To determine the effects of a brief single component of the graded motor imagery (GMI) sequence (mirror therapy) on active range of motion (AROM), pain, fear avoidance, and pain catastrophization in patients with shoulder pain.
To explore feasibility and potential efficacy of on-line interventions for sleep quality following a traumatic brain injury (TBI).
A two parallel-group, randomized controlled pilot study.
In all, 24 participants (mean age: 35.9 ± 11.8 years) who reported experiencing sleep difficulties between 3 and 36 months after a mild or moderate TBI.
Participants were randomized to receive either a cognitive behaviour therapy or an education intervention on-line. Both interventions were self-completed for 20–30 minutes per week over a six-week period.
The Pittsburgh Sleep Quality Index assessed self-reported sleep quality with actigraphy used as an objective measure of sleep quality. The CNS Vital Signs on-line neuropsychological test assessed cognitive functioning and the Rivermead Post-concussion Symptoms and Quality of Life after Brain Injury questionnaires were completed pre and post intervention.
Both programmes demonstrated feasibility for use post TBI, with 83.3% of participants completing the interventions. The cognitive behaviour therapy group experienced significant reductions (F = 5.47, p = 0.04) in sleep disturbance (mean individual change = −4.00) in comparison to controls post intervention (mean individual change = −1.50) with a moderate effect size of 1.17. There were no significant group differences on objective sleep quality, cognitive functioning, post-concussion symptoms or quality of life.
On-line programmes designed to improve sleep are feasible for use for adults following mild-to-moderate TBI. Based on the effect size identified in this pilot study, 128 people (64 per group) would be needed to determine clinical effectiveness.
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via A pilot randomized controlled trial of on-line interventions to improve sleep quality in adults after mild or moderate traumatic brain injuryClinical Rehabilitation – Alice Theadom, Suzanne Barker-Collo, Kelly Jones, Margaret Dudley, Norah Vincent, Valery Feigin, 2017
Epilepsy affects more than 65 million people worldwide. One-third of these patients have seizures that are not controlled by medications. In addition, one-third have brain lesions, the hallmark of the disease, which cannot be located by conventional imaging methods. Researchers at the Perelman School of Medicine at the University of Pennsylvania have piloted a new method using advanced noninvasive neuroimaging to recognize the neurotransmitter glutamate, thought to be the culprit in the most common form of medication-resistant epilepsy. Their work is published today in Science Translational Medicine.
Glutamate is an amino acid which transmits signals from neuron to neuron, telling them when to fire. Glutamate normally docks with the neuron, gives it the signal to fire and is swiftly cleared. In patients with epilepsy, stroke and possibly ALS, the glutamate is not cleared, leaving the neuron overwhelmed with messages and in a toxic state of prolonged excitation.
In localization-related epilepsy, the most common form of medication-resistant epilepsy, seizures are generated in a focused section of the brain; in 65 percent of patients, this occurs in the temporal lobe. Removal of the seizure-generating region of the temporal lobe, guided by preoperative MRI, can offer a cure. However, a third of these patients have no identified abnormality on conventional imaging studies and, therefore, more limited surgical options.
“Identification of the brain region generating seizures in location-related epilepsy is associated with significantly increased chance of seizure freedom after surgery,” said the new study’s lead author, Kathryn Davis, MD, MSTR, an assistant professor of Neurology at Penn. “The aim of the study was to investigate whether a novel imaging method, developed at Penn, could use glutamate to localize and identify the epileptic lesions and map epileptic networks in these most challenging patients.”
“We theorized that if we could develop a technique which allows us to track the path of and make noninvasive measurements of glutamate in the brain, we would be able to better identify the brain lesions and epileptic foci that current methods miss,” said senior author Ravinder Reddy, PhD, a professor of Radiology and director of Penn’s Center for Magnetic Resonance and Optical Imaging.
Reddy’s lab developed the glutamate chemical exchange saturation transfer (GluCEST) imaging method, a very high resolution magnetic resonance imaging contrast method not available before now, to measure how much glutamate was in different regions of the brain including the hippocampi, two structures within the left and right temporal lobes responsible for short- and long-term memory and spatial navigation and the most frequent seizure onset region in adult epilepsy patients.
The study tested four patients with medication-resistant epilepsy and 11 controls. In all four patients, concentrations of glutamate were found to be higher in one of the hippocampi, and confirmatory methods (electroencephalography and magnetic resonance spectra) verified independently that the hippocampus with the elevated glutamate was located in the same hemisphere as the epileptic focus/lesion. Consistent lateralization to one side was not seen in the control group.
While preliminary, this work indicates the ability of GluCEST to detect asymmetrical hippocampal glutamate levels in patients thought to have nonlesional temporal lobe epilepsy. The authors say this approach could reduce the need for invasive intracranial monitoring, which is often associated with complications, morbidity risk, and added expense.
“This demonstration that GluCEST can localize small brain hot spots of high glutamate levels is a promising first step in our research,” Davis said. “By finding the epileptic foci in more patients, this approach could guide clinicians toward the best therapy for these patients, which could translate to a higher rate of successful surgeries and improved outcomes from surgery or other therapies in this difficult disease.”
To determine the effects of a brief single component of the graded motor imagery (GMI) sequence (mirror therapy) on active range of motion (AROM), pain, fear avoidance, and pain catastrophization in patients with shoulder pain.
Single-blind case series.
Three outpatient physical therapy clinics.
Patients with shoulder pain and limited AROM (N=69).
Patients moved their unaffected shoulder through comfortable AROM in front of a mirror so that it appeared that they were moving their affected shoulder.
We measured pain, pain catastrophization, fear avoidance, and AROM in 69 consecutive patients with shoulder pain and limited AROM before and immediately after mirror therapy.
There were significant differences in self-reported pain (P=.014), pain catastrophization (P<.001), and the Tampa Scale of Kinesiophobia (P=.012) immediately after mirror therapy; however, the means did not meet or exceed the minimal detectable change (MDC) for each outcome measure. There was a significant increase (mean, 14.5°) in affected shoulder flexion AROM immediately postmirror therapy (P<.001), which exceeded the MDC of 8°.
A brief mirror therapy intervention can result in statistically significant improvements in pain, pain catastrophization, fear avoidance, and shoulder flexion AROM in patients presenting with shoulder pain with limited AROM. The immediate changes may allow a quicker transition to multimodal treatment, including manual therapy and exercise in these patients. Further studies, including randomized controlled trials, are needed to investigate these findings and determine longer-term effects.
By the time epilepsy patient Erika Fleck came to Loyola Medicine for a second opinion, she was having three or four seizures a week and hadn’t been able to drive her two young children for five years.
“It was no way to live,” she said.
Loyola epileptologist Jorge Asconapé, MD, recommended surgery to remove scar tissue in her brain that was triggering the seizures. Neurosurgeon Douglas Anderson, MD, performed the surgery, called an amygdalohippocampectomy. Ms. Fleck hasn’t had a single seizure in the more than three years since her surgery.
“I’ve got my life back,” she said. “I left my seizures at Loyola.”
Surgery can be an option for a minority of patients who do not respond to medications or other treatments and have epileptic scar tissue that can be removed safely. In 60 to 70 percent of surgery patients, seizures are completely eliminated, and the success rate likely will improve as imaging and surgical techniques improve, Dr. Anderson said.
Traditionally, patients would have to try several medications with poor results for years or decades before being considered for surgery, according to the Epilepsy Foundation. “More recently, surgery is being considered sooner,” the foundation said. “Studies have shown that the earlier surgery is performed, the better the outcome.” (Ms. Fleck is a service coordinator for the Epilepsy Foundation North/Central Illinois Iowa and Nebraska.)
Dr. Asconapé said Ms. Fleck was a perfect candidate for surgery because the scar tissue causing her seizures was located in an area of the brain that could be removed without damaging critical structures.
Ms. Fleck experienced complex partial seizures, characterized by a deep stare, unresponsiveness and loss of control for a minute or two. An MRI found the cause: A small area of scar tissue in a structure of the brain called the hippocampus. The subtle lesion had been overlooked at another center.
Epilepsy surgery takes about three hours, and patients typically are in the hospital for two or three days. Like all surgery, epilepsy surgery entails risks, including infection, hemorrhage, injury to other parts of the brain and slight personality changes. But such complications are rare, and they pose less risk to patients than the risk of being injured during seizures, Dr. Asconapé said.
Loyola has been designated a Level Four Epilepsy Center by the National Association of Epilepsy Centers. Level Four is the highest level of specialized epilepsy care available. Level Four centers have the professional expertise and facilities to provide the highest level of medical and surgical evaluation and treatment for patients with complex epilepsy.
Loyola’s comprehensive, multidisciplinary Epilepsy Center offers a comprehensive multidisciplinary approach to epilepsy and seizure disorders for adults and children as young as two years old. Pediatric and adult epileptologist consultation and state-of-the-art neuroimaging and electrodiagnostic technology are used to identify and assess complex seizure disorders by short- and long-term monitoring.
Children whose mothers have taken anti-epilepsy medicine during pregnancy, do not visit the doctor more often than children who have not been exposed to this medicine in utero. This is the result of a new study from Aarhus.
Previous studies have shown that anti-epilepsy medicine may lead to congenital malformations in the foetus and that the use of anti-epilepsy medicine during pregnancy affects the development of the brain among the children. There is still a lack of knowledge in the area about the general health of children who are exposed to anti-epilepsy medicine in foetallife. But this new study is generally reassuring for women who need to take anti-epilepsy medicine during their pregnancy.
Being born to a mother who has taken anti-epilepsy medicine during pregnancy appears not to harm the child’s health. These are the findings of the first Danish study of the correlation between anti-epilepsy medicine and the general health of the child which has been carried out by the Research Unit for General Practice, Aarhus University and Aarhus University Hospital.
The results have just been published in the international scientific journal BMJ Open.
The researchers have looked into whether children who have been exposed to the mother’s anti-epilepsy medicine have contact with their general practitioner (GP) more often than other children – and there are no significant differences.
No reason til worry
“Our results are generally reassuring for women who need to take anti-epilepsy medicine during their pregnancy, including women with epilepsy,” says Anne Mette Lund Würtz, who is one of the researchers behind the project.
The difference in the number of contacts to the general practitioner between exposed and non-exposed children is only three per cent.
“The small difference we found in the number of contacts is primarily due to a difference in the number of telephone contacts and not to actual visits to the GP. At the same time, we cannot rule out that the difference in the number of contacts is caused by a small group of children who have more frequent contact with their GP because of illness,” explains Anne Mette Lund Würtz.
Of the 963,010 children born between 1997 and 2012, who were included in the survey, anti-epilepsy medicine was used in 4,478 of the pregnancies that were studied.
Anti-epilepsy medicine is also used for the treatment of other diseases such as migraine and bipolar disorder. The study shows that there were no differences relating to whether the women who used anti-epilepsy medicine during pregnancy were diagnosed with epilepsy or not.
Background for the results
Type of study: The population study was carried out using the Danish registers for the period 1997-2013.
The analyses takes into account differences in the child’s gender and date of birth, as well as the mother’s age, family situation, income, level of education, as well as any mental illness, use of psychiatric medicine and insulin, and substance abuse.
Brain plasticity is the phenomenon by which the brain can rewire and reorganize itself in response to changing stimulus input. Brain plasticity is at play when one is learning new information (at school) or learning a new language and occurs throughout one’s life.
Brain plasticity is particularly important after a brain injury, as the neurons in the brain are damaged after a brain injury, and depending on the type of brain injury, plasticity may either include repair of damaged brain regions or reorganization/rewiring of different parts of the brain.
A lot is known about brain plasticity immediately after an injury. Like any other injury to the body, after an initial negative reaction to the injury, the brain goes through a massive healing process, where the brain tries to repair itself after the injury. Research tells us exactly what kinds of repair processes occur hours, days and weeks after the injury.
What is not well understood is how recovery continues to occur in the long term. So, there is a lot research showing that the brain is plastic, and undergoes recovery even months after the brain damage, but what promotes such recovery and what hinders such recovery is not well understood.
It is well understood that some rehabilitative training promotes brain injury and most of the current research is focused on this topic.
Human brain plasticity has mostly been studied using non-invasive imaging methods, because these techniques allow us to measure the gray matter (neurons), white matter (axons) at a somewhat coarse level. MRI and fMRI techniques provide snapshots and video of the brain in function, and that allows us to capture changes in the brain that are interpreted as plasticity.
Also, more recently, there are invasive stimulation methods such as transcranial direct current stimulation or transcranial magnetic stimulation which allow providing electric current or magnetic current to different parts of the brain and such stimulation causes certain changes in the brain.
One of the biggest shifts in our understanding of brain plasticity is that it is a lifelong phenomenon. We used to previously think that the brain is plastic only during childhood and once you reach adulthood, the brain is hardwired, and no new changes can be made to it.
However, we now know that even the adult brain can be modified and reorganized depending on what new information it is learning. This understanding has a profound impact on recovery from brain injury because it means that with repeated training/instruction, even the damaged brain is plastic and can recover.
One reason why rehabilitation after brain injury is so complex is because no two individuals are alike. Each individual’s education and life experiences have shaped their brain (due to plasticity!) in unique ways, so after a brain injury, we cannot expect that recovery in two individuals will be occur the same way.
Personalized medicine allows the ability to tailor treatment for each individual taking into account their strengths and weaknesses and providing exactly the right kind of therapy for that person. Therefore, one size treatment does not fit all, and individualized treatments prescribed to the exact amount of dosage will become a reality.
I am not sure we understand what automedicine can and cannot do just yet, so it’s a little early to comment on the reality. Using data to improve our algorithms to precisely deliver the right amount of rehabilitation/therapy will likely be a reality very soon, but it is not clear that it will eliminate the need for doctors or rehabilitation professionals.
The future for people recovering from strokes and brain injuries is more optimistic than it has ever been for three important reasons. First, as I pointed above, there is tremendous amount of research showing that the brain is plastic throughout life, and this plasticity can be harnessed after brain injury also.
Second, recent advances in technology allow patients to receive therapy at their homes at their convenience, empowering them to take control of their therapy instead of being passive consumers.
Finally, the data that is collected from individuals who continuously receive therapy provides a rich trove of information about how patients can improve after rehabilitation, what works and what does not work.
Constant Therapy’s vision incorporates all these points and its goal to provide effective, efficient and reasonable rehabilitation to patients recovering from strokes and brain injury.
Swathi Kiran is Professor in the Department of Speech and Hearing Sciences at Boston University and Assistant in Neurology/Neuroscience at Massachusetts General Hospital. Prior to Boston University, she was at University of Texas at Austin. She received her Ph.D from Northwestern University.
Her research interests focus around lexical semantic treatment for individuals with aphasia, bilingual aphasia and neuroimaging of brain plasticity following a stroke.
She has over 70 publications and her work has appeared in high impact journals across a variety of disciplines including cognitive neuroscience, neuroimaging, rehabilitation, speech language pathology and bilingualism.
She is a fellow of the American Speech Language and Hearing Association and serves on various journal editorial boards and grant review panels including at National Institutes of Health.
Her work has been continually funded by the National Institutes of Health/NIDCD and American Speech Language Hearing Foundation awards including the New Investigator grant, the New Century Scholar’s Grant and the Clinical Research grant. She is the co-founder and scientific advisor for Constant Therapy, a software platform for rehabilitation tools after brain injury.
Traumatic Brain Injury Rehabilitation Educational Resources > FINR Educational Materials > FINR Brain Atlas – 3D Brain Model
3D Brain Model – Explore our interactive 3-dimensional brain atlas to discover where structures are located within the brain, their purpose, and explore brain injury models. All structures and models are accompanied by easy-to-understand detailed explanations.
It is our hope that this model assists to further the understanding of brain injury by those affected.
Find the FINR 3D Brain model application for the iPhone, iPod Touch, and the iPad in the iTunes App Store.
To identify and critically appraise the content, readability, accessibility and usability of websites providing information on cognitive rehabilitation for the families of adults with traumatic brain injury (TBI).
Columbia University Medical Center (CUMC) researchers have discovered how a new epilepsy drug works, which may lead the way to even more effective and safer medications.
The findings were published today in Neuron.
The most commonly used anti-epilepsy drugs are ineffective for about 30 percent of people with seizure disorders.
A new direction in the treatment of epilepsy is aimed at inhibiting AMPA receptors, which help transmit electrical signals in the brain and play a key role in propagating seizures. Currently, perampanel is the only FDA-approved drug that targets AMPA receptors. But because perampanel is associated with significant side effects, its clinical use has been limited.
“The problem is that AMPA receptors are heavily involved in the central nervous system, so if you inhibit their function, you cause an array of unwanted effects,” said study leader Alexander I. Sobolevsky, PhD, professor of biochemistry and molecular biophysics at CUMC. “If we hope to design better drugs for epilepsy, we need to learn more about the structure and function of these receptors.”
In this study, Dr. Sobolevsky employed a technique called crystallography to determine how perampanel and two other inhibitors interact with the AMPA receptors to stop transmission of electrical signals. The study was conducted using rat AMPA receptors, which are almost identical to human receptors.
In the new study, the researchers were able to pinpoint exactly where the drugs bind to AMPA receptors.
“Our data suggest that the inhibitors wedge themselves into the AMPA receptor, which prevents the opening of a channel within the receptor,” said Dr. Sobolevsky. When that channel is closed, ions cannot pass into the cell to trigger an electrical signal.
According to the researchers, these findings may allow drug makers to develop medications that are highly selective for the AMPA receptors, which could be safer and more effective than currently available anti-epilepsy drugs.
Healthcare has a long history of benefiting from new technologies, and it started using virtual reality surprisingly early. Education, rehabilitation and early detection are the three main areas where VR can contribute the most.
Education and visualisation
VR can help education in two distinct ways. First, it can help medical students and medical professionals to practice complex medical treatments, such as surgeries. Some universities, including Stanford, have been using virtual reality for years now in medical training. As a student you can see exactly the same as your professor conducting an operation. Practicing in virtual scenarios is cost effective, and very accessible.
VR can also help people who are not medical professionals, but who are living with a medical condition, or just want to learn more about a specific medical symptom. Since virtual reality can simulate any medical condition it can teach parents how to raise a child with disabilities. It helps to understand blindness, colour blindness, autism, mental issues, or as seen in the video, just a “simple” migraine.
Rehabilitation and assessment
A small circle of healthcare professionals has been experimenting with virtual reality in brain damage recovery and assessment for quite some time now. The scientific paper CyberPsychology & Behavior published a whole study on using VR in brain damage rehabilitation as early as 2005. These techniques are now getting adopted on a much wider scale.
The military, also well-known for utilising the latest technologies, is now using VR for post traumatic stress disorder (PTSD) rehabilitation, helping soldiers who returned from war zones. It’s also being used in psychiatry in exposure therapies, helping patients to overcame their fears. DEEP is using VR as a meditation tool.
The possibilities of using virtual reality in rehabilitation and neurological assessment are endless.
Early detection and the power of virtual reality in changing habits
Virtual reality can be combined with gaming and data visualisation. Vivid Vision is using VR to detect and analyse eye problems like amblyopia and strabismus, through VR vision analysis and simple games. Unello Designs is developing VR tools for stress relief, meditation, relaxation and to help patients overcoming phobias. VR is also used to cure fears like agoraphobia, anxiety or even to help quitting bad habits. And we haven’t even started talking about wellness and fitness (check VirZOOM for example), a huge market on its own.
Healthcare is an incredibly exciting field, as both virtual reality and biotechnology are developing in a breathtaking pace. The synergies will profoundly change the whole industry in the upcoming decades.