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

Abstract

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

[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

[Research Report] Functional level during the first 2 years after moderate and severe traumatic brain injury – CNS

Research Reports – Functional level during the first 2 years after moderate and severe traumatic brain injury

Brain Inj. 2015 Sep 11:1-8. [Epub ahead of print]

Sandhaug M(1,)(2), Andelic N(3,)(4), Langhammer B(1,)(5), Mygland A(6,)(7,)(8).

BACKGROUND: Long-term outcomes after TBI are examined to a large extent, butlongitudinal studies with more than 1-year follow-up time after injury have beenfewer in number. The course of recovery may vary due to a number of factors and it is still somewhat unclear which factors are contributing.

AIM: The aim of this study was to describe the functional level at four time points up to 24 months after traumatic brain injury (TBI) and to evaluate the predictive impact of pre-injury and injury-related factors.

DESIGN: A cohort study.

SETTING: Outpatient.

POPULATION: Sixty-five patients with moderate (n = 21) or severe (n = 44) TBI.

METHODS: The patients with TBI were examined with Functional Independence Measure(FIM) and Glasgow Outcome Scale Extended (GOSE) at 3 months, 12 months and 24months after injury. Possible predictors were analysed in a regression modelusing FIM total score at 24 months as the outcome measure.

RESULTS: FIM scores improved significantly from rehabilitation unit discharge to 24 months after injury, with peak levels at 3 and 24 months after injury(p < 0.001), for the whole TBI group and the group with severe TBI. The moderateTBI group did not show significant FIM score improvement during this time period. GOSE scores for the whole group and the moderate group improved significantlyover time, but the severe group did not. FIM at admission to the rehabilitation unit and GCS score at admission to the rehabilitation unit were closest to being significant predictors of FIM total scores 24 months after injury (B = 0.265 and2.883, R(2 )= 0.39, p = 0.073, p = 0.081).

CONCLUSION: FIM levels improved during the period from rehabilitation unitdischarge to 3 months follow-up; thereafter, there was a ‘plateauing’ of recovery. In contrast, GOSE ‘plateauing’ of recovery was at 12 months.

CLINICAL REHABILITATION IMPACT: The study results may indicate that two of themost used outcome measures in TBI research are more relevant for assessment of the functional recovery in a sub-acute phase than in later stages of TBI recovery.

Source: Traumatic Brain Injury Resource Guide – Research Reports – Functional level during the first 2 years after moderate and severe traumatic brain injury

[ARTICLE] Clinical Assessments for Predicting Functional Recovery after Stroke – Full Text PDF

Abstract

Despite on-going technological developments, clinical assessment remains an essential tool to evaluate the effects of rehabilitation treatment and to predict functional recovery. This paper provides a review of clinical assessment for stroke patients focusing on predictive value of motor, function and participation assessment, taking into consideration some specific evaluations for upper and lower limb function, trunk control, balance and walking. In the future an increased integration between clinical assessment, neurophysiology and neuroimaging will be required, in order to apply specific evaluation pathways to reach a more accurate and customized prognostic stratification.

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[ARTICLE] Magnetic stimulation and movement-related cortical activity for acute stroke with hemiparesis

Abstract

Background and purpose

This double-blind, randomized, placebo-controlled study investigated the beneficial effects of repetitive transcranial magnetic stimulation (rTMS) to patients with motor paresis in acute subcortical stroke on functional recovery and electrophysiological measures.

Methods

Twenty patients with acute stroke were randomized into real rTMS (n = 10) or sham (n = 10) groups. Patients received five daily sessions of rTMS with 1200 pulses at 1 Hz for 20 min or sham stimulation over the contralesional motor cortex. Movement-related cortical potential MRCP, consisting of the Bereitschaftpotential, negative slope (NS′) and motor potential (MP), was recorded during self-paced wrist extension of the affected limb associated with assessment of the Fugl−Meyer assessment (FMA) of the upper extremity, the pegboard test and the grip strength before and after the rTMS session.

Results

Real rTMS improved the FMA and pegboard test scores compared to the sham group in the affected hand. This improvement was associated with increases in the MP and NS′ over the front-central sites in the ipsilesional hemisphere, whereas the sham group did not show significant changes in MRCP components by rTMS.

Conclusions

Our findings suggest that low-frequency rTMS to the contralesional motor cortex facilitates functional recovery of paretic limbs in acute stroke patients through enhancing the the neuronal activity of ipsilesional motor and pre-motor areas.

via Magnetic stimulation and movement-related cortical activity for acute stroke with hemiparesis – Matsuura – 2015 – European Journal of Neurology – Wiley Online Library.

[ARTICLE] The lingering effects of a busted myth—false time limits in stroke rehabilitation

ABSTRACT

It was once falsely believed that neurological and functional recovery after stroke occurred only in the first six months after lesion. The perception of this “6 month myth” continues to negatively impact the attitudes of patients towards their rehabilitation and on the clinicians and therapists making optimal training plans.

Here we briefly outline some evidence that debunked the “6-month myth”, where the concept of this temporal limit may have originated, and the lingering misunderstanding that individuals with stroke reach a plateau of recovery after six months even with rehabilitation training. We present evidence that significant functional improvement can occur years after stroke when rehabilitation training is applied.

We frame the concepts of active and passive neurological recovery and that active neurological recovery continues far beyond any temporal limit. Because the effects of this busted “6 month myth” persist, we aim to remind active physicians, therapists, exercise professionals and people with stroke to continuously seek opportunities for active rehabilitation training.

Meanwhile, trained and certified exercise professionals can play critical roles in facilitating rehabilitative training for community-dwelling stroke survivors.

via The lingering effects of a busted myth—false time limits in stroke rehabilitation – Applied Physiology, Nutrition, and Metabolism.

[WEB SITE] MediTouch physical therapy solutions

MediTouch Ltd. manufactures innovative physical therapy solutions for hospital, primary and home care use. The products utilize wearable motion capture devices and dedicated rehabilitation software. The MediTouch physical therapy solutions allow patients with upper and/or lower extremity movement dysfunction to practice intensive virtual functional task training of single and multi joints. In this way our systems implement impairment oriented training (IOT) with augmented motion feedback to give a tailored arm or leg exercise physical therapy program that allows the patient to achieve better functional recovery.

 

 

via Meditouch Ltd.

[ARTICLE] Effectiveness of the treatment of hemiplegic patient’s hand with robotic rehabilitation glove “Gloreha”: preliminary results – Full Text PDF

Introduction

It is well established that recovery of motor function of the upper limb, regardless the aetiology of the impairment, is essential for gaining independence in daily living activities. In fact this happens after a cerebrovascular disease as well as after brain surgery or other pathologies. [1-2]

The complexity of the recovery course requires an intensive approach: mechanical devices for passive motion of the limb can help to add some intensity to treatment. [3-6] Recent studies have confirmed how the sensory-sensory stimulation has a crucial role in motor re-learning in neurological patients, even when it is only passively administered. [7-9]

Moreover, virtual reality combined to robotics is able to stimulate patient with an interactive environment. It is also postulated that virtual reality, among other actions, can involve the mirror brain cells by means of visual stimuli with a positive influence on functional recovery. [10]

In this perspective, a few years ago, Gloreha was developed: a robotic, glove shaped device, for hand rehabilitation. The device provides passive mechanical motion and, while moving the fingers, allows patient to observe on a screen, his own action going on. [11] (Fig. 1) Aim of this study is to evaluate the short-term effects of the use of Gloreha device in neurooncological patients affected by upper limb impairment during rehabilitation course, after tumour removal.

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[ARTICLE] Effect of Central Versus Peripheral Stimulation on Hand Function in Stroke Patients – Full Text PDF

Abstract

Background and Purpose: More than 60% of stroke survivors suffer from persistent neurological deficits that impair activities of daily living. Electrical stimulation is shown to be effective in enhancing the upper extremity functional recovery in stroke patients. The goal of this study was to compare between the effect of central and peripheral stimulation on hand function in these patients.

Patients and Methods: This study was conducted on forty five stroke patients from both sexes, their ages ranged from 45 to 60 years. The patients were divided into three equal groups. The study group (I) received anodal transcranial direct current stimulation in addition to the selected physical therapy program. The study group (II) received neuromuscular electrical stimulation in addition to the selected physical therapy program and the control group (III) received the selected physical therapy program only. Hand function was measured using Jebsen Taylor Hand Function Test (JTT).

Results: There was a statistically significant decrease of the mean values of JTT test score in group I and group II post treatment while the changes in group III were not significant. There was a significant decrease in the mean value of JTT test in group I compared with group II and group III.

Conclusion: Both Central and peripheral stimulation are effective modalities in improvement of hand function post stroke while the central stimulation is more effective than the peripheral one.

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