate. In the presence of spasticity, stroke survivors have less control and isolated activation; activation is more diffuse and divergent [7,8]. Therefore, a variety of ankle–foot deformities could be observed, depending on the severity of spasticity and weakness of individual muscles.

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Figure 1. The muscles involved in ankle movement. EHL: extensor hallucis longus; EDL: extensor digitorum longus; FHL: flexor hallucis longus; FDL: flexor digitorum longus; Gastroc: gastrocnemius. Note: Tendons of the soleus and gastrocnemius merge and form the Achilles tendon. The soleus tendon is located in the medial portion of the Achilles tendon, thus contributing more to inversion, while the gastrocnemius tendon forms the lateral portion and contributes more to eversion. They plantarflex the ankle joint when acting together [9,10].

Among the spectrum of treatment options for ankle and foot deformities and gait disorders, interventions such as botulinum toxin (BoNT) injection and phenol neurolysis are commonly used to manage spasticity of the ankle and foot muscles [2,4,11,12]. To achieve the best clinical outcomes, it is important to identify the primary causes of the deformity. Based on the assessment from instrumented gait analysis, BoNT treatment for spasticity of target muscles has shown to improve gait pattern and walking speed [13,14,15]. However, an instrumented gait analysis lab is not available in most clinics and it is not practical to perform a computer assisted gait analysis for every patient. Understanding common ankle and foot spasticity patterns is helpful to guide our clinical assessment and development of a treatment plan. These common ankle and foot spasticity patterns are presented here through sample cases. In all cases, no significant component of contracture was detected. The common ankle and foot spasticity patterns include: equinus, varus, equinovarus, and striatal toe.[…]



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[ARTICLE] Effects of sensory stimulation on upper limb strength, active joint range of motion and function in chronic stroke virtual reality training – Full text PDF


Objective: This study aimed to investigate the upper limb strength, active joint range of motion (AROM), and upper limb function in persons with chronic stroke using virtual reality training in combination with upper limb sensory stimulation.
Design: Two-group pretest-posttest design.
Methods: 20 subjects were divided into two groups of 10, the sensory motor stimulation and virtual reality training (SMVR) and virtual reality training (VR) groups. The training was conducted for 30 minutes per session, three times a week for 8 weeks.The participants’ upper limb strength was measured via the hand-held dynamometer, joint angle AROM was measured via dual inclinometer, function was measured using the Jebson-Taylor hand function test and the manual function test.
Results: Significant differences were observed in all groups before and after the training for upper extremity strength, AROM, and function (p<0.05). Between the two groups, the SMVR group showed significant improvement in muscle strength, AROM, and Jebsen-Taylor hand function test scores compared with the VR groups (p<0.05).
Conclusions: In this study, we confirmed that sensory stimulation and VR had positive effects on upper extremity strength, AROM, and function of persons with chronic stroke. The results suggest that in the future, VR in combination with sensory stimulation of the upper limb is likely to become an effective method (a rehabilitation training program) to improve the upper limb function of persons with chronic stroke.

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[ARTICLE] Effect of mirror therapy on hand functions in Egyptian chronic stroke patients – Full Text



Most stroke survivors (more than 60%) suffer from persistent neurological impairments that significantly affect activities of daily living. Hand functions are essential for doing daily living and working activities. Mirror therapy is shown to be effective in improving hand functional recovery in stroke patients.


This study aimed to determine the effect of mirror therapy on improving hand functions in Egyptian chronic stroke patients.

Subjects and methods

Thirty chronic ischemic stroke patients from both sexes participated in the study. Their ages ranged from 45 to 65 years. They were randomly assigned into two equal groups: the study group that received a selected physical therapy program in addition to the mirror therapy and the control group that received the same selected physical therapy program but without a mirror therapy. Treatment sessions were conducted three times per week for 8 weeks. Range of motion (ROM) of the wrist extension and forearm supination, hand grip strength, and the time of Jebson Hand Function Test (JHFT) were measured before and after the treatment program.


There were statistically significant increases in the range of motion of the wrist extension and forearm supination and hand grip strength with a decrease in the time of Jebson Hand Function Test in both groups post-treatment. Post-treatment improvement was more significant in the study group compared to the control group.


Mirror therapy had a positive effect on improving hand motor functional skills in a sample of Egyptian chronic stroke patients.


Upper limb paresis is one of the most common and disabling consequences of stroke that significantly limits activity. It has been stated that 85% of stroke patients complain of hemiparesis and that 55 to 75% of them continue to have deficits in the upper extremity activities [1]. Approximately 30–66% of stroke patients never recover hand motor functional skills, which seriously impacts their performance of the activities of daily life [2].

Numerous rehabilitation techniques for stroke patients have been used to improve hand motor functional skills. These techniques include exercise training for the arm paresis [3], impairment-oriented training of the arm or Bobath therapy for severe arm paresis after stroke, functional electrical stimulation [4], robot-assisted rehabilitation [5], and bilateral arm training [6] constraint-induced movement therapy [78]. However, most of those rehabilitation techniques for the upper extremity paresis are intensive, involve high equipment costs, and require therapist’s manual interaction for a long time, which makes the administration of those treatments difficult for all patients [9].

Mirror therapy (MT) is a cheap, easy, and, most importantly, patient-directed treatment that may improve the recovery of hand motor functional skills [10,11,12,13]. MT consists of repeated bilateral, symmetrical movements in which the patient moves the affected body part as much as he/she could while observing the reflection of the same unaffected body part in a mirror placed in between those body parts while obscuring the affected part [14]. Researches of neural activities stated that MT might stimulate the areas within the somatosensory and premotor cortex and/or the mirror neuron system in the fronto-temporal region and superior temporal gyrus. This cortical stimulation might produce motor output in patients with stroke [1516].

This study was designed to assess the efficacy of mirror therapy on improving hand motor functions in a sample of Egyptian chronic stroke patients.[…]


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[NEWS] MindMaze and Mount Sinai Launch at Home Tele-Neurorehabilitation Program for Stroke Patients

Hospital leverages FDA-cleared MindMotion GO™ to deliver direct-to-patient therapy, enabling essential continuum of care during pandemic

Sep 30, 2020, 08:00 ET

NEW YORK and LAUSANNE, Switzerland, Sept. 30, 2020 /PRNewswire/ — MindMaze, a global leader in brain technology, and Mount Sinai Health System, the largest academic medical system in New York City, today announced an innovative at home tele-neurorehabilitation program for stroke patients, utilizing the FDA-cleared and CE-marked MindMotion GO™. With this first-of-its-kind mobile neurorehabilitation therapy system from MindMaze, patients can continue their recovery at home with virtual support from clinicians at Mount Sinai’s Abilities Research Center (ARC). This initiative expands patient access to MindMotion GO, which has been adopted by the Rehabilitation Innovation team at Mount Sinai since June to provide critical neurorehabilitation across the continuum of care.


With the COVID-19 pandemic impacting all aspects of public health, including limiting patients’ access to important rehabilitation intervention, access to tele-neurorehabilitation has never been more essential. Using MindMaze’s gamified digital therapy program, Mount Sinai patients can seamlessly transition between inpatient to outpatient rehabilitation and continue their recovery at home while still receiving support and care from their physical therapists. Designed to keep acute and chronic stroke patients training for longer periods, MindMotion GO guides a complete range of body parts including the upper and lower limbs, hands, and trunk, to improve motor and task functions.

“The COVID-19 pandemic has set back the recovery and rehabilitation of stroke patients worldwide, underscoring the need for cutting-edge digital neurotherapeutics,” said Tej Tadi, CEO and founder of MindMaze. “MindMotion GO has enabled thousands of stroke patients to recover within the safety of their homes. We are excited to collaborate with Mount Sinai to expand access to the telerehabilitation solutions patients need and rightly deserve.”

Clinicians can create personalized therapy with MindMotion GO’s array of engaging therapeutic games and provide patients with essential real-time audio and visual feedback. Furthermore, therapists can monitor the quality of each patient’s movements through MindMotion GO’s full-body motion capture technology and the accompanying hand dexterity hardware, offering a tactical level of support similar to being physically present with patients.

“At Mount Sinai, we are committed to delivering exceptional medical care and using the latest technology and virtual platforms to meet the needs of our patients. With MindMotion GO, we’ve been able to provide our patients with continued access to top-tier telerehabilitation and support despite constant changes in the traditional hospital and treatment settings,” said Dr. David Putrino, Ph.D., Director of Rehabilitation Innovation for the Mount Sinai Health System. “We look forward to growing this program as we’ve seen our patients enjoy a new level of ownership over their treatment, helping them make great strides in their recovery.”

For more information, please visit or

About MindMaze
MindMaze is a global leader in brain technology with a mission to accelerate humanity’s ability to recover, learn and adapt. With over a decade of work at the intersection of neuroscience, biosensing, engineering, mixed reality and artificial intelligence, the company is at the forefront of building innovative neurotechnology that will empower the next generation of human-machine interfaces. Its healthcare division is addressing some of the most challenging problems in neurology, including strokes, Alzheimer’s and Parkinson’s, by creating THE only universal platform for brain health. MindMaze’s pioneering FDA cleared and CE marked neuro-digital therapeutics accelerate patients’ recovery from many critical neurological conditions. MindMaze Labs is the company’s R&D division tasked with bringing ground-breaking neuroscience to everyday life. Founded in 2012 by CEO Dr Tej Tadi, MindMaze is the first Swiss Unicorn with offices in Lausanne, Baltimore, London, Paris and Mumbai. Learn more at

About the Mount Sinai Health System
The Mount Sinai Health System is New York City’s largest academic medical system, encompassing eight hospitals, a leading medical school, and a vast network of ambulatory practices throughout the greater New York region. Mount Sinai is a national and international source of unrivaled education, translational research and discovery, and collaborative clinical leadership ensuring that we deliver the highest quality care—from prevention to treatment of the most serious and complex human diseases. The Health System includes more than 7,200 physicians and features a robust and continually expanding network of multispecialty services, including more than 400 ambulatory practice locations throughout the five boroughs of New York City, Westchester, and Long Island. The Mount Sinai Hospital is ranked No. 14 on U.S. News & World Report’s “Honor Roll” of the Top 20 Best Hospitals in the country and the Icahn School of Medicine as one of the Top 20 Best Medical Schools in country. Mount Sinai Health System hospitals are consistently ranked regionally by specialty and our physicians in the top 1% of all physicians nationally by U.S. News & World Report.

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Consort Partners for MindMaze


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