Posts Tagged functional recovery

[Abstract] Effects of Transcranial direct current stimulation with sensory modulation on stroke motor rehabilitation: A randomized controlled trial  




To test whether a multi-strategy intervention enhanced recovery immediately and longitudinally in patients with severe to moderate upper extremity (UE) paresis.


Double-blind randomized controlled trial with placebo control.


An outpatient department of a local medical center.


People (n = 25) with chronic stroke were randomly assigned to 2 groups. Participants in the transcranial direct current stimulation with sensory modulation (tDCS-SM) and in the control group were 55.3±11.5 (n=14) and 56.9±13.5 (n=11) years old, respectively.


8-week intervention. The tDCS-SM group received bilateral tDCS, bilateral cutaneous anesthesia, and high repetitions of passive movements on the paretic hand. The control group received the same passive movements but with sham tDCS and sham anesthesia. During the experiment, all participants continued their regular rehabilitation.

Main outcome measures

Voluntary UE movement, spasticity, UE function, and basic activities of daily living. Outcomes were assessed at baseline, at post-intervention, and at 3- and 6-month follow-ups.


No significant differences were found between groups. However, there was a trend that the voluntary UE movement improved more in the tDCS-SM group than in the control group, with a moderate immediate effect (partial η2, ηp2 = 0.14, p = 0.07) and moderate long-term effects (ηp2 =0.17, p = 0.05 and ηp2 = 0.12, p = 0.10). Compared with the control group, the tDCS-SM group had a trend of a small immediate effect (ηp2 = 0.02 – 0.04) on reducing spasticity but no long-term effect. A trend of small immediate and long-term effects in favor of tDCS-SM was found on UE function and daily function recovery (ηp2= 0.02 – 0.09).


Accompanied with traditional rehabilitation, tDCS-SM had a non-significant trend of having immediate and longitudinal effects on voluntary UE movement recovery in patients with severe to moderate UE paresis after stroke, but its effects on spasticity reduction and functional recovery may be limited. (NCT01847157)

Source: Effects of Transcranial direct current stimulation with sensory modulation on stroke motor rehabilitation: A randomized controlled trial – Archives of Physical Medicine and Rehabilitation


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[ARTICLE] Cognitive and functional outcomes following inpatient rehabilitation in patients with acquired brain injury: A prospective follow-up study – Full Text


Objectives: To study the effects of cognitive retraining and inpatient rehabilitation to study the effects of cognitive retraining and inpatient rehabilitation in patients with acquired brain injury (ABI).

Design and Setting: This was a prospective follow-up study in a neurological rehabilitation department of quaternary research hospital.

Patients and Methods: Thirty patients with ABI, mean age 36.43 years (standard deviation [SD] 12.6, range 18–60), mean duration of illness 77.87 days (SD 91.78, range 21–300 days) with cognitive, physical, and motor-sensory deficits underwent inpatient rehabilitation for minimum of 14 sessions over a period of 3 weeks. Nineteen patients (63%) reported in the follow-up of minimum 3 months after discharge. Type of ABI, cognitive status (using Montreal Cognitive assessment scale [MoCA] and cognitive Functional Independence Measure [Cog FIM]®), and functional status (motor FIM®) were noted at admission, discharge, and follow-up and scores were compared.

Results: Patients received inpatient rehabilitation addressing cognitive and functional impairments. Baseline MoCA, motor FIM, and Cog FIM scores were 15.27 (SD = 7.2, range 3–30), 31.57 (SD = 15.6, range 12–63), and 23.47 (SD = 9.7, range 5–35), respectively. All the parameters improved significantly at the time of discharge (MoCA = 19.6 ± 7.4 range 3–30, motor FIM® = 61.33 ± 18.7 range 12–89, Cog FIM® =27.23 ± 8.10 range 9–35). Patients were discharged with home-based programs. Nineteen patients reported in follow-up and observed to have maintained cognition on MoCA (18.8 ± 6.8 range 6–27), significantly improved (P < 0.01) on Cog FIM® (28.0 ± 7.7 range 14–35) and motor FIM® =72.89 ± 16.2 range 40–96) as compare to discharge scores.

Conclusions: Cognitive and functional outcomes improve significantly with dedicated and specialized inpatient rehabilitation in ABI patients, which is sustainable over a period.


Acquired brain injury (ABI) is defined as “damage to the brain, which occurs after birth and is not related to a congenital or a degenerative disease.” “These impairments may be temporary or permanent and cause physical, functional disability, or psychosocial maladjustment.”[1],[2] By this definition, ABI encompasses a wide variety of disorders of varying etiologies such as vascular, hypoxic, malignant, and traumatic. There are often long-lasting effects on domains of cognition, motor, behavior, and personality in affected individuals.[3] Cognitive impairment is common sequelae and important marker for prediction of rehabilitation outcomes, and cognitive outcome can be modified through targeted interventions.[4]

Studies suggest that traumatic brain injury (TBI) and stroke are the two main causes of ABI and regarded as important public health problem.[5] The incidence of TBI from 23 reports was found to vary greatly among European countries. Most rates were in the range 150–300/100,000 people per year.[6] The prevalence of stroke In western developed world ranges from 500 to 600/100,000. Rates per 100,000 from developing countries are also variable and range from 58 in India and 76 in the United Republic of Tanzania to 620 in China and 690 in Thailand.[7] Between 1.5 and 2 million persons are injured and 1 million die every year in India following TBI.[8] Cardiovascular diseases including stroke caused 19% of deaths in India between 2001 and 2003 and this is estimated to rise to 36% by 2030.[9] According to disease burden in India report September 2005, central nervous system malignancies (included in ABI) comprise 2% of the total cancer burden.[10] Other causes of ABI such as meningoencephalitis and stroke mimics also contribute to this pool of patients.

The majority of ABI survivors continue to live with disabilities without access to comprehensive rehabilitation services and remain a burden on caregivers and society.[11],[12] Physical and cognitive deficits are most commonly observed in these patients but are not adequately addressed due to lack of approachable rehabilitation services and awareness.[13],[14] Many of these patients opt for complementary and alternative medicine, which are popular in India but demonstrate questionable benefits.[15]

It is evident, both clinically and scientifically, that the improvement in motor control after ABI is training dependent, responding best to repetitive task training with continuous modification of the program to keep training tasks challenging to the patients (activity-based recovery and neural plasticity).[16],[17] Single or multiple domains of cognition can be affected in these patients depending on the site (s) and severity of injury. Disturbances in memory, attention, and/or executive functions are commonly involved. Deficits in language and speech, learning, abstract thinking, and orientation occur in severe cases. It is well established that cognitive deficits interfere with rehabilitation efforts and also result in a greater negative impact on quality of life.[18] Cognitive rehabilitation (CR) is a specialized treatment procedure designed to improve the cognition affected by internal or external injury to the brain. There are two types of CR: restorative and compensatory rehabilitation.[19],[20],[21] Restorative rehabilitation enables the patient to develop lost functions through specialized computerized and manual cognitive exercises. Compensatory rehabilitation helps the patient to train and use aids and tools to overcome the impairment. The objective of the present study was to rehabilitate ABI patients in all affected domains including cognitive, physical, sensory-motor, and behavior with customized inpatient programs. Another objective was to observe the effect of inpatient rehabilitation in improving cognition and functionality of the patients (by comparing admission and discharge scores). We also tried to observe whether the benefits of inpatient rehabilitation are sustainable by assessing the patients in follow-up examination a minimum of 3 months after discharge.[…]

Continue —>  Cognitive and functional outcomes following inpatient rehabilitation in patients with acquired brain injury: A prospective follow-up study Patil M, Gupta A, Khanna M, Taly AB, Soni A, Kumar J K, Thennarasu K – J Neurosci Rural Pract

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Provisional Abstract:
Background and Purpose: This case report describes a task-specific program for gait and functional recovery in a young man with severe chronic traumatic brain injury (TBI).

Case Description: The individual was a 26-year-old man 4 years post TBI with severe motor impairments who had not walked outside of therapy since his injury. He had received extensive gait training prior to initiation of services. His goal was to recover the ability to walk.

Intervention: The primary focus of the interventions was the restoration of gait. A variety of interventions were used, including locomotor treadmill training, electrical stimulation, orthoses and specialized assistive devices. A total of 79 treatments were delivered over a period of 62 weeks.

Outcomes: At the conclusion of therapy, the client was able to walk independently with a gait trainer for over 3000 feet and walked in the community with the assistance of his mother using a rocker bottom crutch for distances of up to 350 feet.

Discussion: Given the chronicity of this individual’s injury, the magnitude of his functional improvements were unexpected. However, very intentional interventions were selected in the development of his treatment plan. His potential was realized by structuring practice of the salient task, i.e. walking, with adequate intensity and frequency.

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[ARTICLE] Eclectic/mixed model method for upper extremity functional recovery in stroke rehabilitation: A pilot study


Background: Eclectic treatment method is a flexible approach that uses techniques drawn from various schools of thought involving several treatment methods and allows the therapist to adapt to each client’s individual needs. Wider application for eclectic approach is however limited in stroke rehabilitation. Aim: The objective is to find out whether eclectic approach improves upper extremity (UE) functional recovery in acute stroke rehabilitation. Methodology: Twenty-five postacute unilateral supratentorial stroke subjects recruited from tertiary care hospitals recovered with Stage 2–5 in Brunnstorm stage of UE motor recovery (BRS-UE) underwent 45 min of eclectic approach for UE every day involving seven different treatment methods (5 min for each method) for 6 days consecutively. The outcome was UE subscale of the Fugl-Meyer Motor test (UE-FM), UE subscale of the Stroke Rehabilitation Assessment of Movement (UE-STREAM), Wolf Motor Function test (WMFT-FAS), and Stroke Impact Scale-16 (SIS-16) was collected at the end of the sixth session. Results: All the participants showed significant improvement in all the outcome measures. The Stage 2 and 3 subjects showed UE-STREAM (P = 0.007) WMFT-FAS (P < 0.001), SIS (P = 0.023) respectively and for Stage 4 and 5 the subjects have shown UE FM (P < 0.001), WMFT-FAS (P < 0.001), SIS (P = 0.004) with large magnitude of treatment effect for all stages of BRS-UE. Conclusion: Our study findings are in favor of integrating eclectic approach than single intervention/approach in clinical practice to improve the UE functional recovery for motor rehabilitation when the stroke occurs.


Globally, stroke is the third major cause of mortality and a major health issue in low- and middle-income countries like India.[1]Eighty percent of stroke survivors experience motor impairments (hemiparesis) typically affecting movement of the face, arm, trunk, and leg of one side of the body often persistent and disabling them. These residual impairments limit their functional independence and predisposing them to restrict their participation in community and social roles.[2],[3]

Upper limb hemiparesis is one of the primary impairments following the stroke. It is often reported to be incomplete in functional recovery and to restore the motor skills. The studies on recovery of voluntary arm movements have also shown that 5–20% of stroke survivors achieved complete functional recovery and 30–60% of paretic arm can never have complete recovery during the first 6 months after the stroke.[4],[5] Common upper extremity (UE) impairments after the stroke include paresis, loss of fractionated movement, abnormal muscle tone and/or changes in somatosensation, shoulder pain, and subluxation which prevents the functional use of the arm, bimanual tasks and also for fine motor skills.[6],[7] Post stroke, persistent arm motor impairment (a period of 1 year or above) can be associated with anxiety and poorer perception of health-related quality of life and subjective well-being.[8],[9]

One of the primary aims of the stroke rehabilitation is to improve the arm functions and to regain the gross and fine motor skills. Currently, the existing rehabilitation protocols that are designed to improve UE functions include the various treatment methods/interventions such as Roods, Brunnstorm, proprioceptive neuromuscular facilitation, neuro-developmental therapy techniques, repetitive/task-specific training, strength training, sensorimotor interventions, constraint-induced movement therapy, virtual reality, spasticity treatment, electromyographic/biofeedback, transcutaneous electrical nerve stimulation, neuromuscular electrical stimulation, functional electric stimulation, motor imagery, mirror therapy, and bilateral arm training.[10] However, recent systematic reviews have concluded that there is insufficient evidence observed for any intervention or approach that can currently be used in routine practice to improve the paretic upper limb functions.[11]

An eclectic therapy is a therapeutic approach that incorporates a variety of therapeutic principles and philosophies to create the ideal treatment program to meet the specific needs of the patient or client. The intervention of an eclectic approach is based on the stable principles of the classic traditional methods but is open to refining and can be used in conjunction with the elements of other various new methods, thus providing a framework for designing an optimal neurorehabilitation protocol.[12],[13] The studies have shown that the eclectic approach is suitable for a diverse and complex set of patients.[14],[15],[16] However, wider application of eclectic approach in stroke rehabilitation is limited in literature.

Continue —> Eclectic/mixed model method for upper extremity functional recovery in stroke rehabilitation: A pilot study Kumar K V, Joshua AM, Kedambadi R, Mithra P P – J Nat Sc Biol Med

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[ARTICLE] Comparison of Two Post-Stroke Rehabilitation Programs: A Follow-Up Study among Primary versus Specialized Health Care – Full Text HTML




To compare home-based rehabilitation (RITH) and standard outpatient rehabilitation in a hospital setting, in terms of improving the functional recovery and quality of life of stroke patients.

Study Design and Setting

This was a prospective cohort study in Andalusia (Spain).


One hundred and forty-five patients completed the outcome data.


Daily activities were measured by the Barthel index, Canadian Neurological Scale (to assess mental state), Tinetti scale (balance and gait), and Short Form Health Survey-36 (SF-36 to compare the quality of life).


No statistically significant differences were found between the two groups regarding the clinical characteristics of patients in the initial measurement, except for age and mental state (younger and with greater neurological impairment in the hospital group). After physical therapy, both groups showed statistically significant improvements from baseline in each of the measures. These improvements were better in RITH patients than in the hospital patients on all functionality scales with a smaller number of sessions.


Home rehabilitation is at least as effective as the outpatient rehabilitation programs in a hospital setting, in terms of recovery of functionality in post-stroke patients. Overall quality of life is severely impaired in both groups, as stroke is a very disabling disease that radically affects patients’ lives.

Continue —> PLOS ONE: Comparison of Two Post-Stroke Rehabilitation Programs: A Follow-Up Study among Primary versus Specialized Health Care

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[ARTICLE] Music Upper Limb Therapy—Integrated: An Enriched Collaborative Approach for Stroke Rehabilitation – Full Text 

Stroke is a leading cause of disability worldwide. It leads to a sudden and overwhelming disruption in one’s physical body, and alters the stroke survivors’ sense of self. Long-term recovery requires that bodily perception, social participation and sense of self are restored; this is challenging to achieve, particularly with a single intervention. However, rhythmic synchronization of movement to external stimuli facilitates sensorimotor coupling for movement recovery, enhances emotional engagement, and has positive effects on interpersonal relationships.

In this proof-of-concept study, we designed a group music-making intervention, Music Upper Limb Therapy-Integrated (MULT-I), to address the physical, psychological and social domains of rehabilitation simultaneously, and investigated its effects on long-term post-stroke upper limb recovery. The study used a mixed-method pre-post design with one-year follow up.

Thirteen subjects completed the 45-minute intervention twice a week for six weeks. The primary outcome was reduced upper limb motor impairment on the Fugl-Meyer Scale. Secondary outcomes included sensory impairment (two-point discrimination test), activity limitation (Modified Rankin scale), well-being (WHO well-being index), and participation (Stroke Impact Scale). Repeated measures ANOVA was used to test for differences between pre- and post-intervention, and one-year follow up scores. Significant improvement was found in upper limb motor impairment, sensory impairment, activity limitation, and well-being immediately post-intervention that persisted at 1 year. Activities of daily living and social participation improved only from post-intervention to one-year follow up. The improvement in upper limb motor impairment was more pronounced in a subset of lower functioning individuals as determined by their pre-intervention wrist range of motion. Qualitatively, subjects reported new feelings of ownership of their impaired limb, more spontaneous movement, and enhanced emotional engagement.

The results suggest that the MULT-I intervention may help stroke survivors re-create their sense of self by integrating sensorimotor, emotional and interoceptive information, and facilitate long-term recovery across multiple domains of disability, even in the chronic stage post-stroke. Randomized controlled trials are warranted to confirm the efficacy of this approach. Clinical Trial Registration: National Institutes of Health,, NCT01586221.

Continue —> Frontiers | Music Upper Limb Therapy—Integrated: An Enriched Collaborative Approach for Stroke Rehabilitation | Frontiers in Human Neuroscience

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[ARTICLE] Stroke research at the crossroads – where are we heading? – Full Text HTML


Stroke causes 5.7 million deaths annually. This ranks stroke as the second most common cause of death and, additionally, it is a major cause of disability. Because of an ageing population, stroke incidence and costs will greatly increase in the future. This makes stroke an ongoing social and economic burden, in contrast to the only very limited therapeutic options.

In the last decade vast sums were spent on translational research focused on neuroprotective strategies in the acute phase of ischaemic stroke. A plethora of candidate agents were tested in experimental models and preclinical studies, but none was proven effective in clinical trials. This gave rise to discussions about the possible reasons for this failure, ending up mainly with criticism of methodological aspects of the preclinical and clinical studies, or of the relevance of animal studies in drug development. Indeed, the question could rather be whether neuroprotection is the right target for successful stroke treatment. In this context, a paradigm change can currently be observed: the focus of experimental and translational stroke research is shifting from early neuroprotection to delayed mechanisms such as stroke-associated comorbidities, regeneration and plasticity.

In this review we highlight a few recently emerging fields in translational stroke research. One such topic is the crosstalk between immunity and the injured brain as key pathomechanism in stroke. On one hand, innate and adaptive immune cells play an important role in the fate of injured brain tissue after stroke; on the other, peripheral immune alterations are critically involved in post-stroke comorbidities.

Another emerging research area is the analysis of mechanisms involved in regeneration and neuronal plasticity after stroke. Here, we discuss the current understanding of basic mechanisms involved after brain injury, clinical imaging approaches and therapeutic strategies to promote regeneration in stroke patients.

Continue —> SMW – Swiss Medical Weekly – Stroke research at the crossroads – where are we heading?

Figure 1 Multiphasic brain interactions after stroke and opportunities for treatment. Previous neuroprotective strategies targeted pathological mechanisms in a very narrow window of opportunity in the (hyper-) acute phase after stroke (orange). Recently, the focus of translational stroke research has shifted towards understanding pathological processes in the subacute and chronic phase such as neuroinflammation and neuroregeneration (green). These targets have the potential for novel therapeutic approaches which are suitable for a larger population of stroke patients then neuroprotective agents or thrombolysis.


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[ARTICLE] A new treatment in the rehabilitation of the paretic upper limb after stroke: the ARAMIS prototype and treatment protocol – Full Text PDF


Background. In recent years, as part of the rehabilitation of post stroke patients, the use of robotic technologies to improve recovery of upper limb has become more widespread. The Automatic Recovery Arm Motility Integrated System (ARAMIS) is a concept robot and prototype designed to promote the functional interaction of the arms in the neurorehabilitation of the paretic upper limb. Two computer-controlled, symmetric and interacting exoskeletons compensate for the inadequate strength and accuracy of the paretic arm and the effect of gravity during rehabilitation. Rehabilitation is possible in 3 different modalities; asynchronous, synchronous and active-assisted.

Objectives. To compare the effectiveness of robotic rehabilitation by an exoskeleton prototype system with traditional rehabilitation in motor and functional recovery of the upper limb after stroke.

Methods. Case-control study, 52 patients enrolled in the study, 28 cases (women: 8, age: 65 ± 10 yrs) treated with ARAMIS and 24 controls (women: 11, age: 69 ± 7 yrs) with conventional rehabilitation. Motor impairment assessed before and after treatment with Fugl-Meyer scale and Motricity Index, level of disability assessed with the Functional Independence Measure. A questionnaire was also administered to assess the patient’s tolerance to robotic therapy.

Results. After 28 ± 4 sessions over a 54 ± 3.6-day period, the patients treated by ARAMIS had an improvement on the Fugl-Meyer scale (global score from 43 ± 18 to 73 ± 29; p < 0.00001), Motricity Index scale (p < 0.004) and Functional Independence Measure (p < 0.001). A lesser degree of improvement was achieved using conventional rehabilitation, the Fugl-Meyer global score of the control group improved from 41 ± 13 to 58 ± 16 (p < 0.006) and the motor function item from 9.4 ± 4.1 to 14.9 ± 5.8 (p < 0.023).

Conclusions. Motor improvement was greater at the wrist and hand than at shoulder and elbow level in patients treated by ARAMIS and controls, but it was significantly greater in ARAMIS-treated patients than in controls. The results indicate a greater efficacy of ARAMIS compared to conventional rehabilitation.

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[Abstract] Enhancement of motor relearning and functional recovery in stroke patients: non-invasive strategies for modulating the central nervous system. – PubMed

INTRODUCTION: Most of the stroke survivors do not recover the basal state of the affected upper limb, suffering from a severe disability which remains during the chronic phase of the illness. This has an extremely negative impact in the quality of life of these patients. Hence, neurorehabilitation strategies aim at the minimization of the sensorimotor dysfunctions associated to stroke, by promoting neuroplasticity in the central nervous system.

DEVELOPMENT: Brain reorganization can facilitate motor and functional recovery in stroke subjects. None-theless, after the insult, maladaptive neuroplastic changes can also happen, which may lead to the appearance of certain sensori-motor disorders such as spasticity. Noninvasive brain stimulation strategies, like transcranial direct current stimulation or transcranial magnetic stimulation, are widely used techniques that, when applied over the primary motor cortex, can modify neural networks excitability, as well as cognitive functions, both in healthy subjects and individuals with neurological disorders. Similarly, brain-machine-interface systems also have the potential to induce a brain reorganization by the contingent and simultaneous association between the brain activation and the peripheral stimulation.

CONCLUSION: This review describes the positive effects of the previously mentioned neurorehabilitation strategies for the enhancement of cortical reorganization after stroke, and how they can be used to alleviate the symptoms of the spasticity syndrome.

Source: [Enhancement of motor relearning and functional recovery in stroke patients: non-invasive strategies for modulating the central nervous system]. – PubMed – NCBI

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[WEB SITE] Longer, intense rehabilitation boosts recovery after brain injury – Medical News Today

Animal studies suggest greater emphasis for better results and highlight key role of brain system in rebuilding structure and function.

Cognitive and functional recovery after a stroke or traumatic injury requires intense rehabilitative therapy to help the brain repair and restructure itself. New findings by researchers at University of California, San Diego School of Medicine report that not only is rehabilitation vital – in an animal model, rats with cortical injury that did not receive intensive rehab did not rebuild brain structure or recover function – but that a longer, even more intense period of rehabilitation may produce even greater benefit.


A cultured neuron in green is shown with hundreds of protruding dendritic spines. The dendrites of other neurons labeled in blue, with adjacent glial cells depicted in red. Credit: UC San Diego Health

“This has implications for medical practice and medical insurance,” said senior study author Mark Tuszynski, MD, PhD, professor in the Department of Neurosciences and director of the Center for Neural Repair at UC San Diego School of Medicine, and a neurologist with the VA San Diego Healthcare System. “Typically, insurance supports brief periods of rehab to teach people to get good enough to go home. These findings suggest that if insurance would pay for longer and more intensive rehab, patients might actually recover more function.”

The findings are published in the February 22 online early edition of PNAS.

In recent years, numerous studies have documented the surprising plasticity or ability of the adult central nervous system to recover from injury. The emerging question has been how to best encourage the repair and regrowth of damaged nerve cells and connections.

To better understand what happens at the molecular and cellular levels and how rehabilitation might be made more effective after brain injury, researchers studied rats relearning skills and physical abilities. They found rats that received intensive therapy for an extended period of time showed significant restructuring of the brain around the damage site: Surviving neurons sprouted greater numbers of dendritic spines, which made more connections with other neurons. The result, said Tuszynski, was a dramatic 50 percent recovery of function.

Animals that did not undergo intensive rehabilitation did not rebuild brain structure or recover function.

Additionally, the researchers found that a key system in the brain – the basal forebrain cholinergic system – is critical to rehabilitation. Structures in this part of the brain, such as the nucleus basalis, produce acetylcholine, a chemical released by nerve cells to send signals to other cells. Specifically, motor neurons release acetylcholine to activate muscles.

Damage to the cholinergic system, which can occur naturally during aging, completely blocks brain plasticity mediated by rehabilitation and significantly reduces functional recovery. Tuszynski said the finding suggests that a class of drugs called cholinesterase inhibitors, which boost the levels and persistence of acetylcholine and are used in some treatments for Alzheimer’s disease, might further improve functional outcomes after brain injury.

“We did not try to do this in our study,” said Tuszynski, “but we did suggest future studies could be done to look at this possibility.”

Source: Longer, intense rehabilitation boosts recovery after brain injury – Medical News Today

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