Posts Tagged cognition

[ARTICLE] Follow-up after 5.5 years of treatment with methylphenidate for mental fatigue and cognitive function after a mild traumatic brain injury – Full Text

Objective: Prolonged mental fatigue and cognitive impairments are common after a mild traumatic brain injury (TBI). This sets limits for rehabilitation and for regaining the capacity for work and participation in social life.

Method: This follow-up study, over a period of approximately 5.5 years was designed to evaluate the effect and safety of methylphenidate treatment for mental fatigue after a mild TBI. A comparison was made between those who had continued, and those who had discontinued the treatment. The effect was also evaluated after a four-week treatment break.

Results: Significant improvement in mental fatigue, depression, and anxiety for the group treated with methylphenidate (p < .001) was found, while no significant change was found for the group without methylphenidate. The methylphenidate treatment group also improved their processing speed (p = .008). Withdrawal produced a pronounced and significant deterioration in mental fatigue, depression, and anxiety and a slower processing speed. This indicates that the methylphenidate effect is reversible if discontinued and that continued methylphenidate treatment can be a prerequisite for long-term improvement. The effect was found to be stable and safe over the years.

Conclusion: We suggest methylphenidate to be a possible treatment option for patients with post-TBI symptoms including mental fatigue and cognitive symptoms.

Introduction

Long-term mental fatigue and cognitive impairment are common after a mild, moderate or severe traumatic brain injury (TBI) and these can have a significant impact on work, well-being and quality of life (1). Fatigue and concentration deficits are acknowledged as being one of the most distressing and long-lasting symptoms following mild TBI (1). There is currently no approved treatment (2), although the most widely used research drug for cognitive impairments after TBI is methylphenidate (3). A few studies have used methylphenidate for mental fatigue after TBI with promising results including our own (4,5). Other clinical trials of drugs have reported improvements in mental fatigue ((−)-osu6162 (6)) or none ((−)-osu616, modafinil (79)).

In our feasibility study of methylphenidate (not placebo controlled) we reported decreased mental fatigue, improved processing speed and enhanced well-being with a “normal” dose of methylphenidate compared to no methylphenidate for people suffering from post-traumatic brain injury symptoms (4). We tested methylphenidate in two different dosages and found that the higher dose (20 mg three times/day) had the better effect compared to the lower dose. We also found methylphenidate to be well tolerated by 80% of the participants. Adverse events were reported as mild and the most commonly reported side-effects included restlessness, anxiety, headache, and increased heart rate; no dependence or misuse were detected (10). However, a careful monitoring for adverse effects is needed, as many patients with TBI are sensitive to psychotropic medications (11).

Participants who experienced a positive effect with methylphenidate were allowed to continue the treatment. We have reported the long-term positive effects on mental fatigue and processing speed after 6 months (12) and 2 years (13). No serious adverse events were reported (13)(Figure 1). In a 30-week double-blind-randomized placebo-controlled trial, Zhang et al. reported that methylphenidate decreased mental fatigue and improved cognitive function in the participants who had suffered a TBI. Moreover, social and rehabilitation capacity and well-being were improved (5). Other studies evaluating methylphenidate treatment after TBI have focused only on cognitive function reporting improved cognitive function with faster information processing speed and enhanced working memory and attention span (1421). A single dose of methylphenidate improved cognitive function and brain functionality compared to placebo in participants suffering from post-TBI symptoms (22,23). Most of these have been short-term studies covering a period between 1 day and 6 weeks and included participants suffering from mild or more severe brain injuries.

This clinical follow-up study was designed to evaluate the long-term effect and safety of methylphenidate treatment. We also evaluated the effect after a four-week treatment break and compared the subjective and objective effects with and without methylphenidate. Patients who had discontinued methylphenidate during this long-term study were also included in this follow-up, as it was our intention to compare the long-term effects on mental fatigue in patients with and without methylphenidate treatment.

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Continue —->  Follow-up after 5.5 years of treatment with methylphenidate for mental fatigue and cognitive function after a mild traumatic brain injury: Brain Injury: Vol 0, No 0

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[ARTICLE] Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE): A pilot clinical trial for chronic traumatic brain injury – Full Text

Abstract

BACKGROUND:

Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation. However, little is known about the effectiveness of VR rehabilitation for TBI-related cognitive deficits. In response to these clinical and research gaps, we developed Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), an intervention designed to improve cognitive performance, driving safety, and neurobehavioral symptoms.

OBJECTIVE:

This pilot clinical trial was conducted to examine feasibility and preliminary efficacy of NeuroDRIVE for rehabilitation of chronic TBI.

METHODS:

Eleven participants who received the intervention were compared to six wait-listed participants on driving abilities, cognitive performance, and neurobehavioral symptoms.

RESULTS:

The NeuroDRIVE intervention was associated with significant improvements in working memory and visual search/selective attention— two cognitive skills that represented a primary focus of the intervention. By comparison, no significant changes were observed in untrained cognitive areas, neurobehavioral symptoms, or driving skills.

CONCLUSIONS:

Results suggest that immersive virtual environments can provide a valuable and engaging means to achieve some cognitive rehabilitation goals, particularly when these goals are closely matched to the VR training exercises. However, additional research is needed to augment our understanding of rehabilitation for driving skills, cognitive performance, and neurobehavioral symptoms in chronic TBI.

1. Introduction

Each year, emergency departments treat approximately 2.5 million traumatic brain injuries (TBIs) (). TBI can affect a wide range of brain systems, resulting in sensorimotor deficits (e.g., coordination, visual perception), cognitive deficits (e.g., memory, attention), emotional dysregulation (e.g., irritability, depression), and somatic symptoms (e.g., headache, fatigue) (). These TBI-related impairments can have significant life consequences. Studies conducted across a wide range of neurological and psychiatric conditions show that neuropsychological abilities are strongly associated with functional skills and employment outcomes (). For example, challenges in attention and concentration could result in distractibility and errors in work settings, and deficits in executive functions could lead to poor organization and problems with setting and achieving occupational goals. As many as 3.2–5.3 million people in the US are living with TBI-related disability ().

Rehabilitation has been shown to improve outcomes for those experiencing chronic effects of TBI (). Previously-validated rehabilitation approaches for TBI include both ‘cognitive’ and ‘functional’ approaches. ‘Cognitive’ methods of rehabilitation are focused on improving performance on individual cognitive tasks, with the hope that these gains will generalize to functional activities (). Restorative cognitive training approaches have been shown to improve cognitive functioning across multiple conditions such as schizophrenia, traumatic brain injury, and normal aging (). Some of the most promising results to date have been demonstrated for training of attention and working memory, which have been shown to correspond to changes in functional brain activity (). Evidence suggests that the format of therapist-guided rehabilitation is able to harness some of the well-established benefits of the therapeutic relationship, and may be preferable to computer-guided training (). While there is some evidence indicating that benefits of cognitive remediation extend to untrained tasks, a number of studies have shown that improvements in performance on individual cognitive tasks tend to generalize very weakly, if at all, to other cognitive tasks and functional abilities (). This weak transfer of training might be attributable to low levels of correspondence between the cognitive and sensorimotor demands of rehabilitation tasks and those encountered during challenging real-world situations.

In contrast to methods of rehabilitation that rely upon generalization of cognitive benefits to functional outcomes, ‘functional’ methods of rehabilitation focus on improving performance on real-life activities through direct practice of those activities (). This approach requires effective targeting of specific functional tasks that are relevant to each patient and may be limited by the physical environments available within the treatment setting (e.g., a simulated home environment used to practice activities of daily living). However, the basic functional tasks that are often emphasized in functional rehabilitation (e.g., self-care, food preparation) may not be sufficiently challenging to address more subtle or ‘higher order’ cognitive and functional deficits that many mild to moderate TBI patients experience in the long-term phase of recovery ().

Virtual reality (VR) technology may provide an effective means to integrate cognitive and functional approaches to TBI rehabilitation (). The guiding concept for VR rehabilitation is to provide an immersive, engaging, and realistic environment in which to practice cognitive, sensorimotor, and functional skills. VR scenarios can simulate a wide range of real or imagined tasks and environments. While VR may not be necessary for tasks that are easily recreated in existing therapy environments, it is particularly well-suited for tasks that are challenging or dangerous to recreate within real-world treatment environments, such as driving an automobile ().

Driving is one of the most universal, cognitively challenging, and potentially-dangerous activities of everyday life. Safe driving requires continuous synchronization of processes like reaction time, visuo-spatial skills, attention, executive function, and planning (). Whereas it would be obviously unsafe to place an impaired patient into many real-world driving situations, VR allows for safe assessment and rehabilitation of driving-relevant skills at the true limits of the individual’s current capabilities. Individuals with TBI are at elevated risk for motor vehicle accidents and other driving difficulties (). Many individuals with severe TBI never return to driving (), and an estimated 63% of those with severe TBI who do return to driving are involved in motor vehicle accidents (). Available evidence suggests that deficits in attention and visual search may underlie these driving impairments. While most of this research has been conducted with moderate-to-severe TBI populations, these issues are not exclusive to severe forms of TBI. Individuals recovering from mild TBI have also been found to exhibit slower detection of driving hazards in simulated driving experiments () and to be at increased risk for real-world motor vehicle accidents ().

Previous results suggest that VR driving rehabilitation can be effective for improving driving skills among those with moderate-to-severe TBI (). However, these findings have not been replicated or validated for those with symptomatic mild TBI. Additionally, little is known about the effectiveness of VR rehabilitation programs for TBI-related cognitive deficits (). In response to these clinical and research gaps, we developed an intervention known as Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE), which was designed to improve cognitive performance and overall driving safety by providing integrated training in these skills. In contrast to intervention approaches that are geared toward more severely impaired individuals, NeuroDRIVE was designed for use with a wide range of TBI patients (i.e., mild, moderate, or severe TBI) who are seeking treatment in these areas and have the capability to engage in the driving process. This pilot clinical trial examined feasibility and preliminary efficacy of NeuroDRIVE for improving VR driving performance, cognitive performance, and symptom outcomes among those with chronic TBI. Given the focus of the intervention, effects on attention and working memory were of particular interest. Additionally, we have provided the NeuroDRIVE treatment manual as a supplementary document to facilitate continued development of VR rehabilitation for those with TBI.

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Continue —-> Neurocognitive Driving Rehabilitation in Virtual Environments (NeuroDRIVE): A pilot clinical trial for chronic traumatic brain injury

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Fig.2
T3 VR Driving Simulator.

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[VIDEO] Disorder of Consciousness & Cognitive Recovery Following TBI Levels 1-10 – YouTube

Recovery from a Traumatic Brain Injury is a complex neurological process. Severe injuries commonly result in a wide range of impaired consciousness. Consciousness refers often to a person’s awareness of self and their interactions with their environment. Mild injuries may sometimes cause brief timeframes of impaired consciousness such as confusion or disorientation. However severe injuries may have a period of time whereby they have complete unconsciousness and no awareness of themselves or the world around them. Terms such as Coma, Vegetative State, Minimal Conscious State, Emerging Consciousness and Post-Traumatic Confusion or Post Traumatic Amnesia are often used by professionals caring for your family member but can be confusing to understand.

This video presentation is intended to demonstrate general patterns of improving consciousness and cognition following severe TBI. In this video, you may learn basic anatomy of TBI and what happens behaviorally step-step with improving consciousness. Your family member may not follow this sequence exactly and may skip steps depending on their more specific type of injury. Furthermore, as consciousness improves your family member may also have different types of impairments in their thinking abilities , referred to as Cognition. This presentation will highlight a step wise sequence of improving cognition and offer you as family members helpful suggestions on how to better assist your loved one during the rehabilitation process.

To learn more about Craig Hospital’s Brain Injury program visit: https://craighospital.org/programs/tr…

 

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[Abstract] Poststroke Fatigue Is Related to Motor and Cognitive Performance

Abstract

Background and Purpose: Poststroke fatigue (PSF) is a common debilitating and persistent symptom after stroke. The relationship between PSF and motor and cognitive function remains inconclusive partly due to lack of control for effects of depression and use of insensitive measures. We examined the relationship between PSF and motor and cognitive performance using a comprehensive set of behavioral measures and excluding individuals with depression.

Methods: Fifty-three individuals poststroke (16 female) were included (median age: 63 years, median months poststroke: 20 months). Poststroke fatigue was quantified using the Fatigue Severity Scale (FSS) and cognitive performance was measured with the Montreal Cognitive Assessment, simple and choice reaction time (SRT and CRT) tasks. Lower extremity motor performance included Fugl-Meyer Motor Assessment, 5 times sit-to-stand test (5 × STS), Berg Balance Scale, Functional Ambulation Category, and gait speed. Upper extremity motor performance was indexed with Fugl-Meyer, grip strength, and Box and Block test. Spearman correlation and stepwise linear regression analyses were performed to examine relationships.

Results: Two motor performance measures, Berg Balance Scale and Functional Ambulation Category, were significantly correlated with FSS (ρ = −0.31 and −0.27, respectively) while all cognitive measures were significantly correlated with FSS (ρ = −0.28 for Montreal Cognitive Assessment, 0.29 for SRT, and 0.29 for CRT). Regression analysis showed that Berg Balance Scale was the only significant determinant for FSS (R2 = 0.11).

Discussion and Conclusions: Functional gait, balance, and cognitive performance are associated with PSF. Fatigue should be considered when planning and delivering interventions for individuals with stroke. Future studies are needed to explore the potential efficacy of balance and cognitive training in PSF management.

Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A287).

 

via Poststroke Fatigue Is Related to Motor and Cognitive Perform… : Journal of Neurologic Physical Therapy

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[WEB SITE] Nootropics: Types, safety, and risks of smart drugs

Last reviewed 

Nootropics, or “smart drugs,” are a class of substances that can boost brain performance. They are sometimes called cognition enhancers or memory enhancing substances.

Prescription nootropics are medications that have stimulant effects. They can counteract the symptoms of medical conditions such as attention deficit hyperactivity disorder (ADHD), narcolepsy, or Alzheimer’s disease.

Nonprescription substances that can enhance brain performance or focus — such as caffeine and creatine — are also considered nootropics. They do not treat diseases but may have some effects on thinking, memory, or other mental functions.

This article looks at prescription and nonprescription smart drugs, including their uses, side effects, and safety warnings.

Prescription nootropics

a woman taking nootropics at her desk.

A person may take a nootropic to treat ADHD, narcolepsy, or dementia.

Prescription nootropics include:

  • modafinil (Provigil), a stimulant that addresses the sudden drowsiness of narcolepsy
  • Adderall, which contains amphetamines to treat ADHD
  • methylphenidate (Ritalin), a stimulant that can manage symptoms of narcolepsy and ADHD
  • memantine (Axura), which treats symptoms of Alzheimer’s disease

While these can be effective in treating specific medical conditions, a person should not take them without a prescription.

Like any prescription medications, they carry risks of side effects and interactions, and a person should only take them under a doctor’s care.

Common side effects of prescription nootropics include:

Some evidence suggests that people who use prescription nootropics to improve brain function have a higher risk of impulsive behaviors, such as risky sexual practices.

Healthcare providers should work closely with people taking prescription nootropics to manage any side effects and monitor their condition.

Over-the-counter nootropics

The term “nootropic” can also refer to natural or synthetic supplements that boost mental performance. The following sections discuss nootropics that do not require a prescription.

Caffeine

Many people consume beverages that contain caffeine, such as coffee or tea, because of their stimulant effects. Studies suggest that caffeine is safe for most people in moderate amounts.

Having a regular cup of coffee or tea may be a good way to boost mental focus. However, extreme amounts of caffeine may not be safe.

The Food and Drug Administration (FDA) recommend that people consume no more than 400 milligrams (mg) of caffeine a day. This is the amount in 4–5 cups of coffee.

Caffeine pills and powders can contain extremely high amounts of the stimulant. Taking them can lead to a caffeine overdose and even death, in rare cases.

Women who are pregnant or may become pregnant may need to limit or avoid caffeine intake. Studies have found that consuming 4 or more servings of caffeine a day is linked to a higher risk of pregnancy loss.

L-theanine

L-theanine is an amino acid that occurs in black and green teas. People can also take l-theanine supplements.

A 2016 review reported that l-theanine may increase alpha waves in the brain. Alpha waves may contribute to a relaxed yet alert mental state.

L-theanine may work well when paired with caffeine. Some evidence suggests that this combination helps boost cognitive performance and alertness. Anyone looking to consume l-theanine in tea should keep the FDA’s caffeine guidelines in mind.

There are no dosage guidelines for l-theanine, but many supplements recommend taking 100–400 mg per day.

Omega-3 fatty acids

person at desk holding omega 3 supplements in palm

Studies have shown that omega-3 fatty acids are important to fight against brain aging.

These polyunsaturated fats are found in fatty fish and fish oil supplements. This type of fat is important for brain health, and a person must get it from their diet.

Omega-3s help build membranes around the body’s cells, including the neurons. These fats are important for repairing and renewing brain cells.

A 2015 review found that omega-3 fatty acids protect against brain aging. Other research has concluded that omega-3s are important for brain and nervous system function.

However, a large analysis found “no benefit for cognitive function with omega‐3 [polyunsaturated fatty acids] supplementation among cognitively healthy older people.” The authors recommend further long term studies.

A person can get omega-3 supplements in various forms, including fish oil, krill oil, and algal oil.

These supplements carry a low risk of side effects when a person takes them as directed, but they may interact with medications that affect blood clotting. Ask a doctor before taking them.

Racetams

Racetams are synthetic compounds that can affect neurotransmitters in the brain. Some nootropic racetams include:

  • piracetam
  • pramiracetam
  • phenylpiracetam
  • aniracetam

A study conducted in rats suggests that piracetam may have neuroprotective effects.

One review states that “Some of the studies suggested there may be some benefit from piracetam, but, overall, the evidence is not consistent or positive enough to support its use for dementia or cognitive impairment.” Confirming this will require more research.

There is no set dosage for racetams, so a person should follow instructions and consult a healthcare provider. Overall, studies have no found adverse effects of taking racetams as directed.

Ginkgo biloba

Ginkgo biloba is a tree native to China, Japan, and Korea. Its leaves are available as an herbal supplement.

2016 study found that gingko biloba is “potentially beneficial” for improving brain function, but confirming this will require more research.

Ginkgo biloba may help with dementia symptoms, according to one review, which reported the effects occurring in people who took more than 200 mg per day for at least 5 months.

However, the review’s authors note that more research is needed. Also, with prescription nootropics available, ginkgo biloba may not be the most safe or effective option.

Panax ginseng

Panax ginseng is a perennial shrub that grows in China and parts of Siberia. People use its roots for medicinal purposes.

People should not confuse Panax ginseng with other types of ginseng, such as Siberian or American varieties. These are different plants with different uses.

2018 review reports that Panax ginseng may help prevent certain brain diseases, including Alzheimer’s disease, Parkinson’s disease, and Huntington’s disease. It also may help with brain recovery after a stroke.

Panax ginseng interacts with many medications, so consult a doctor before taking it. A typical dosage for mental function is 100–600 mg once or twice a day.

Rhodiola

Some evidence suggests that Rhodiola rosea L., also known as rhodiola or roseroot, can help with cognitive ability.

One review reported that rhodiola may have neuroprotective effects and may help treat neurodegenerative diseases.

Another review found that rhodiola helped regulate neurotransmitters in the brain, having a positive effect on mood.

Rhodiola capsules have varying strengths. Usually, a person takes a capsule once or twice daily.

Creatine

Creatine is an amino acid, which is a building block of protein. This supplement is popular among athletes because it may help improve exercise performance. It may also have some effects on mental ability.

A 2018 review found that taking creatine appears to help with short term memory and reasoning. Whether it helps the brain in other ways is unclear.

The International Society of Sports Nutrition report that creatine supplementation of up to 30 grams per day is safe for healthy people to take for 5 years.

Another 2018 review notes that there has been limited research into whether this supplement is safe and effective for adolescent athletes.

Do nootropics work?

Some small studies show that some nootropic supplements can affect the brain. But there is a lack of evidence from large, controlled studies to show that some of these supplements consistently work and are completely safe.

Because of the lack of research, experts cannot say with certainty that over-the-counter nootropics improve thinking or brain function — or that everyone can safely use them.

For example, one report on cognitive enhancers found that there is not enough evidence to indicate that they are safe and effective for healthy people. The researchers also point to ethical concerns.

However, there is evidence that omega-3 fatty acids can benefit the brain and overall health. In addition, caffeine can improve mental focus in the short term.

Notes on the safety of nootropics

doctor and patient in office discussing adrenal cancer

A person should talk to a doctor about any interactions supplements may have with existing medications.

Also, some supplements may not contain what their labels say. A study of rhodiola products, for example, found that some contain contaminants or other ingredients not listed on the label.

For this reason, it is important to only purchase supplements from reputable companies that undergo independent testing.

BUYING NOOTROPICSA prescription is necessary for some nootropics, such as Provigil and Adderall. Over-the-counter nootropics are available in some supermarkets and drug stores, or people can choose between brands online:

Not all of these supplements are recommended by healthcare providers and some may interact with medications. Always speak to a doctor before trying a supplement.

Summary

Many doctors agree that the best way to boost brain function is to get adequate sleep, exercise regularly, eat a healthy diet, and manage stress.

For people who want to boost their cognitive function, nootropic supplements may help, in some cases. Anyone interested in trying a nootropic should consult a healthcare professional about the best options.

 

via Nootropics: Types, safety, and risks of smart drugs

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[WEB SIDE] RPW Technology Announces The Launch Of Liftid Neurostimulation

OSSINING, N.Y.Aug. 16, 2019 /PRNewswire/ — RPW Technology, LLC introduces Liftid Neurostimulation (www.GetLiftid.com), a transcranial direct current stimulation (tDCS) recreational device for consumers that can improve attention, productivity, and memory through mild electrical stimulation. Liftid uses a constant, low-level electric current, passed through two electrodes placed on the forehead area, to stimulate the brain. tDCS is one of the hottest categories in neuroscience today and supported by over 4,000 published studies.

Maximize attention and elevate performance with LIFTiD Neurostimulation.

 

Dr. Ted Schwartz, MD, a New York based neurosurgeon and RPW’s lead scientist, explains, “As has been shown in several studies, tDCS delivers a small amount of electrical current to the cerebral cortex, rendering neurons in the brain more likely to fire. As a result, the user demonstrates increased abilities, alertness and focus.”

In today’s world, most working professionals, college and grad students, video gamers, musicians, and athletes are chemically stimulating their brains through caffeine, sugar, snacks, and performance enhancers. Liftid Neurostimulation uses a safe and effective technology as an alternative to these forms of chemical stimulation.

RPW Technology is proud to be on the forefront of this emerging technology by bringing to market a tDCS device for healthy individuals (ages 18 & up) that is stylish, extremely lightweight (70 grams) including a soft, comfortable, adjustable headband, and easy to operate. Designed and developed by a team of world renowned neuroscientists, Liftid is preset for a 20 minute stimulation session and has many unique features built-in to the device. Using Liftid Neurostimulation for 20 minutes a day trains the brain to maximize attention, focus, alertness, and memory, thus putting the Liftid user in the right mindset to accomplish tasks and elevate performance.

For more information, purchase, and/or instructional video, please visit the Liftid Neurostimulation website at: www.GetLiftid.com. Unit price is $149.00, which includes an attractive and functional storage case with custom accessories and free shipping within the United States. Liftid is packaged for retail sales.

RPW Technology is a New York startup dedicated to the development and marketing of transcranial electrical stimulation devices. The company, in association with Dr. Schwartz and several neuroscientists, set out to develop a high quality, hi-tech, recreational tDCS device to introduce to consumers worldwide.

Contact for RPW Technology, LLC:
Bridget Argana
Orca Communications Unlimited, LLC
bridget.argana@orcapr.com
(480) 231-3582

Cision View original content to download multimedia:http://www.prnewswire.com/news-releases/rpw-technology-announces-the-launch-of-liftid-neurostimulation-300902988.html

SOURCE RPW Technology, LLC

via RPW Technology Announces The Launch Of Liftid Neurostimulation | BioSpace

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[ARTICLE] What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes – Full Text

Abstract

Background

Virtual-reality based rehabilitation (VR) shows potential as an engaging and effective way to improve upper-limb function and cognitive abilities following a stroke. However, an updated synthesis of the literature is needed to capture growth in recent research and address gaps in our understanding of factors that may optimize training parameters and treatment effects.

Methods

Published randomized controlled trials comparing VR to conventional therapy were retrieved from seven electronic databases. Treatment effects (Hedge’s g) were estimated using a random effects model, with motor and functional outcomes between different protocols compared at the Body Structure/FunctionActivity, and Participation levels of the International Classification of Functioning.

Results

Thirty-three studies were identified, including 971 participants (492 VR participants). VR produced small to medium overall effects (g = 0.46; 95% CI: 0.33–0.59, p < 0.01), above and beyond conventional therapies. Small to medium effects were observed on Body Structure/Function (g = 0.41; 95% CI: 0.28–0.55; p < 0.01) and Activity outcomes (g = 0.47; 95% CI: 0.34–0.60, p < 0.01), while Participation outcomes failed to reach significance (g = 0.38; 95% CI: -0.29-1.04, p = 0.27). Superior benefits for Body Structure/Function (g = 0.56) and Activity outcomes (g = 0.62) were observed when examining outcomes only from purpose-designed VR systems. Preliminary results (k = 4) suggested small to medium effects for cognitive outcomes (g = 0.41; 95% CI: 0.28–0.55; p < 0.01). Moderator analysis found no advantage for higher doses of VR, massed practice training schedules, or greater time since injury.

Conclusion

VR can effect significant gains on Body Structure/Function and Activity level outcomes, including improvements in cognitive function, for individuals who have sustained a stroke. The evidence supports the use of VR as an adjunct for stroke rehabilitation, with effectiveness evident for a variety of platforms, training parameters, and stages of recovery.

Background

Stroke is one of the leading global causes of disability [], with over 17 million individuals worldwide sustaining a stroke each year []. Although stroke mortality is decreasing with improvements in medical technology [], the neurological trauma resulting from stroke can be devastating, and the majority of stroke survivors have substantial motor [], cognitive [] and functional rehabilitation needs [], and much reduced quality of life []. Targeted rehabilitation can help address some of these post-stroke deficits, however, historically, many individuals, in particular patients with cognitive impairment, have difficulty engaging in standard therapies [] at a level that will produce meaningful and lasting improvements []. Enriched and interactive rehabilitation programs are clearly needed to minimize functional disability [], increase participation in age-appropriate roles and activities [], lead to greater motivation and treatment compliance [], and reduce the long-term expense of care in stroke survivors [].

Virtual reality

Virtual reality refers to simulated interactions with environments and events that are presented to the performer with the aid of technology. These so-called virtual environments may mirror aspects of the real world or represent spaces that are far removed from it, while allowing various forms of user interaction through movement and/or speech []. Virtual reality based rehabilitation, or Virtual Rehabilitation (VR), shows considerable promise as a safe, engaging, interactive, patient-centered and relatively inexpensive medium for rehabilitation training []. VR has the potential to target a wide range of motor, functional, and cognitive issues [], affords methods that automatically record and track patient performance [], and offers a high level of flexibility and control over therapeutic tasks []. This scalability allows patients to train at the highest intensity that would be possible for their individual ability [], while keeping the experience of interaction with therapeutic tasks enjoyable and compelling []. At the same time, VR may enable patients with a neurodisability (like stroke) to practice without excessive physical fatigue [] which otherwise may deter continued effort and engagement in therapy [].

Currently, there are two main types of VR: purpose-designed Virtual Environments (VE) and Commercial Gaming (CG) systems. Both types of systems can provide augmented feedback, additional forms of sensory feedback about the patient’s movement over and above the feedback that is provided as a natural consequence of the movement itself []. VE systems are often designed by rehabilitation scientists (and others) to enhance the delivery of augmented feedback in order to develop the patient’s sense of position in space [], to reinforce different movement parameters (like trajectory and endpoint) and reduce extraneous movements (e.g. excessive trunk displacement) [].

VE systems are also more likely to involve specially designed tangible user interfaces used in mixed reality rehabilitation systems [] or training of daily functional activities []. By comparison, CG rehabilitation systems are typically “off-the-shelf” devices such as Wii (Nintendo), Xbox (Microsoft) and PlayStation (Sony), which have the advantage of being readily available and relatively inexpensive when compared with VE systems []. On the other hand, CG systems are typically designed for able-bodied participants and may not consider the physiological, motor, and cognitive aspects of recovery in rehabilitation, and may lack the scalability of purpose-designed VE systems [].

Systematic reviews comparing VE and CG systems

There is conflicting evidence about the relative effectiveness of VE- and CG-based VR systems. In a recent Cochrane review of VR following stroke [], VE systems demonstrated a significant treatment effect on upper-limb function when compared to controls (d = 0.42; 95%CI: 0.07–0.76), while the effect for CG systems failed to reach significance (d = 0.50; 95%CI: -0.04-1.04); a caveat, however, was that only two of nine studies (22%) in these comparisons were CG-based. In contrast, a meta-analysis by Lohse and colleagues of VR following stroke [] found no significant difference between VE (g = 0.43, based on 13 studies) and CG interventions (g = 0.76, based on three studies) on Body Structure/Function level outcomes. For Activity level outcomes, CG interventions showed a large but non-significant effect (g = 0.76, p = 0.14), but was based on only four of 26 studies (15%); VE interventions, however, showed a significant treatment effect (g = 0.54, p < .001). Taken together, these two reviews suggest benefits of VE systems, while previous analyses of CG treatment effects have been underpowered and inconclusive.

Cognition and VR

Cognitive impairments, including difficulties in attention, language, visuospatial skills, memory, and executive function are common and persistent sequelae of stroke [] and exert considerable influence on rehabilitation outcomes []. Cognitive dysfunction may reduce the ability to (re-)acquire motor [] and functional skills [], and decrease engagement and participation in rehabilitation program []. While the important role of cognition in both conventional and VR-based rehabilitation is increasingly recognized [] the impact of VR on cognitive function has not yet been formally evaluated in a quantitative review.

Analysis of individual domains of functioning

The World Health Organization’s International Classification of Functioning, Disability, and Health (ICF-WHO []) is currently one of the most widely used classification systems. It is a foundation for understanding outcome effects in clinical practice [] and the preferred means for translating clinical findings in a patient-centered manner []. Under the ICF-WHO, disability and functioning are seen to arise by the interaction of the health condition, the environment, and personal factors, and can be measured at three main levels: (i) Body Structure/Function, (ii) Activity (or skill), and (iii) Participation. The ICF-WHO has been used to classify outcome measures in studies of VR (for example []) and in recent systematic reviews []. A brief critique of these reviews reveals a number of important conclusions, but also some significant gaps in the research.

An early systematic review by Crosbie and colleagues [] examined the efficacy of VR for stroke upon motor and cognitive outcomes. Of the 11 studies reviewed (up to 2005), only five addressed upper-limb function and two addressed cognitive outcomes. Overall, the review reported significant benefits of VR, but only three studies were RCTs and no effect size estimates were reported. At around the same time, a systematic review by Henderson and colleagues [] showed that there was very good evidence that immersive VR was more beneficial than no therapy for upper-limb rehabilitation in adult stroke, but insufficient evidence for non-immersive VR. Comparisons with traditional physical therapy were less impressive, however.

A 2016 systematic review by Vinas-Diz and colleagues [] included both controlled clinical trials and randomized controlled trials (RCTs) in stroke, and spanned 2009–2014. The review included 25 papers: four systematic reviews [] and 21 original trials. Evidence for treatment efficacy on upper-limb function was strong on a mix of measures like the Fugl-Meyer Test, Wolf Motor Function Test, and Motricity Index. However, a quantitative analysis of the effects was not undertaken, and important aspects of treatment implementation like dose and session scheduling were not formally examined.

A recent systematic review by Santos-Palma and colleagues [] examined the efficacy of VR on motor outcomes for stroke using the ICF-WHO framework, covering work published up to June 2015. Of the studies deemed high quality, 20 examined outcomes at the Body Structure/Function level, 17 at the Activity level, and eight examined Participation. Intriguingly, positive outcomes were evident only at the Body Structure/Function level, while results for Activity and Participation were not conclusive. Unfortunately, only three studies addressed manual ability at the Activity level, which severely limited any evaluation of skill-specific effects.

In a combined systematic review and meta-analysis of 37 RCTs published between 2004 and 2013, Laver and colleagues [] present a more comprehensive examination of the effects of VR on upper-limb function. As well, they classified outcomes broadly into upper-limb function, Activities of Daily Living (ADLs) and other aspects of motor function. In general, study quality was low, and the risk of bias high, in roughly one-half of the studies. Outcomes were significant for upper-limb function (d = 0.28) and ADLs (d = 0.43), but somewhat smaller than those reported by Lohse and colleagues []. Results for other aspects of motor function, including several at what may be considered the Body Structure/Function level, were non-significant. Dose varied considerably between studies, ranging from less than 5 h to more than 21 h in total. In general, studies that used higher doses (> 15 h of therapy) were reported as more effective. Unfortunately, results could not be pooled for cognitive outcomes, and the importance of additional treatment implementation parameters like training frequency and duration, and the impact of specific study design factors including the recovery stage of participants and type of control group (i.e. active vs passive) were not determined.

An updated systematic review by Laver and colleagues [], included an additional 35 studies that reported outcomes for upper limb function and activity. A subset of only 22 studies that compared VR with conventional therapy showed no significant effect of VR on upper-limb function (d = 0.07). As well, there was no significant difference between higher (> 15 h of therapy), and lower levels of dose. However, when VR was used in addition to usual care (10 studies; 210 participants), there was a significant effect on upper-limb outcomes (d = 0.49). As before, no significant difference was shown between high and low dose studies. Unfortunately, analysis of cognitive outcomes, and moderator analyses including study quality, and implementation parameters (e.g., daily intensity, weekly intensity, treatment frequency, and total number of sessions) were not included in the updated review. As well, the assessment of study quality was limited to the 5-item GRADE system, the ICF classification system was not given full consideration, and no distinction was drawn between treatment as usual (TAU) and active control groups (TAU + some form of additional therapy).

Taken together, recent reviews on the use of VR for adult stroke show encouraging evidence of efficacy at the level of Body Structure/Function, but mixed results for Activity and ADLs, and a paucity of evidence bearing on Participation. The impact and effectiveness of VR on cognitive outcomes also remains poorly understood, despite the important role of cognitive dysfunction in learning and rehabilitation [], and increased evidence of interconnection between cognitive function and motor deficits at the Body Structure/Function, Activity and Participation levels of the ICF []. VE-based platforms have been suggested to be superior to CG approaches [] in promoting motor function, but until recently there have been few CG studies available for analysis. As well, other design factors that may moderate treatment effects (like stage of recovery, control group type) have either not been explored or are too few in number to draw firm conclusions. There has been considerable variation in the total dose of VR therapy [], and no analysis has yet tested the dose-response relationship in moderator analyses. Finally, the bulk of conclusions have relied on qualitative synthesis, and there is a paucity of quantitative analysis of empirical data to inform opinion.

In view of limitations in past reviews and continued acceleration in VR the aim of our review was to conduct a systematic literature review and meta-analysis to re-evaluate the strength of evidence bearing on VR of upper-limb function and cognition in stroke. This review is critical given evidence that stroke rehabilitation needs to better optimize intervention techniques during the recovery windows that exist in the acute phase [] and beyond. Focusing only on RCTs, we consider outcomes across levels of the ICF-WHO, and analyze the moderating effect of design factors and dose-related parameters.

Methods

The current review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [], it should be noted that the protocol was not registered.

Data sources and search strategy

Scopus, Cochrane Database, CINAHL, The Allied and Complementary Medicine Database, Web of Science, MEDLINE, Pre-Medline, PsycEXTRA, and PsycINFO databases were systematically searched from inception until 28 June 2017. Boolean search terms included the following: “strokecerebrovascular disease, or cerebrovascular attack” and “Virtual realityAugmentrealityvirtual gam*” (see Appendix for an example of the full MEDLINE search strategy).

Inclusion and exclusion criteria

RCT studies published in English in peer-reviewed journals, utilizing a VR intervention to address either motor (upper-limb), cognitive, or activities of daily living in stroke patients were included in the current review (see Fig. 1). VR was defined as a type of user-computer interface that involves real-time simulation of an activity/environment, enabling the user to interact with the environment using motor actions and sensory systems. Comparison groups included “usual care”, “standard care” or “conventional therapy”, involving physical therapy and/or occupational therapy. Studies were excluded that applied a “hybrid” approach combining virtual reality with exogenous stimulation or robotics, targeted lower limb function, recruited a mixed study cohort including non-stroke participants, or did not utilize motor, cognitive, or participation outcome measures.

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Fig. 1
Population, Intervention, Comparison, Outcome (PICO) Question and the main variables included in the systematic literature review and meta-analysis

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Continue —-> What do randomized controlled trials say about virtual rehabilitation in stroke? A systematic literature review and meta-analysis of upper-limb and cognitive outcomes

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[BLOG POST] Me, Myself, and My (More or Less) Creative I (after traumatic brain injury)

By Bill Herrin

Working with the topic of brain injury at Lash & Associates Publishing, I’ve heard on quite a few occasions that TBI can seriously alter a person’s ability to do certain things that they were once highly skilled at. Some basic things can also be affected, like driving a car, riding a bicycle, outdoor activities, walking/balance and more.

Many may also sustain a brain injury that affects them on an even deeper level – such as paralysis, cognition, thought patterns, speech, logic, etc. The one thing that is very intriguing about TBI is how it can affect creativity – and how it may change a more logical “left-brained” person, and make them more creative, imaginative, musical, or artistic. This also could bring the opposite effect to a more “right-brained” person and erase most or all of their previous creative strengths and talents. Although I’m not a TBI Survivor, I truly empathize with those who have dealt with these extreme changes and thought that it would be an interesting topic to explore.

One such case was Hilary Zayed. She worked as a teacher, was a flutist, a passionate horseback rider, and a mother of 2 grown children when she had a brain injury. Her recovery and subsequent reinvention of her prior life came with much hard work. She couldn’t enjoy music like she used to, so she worked toward finding a creative outlet – and soon discovered the art of making mosaics, paintings, and more.

After three years of being at home with a rotation of visiting nurses – often lying on the couch, she started to maneuver down the stairs to her art studio/space more and more. Some health professionals encouraged her to exhibit her works (art and writing), and soon she found herself doing several other solo shows across the Northeast. She found that sharing her experience through her art opened doors for others to be inspired to try harder after their own TBI. Here is a quote taken directly from Hilary’s book titled: Reinventing Oneself After Loss:

“One of the biggest lessons I learned was the importance of sharing my experience. It seemed to speak to people and inspire them to do the same. It felt as if the “butterfly effect” was happening and I was the one with the moving wings. As I finish writing this personal journey it has been almost seven years. I cannot say that I have fully reinvented myself but I have attempted to stay on course, refine my goals and continue to work hard on moving through

obstacles and leaning forward. Oddly, it was leaning forward on my horse, that fateful day, which changed my life. That action gave me the gift of making art and writing about it, on this journey to reinvent myself after loss.

May you find the courage to move forward as you deal with loss.”*

With every instance of people that make gains creatively after TBI, there are also people who suffer losses in the same arena. Being creative, artistic, musical, inventor, a writer, etc. is a gift that can be rewarding, and even help a person identify with others on a huge level. Losing that creative spark can be a harsh reality. Overall “loss of self” is basically the same thing, but it’s a huge transition for a creative person.

Shown below, I’m referencing an incredible article (by Dahlia W. Zaidel) that discusses the neurological changes that can take place in the brain of a creative person after a TBI, and also changes in a less creative person…here’s an excerpt:
“Neurological cases of visual artists who had practiced their craft professionally prior to the brain damage can help point the way to neuroanatomical and neurofunctional underpinnings of creativity. Approximately 50 or so cases with unilateral brain damage (largely in one side of the brain, and where the etiology is commonly stroke or tumor) have by now been described in the neurological literature (Rose, 2004Bogousslavsky and Boller, 2005Zaidel, 20052013a,cFinger et al., 2013Mazzucchi et al., 2013Piechowski-Jozwiak and Bogousslavsky, 2013).

The key questions concern post-damage alterations in creativity, as well as loss of talent, or skill. A review of the majority of these neurological cases suggests that, on the whole, they go on producing art, sometimes prolifically, despite the damage’s laterality or localization (Zaidel, 2005). Importantly, post-damage output has revealed that their creativity does not increase, nor diminish (Zaidel, 200520102013b). Given that the damage arises unilaterally (only one or the other hemisphere), artistic creativity in the healthy brain can not simply be attributed to a single hemisphere, dedicated neural “regional center”, network, or pathway, but rather to a diffusely represented capacity in the brain. Indeed, it would further seem that creativity is highly sensitive to brain damage, more so than artistic productivity, talent, or skill.

We could speculate that in the healthy brain cognitive associative networks in the left hemisphere alone, in the right hemisphere alone, or both hemispheres working together contribute to the creative process in art. However, recent functional neuroimaging evidence based on non-artistic behavior in healthy volunteers points to greater left hemisphere involvement in creativity (Gonen-Yaacovi et al., 2013). Where do the original ideas in the artwork arise, is a complex question that researchers would like understand (Dietrich and Kanso, 2010Heilman and Acosta, 2013Jung and Haier, 2013). The likely answer with regards to the cerebral hemispheres is that both are functional in exceptional creativity, but with each hemisphere contributing a different facet, yet little understood, to the creativity process (Zaidel, 2013d).”**

From the most basic approaches to eye/hand coordination, thought and cognition, and creative expression – to advanced creativity and artistic endeavors after TBI, the persistence and determination required to persevere takes incredible inner strength. As I often say, every person’s TBI is different, and each has its own starting point – and the ending point remains to be determined. Finding your way through the maze of TBI (of which there may be many causes such as concussions, blast injuries, stroke, etc.) is one of total commitment to stay the course. Time, along with effort brings results for many TBI survivors, but not all.

It’s my hope to encourage you in your creative outlets, to find solace in your “new normal”, and to express yourself through creativity…and creativity doesn’t just have to be visual arts, it can be writing, crafting, music, knitting or crocheting, poetry, relaxing with an adult coloring book, and lots more. Everything we see around us was created by someone – including the devices we are reading this post on! Make the most of every day, and my prayer for all of us is that we find abundant personal reward from all that we aspire to accomplish in life…creative or otherwise!

Feel free to leave a comment, and share your story regarding the changes in creativity, too. It may inspire, it may not…but your story is important – and it’s worth sharing!

**Here is the link to the entire referenced article by Dahlia W. Zaidel:

https://www.frontiersin.org/articles/10.3389/fnhum.2014.00389/full

via Me, Myself, and My (More or Less) Creative I (after traumatic brain injury)

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[WEB SITE] Parenting After Brain Injury

Parenting After Brain Injury

Parenting is a challenging life role for all people, yet one of the most valued roles within society. Brain Injury frequently occurs at a life stage where people are yet to complete their parenting responsibilities. For people with acquired brain injury (ABI), facing cognitive, physical, communication, behavioural and psychological challenges, parenting can present complex challenges. In addition, persons with ABI often face societal and environmental barriers. These fact sheets have been developed to assist parents with an ABI and their partners to improve their knowledge and skills to meet the ongoing challenges of parenting. family walking together
little girl finger painting boy doing his homework two little girls arguing

Encouraging your
Developing Child

Setting Routines

Managing Behaviour

Other Useful Parenting Website Links and Resources

Parenting Fact Sheet References and Acknowledgements
Return to Support for Families

Contact ABIOS
abios@health.qld.gov.au

Last updated: 20 March 2017

via Parenting After Brain Injury | Queensland Health

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[Abstract] Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology

Highlights

  • Virtual reality technology improves cognitive function post-traumatic brain injury.
  • Optimal treatment protocol is; 10–12 sessions, 20–40 min in duration with 2–4 sessions per week.
  • There was weak evidence for positive effect of virtual reality on attention.

Abstract

Background

Traumatic brain injury (TBI) can causes numerous cognitive impairments usually in the aspects of problem-solving, executive function, memory, and attention. Several studies has suggested that rehabilitation treatment interventions can be effective in treating cognitive symptoms of brain injury. Virtual reality (VR) technology potential as a useful tool for the assessment and rehabilitation of cognitive processes.

Objectives

The aims of present systematic review are to examine effects of VR training intervention on cognitive function, and to identify effective VR treatment protocol in patients with TBI.

Methods

PubMed, Scopus, PEDro, REHABDATA, EMBASE, web of science, and MEDLINE were searched for studies investigated effect of VR on cognitive functions post TBI. The methodological quality were evaluated using PEDro scale. The results of selected studies were summarized.

Results

Nine studies were included in present study. Four were randomized clinical trials, case studies (n = 3), prospective study (n = 1), and pilot study (n = 1). The scores on the PEDro ranged from 0 to 7 with a mean score of 3. The results showed improvement in various cognitive function aspects such as; memory, executive function, and attention in patients with TBI after VR training.

Conclusion

Using different VR tools with following treatment protocol; 10–12 sessions, 20–40 min in duration with 2–4 sessions per week may improves cognitive function in patients with TBI. There was weak evidence for effects of VR training on attention post TBI.

via Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology – Journal of Clinical Neuroscience

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