Posts Tagged Motor function

[Abstract] Tele-Rehabilitation after Stroke: An Updated Systematic Review of the Literature

Abstract

BACKGROUND:

Tele-rehabilitation for stroke survivors has emerged as a promising intervention for remotely supervised administration of physical, occupational, speech, and other forms of therapies aimed at improving motor, cognitive, and neuropsychiatric deficits from stroke.

OBJECTIVE:

We aimed to provide an updated systematic review on the efficacy of tele-rehabilitation interventions for recovery from motor, higher cortical dysfunction, and poststroke depression among stroke survivors.

METHODS:

We searched PubMed and Cochrane library from January 1, 1980 to July 15, 2017 using the following keywords: “Telerehabilitation stroke,” “Mobile health rehabilitation,” “Telemedicine stroke rehabilitation,” and “Telerehabilitation.” Our inclusion criteria were randomized controlled trials, pilot trials, or feasibility trials that included an intervention group that received any tele-rehabilitation therapy for stroke survivors compared with a control group on usual or standard of care.

RESULTS:

This search yielded 49 abstracts. By consensus between 2 investigators, 22 publications met the criteria for inclusion and further review. Tele-rehabilitation interventions focused on motor recovery (n = 18), depression, or caregiver strain (n = 2) and higher cortical dysfunction (n = 2). Overall, tele-rehabilitation interventions were associated with significant improvements in recovery from motor deficits, higher cortical dysfunction, and depression in the intervention groups in all studies assessed, but significant differences between intervention versus control groups were reported in 8 of 22 studies in favor of tele-rehabilitation group while the remaining studies reported nonsignificant differences.

CONCLUSION:

This updated systematic review provides evidence to suggest that tele-rehabilitation interventions have either better or equal salutary effects on motor, higher cortical, and mood disorders compared with conventional face-to-face therapy.

 

via Tele-Rehabilitation after Stroke: An Updated Systematic Review of the Literature. – PubMed – NCBI

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[WEB SITE] What we learned about mirror therapy from almost 2000 patients

What we learned about mirror therapy from almost 2000 patients

September 3, 2018
 

Stroke tends to affect one side more than the other. It can leave us feeling off-balance and weaker on one side. Sometimes, people may be unable to stand up straight, or even use their arm or leg on their affected side. Physical therapy and exercises bring you a long way on your recovery path. But is there something else that can help?

A creative way to use a mirror

Sometimes, people try a treatment called mirror therapy. Mirror therapy involves placing a mirror in a particular way so you can see the good side of your body reflected to represent your affected side. The mirror stands in line with the middle of your body. That way, you see the unaffected half reflected in it, as if its the affected side of your body. It creates the optical illusion that your weak hand or leg is moving normally again. Initially, this technique was meant for people suffering from chronic pain. Now, stroke patients can benefit from mirror therapy too. It’s pretty easy to set up, even if you might be severely disabled. You can also do it on your own at home!

Does mirror therapy work?

But, does it even work? German researchers took on the enormous task of looking at the 62 studies out there about mirror therapy and stroke. Compiling all these studies, a total of 1982 patients were included. The data showed that mirror therapy resulted in moderate improvement of motor function and daily activities. Mirror therapy also seemed to work well for people suffering from post-stroke complex regional pain syndrome, which is a chronic pain caused by damage to the nerves. However, authors couldn’t tell if mirror therapy helped with neglect, which is when people have a hard time noticing things in the visual field on their bad side.

Try it today with your regular therapy!

It looks like mirror therapy really can’t hurt you if you want to try it. But don’t think that it could replace the efforts of hard work and physical therapy! We shouldn’t use mirror therapy instead of these other standard therapies but as a supplement. Right now, we just don’t know if it is as good as other treatments. But it wouldn’t hurt to try it along with the training you do with your therapist!

The lead author of this study was Dr. Holm Thieme, the Erste Europäische Schule für Physiotherapie, Ergotherapie und Logopädie, Klinik Bavaria Kreischa, Kreischa,  Saxony, Germany.

 

via What we learned about mirror therapy from almost 2000 patients – Strokemark : Strokemark

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[Systematic Review] Mirror therapy for improving motor function after stroke – Abstract

Abstract

Background

Mirror therapy is used to improve motor function after stroke. During mirror therapy, a mirror is placed in the person’s midsagittal plane, thus reflecting movements of the non‐paretic side as if it were the affected side.

Objectives

To summarise the effectiveness of mirror therapy compared with no treatment, placebo or sham therapy, or other treatments for improving motor function and motor impairment after stroke. We also aimed to assess the effects of mirror therapy on activities of daily living, pain, and visuospatial neglect.

Search methods

We searched the Cochrane Stroke Group’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED, PsycINFO and PEDro (last searched 16 August 2017). We also handsearched relevant conference proceedings, trials and research registers, checked reference lists, and contacted trialists, researchers and experts in our field of study.

Selection criteria

We included randomised controlled trials (RCTs) and randomised cross‐over trials comparing mirror therapy with any control intervention for people after stroke.

Data collection and analysis

Two review authors independently selected trials based on the inclusion criteria, documented the methodological quality, assessed risks of bias in the included studies, and extracted data. We assessed the quality of the evidence using the GRADE approach. We analysed the results as standardised mean differences (SMDs) or mean differences (MDs) for continuous variables, and as odds ratios (ORs) for dichotomous variables.

Main results

We included 62 studies with a total of 1982 participants that compared mirror therapy with other interventions. Of these, 57 were randomised controlled trials and five randomised cross‐over trials. Participants had a mean age of 59 years (30 to 73 years). Mirror therapy was provided three to seven times a week, between 15 and 60 minutes for each session for two to eight weeks (on average five times a week, 30 minutes a session for four weeks).When compared with all other interventions, we found moderate‐quality evidence that mirror therapy has a significant positive effect on motor function (SMD 0.47, 95% CI 0.27 to 0.67; 1173 participants; 36 studies) and motor impairment (SMD 0.49, 95% CI 0.32 to 0.66; 1292 participants; 39 studies). However, effects on motor function are influenced by the type of control intervention. Additionally, based on moderate‐quality evidence, mirror therapy may improve activities of daily living (SMD 0.48, 95% CI 0.30 to 0.65; 622 participants; 19 studies). We found low‐quality evidence for a significant positive effect on pain (SMD −0.89, 95% CI −1.67 to −0.11; 248 participants; 6 studies) and no clear effect for improving visuospatial neglect (SMD 1.06, 95% CI −0.10 to 2.23; 175 participants; 5 studies). No adverse effects were reported.

Authors’ conclusions

The results indicate evidence for the effectiveness of mirror therapy for improving upper extremity motor function, motor impairment, activities of daily living, and pain, at least as an adjunct to conventional rehabilitation for people after stroke. Major limitations are small sample sizes and lack of reporting of methodological details, resulting in uncertain evidence quality.

 

Plain language summary

Review question
Does mirror therapy improve movement, the performance of daily activities, pain, and lack of attention to and awareness of the affected field of vision (visuospatial neglect) after stroke.

Backround
Paralysis of the arm or leg is common after stroke and frequently causes problems with activities of daily living such as walking, dressing, or eating. Mirror therapy (MT) is a rehabilitation therapy in which a mirror is placed between the arms or legs so that the image of a moving non‐affected limb gives the illusion of normal movement in the affected limb. By this setup, different brain regions for movement, sensation, and pain are stimulated. However, the precise working mechanisms of mirror therapy are still unclear. We conducted a search for literature in various databases and extracted the data of relevant studies.

Search date
This review identified studies up to 16 August 2017.

Study characteristics
We found 62 relevant studies, of which 57 randomly allocated participants to receive either MT or a control therapy (randomised controlled trials) and five provided both therapies to all participants, but in random order (cross‐over trials). The studies involved a total of 1982 participants with a mean age of 59 years (30 to 73 years) after stroke. Mirror therapy was provided three to seven times a week, between 15 and 60 minutes for each session for two to eight weeks (on average five times a week, 30 minutes a session for four weeks).

Key results
At the end of treatment, mirror therapy moderately improved movement of the affected upper and lower limb and the ability to carry out daily activities for people within and also beyond six months after the stroke. Mirror therapy reduced pain after stroke, but mainly in people with a complex regional pain syndrome. We found no clear effect for visuospatial neglect. The beneficial effects on movement were maintained for six months, but not in all study groups. No adverse effects were reported.

Quality of the evidence
The studies provide moderately‐reliable evidence that MT improves movement (motor function, motor impairment) and the performance of daily activities. However, there was only low reliability that MT decreases pain and visuospatial neglect. This may be due to the small number of studies. Further research is needed, with larger methodologically‐sound studies.

 

via Mirror therapy for improving motor function after stroke – Thieme, H – 2018 | Cochrane Library

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[Abstract] Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial

Abstract

OBJECTIVE:

To determine the effects of inclusion of deep dry needling into a treatment session following the Bobath concept on spasticity, motor function and postural control after a stroke.

METHODS:

26 patients who had suffered a stroke were randomly assigned to one of two treatment groups: Bobath only, or Bobath plus dry needling. Both groups received a session including strengthening, stretching and reconditioning exercises following the principles of the Bobath concept. Patients in the Bobath plus dry needling group also received a single session of ultrasound-guided dry needling of the tibialis posterior. Spasticity (Modified Modified Ashworth Scale), function (Fugl-Meyer Scale) and stability limits (computerised dynamic posturography using the SMART EquiTest System) were collected before and 10 min after treatment by a blinded assessor. The parameters of the stability limits included movement velocity (MVL), maximum excursion (MXE), end-point excursion (EPE) and directional control (DCL).

RESULTS:

A greater number of individuals receiving Bobath plus dry needling exhibited a decrease in spasticity after treatment (P<0.001). Analysis of covariance (ANCOVA) showed that patients receiving Bobath plus dry needling exhibited greater improvements in the balance (0.8, 95% CI 0.2 to 1.4), sensory (1.7, 95% CI 0.7 to 2.7) and range of motion (3.2, 95% CI 2.0 to 4.4) domains of the Fugl-Meyer Scale than those receiving Bobath only. ANCOVA also found that subjects receiving dry needling showed a greater increase in MVL non-affected forward direction, EPE non-affected direction, MXE backward and MXE affected/non-affected, DCL backward and DCL affected backward direction, than those who did not receive it.

CONCLUSIONS:

The inclusion of deep dry needling into a treatment session following the Bobath concept was effective at decreasing spasticity and improving balance, range of motion and the accuracy of maintaining stability in patients who had experienced a stroke.

 

via Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. – PubMed – NCBI

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[ARTICLE] Effects of 8-week sensory electrical stimulation combined with motor training on EEG-EMG coherence and motor function in individuals with stroke – Full Text

 

Abstract

The peripheral sensory system is critical to regulating motor plasticity and motor recovery. Peripheral electrical stimulation (ES) can generate constant and adequate sensory input to influence the excitability of the motor cortex. The aim of this proof of concept study was to assess whether ES prior to each hand function training session for eight weeks can better improve neuromuscular control and hand function in chronic stroke individuals and change electroencephalography-electromyography (EEG-EMG) coherence, as compared to the control (sham ES). We recruited twelve subjects and randomly assigned them into ES and control groups. Both groups received 20-minute hand function training twice a week, and the ES group received 40-minute ES on the median nerve of the affected side before each training session. The control group received sham ES. EEG, EMG and Fugl-Meyer Assessment (FMA) were collected at four different time points. The corticomuscular coherence (CMC) in the ES group at fourth weeks was significantly higher (p = 0.004) as compared to the control group. The notable increment of FMA at eight weeks and follow-up was found only in the ES group. The eight-week rehabilitation program that implemented peripheral ES sessions prior to function training has a potential to improve neuromuscular control and hand function in chronic stroke individuals.

Introduction

Stroke is one of the leading contributing factors to the loss of functional abilities and independence in daily life in adults1. The most common and widely observed impairment following stroke is motor impairment, which can be regarded as a loss or limitation of function in muscle control or movement2,3,4,5. Most stroke survivors later regain the ability to walk independently, but only fewer than 50% of them will have fully recovered upper extremity functions6,7. From a review focusing on motor recovery after stroke, it has been indicated that the recovery of both arm and hand function among subacute and chronic stroke survivors is limited in current neural rehabilitation settings4; therefore, additional management with activating plasticity before or during performing motor training is necessary for better motor recovery.

The fundamental principle of stroke rehabilitation is inducing brain plasticity by sensory or proprioceptive input in order to facilitate motor functions8,9. It has been demonstrated that strong sensory input can induce plastic changes in the motor cortex via direct or indirect pathways10,11,12,13,14,15,16,17. In this case, electrical stimulation (ES) that provides steady and adequate somatosensory input can be an ideal method of stimulating the motor cortex.

Recent studies using functional magnetic resonance imaging (fMRI) or transcranial magnetic stimulation (TMS) suggest that ES on peripheral nerves can increase motor-evoked potential (MEP)18,19,20, increase the active voxel count in the corresponding motor cortex13, and increase blood-oxygen-level dependent (BOLD) signals in fMRI, suggesting peripheral ES induced higher excitability and activation level of cortical neurons21. Since the expansion of the motor cortical area or increase in the excitability of neural circuits is associated with learning new motor skills22,23,24,25,26, clinicians should take advantage and assist patients with stroke on motor tasks training during this period of time. Celnik and colleagues27 found that the hand function of chronic stroke subjects improved immediately after two-hour peripheral nerve stimulation combined with functional training, and the effect lasted for one day. Based on previous studies, the ES that increases corticomuscular excitability may turn out to be an ideal intervention added prior to traditional motor training to “activate” the neural circuit, so that patients may get the most out of the training. According to a recent study that applied single session peripheral ES on post-stroke individuals, the corticomuscular coherence (CMC), which is the synchronization level between EEG and EMG, increased significantly and was accompanied by improvement in the steadiness of force output28.

To our knowledge, however, there is no study investigating the long-term effect of ES combined with functional training on both motor performance and cortical excitability. We targeted the median nerve because its distribution covered the dorsal side of index, middle, and half of ring finger and the palmar side of the first three fingers and half of the ring finger. Besides, median nerve is in charge of the flexion of the first three fingers, which combined they accounts for most of the functional tasks of hand. Therefore, the purpose of this pilot study was to preliminarily evaluate the effect of eight-week ES-combined hand functional training among chronic stroke patients based on CMC and motor performance. We followed up for four weeks after the intervention ceased and examined the lasting effect. We hypothesized that those who received intervention with ES would have better hand function and higher CMC than those who received intervention with sham ES. We also hypothesized that the effect would last for at least four weeks during our follow-up.[…]

Continue —> Effects of 8-week sensory electrical stimulation combined with motor training on EEG-EMG coherence and motor function in individuals with stroke | Scientific Reports

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[Abstract] Adding electrical stimulation during standard rehabilitation after stroke to improve motor function. A systematic review and meta-analysis

Abstract

Background

Clinical studies have shown that sensory input improves motor function when added to active training after neurological injuries in the spinal cord.

Objective

We aimed to determine the effect on motor function of extremities of adding an electrical sensory modality without motor recruitment before or with routine rehabilitation for hemiparesis after stroke by a comprehensive systematic review and meta-analysis.

Methods

We searched databases including MEDLINE via PubMed and the Cochrane Central Register of Controlled Trials from 1978 to the end of November 2017 for reports of randomized controlled trials or controlled studies of patients with a clinical diagnosis of stroke who underwent 1) transcutaneous electrical nerve stimulation (TENS) or peripheral electromyography-triggered sensory stimulation over a peripheral nerve and associated muscles or 2) acupuncture to areas that produced sensory effects, without motor recruitment, along with routine rehabilitation. Outcome measures were motor impairment, activity, and participation outcomes defined by the International Classification of Functioning, Disability and Health.

Results

The search yielded 11 studies with data that could be included in a meta-analysis. Electrical sensory inputs, when paired with routine therapy, improved peak torque dorsiflexion (mean difference [MD] 2.44 Nm, 95% confidence interval [CI] 0.26–4.63). On subgroup analysis, the combined therapy yielded a significant difference in terms of sensory stimulation without motor recruitment only on the Timed Up and Go test in the chronic phase of stroke (MD 3.51 sec, 95% CI 3.05–3.98). The spasticity score was reduced but not significantly (MD − 0.83 points, 95% CI -1.77 − 0.10).

Conclusion

Electrical sensory input can contribute to routine rehabilitation to improve early post-stroke lower-extremity impairment and late motor function, with no change in spasticity. Prolonged periods of sensory stimulation such as TENS combined with activity can have beneficial effects on impairment and function after stroke.

via Adding electrical stimulation during standard rehabilitation after stroke to improve motor function. A systematic review and meta-analysis – ScienceDirect

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[WEB SITE] Electrically Stimulating the Brain May Restore Movement After Stroke

Findings Suggest Potential for Brain Implants to Treat Stroke Patients

UC San Francisco scientists have improved mobility in rats that had experienced debilitating strokes by using electrical stimulation to restore a distinctive pattern of brain cell activity associated with efficient movement. The researchers say they plan to use the new findings to help develop brain implants that might one day restore motor function in human stroke patients.

After a stroke, roughly one-third of patients recover fully, one-third have significant lingering movement problems, and one-third remain virtually paralyzed, said senior author Karunesh Ganguly, MD, PhD, associate professor of neurology and a member of the UCSF Weill Institute for Neurosciences. Even patients who experience partial recovery often continue to struggle with “goal-directed” movements of the arms and hands, such as reaching and manipulating objects, which can be crucial in the workplace and in daily living.

Headshot of Karunesh Ganguly, MD, PhD, associate professor of neurology, study's senior author.
Karunesh Ganguly, MD, PhD, associate professor of neurology, study’s senior author.

 

“Our main impetus was to understand how we can develop implantable neurotechnology to help stroke patients,” said Ganguly, who conducts research at the San Francisco VA Health Care System. “There’s an enormous field growing around the idea of neural implants that can help neural circuits recover and improve function. We were interested in trying to understand the circuit properties of an injured brain relative to a healthy brain and to use this information to tailor neural implants to improve motor function after stroke.”

Over the past 20 years, neuroscientists have presented evidence that coordinated patterns of neural activity known as oscillations are important for efficient brain function.  More recently, low-frequency oscillations (LFOs)—which were first identified in studies of sleep—have been specifically found to help organize the firing of neurons in the brain’s primary motor cortex. The motor cortex controls voluntary movement, and LFOs chunking the cells’ activity together to ensure that goal-directed movements are smooth and efficient.

In the new study, published in the June 18, 2018 issue of Nature Medicine, the researchers first measured neural activity in rats while the animals reached out to grab a small food pellet, a task designed to emulate human goal-directed movements. They detected LFOs immediately before and during the action, which inspired the researchers to investigate how these activity patterns might change after stroke and during recovery.

To explore these questions, they caused a stroke in the rats that impaired the animals’ movement ability, and found that LFOs diminished. In rats that were able to recover, gradually making faster and more precise movements, the LFOs also returned. There was a strong correlation between recovery of function and the reemergence of LFOs: animals that fully recovered had stronger low-frequency activity than those that partially recovered, and those that didn’t recover had virtually no low-frequency activity at all.

To try to boost recovery, the researchers used electrodes to both record activity and to deliver a mild electrical current to the rats’ brains, stimulating the area immediately surrounding the center of the stroke damage. This stimulation consistently enhanced LFOs in the damaged area and appeared to improve motor function: when the researchers delivered a burst of electricity right before a rat made a movement, the rat was up to 60 percent more accurate at reaching and grasping for a food pellet.

“Interestingly, we observed this augmentation of LFOs only on the trials where stimulation was applied,” said Tanuj Gulati, PhD, a postdoctoral researcher in the Ganguly lab who is co-first author of the study, along with Dhakshin Ramanathan, MD, PhD, now assistant professor of psychiatry at UC San Diego, and Ling Guo, a neuroscience graduate student at UCSF.

“We are not creating a new frequency, we are amplifying the existing frequency,” added Ganguly. “By amplifying the weak low-frequency oscillations, we are able to help organize the task-related neural activity. When we delivered the electrical current in step with their intended actions, motor control actually got better.”

The researchers wanted to know whether their findings might also apply to humans, so they analyzed recordings made from the surface of the brain of an epilepsy patient who had suffered a stroke that had impaired the patient’s arm and hand movements. The recordings revealed significantly fewer LFOs than recordings made in two epilepsy patients who hadn’t had a stroke. These findings suggest that, just like in rats, the stroke had caused a loss of low-frequency activity that impaired the patient’s movement.

Physical therapy is the only treatment currently available to aid stroke patients in their recovery. It can help people who are able to recover neurologically get back to being fully functional more quickly, but not those whose stroke damage is too extensive. Ganguly hopes that electrical brain stimulation can offer a much-needed alternative for these latter patients, helping their brain circuits to gain better control of motor neurons that are still functional. Electrical brain stimulation is already widely used to help patients with Parkinson’s disease and epilepsy, and Ganguly believes stroke patients may be the next to benefit.

Other UCSF contributors to the work included Gray Davidson; April Hishinuma; Seok-Joon Won, PhD, associate adjunct professor of neurology; Edward Chang, MD, professor of neurosurgery and William K. Bowes Jr. Biomedical Investigator; and Raymond Swanson, MD, professor of neurology. They were joined by Robert T. Knight, MD, professor of psychology and neuroscience at UC Berkeley.

The research was supported in part by funding from the National Institute of Neurological Disorders and Stroke; the National Institute of Mental Health; the Agency for Science, Technology, and Research (A*STAR), in Singapore; the U.S. Department of Veterans Affairs, and the Burroughs Wellcome Fund.

 

via Electrically Stimulating the Brain May Restore Movement After Stroke | UC San Francisco

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[Abstract] Effects of Kinect-based virtual reality game training on upper extremity motor recovery in chronic stroke.

Abstract

BACKGROUND:

Therapeutic benefits of Kinect-based virtual reality (VR) game training in rehabilitation encourage its use to improve motor function.

OBJECTIVE:

To assess the effects of Kinect-based VR training on motor recovery of the upper extremity and functional outcomes in patients with chronic stroke.

METHODS:

In this randomized controlled trial, group A received 20 sessions of physical therapy (PT) + 20 sessions of Kinect-based VR training and group B received only 20 sessions of PT. Clinical outcome measures were assessed at baseline and at the end of the treatments. Primary outcome measures that assess stroke patients’ motor function included upper extremity (UE) Fugl-Meyer Assessment (FMA). Secondary outcome measures were Brunnstrom Recovery Stages (BRS), Modified Ashworth Scale (MAS), Box and Block test (BBT), Motricity index (MI), and active range of motion (AROM) measurement.

RESULTS:

Statistically significant improvements in game scores (p < 0.05) were observed in group A. In within-group analysis, there were statistically significant improvements in all clinical outcome measures except for the BRS-hand, MAS-distal, and MAS-hand in group A; MAS-(proximal, distal, hand) and BRS-(UE, hand) in group B compared with baseline values. Differences from baseline of FMA, MI, and AROM (except adduction of shoulder and extension of elbow) were greater in group A (p < 0.05).

CONCLUSIONS:

To conclude, our results suggest that the adjunct use of Kinect-based VR training may contribute to the improvement of UE motor function and AROM in chronic stroke patients. Further studies with a larger number of subjects with longer follow-up periods are needed to establish its effectiveness in neurorehabilitation.

 

via Effects of Kinect-based virtual reality game training on upper extremity motor recovery in chronic stroke. – PubMed – NCBI

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[Abstract] Tele-Rehabilitation after Stroke: An Updated Systematic Review of the Literature.

Abstract

BACKGROUND:

Tele-rehabilitation for stroke survivors has emerged as a promising intervention for remotely supervised administration of physical, occupational, speech, and other forms of therapies aimed at improving motor, cognitive, and neuropsychiatric deficits from stroke.

OBJECTIVE:

We aimed to provide an updated systematic review on the efficacy of tele-rehabilitation interventions for recovery from motor, higher cortical dysfunction, and poststroke depression among stroke survivors.

METHODS:

We searched PubMed and Cochrane library from January 1, 1980 to July 15, 2017 using the following keywords: “Telerehabilitation stroke,” “Mobile health rehabilitation,” “Telemedicine stroke rehabilitation,” and “Telerehabilitation.” Our inclusion criteria were randomized controlled trials, pilot trials, or feasibility trials that included an intervention group that received any tele-rehabilitation therapy for stroke survivors compared with a control group on usual or standard of care.

RESULTS:

This search yielded 49 abstracts. By consensus between 2 investigators, 22 publications met the criteria for inclusion and further review. Tele-rehabilitation interventions focused on motor recovery (n = 18), depression, or caregiver strain (n = 2) and higher cortical dysfunction (n = 2). Overall, tele-rehabilitation interventions were associated with significant improvements in recovery from motor deficits, higher cortical dysfunction, and depression in the intervention groups in all studies assessed, but significant differences between intervention versus control groups were reported in 8 of 22 studies in favor of tele-rehabilitation group while the remaining studies reported nonsignificant differences.

CONCLUSION:

This updated systematic review provides evidence to suggest that tele-rehabilitation interventions have either better or equal salutary effects on motor, higher cortical, and mood disorders compared with conventional face-to-face therapy.

 

via Tele-Rehabilitation after Stroke: An Updated Systematic Review of the Literature. – PubMed – NCBI

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[WEB SITE] How Virtual Avatars Help Stroke Patients Improve Motor Function

At USC, Dr. Sook-Lei Liew is testing whether watching a virtual avatar that moves in response to brain commands can activate portions of the brain damaged by stroke.
Dr. Sook-Lei Liew (Photo: Nate Jensen)

Photo: Nate Jensen

I am hooked up to a 16-channel brain machine interface with 12 channels of EEG on my head and ears and four channels of electromyography (EMG) on my arms. An Oculus Rift occludes my vision.

Two inertial measurement units (IMU) are stuck to my wrists and forearms, tracking the orientation of my arms, while the EMG monitors my electrical impulses and peripheral nerve activity.

Dr. Sook-Lei Liew, Director of USC’s Neural Plasticity and Neurorehabilitation Laboratory, and Julia Anglin, Research Lab Supervisor and Technician, wait to record my baseline activity and observe a monitor with a representation of my real arm and a virtual limb. I see the same image from inside the Rift.

“Ready?” asks Dr. Liew. “Don’t move—or think.”

I stay still, close my eyes, and let my mind go blank. Anglin records my baseline activity, allowing the brain-machine interface to take signals from the EEG and EMG, alongside the IMU, and use that data to inform an algorithm that drives the virtual avatar hand.

“Now just think about moving your arm to the avatar’s position,” says Dr. Liew.

I don’t move a muscle, but think about movement while looking at the two arms on the screen. Suddenly, my virtual arm moves toward the avatar appendage inside the VR world.

VR rehab at USC

Something happened just because I thought about it! I’ve read tons of data on how this works, even seen other people do it, especially inside gaming environments, but it’s something else to experience it for yourself.

“Very weird isn’t it?” says David Karchem, one of Dr. Liew’s trial patients. Karchem suffered a stroke while driving his car eight years ago, and has shown remarkable recovery using her system.

“My stroke came out of the blue and it was terrifying, because I suddenly couldn’t function. I managed to get my car through an intersection and call the paramedics. I don’t know how,” Karchem says.

He gets around with a walking stick today, and has relatively normal function on the right side of his body. However, his left side is clearly damaged from the stroke. While talking, he unwraps surgical bandages and a splint from his left hand, crooked into his chest, to show Dr. Liew the progress since his last VR session.

As a former software engineer, Karchem isn’t fazed by using advanced technology to aid the clinical process. “I quickly learned, in fact, that the more intellectual and physical stimulation you get, the faster you can recover, as the brain starts to fire. I’m something of a lab rat now and I love it,” he says.

REINVENT Yourself

Karchem is participating in Dr. Liew’s REINVENT (Rehabilitation Environment using the Integration of Neuromuscular-based Virtual Enhancements for Neural Training) project, funded by the American Heart Association, under a National Innovative Research Grant. It’s designed to help patients who have suffered strokes reconnect their brains to their bodies.

VR rehab at USC (Photo: Nate Jensen)“My PhD in Occupational Science, with a concentration in Cognitive Neuroscience, focused on how experience changes brain networks,” explains Dr. Liew. “I continued this work as a Postdoctoral Fellow at the National Institute of Neurological Disorders and Stroke at the National Institutes of Health, before joining USC, in my current role, in 2015.

“Our main goal here is to enhance neural plasticity or neural recovery in individuals using noninvasive brain stimulation, brain-computer interfaces and novel learning paradigms to improve patients’ quality of life and engagement in meaningful activities,” she says.

Here’s the science bit: the human putative mirror neuron system (MNS) is a key motor network in the brain that is active both when you perform an action, like moving your arm, and when you simply watch someone else—like a virtual avatar—perform that same action. Dr. Liew hypothesizes that, for stroke patients who can’t move their arm, simply watching a virtual avatar that moves in response to their brain commands will activate the MNS and retrain damaged or neighboring motor regions of the brain to take over the role of motor performance. This should lead to improved motor function.

“In previous occupational therapy sessions, we found many people with severe strokes got frustrated because they didn’t know if they were activating the right neural networks when we asked them to ‘think about moving’ while we physically helped them to do so,” Dr. Liew says. “If they can’t move at all, even if the right neurological signals are happening, they have no biological feedback to reinforce the learning and help them continue the physical therapy to recover.”

For many people, the knowledge that there’s “intent before movement”—in that the brain has to “think” about moving before the body will do so, is news. We also contain a “body map” inside our heads that predicts our spacetime presence in the world (so we don’t bash into things all the time and know when something is wrong). Both of these brain-body elements face massive disruption after a stroke. The brain literally doesn’t know how to help the body move.

What Dr. Liew’s VR platform has done is show patients how this causal link works and aid speedier, and less frustrating, recovery in real life.

From the Conference Hall to the Lab

She got the idea while geeking out in Northern California one day.

“I went to the Experiential Technology Conference in San Francisco in 2015, and saw demos of intersections of neuroscience and technology, including EEG-based experiments, wearables, and so on. I could see the potential to help our clinical population by building a sensory-visual motor contingency between your own body and an avatar that you’re told is ‘you,’ which provides rewarding sensory feedback to reestablish brain-body signals.

“Inside VR you start to map the two together, it’s astonishing. It becomes an automatic process. We have seen that people who have had a stroke are able to ’embody’ an avatar that does move, even though their own body, right now, cannot,” she says.

VR rehab at USC

Dr. Liew’s system is somewhat hacked together, in the best possible Maker Movement style; she built what didn’t exist and modified what did to her requirements.

“We wanted to keep costs low and build a working device that patients could actually afford to buy. We use Oculus for the [head-mounted display]. Then, while most EEG systems are $10,000 or more, we used an OpenBCI system to build our own, with EMG, for under $1,000.

“We needed an EEG cap, but most EEG manufacturers wanted to charge us $200 or more. So, we decided to hack the rest of the system together, ordering a swim cap from Amazon, taking a mallet and bashing holes in it to match up where the 12 positions on the head electrodes needed to be placed (within the 10-10 international EEG system). We also 3D print the EEG clips and IMU holders here at the lab.

VR rehab at USC

“For the EMG, we use off-the-shelf disposable sensors. This allows us to track the electromyography, if they do have trace muscular activity. In terms of the software platform, we coded custom elements in C#, from Microsoft, and implemented them in the Unity3D game engine.”

Dr. Liew is very keen to bridge the gap between academia and the tech industry; she just submitted a new academic paper with the latest successful trial results from her work for publication. Last year, she spoke at SXSW 2017 about how VR affects the brain, and debuted REINVENT at the conference’s VR Film Festival. It received a “Special Jury Recognition for Innovative Use of Virtual Reality in the Field of Health.”

Going forward, Dr. Liew would like to bring her research to a wider audience.

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“I feel the future of brain-computer interfaces splits into adaptive, as with implanted electrodes, and rehabilitative, which is what we work on. What we hope to do with REINVENT is allow patients to use our system to re-train their neural pathways, [so they] eventually won’t need it, as they’ll have recovered.

“We’re talking now about a commercial spin-off potential. We’re able to license the technology right now, but, as researchers, our focus, for the moment, is in furthering this field and delivering more trial results in published peer-reviewed papers. Once we have enough data we can use machine learning to tailor the system precisely for each patient and share our results around the world.”

If you’re in L.A., Dr. Liew and her team will be participating in the Creating Reality VR Hackathon from March 12-15 at USC. Details here.

via How Virtual Avatars Help Stroke Patients Improve Motor Function | News & Opinion | PCMag.com

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