Posts Tagged Neurological
[ARTICLE] Movement visualisation in virtual reality rehabilitation of the lower limb: a systematic review – Full Text
Virtual reality (VR) based applications play an increasing role in motor rehabilitation. They provide an interactive and individualized environment in addition to increased motivation during motor tasks as well as facilitating motor learning through multimodal sensory information. Several previous studies have shown positive effect of VR-based treatments for lower extremity motor rehabilitation in neurological conditions, but the characteristics of these VR applications have not been systematically investigated. The visual information on the user’s movement in the virtual environment, also called movement visualisation (MV), is a key element of VR-based rehabilitation interventions. The present review proposes categorization of Movement Visualisations of VR-based rehabilitation therapy for neurological conditions and also summarises current research in lower limb application.
A systematic search of literature on VR-based intervention for gait and balance rehabilitation in neurological conditions was performed in the databases namely; MEDLINE (Ovid), AMED, EMBASE, CINAHL, and PsycInfo. Studies using non-virtual environments or applications to improve cognitive function, activities of daily living, or psychotherapy were excluded. The VR interventions of the included studies were analysed on their MV.
In total 43 publications were selected based on the inclusion criteria. Seven distinct MV groups could be differentiated: indirect MV (N = 13), abstract MV (N = 11), augmented reality MV (N = 9), avatar MV (N = 5), tracking MV (N = 4), combined MV (N = 1), and no MV (N = 2). In two included articles the visualisation conditions included different MV groups within the same study. Additionally, differences in motor performance could not be analysed because of the differences in the study design. Three studies investigated different visualisations within the same MV group and hence limited information can be extracted from one study.
The review demonstrates that individuals’ movements during VR-based motor training can be displayed in different ways. Future studies are necessary to fundamentally explore the nature of this VR information and its effect on motor outcome.
Virtual reality (VR) in neurorehabilitation has emerged as a fairly recent approach that shows great promise to enhance the integration of virtual limbs in one`s body scheme  and motor learning in general . Virtual Rehabilitation is a “group [of] all forms of clinical intervention (physical, occupational, cognitive, or psychological) that are based on, or augmented by, the use of Virtual Reality, augmented reality and computing technology. The term applies equally to interventions done locally, or at a distance (tele-rehabilitation)” . The main objectives of intervention for facilitating motor learning within this definition are to (1) provide repetitive and customized high intensity training, (2) relay back information on patients’ performance via multimodal feedback, and (3) improve motivation [2, 4]. VR therapies or interventions are based on real-time motion tracking and computer graphic technologies displaying the patients’ behaviour during a task in a virtual environment.
The interaction of the user and Virtual environment can be described as a perception and action loop . This motor performance is displayed in the virtual environment and subsequently, the system provides multimodal feedback related to movement execution. Through external (e.g. vision) and internal (proprioception) senses the on-line sensory feedback is integrated into the patient’s mental representation. If necessary, the motor plan is corrected in order to achieve the given goal .
A previous Cochrane Review from Laver, George, Thomas, Deutsch, and Crotty  on Virtual Reality for stroke rehabilitation showed positive effects of VR intervention for motor rehabilitation in people post-stroke. However, grouped analysis from this review on recommendation for VR intervention provides inconclusive evidence. The author further comments that “[…] virtual reality interventions may vary greatly […], it is unclear what characteristics of the intervention are most important” (, p. 14).
Virtual rehabilitation system provides three different types of information to the patient: movement visualisation, performance feedback and context information . During a motor task the patient’s movements are captured and represented in the virtual environment (movement visualisation). According to the task success, information about the accomplished goal or a required movement alteration is transmitted through one or several sensory modalities (performance feedback). Finally, these two VR features are embedded in a virtual world (context information) that can vary from a very realistic to an abstract, unrealistic or reduced, technical environment.
Performance feedback often relies on theories of motor learning and is probably the most studied information type within VR-based motor rehabilitation. Moreover, context information is primarily not designed with a therapeutic purpose. Movement observation, however, plays an important role for central sensory stimulation therapies, such as mirror therapy or mental training. The observation or imagination of body movements facilitates motor recovery [7, 8, 9] and provides new possibilities for cortical reorganization and enhancement of functional mobility. Thus, it appears that movement visualisation may also play an important role in motor rehabilitation [10, 11, 12], although this aspect is yet to be systematically investigated .
The main goal of the present review is to identify various movement visualisation groups in VR-based motor interventions for lower extremities, by means of a systematic literature search. Secondarily, the included studies are further analysed for their effect on motor learning. This will help guide future research in rehabilitation using VR.
An interim analysis of the review published in 2013 showed six MV groups for upper and lower extremity training and additional two MV groups directed only towards lower extremity training. In this paper, we analysed only studies involving lower limb training, leading to a revision and expansion of the previously published MV groups findings [13, 14, 15].
[ARTICLE] Does the Finger-to-Nose Test measure upper limb coordination in chronic stroke? – Full Text
We aimed to kinematically validate that the time to perform the Finger-to-Nose Test (FNT) assesses coordination by determining its construct, convergent and discriminant validity.
Experimental, criterion standard study. Both clinical and experimental evaluations were done at a research facility in a rehabilitation hospital. Forty individuals (20 individuals with chronic stroke and 20 healthy, age- and gender-matched individuals) participated.. Both groups performed two blocks of 10 to-and-fro pointing movements (non-dominant/affected arm) between a sagittal target and the nose (ReachIn, ReachOut) at a self-paced speed. Time to perform the test was the main outcome. Kinematics (Optotrak, 100Hz) and clinical impairment/activity levels were evaluated. Spatiotemporal coordination was assessed with slope (IJC) and cross-correlation (LAG) between elbow and shoulder movements.
Compared to controls, individuals with stroke (Fugl-Meyer Assessment, FMA-UE: 51.9 ± 13.2; Box & Blocks, BBT: 72.1 ± 26.9%) made more curved endpoint trajectories using less shoulder horizontal-abduction. For construct validity, shoulder range (β = 0.127), LAG (β = 0.855) and IJC (β = −0.191) explained 82% of FNT-time variance for ReachIn and LAG (β = 0.971) explained 94% for ReachOut in patients with stroke. In contrast, only LAG explained 62% (β = 0.790) and 79% (β = 0.889) of variance for ReachIn and ReachOut respectively in controls. For convergent validity, FNT-time correlated with FMA-UE (r = −0.67, p < 0.01), FMA-Arm (r = −0.60, p = 0.005), biceps spasticity (r = 0.39, p < 0.05) and BBT (r = −0.56, p < 0.01). A cut-off time of 10.6 s discriminated between mild and moderate-to-severe impairment (discriminant validity). Each additional second represented 42% odds increase of greater impairment.
For this version of the FNT, the time to perform the test showed construct, convergent and discriminant validity to measure UL coordination in stroke.
Upper-limb (UL) coordination deficits are commonly observed in neurological patients (e.g., cerebellar ataxia, stroke, etc.). In healthy subjects, goal-directed movement requires synchronized interaction (coordination) between multiple effectors [1, 2, 3]. Characterizing UL coordination, however, is challenging for clinicians and researchers because of lack of consensus regarding its definition (e.g., see [4, 5, 6, 7]). Nevertheless, definitions usually describe coordinated movement as involving specific patterns of temporal (timing between joints) and spatial (joint movement pattern) variability [1, 2, 8]. However, trajectory formation differs for reaches made in a body-centered frame of reference (egocentric) compared to those relying on mapping of extrinsic space and visuo-motor transformations [9, 10] made away from the body (exocentric). Thus, coordination can be defined as the skill of adjusting temporal and spatial aspects of joint rotations according to the task .
Damage to descending pathways due to stroke can lead to movement deficits defined at two levels. At the end-effector level (e.g. hand), variables describe movement performance (time, straightness, smoothness, precision), whereas at the interjoint level, variables describe movement quality (joint ranges of motion, interjoint coordination) . These variables may be affected differently for egocentric and exocentric movements.
Although it is widely recognized that training can improve performance of functional tasks even years after a stroke , a valid tool for the measurement of coordination has not yet been established. In healthy individuals, coordinated movements are described in terms of spatial variables, related to the positions of different joints or body segments in space and/or temporal variables, related to the timing between movements of joints/segments during the task . Consideration of task specificity is important in characterizing coordination. In addition, movement may be affected by abnormal stereotypical UL movement synergies and concomitant reduction in kinematic redundancy [10, 14] as well as deficits reducing both movement performance and quality [15, 16].
In clinical practice, coordination is assumed to be measured by the time to perform alternating movements with different end effectors (e.g., supination/pronation of the forearm, sliding the heel up and down the anterior aspect of the shin). Another task commonly used to assess coordination is the Finger-to-Nose test (FNT) [17, 18]. In the standard neurological exam , the individual alternately touches their nose and the evaluator’s stationary or moving finger while lying supine, sitting or standing. In the Fugl-Meyer UL Assessment (FMA-UL) , the FNT is objectively measured as the difference in time to alternately touch the knee and nose five times between the more- and less-affected arm on a 0 to 2 point scale. Aside from FNT-time, two other features of endpoint performance, arm trajectory straightness/smoothness (tremor) and precision (dysmetria), are estimated qualitatively  for a total of six points.
However, the construct validity of FNT-time as an UL coordination measure in individuals with stroke has not been established using detailed kinematic assessment, where construct validity is defined as the degree to which experimentally-determined and theoretical definitions match . For clinicians to use FNT as part of the UL assessment, this assumption must be verified along with its convergent and discriminant validity.
The study objectives were to determine construct, convergent and discriminant validity of FNT-time to measure UL coordination in individuals with chronic stroke using kinematic analysis. We characterized movement parameters during performance of FNT between healthy and stroke subjects. We also related FNT outcomes (time, trajectory straightness, precision) to UL impairment severity and activity limitations. We hypothesized that FNT-time would 1) be related to interjoint coordination measures (construct validity); 2) be correlated with other measures of UL impairment and/or activity limitations (convergent validity); and 3) discriminate between levels of UL impairment (discriminant validity). Preliminary data have appeared in abstract form .
[Αbstract] Using robot fully assisted functional movements in upper-limb rehabilitation of chronic stroke patients: preliminary results. – PubMed
Eur J Phys Rehabil Med. 2016 Nov 9. [Epub ahead of print]
BACKGROUND: Robotic rehabilitation is promising to promote function in stroke patients. The assist as needed training paradigm has shown to stimulate neuroplasticity but often cannot be used because stroke patients are too impaired to actively control the robot against gravity.
AIM: To verify whether a rehabilitation intervention based on robot fully assisted Reaching against gravity (RCH) and Hand-to-Mouth (HTM) can promote upper-limb function in chronic stroke.
DESIGN: Cohort study.
SETTING: Chronic stroke outpatients referring to the Robotic Rehabilitation Lab of a Rehabilitation Centre.
POPULATION: Ten chronic stroke patients with mild to moderate upper-limb hemiparesis.
METHODS: Patients underwent 12 sessions (3 per week) of robotic treatment using an end- effector robot Every session consisted of 20 minutes each of RCH and HtM; movements were fully assisted, but patients were asked to try to actively participate. The Fugl-Meyer Assessment (FMA) was the primary outcome measure; Medical Research Council and Modified Ashworth Scale were the secondary outcome measures.
RESULTS: All patients, but one, show functional improvements (FMA section A-D, mean increment 7.2±3.9 points, p<0.008).
CONCLUSION: This preliminary study shows that a robotic intervention based on functional movements, fully assisted, can be effective in promoting function in chronic stroke patients. These results are promising considering the short time of the intervention (1 month) and the time from the stroke event, which was large (27±20 months). A larger study, comprehensive of objective instrumental measures, is necessary to confirm the results.
CLINICAL REHABILITATION IMPACT: This intervention could be extended even to subacute stroke and other neurological disorders.
BACKGROUND: Stroke is the second most common cause of death in the world and in China it has now become the main cause of death. It is also a main cause of adult disability and dependency. Acupuncture for stroke has been used in China for hundreds of years and is increasingly practiced in some Western countries. This is an update of the Cochrane review originally published in 2006 .
OBJECTIVES: To determine the efficacy and safety of acupuncture therapy in people with subacute and chronic stroke. We intended to test the following hypotheses: 1) acupuncture can reduce the risk of death or dependency in people with subacute and chronic stroke at the end of treatment and at follow-up; 2) acupuncture can improve neurological deficit and quality of life after treatment and at the end of follow-up; 3) acupuncture can reduce the number of people requiring institutional care; and 4) acupuncture is not associated with any intolerable adverse effects.
SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (June 2015), the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library 2015, Issue 7), MEDLINE (1966 to July 2015, Ovid), EMBASE (1980 to July 2015, Ovid), CINAHL (1982 to July 2015, EBSCO), and AMED (1985 to July 2015, Ovid). We also searched the following four Chinese medical databases: China Biological Medicine Database (July 2015); Chinese Science and Technique Journals Database (July 2015); China National Infrastructure (July 2015), and Wan Fang database (July 2015).
SELECTION CRITERIA: Truly randomised unconfounded clinical trials among people with ischaemic or haemorrhagic stroke, in the subacute or chronic stage, comparing acupuncture involving needling with placebo acupuncture, sham acupuncture, or no acupuncture.
DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials for inclusion, assessed quality, extracted and cross-checked the data.
MAIN RESULTS: We included 31 trials with a total of 2257 participants in the subacute or chronic stages of stroke. The methodological quality of most of the included trials was not high. The quality of evidence for the main outcomes was low or very low based on the assessment by the system of Grades of Recommendation, Assessment, Development and Evaluation (GRADE).Two trials compared real acupuncture plus baseline treatment with sham acupuncture plus baseline treatment. There was no evidence of differences in the changes of motor function and quality of life between real acupuncture and sham acupuncture for people with stroke in the convalescent stage.Twenty-nine trials compared acupuncture plus baseline treatment versus baseline treatment alone. Compared with no acupuncture, for people with stroke in the convalescent phase, acupuncture had beneficial effects on the improvement of dependency (activity of daily living) measured by Barthel Index (nine trials, 616 participants; mean difference (MD) 9.19, 95% confidence interval (CI) 4.34 to 14.05; GRADE very low), global neurological deficiency (seven trials, 543 participants; odds ratio (OR) 3.89, 95% CI 1.78 to 8.49; GRADE low), and specific neurological impairments including motor function measured by Fugl-Meyer Assessment (four trials, 245 participants; MD 6.16, 95% CI 4.20 to 8.11; GRADE low), cognitive function measured by the Mini-Mental State Examination (five trials, 278 participants; MD 2.54, 95% CI 0.03 to 5.05; GRADE very low), depression measured by the Hamilton Depression Scale (six trials, 552 participants; MD -2.58, 95% CI -3.28 to -1.87; GRADE very low), swallowing function measured by drinking test (two trials, 200 participants; MD -1.11, 95% CI -2.08 to -0.14; GRADE very low), and pain measured by the Visual Analogue Scale (two trials, 118 participants; MD -2.88, 95% CI -3.68 to -2.09; GRADE low). Sickness caused by acupuncture and intolerance of pain at acupoints were reported in a few participants with stroke in the acupuncture groups. No data on death, the proportion of people requiring institutional care or requiring extensive family support, and all-cause mortality were available in all included trials.
AUTHORS’ CONCLUSIONS: From the available evidence, acupuncture may have beneficial effects on improving dependency, global neurological deficiency, and some specific neurological impairments for people with stroke in the convalescent stage, with no obvious serious adverse events. However, most included trials were of inadequate quality and size. There is, therefore, inadequate evidence to draw any conclusions about its routine use. Rigorously designed, randomised, multi-centre, large sample trials of acupuncture for stroke are needed to further assess its effects.
Update of Acupuncture for stroke rehabilitation. [Cochrane Database Syst Rev. 2006]
Monday, August 1, 2016
“Parents should be aware of the increased risk of [other] problems for their children,” said study author Dr. Richard Chin.
Epilepsy is a chronic seizure disorder. It is estimated that nearly 4 million people in the United States have epilepsy, according to the U.S. Centers for Disease Control and Prevention.
The new study included health information on more than a million Norwegian children from 2008 through 2013. About 6,600 of the children had a diagnosis of epilepsy, the researchers said.
The data showed that nearly four out of five children with epilepsy had at least one other health issue. These included medical, neurological, developmental or psychiatric problems.
Just 30 percent of the children without epilepsy had additional health issues, the study authors found.
Children already diagnosed with “complicated” epilepsy had the highest overall levels of other health issues, but even the children with less complicated epilepsy were at risk compared to the general population. Complicated epilepsy is epilepsy that occurs with other disorders, and those disorders may share the same causes or risk factors with epilepsy, or in some cases they may even be the cause of the epilepsy, the study authors said.
While experts have long been aware of the risk for other health issues in epilepsy patients, Chin said the researchers “were surprised that it was as high as 80 percent.”
Chin is a senior clinical research fellow in pediatric neurosciences and director of the Muir Maxwell Epilepsy Centre, University of Edinburgh and the Royal Hospital for Sick Children Edinburgh in Scotland.
One strength of the new research is the size of the population studied and the wide range of issues the investigators looked at, the study authors said.
After digestive problems, other common medical problems included birth defects not involving the central nervous system, musculoskeletal problems, asthma and other respiratory issues.
Among the common neurological disorders were cerebral palsy, headache and neurologic birth defects (such as spina bifida). Attention-deficit/hyperactivity disorder (ADHD) was more than five times as common in children with epilepsy as in those without, affecting 12 percent of the children with the seizure disorder, the findings showed.
Chin said the study findings are in line with a new view of epilepsy that has been suggested by some experts. “New definition proposals have sought to frame epilepsy as not just a seizure disorder, but as a disorder with a wide range of neurobiological, cognitive, psychological and social aspects,” he said.
Whether the other health issues may decline with age isn’t certain, Chin said.
While the 80 percent figure seems high, “it’s believable,” said Dr. Ian Miller, pediatric neurologist and medical director of the comprehensive epilepsy program at Nicklaus Children’s Hospital in Miami. He reviewed the research.
As for why children with epilepsy may be so prone to other health problems, Miller said he can speculate about several possibilities. Besides Chin’s view that epilepsy is not just a seizure disorder, Miller explained that “kids with epilepsy take medications, which can cause side effects, which then [might] create a second problem.”
Seizures can cause injuries such as falls and fractures, and those can create additional problems, Miller noted.
For now, Chin said, the best advice for parents is to be sure their child is thoroughly assessed for all aspects of their health. Those aspects include their development, psychiatric health, nutrition, growth and sleep quality.
Miller added: “Make sure you discuss any new symptoms with your child’s neurologist and/or pediatrician. Just because you have one medical problem, it won’t protect you from having a second.”
SOURCES: Richard Chin, M.D., Ph.D., senior clinical research fellow, pediatric neurosciences and director, Muir Maxwell Epilepsy Centre, University of Edinburgh and Royal Hospital for Sick Children Edinburgh; Ian Miller, M.D., pediatric neurologist and medical director, comprehensive epilepsy program, Nicklaus Children’s Hospital, Miami; Aug. 1, 2016, Pediatrics, online
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[BOOK] Effective Learning after Acquired Brain Injury: A practical guide to support adults with neurological conditions – Google Books
[BOOK] Effective Learning after Acquired Brain Injury: A practical guide to support adults with neurological conditions
[HANDBOOK] Stroke Rehabilitation Clinician Handbook 2014 – Brain Reorganization, Recovery and Organized Care – Full Text PDF
2. Brain Reorganization, Recovery and Organized Care
Robert Teasell MD, Norhayati Hussein MBBS MRehabMed
2.1 Important Principles of Rehabilitation
2.1.1 Neurological Recovery
• Neurological recovery is defined as recovery of neurological impairments and is often the result of brain recovery/reorganization; it has been increasingly recognized as being influenced by rehabilitation.
• The majority of neurological recovery occurs within the first 1-3 months.
• Afterwards recovery may occur much more slowly for up to one year.
more –> Full Text PDF
…Goebel and his team have developed an advanced software system for the real-time analysis of functional MRI brain scans. He scans the brain and analyzes brain activity in the regions of the brain related to the problem of the patient. The patient is shown this neuro-feedback real-time through a brain-computer interface. Through this feedback, a severely depressed person can visualize how his brain activity influences the way he feels and the way he can control these emotions by personally activating or de-activating activity in relevant parts of his brain, with astonishing results. Goebel also shows us the different neurological responses of different people, from one of the happiest men in the world to a girl with locked-in syndrome…
Bilateral high- and low-frequency rTMS in acute stroke patients with hemiparesis: A comparative study with unilateral high-frequency rTMS, Brain Injury, Informa Healthcare
…The proposed BL-rTMS is safe and feasible and showed a greater improvement of BRS of the affected upper limb compared to HF-rTMS. This novel rTMS approach may be a useful intervention for hemiparetic patients with acute stroke…