Posts Tagged Neurorehabilitation

[ARTICLE] Virtual reality experiences, embodiment, videogames and their dimensions in neurorehabilitation – Full Text

Abstract

Background

In the context of stroke rehabilitation, new training approaches mediated by virtual reality and videogames are usually discussed and evaluated together in reviews and meta-analyses. This represents a serious confounding factor that is leading to misleading, inconclusive outcomes in the interest of validating these new solutions.

Main body

Extending existing definitions of virtual reality, in this paper I put forward the concept of virtual reality experience (VRE), generated by virtual reality systems (VRS; i.e. a group of variable technologies employed to create a VRE). Then, I review the main components composing a VRE, and how they may purposely affect the mind and body of participants in the context of neurorehabilitation. In turn, VRS are not anymore exclusive from VREs but are currently used in videogames and other human-computer interaction applications in different domains. Often, these other applications receive the name of virtual reality applications as they use VRS. However, they do not necessarily create a VRE. I put emphasis on exposing fundamental similarities and differences between VREs and videogames for neurorehabilitation. I also recommend describing and evaluating the specific features encompassing the intervention rather than evaluating virtual reality or videogames as a whole.

Conclusion

This disambiguation between VREs, VRS and videogames should help reduce confusion in the field. This is important for databases searches when looking for specific studies or building metareviews that aim at evaluating the efficacy of technology-mediated interventions.

Background

In the context of stroke rehabilitation, new training approaches mediated by virtual reality and videogames are usually discussed and evaluated together in reviews and meta-analyses for upper limb [], and balance and gait []. Certainly, the expected superiority of virtual reality over conventional therapy post stroke has been questioned when using off-the-shelf (e.g., Nintendo Wii) or ad-hoc videogames. This conclusion, however, is based on the wrong assumption that videogames deliver same experiences than virtual reality applications. In my opinion, this represents a serious confounding factor that may lead to misleading, inconclusive outcomes in the interest of validating these new solutions. Indeed, in Laver’s Cochrane article, a positive effect for virtual reality versus conventional therapy for improving upper limb function post stroke is found only when dedicated virtual reality based interventions, i.e. specifically designed for rehabilitation settings, are used. The effect vanishes when standard off-the-shelf videogames are considered. Indeed, the use of Nintendo Wii (but referring to it as virtual reality) often leads to a non-inferiority clinical outcome, being as effective as conventional therapy [] or alternative playful interventions such as playing cards []. In another study with mobile-based and dedicated games (again referred to as virtual reality), partial functional and motor improvements were observed as compared to standard occupational therapy [].

This heterogeneity in the reported virtual reality and videogames studies for neurorehabilitation calls for use of appropriate labelling for the approaches and variables assessed. A correct identification of the specific factors (and their weight) contributing to any eventual change post treatment are required for interpreting those changes and building further evidence on the specific solution. Therefore, in this paper I propose to reframe the traditional interpretation of the term virtual reality. I advocate disentangling two conceptual components that may help the field standardize its use: virtual reality experience (VRE) and virtual reality systems (VRS). I put emphasis on exposing fundamental similarities and differences between VREs and videogames, often mistakenly used as synonyms or exchangeable terms despite the different underlying interventional techniques and brain mechanisms they can enable. I then use neurorehabilitation as exemplary application field to discuss the implications of differentiating between them.[…]

 

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[Editorial] Proportional Recovery in the Spotlight – Neurorehabilitation and Neural Repair

By Randolph J. Nudo

Prediction of who will recover after stroke has been a perennial focus for both researchers and clinicians in the field of neurorehabilitation. The prospects of applying a population-based model to predict outcome in individual patients might ultimately allow more focused approaches to stroke rehabilitation and foster a better distribution of precious health care resources. Aside from anatomical biomarkers, such as the integrity of the corticospinal tract, recent attention has focused on the proportional recovery rule, formally proposed in this journal more than 10 years ago by Prabhakaran et al,1 who described a surprisingly linear relationship between Fugl-Meyer Assessment upper extremity scores obtained within 3 days after stroke and those obtained at 3 months poststroke, illustrating the general principle of spontaneous recovery with a level of predictability not previously appreciated. This relationship appears to hold for most individuals (so-called “fitters” or “recoverers”), but a subset of individuals (so-called “non-fitters” or “non-recoverers”) fall off the linear regression line. First applied to upper limb motor impairment, the proportional recovery rule has been examined in a variety of motor and nonmotor impairments, and results have generally been in agreement with the initial linear relationship. Recent controversy surrounding the proportional recovery rule has been based on statistical factors such as mathematical coupling and nonlinearity of outcome scales, questioning not only the accuracy but also the underlying validity of this predictive population-based model. Two articles in the current issue of Neurorehabilitation and Neural Repair highlight some of the emerging views and suggestions for future research regarding this model. The first article by Senesh and Reinkensmeyer examines the reasons why “non-fitters” do not recover according to the proportional recovery algorithm. They argue that the local slope of the linear regression reflects the difficulty of test item scores related to arm and hand movement at follow-up, consistent with the view that non-fitters lack sufficient corticospinal tract. They suggest that at least some non-fitters may have a heightened response to intensive movement training and should be targeted early after stroke for such rehabilitative training. In the second article by Kundert et al, the statistical validity of the proportional recovery rule is examined in the context of recent criticisms regarding its underlying assumptions. Despite 2 recent articles critical of statistical relationships of baseline impairment scores to follow-up scores, especially when used for patient-level predictions, Kundert et al contend that the systematic non-artifactual relationship between initial impairment and motor recovery provides a valid statistical and biologically meaningful model, and that future studies of proportional recovery should use more sophisticated analysis techniques and rigorous methods to assess validity, including comparisons to alternative models.

Randolph J. Nudo, PhD
Editor-in-Chief

1. Prabhakaran, S, Zarahn, E, Riley, C, et alInter-individual variability in the capacity for motor recovery after ischemic stroke. Neurorehabil Neural Repair. 2008;22:6471. doi:10.1177/1545968307305302
Google Scholar | SAGE Journals | ISI

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[Abstract] Ergometer training in stroke rehabilitation: systematic review and meta-analysis

Abstract

Objective

Ergometer training is routinely used in stroke rehabilitation. How robust is the evidence of its effects?

Data source

The PubMed database and PEDro database were reviewed prior to 22/01/2019.

Study selection

Randomized controlled trials investigating the effects of ergometer training on stroke recovery were selected.

Data extraction

Two reviewers independently selected the studies, performed independent data extraction, and assessed the risk of bias.

Data synthesis

A total of 28 studies (including 1115 stroke subjects) were included. The data indicates that

(1) ergometer training leads to a significant improvement of walking ability, cardiorespiratory fitness, motor function and muscular force of lower limbs, balance and postural control, spasticity, cognitive abilities, as well as the brain’s resistance to damage and degeneration,

(2) neuromuscular functional electrical stimulation assisted ergometer training is more efficient than ergometer training alone,

(3) high-intensity ergometer training is more efficient that low-intensity ergometer training, and

(4) ergometer training is more efficient than other therapies in supporting cardiorespiratory fitness, independence in activities of daily living, and balance and postural control, but less efficient in improving walking ability.

Conclusion

Ergometer training can support motor recovery after stroke. However, current data is insufficient for evidence-based rehabilitation. More data is required about the effects of ergometer training on cognitive abilities, emotional status, and quality of life in stroke subjects.

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[WEB SITE] Neurorehabilitation: Fighting strokes with robotics

Having a stroke can be a scary experience, but the long road to recovery might be getting shorter, thanks to research out of ECU.

Imagine suddenly losing control of a limb or your ability to communicate.

And while this happens, excruciating pain spreads across your head.

This was Joanna’s experience when she had a  at the age of 44.

“I was sick three days up to having my stroke,” Joanna explains. “I had vomiting, headaches and was not making much sense when talking.”

“Three days later, I was sitting down and then it felt like my head was being squeezed between two vices. Excruciating pain.”

Risk factor

In Australia, strokes affect around 55,000 people a year and are the third most common cause of death and a leading cause of disability.

There’s a range of factors that increase the risk of strokes, including diet, exercise and .

But one of the most telling  is, simply, age.

From the age of 45, the risk of a stroke in men is one in four, and for women, it’s one in five.

Fortunately, our knowledge of strokes and how to combat them has improved a lot in the past few decades.

A big part of the solution is getting help quickly, according to Edith Cowan University (ECU) Professor Dylan Edwards.

“If it’s the blockage of a blood vessel, it can be treated very well by anti-coagulant therapy that will break up the blood clot and restore the blood flow to the brain,” Dylan says.

“Typically, you notice somebody is having a stroke by them having issues with their speech or they have a weakness or funny sensation in one side of their body.”

But surviving a stroke is only part of the journey, and with 65% of stroke survivors suffering from some form of disability, restoring motor skills is a critical part of rehabilitation.

Road to recovery

Recovery from stroke can be a long and frustrating road for even the smallest paralysation.

For stroke survivor Joanna, the frustration she felt not being able to move normally made the recovery process even more challenging.

“The emotional side of having the stroke has affected me more than anything else,” Joanna says.

“You slowly get used to the fact that you can’t move your left side, and you know that you’ll get therapy. But when I had people come visit, when they left, I was in tears [out of frustration].”

Joanna eventually started to get some feeling back in her left side, just to her thumb at first.

“It was still a shock that I had lost all of that, so just a little bit of movement was enough to keep me going and stay motivated.”

Fighting back with technology

At ECU’s Lab for NeuroRehabilitation and Robotics, Dylan and his team have been researching how to help people recover their motor control after a brain or spinal cord injury.

Part of their research focuses on understanding the recovery of stroke survivors, using a robotic sensory platform called the Kinarm Exoskeleton Lab.

“The Kinarm looks like a fancy piece of gym equipment,” Dylan explains. “You sit inside the device and position your arms on top of movable handles, and you’re wheeled into this virtual reality environment.”

For the user in the chair, it feels like you’re playing a series of games, moving the chair’s arms to get a response on the screen—such as bouncing balls off paddles.

But the real work is happening behind the scenes.

“All of this information is acquired by these high-powered computers and analysed for how the person is performing,” Dylan says. “This [helps] identify the precise proprioceptive issue with an individual stroke survivor so we can prescribe therapy more effectively.”

In simplest terms, the Kinarm helps identify issues where the user is telling their arm to move but the resulting movement is not what they were trying to do.

This could be an arm not extending the full distance or slower reaction times.

With strokes usually affecting one side of the body more than the other, the unaffected side can provide a good baseline for what their normal reactions should be.

But what if both sides of the body have been affected? The Kinarm can pick up on that too, detecting deficits in what would be considered the unaffected side and showing this in the test results.

R&R—Robotics and Recovery

For Joanna, using the Kinarm has been a challenging experience, even three years after her stroke.

“It actually made you concentrate more in the game to hit the balls coming down,” she explains.

“I think that made you use the brain to try and keep up with your eye, which it didn’t, but I gave it my best shot. I also noticed my peripheral vision has gone.”

“It highlighted for me the improvements I have got since my stroke, which is nice for me three years on to see how it was then to what I could actually achieve on the Kinarm now.”

The data collected helps doctors prescribe the most beneficial treatment for their patients, based on the results of the tests.

Whether it’s heading towards recovering the function in a limb or something as simple as the mobility of a single joint, Dylan believes even small changes are worth pursuing.

“Some degree of independence—even though it might be apparent to an onlooker or a carer—can be very meaningful for a patient.”

“Small changes that we have made in the past through prescribing therapies effectively are things like being able to stabilise yourself on the train and send a text message.”

Recovering movement and lives

While full recovery from a stroke is not guaranteed, any improvement to quality of life can mean everything for survivors. Restoring simple movements can help patients build up their self-confidence to return to their everyday lives.

“Often stroke patients are in the older age bracket, and many of them are working,” Dylan says. “It’s very depressing to be disengaged from a functional work life, and going back to work might just be having the confidence of turning over a page of paper at your desk.”

As we learn more about how the body and brain recover after these , there’s hope we can find ways to better support those who have experienced extensive motor damage.

While there’s medication and training regimes to follow, at its core, it comes down to the drive to actively engage in recovering.

And even if it’s just through small victories, a spark from ECU’s Lab for NeuroRehabilitation and Robotics could help light the fire of determination in .


Explore further

Regulating blood supply to limbs improves stroke recovery

 

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[Editorial] Virtual reality in stroke rehabilitation: virtual results or real values?

1Laboratory for the Study of Mind and Action in Rehabilitation Technologies, IRCCS Fondazione Santa Lucia, Rome, Italy.

Seven Capital Devices for the Future of Stroke Rehabilitation was the title of a review published seven years ago by our group, in which we analyzed the most promising technologies for neurorehabilitation1. They were: robots, virtual reality, brain computer interfaces, wearable devices for human movement analysis, noninvasive brain stimulators (such as transcranial direct current stimulation and transcranial magnetic stimulation), neuroprostheses, and computers/tablets for electronic clinical records and planning1.

Seven years later, we can now take stock of the situation. We must be honest: on one hand, we can surely affirm that the above-proposed technologies have really been the most developed and applied in these last years, but on the other hand, we should say that questions about their efficacy are still open, as reported by Cochrane reviews highlighting the need of further studies2,3.

However, every month, new studies claiming the efficacy of technological rehabilitation are published, and this continuously-growing amount of literature reveals the lack of definitive proof; otherwise all these studies would have been unnecessary. This “efficacy paradox” could potentially give us many more years of research without any conclusive results, especially because the more technology is adaptable to the needs of the patients (as clinicians want), the less the protocol to test the efficacy of that technology is standardizable (as researchers want)4.

Furthermore, the pressure on researchers to publish, the optimism about the use of technologies of some clinicians, the hopes of patients and their caregivers about new miraculous approaches, and the commercial interests of technology companies, may lead to some misleading claims in the mass media. For example, in many scientific and journalistic papers, some electromechanical devices without any intelligence on board are improperly called “robots”, nonimmersive video games are called “virtual reality”, the expressions “mind power” or “force of thought” are associated with brain computer interfaces1. Market analysts expect that the greatest developing field for robots in the next five years will be rehabilitation, compared with other fields5. Conversely, computers, the Internet and smartphones have changed our lives and were not directly developed for rehabilitation, but this clinical field may benefit from all the developed know-how. Virtual reality should be differentiated by video games, referring to a high-end user-computer interface involving real-time stimulation based on the three “I’s”: immersive experience, interaction, and imagination6.

In this scenario, the recent study by Ogun and colleagues clearly shows all the potentials of using a Leap Motion controller interfaced with 3D immersive virtual reality to improve the upper extremity functions in patients with ischemic stroke7. The Leap Motion controller is an optical tracking system including three infrared light emitters and two infrared cameras for tracking hand and finger kinematics, interfacing them with a virtual environment developed as a human-computer interface. In 2014, our group published the first feasibility pilot study proposing the use of Leap Motion in neurorehabilitation, noting its advantageous features: it is precise, markerless, low-cost, small, and easy to use8.

Ogun and colleagues have confirmed our intuition: they found that virtual reality rehabilitation guided by a Leap Motion controller appeared to be effective in improving upper extremity function and self-care skills (but not functional independence), more than conventional therapy, in a wide sample of patients7.

Many studies have reported that the sense of presence, of body ownership and agency elicited by virtual reality are similar to those in the real environment, and daily life activities have been replicated in virtual environments for training patients. But what is the real value of virtual reality in rehabilitation if it is just a replication of a real environment? Virtual reality can also elicit amusement, arousal and valence, even more than in the real environment, as happens in virtual reality-based video games. Amusement can improve participation, arousal can improve brain activities, valence can improve learning9. It seems to be time for a generation of amusing and immersive virtual reality for improving real outcomes in neurorehabilitation.

REFERENCES

1. Iosa M, Morone G, Fusco A, Bragoni M, Coiro P, Multari M, et al. Seven capital devices for the future of stroke rehabilitation. Stroke Res Treat. 2012;2012:187965. https://doi.org/10.1155/2012/187965 [ Links ]

2. Mehrholz J, Pohl M, Platz T, Kugler J, Elsner B. Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst Rev. 2018 Sep;9:CD006876. https://doi.org/10.1002/14651858.CD006876.pub5 [ Links ]

3. Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017 Nov;11:CD008349. https://doi.org/10.1002/14651858.CD008349.pub4 [ Links ]

4. Iosa M, Morone G, Cherubini A, Paolucci S. The Three laws of neurorobotics: a review on what neurorehabilitation robots should do for patients and clinicians. J Med Biol Eng. 2016;36(1):1–11. https://doi.org/10.1007/s40846-016-0115-2 [ Links ]

5. Ugalmugale S, Mupid S. Healthcare assistive robot market size by product. City: Global Market Insights, 2017. [ Links ]

6. Burdea GC, Coiffet P. Virtual reality technology. 2nd ed. Hoboken, NJ: John Wiley & Sons; 2003. [ Links ]

7. Ögün1 MN, Kurul R, Yaşar MF, Turkoglu SA, Avcı S, Yildiz N. Effect of leap motion-based 3D immersive virtual reality usage on upper extremity function in ischemic stroke patients. Arq Neuropsiquiatr 2019;77(10):681-88. https://doi.org/10.1590/0004-282X20190129 [ Links ]

8. Iosa M, Morone G, Fusco A, Castagnoli M, Fusco FR, Pratesi L, et al. Leap motion controlled videogame-based therapy for rehabilitation of elderly patients with subacute stroke: a feasibility pilot study. Top Stroke Rehabil. 2015 Aug;22(4):306–16. https://doi.org/10.1179/1074935714Z.0000000036 [ Links ]

9. Tieri G, Morone G, Paolucci S, Iosa M. Virtual reality in cognitive and motor rehabilitation: facts, fiction and fallacies. Expert Rev Med Devices. 2018 Feb;15(2):107–17. https://doi.org/10.1080/17434440.2018.1425613 [ Links ]

 

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[Editorial] Proportional Recovery in the Spotlight – Neurorehabilitation and Neural Repair

Prediction of who will recover after stroke has been a perennial focus for both researchers and clinicians in the field of neurorehabilitation. The prospects of applying a population-based model to predict outcome in individual patients might ultimately allow more focused approaches to stroke rehabilitation and foster a better distribution of precious health care resources. Aside from anatomical biomarkers, such as the integrity of the corticospinal tract, recent attention has focused on the proportional recovery rule, formally proposed in this journal more than 10 years ago by Prabhakaran et al,1 who described a surprisingly linear relationship between Fugl-Meyer Assessment upper extremity scores obtained within 3 days after stroke and those obtained at 3 months poststroke, illustrating the general principle of spontaneous recovery with a level of predictability not previously appreciated. This relationship appears to hold for most individuals (so-called “fitters” or “recoverers”), but a subset of individuals (so-called “non-fitters” or “non-recoverers”) fall off the linear regression line. First applied to upper limb motor impairment, the proportional recovery rule has been examined in a variety of motor and nonmotor impairments, and results have generally been in agreement with the initial linear relationship. Recent controversy surrounding the proportional recovery rule has been based on statistical factors such as mathematical coupling and nonlinearity of outcome scales, questioning not only the accuracy but also the underlying validity of this predictive population-based model. Two articles in the current issue of Neurorehabilitation and Neural Repair highlight some of the emerging views and suggestions for future research regarding this model. The first article by Senesh and Reinkensmeyer examines the reasons why “non-fitters” do not recover according to the proportional recovery algorithm. They argue that the local slope of the linear regression reflects the difficulty of test item scores related to arm and hand movement at follow-up, consistent with the view that non-fitters lack sufficient corticospinal tract. They suggest that at least some non-fitters may have a heightened response to intensive movement training and should be targeted early after stroke for such rehabilitative training. In the second article by Kundert et al, the statistical validity of the proportional recovery rule is examined in the context of recent criticisms regarding its underlying assumptions. Despite 2 recent articles critical of statistical relationships of baseline impairment scores to follow-up scores, especially when used for patient-level predictions, Kundert et al contend that the systematic non-artifactual relationship between initial impairment and motor recovery provides a valid statistical and biologically meaningful model, and that future studies of proportional recovery should use more sophisticated analysis techniques and rigorous methods to assess validity, including comparisons to alternative models.

Randolph J. Nudo, PhD
Editor-in-Chief

1. Prabhakaran, S, Zarahn, E, Riley, C, et alInter-individual variability in the capacity for motor recovery after ischemic stroke. Neurorehabil Neural Repair. 2008;22:6471. doi:10.1177/1545968307305302
Google Scholar | SAGE Journals | ISI

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[BOOK] Intelligent Biomechatronics in Neurorehabilitation – Xiaoling Hu – Google Books

Front Cover
Academic PressOct 19, 2019 – Science – 286 pages

Intelligent Biomechatronics in Neurorehabilitation presents global research and advancements in intelligent biomechatronics and its applications in neurorehabilitation. The book covers our current understanding of coding mechanisms in the nervous system, from the cellular level, to the system level in the design of biological and robotic interfaces. Developed biomechatronic systems are introduced as successful examples to illustrate the fundamental engineering principles in the design. The third part of the book covers the clinical performance of biomechatronic systems in trial studies. Finally, the book introduces achievements in the field and discusses commercialization and clinical challenges.

As the aging population continues to grow, healthcare providers are faced with the challenge of developing long-term rehabilitation for neurological disorders, such as stroke, Alzheimer’s and Parkinson’s diseases. Intelligent biomechatronics provide a seamless interface and real-time interactions with a biological system and the external environment, making them key to automation services.

  • Written by international experts in the rehabilitation and bioinstrumentation industries
  • Covers the current understanding of nervous system coding mechanisms, which are the basis for biological and robotic interfaces
  • Demonstrates and discusses robotic rehabilitation effectiveness and automatic evaluation

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[WEB PAGE] Why include music therapy in a neuro-rehabilitation team?

By Wendy L Magee

Abstract

Interdisciplinary neuro-rehabilitation programmes can be enhanced by including music therapy as music interventions can incorporate a patient’s goals across behavioural domains. Neurologically, music is intrinsically motivating, drives motor function and elicits emotional responses. Incorporating live music delivered by trained and qualified professionals ensures interventions are tailored to patients’ needs and goals, assisting with engagement and adherence to treatment. The evidence for the effects of music therapy in neuro-rehabilitation is reviewed, with reference to a recent Cochrane Review.


Summary

  • Music therapy with neurological populations typically engages the patient in active music-making, with the therapist playing live music and adapting musical components moment-by-moment to both meet patient needs and challenge the patient to reach goals
  • In neuro-rehabilitation, interventions range across song-writing to address psychosocial needs, singing and vocalising exercises to target communication goals, and playing instruments or moving to music to meet motor goals
  • Neurologically, music is intrinsically rewarding and motivating, activating neural networks throughout the brain that influence non-musical behaviours, and resulting in changes to brain structures

Music therapy: what is it and what is involved?

The rationale for including music therapy as part of an interdisciplinary rehabilitation programme may not be immediately obvious: unlike other professions that address function within a more clearly defined domain (e.g. physiotherapy for movement disorders; speech and language therapy for speech/language disorders; psychology for cognitive disorders) music therapy addresses function across domains. As defined, music therapy is the clinical and evidence-based use of music interventions to accomplish individualised goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy programme.1 A common misconception is that music therapy is passive listening to recorded music. However, when delivered by a trained professional, music therapy typically actively engages the patient in live music-making, targeting active health goals, with the therapist adjusting musical parameters (tempo, dynamic, rhythm, pulse, melody, harmony) moment-by-moment in immediate response to the patient’s functioning.

Internationally, professionals trained as music therapists are required to adhere to professional standards and codes of conduct: in the UK, music therapists are registered with the Health and Care Professions Council. Music therapy interventions are distinguishable from recreational activities, as they are individually tailored to the individual, goal directed and planned by a health professional. Interventions vary considerably, even when targeting goals within the one domain (i.e. motor; psychosocial; communication) but fall into two broad categories: active or receptive methods.2 Active methods used in neuro-rehabilitation include: song-writing; music-making using acoustic or digital MIDI instruments; movement to music including gait training to rhythmic music or metronome; and singing or vocalising. Receptive methods include: music listening to live or recorded music; and imagery to music. Dosage for effective music interventions vary widely in terms of the number and frequency of contacts, the duration of individual contacts and course of therapy, and the mode of delivery (individual or group).2 Dosage is dependent on the targeted outcome, stage of rehabilitation and setting, so standard recommendations cannot be made.

Why include music therapy in a neuro-rehabilitation team?

The theoretical rationale for using music in neuro-rehabilitation centres upon music’s innate competencies within humans, its cross-cultural purpose for social bonding across cultures, and its neurological capabilities in both healthy and neurologically damaged populations. Music is a universal phenomenon that exists in all known human societies and is considered distinctive to the human condition.3 Cross-culturally, humans engage in musical activity through singing and instrument playing as part of creative play and within ritual. So music is a familiar, meaningful activity with many inherent associations, even for those who are musically untrained. Music is also a social activity, a medium for engaging with others in meaningful collective practices4 and assists with managing social relationships.3 Thus, it facilitates social bonding and interaction as music-making is rarely a solitary activity. In western societies, music-making is realised through singing in choirs and ritual practices and playing instruments in bands and orchestras. Group singing is conducive to social bonding5 and has been found to be a stress-reducing activity as measured through reductions of adrenocorticotropic hormone,5 cortisol and cortisone.6

However, the strongest argument for including music therapy in neuro-rehabilitation lies in its neurological benefits. Neurologically, music is intrinsically rewarding as it activates brain regions involved in reward, motivation, emotion, and arousal.7 Cortical changes in brain damaged patients during music interventions indicate activation of bilateral networks across the frontal, temporal and parietal lobes, cerebellum and limbic areas, stimulating cognitive, motor, and emotional processes.8-10 When integrated with repetitive rehabilitation exercises and drills, music that is tailored to an individual’s performance can enhance the motivation to sustain engagement and may improve patient mood and enhance motivation.11

Music therapy interventions in neuro-rehabilitation: practice and evidence

Music boosts cognition in the brain damaged patient, with reported effects on arousal, attention, orientation, memory, executive function, spatial neglect, and mental flexibility. For patients with Disorders of Consciousness (DOC), maintaining arousal is a significant problem and can interfere with optimal engagement in rehabilitation. Using music that is salient to the patient has been found to promote behaviours indicative of arousal and selective attention12, increase behavioural responses that indicate discrimination13 and awareness.14 Music therapy within interdisciplinary care may prime patient responsiveness in DOC,15 which is particularly useful when part of co-treatment: a music therapist will play live music that is personally salient to the patient, adjusting musical parameters to help the patient achieve and maintain an optimal state of arousal so as to engage in treatment sessions. Music has also been found to improve orientation for patients in post-traumatic amnesia.16 Following middle cerebral artery stroke, music interventions have been shown to be superior in enhancing cognitive recovery, more specifically verbal memory and focused attention, when compared to a language intervention (patient selected audio book listening) or a control condition (standard rehabilitation).8 Similar results have been found with mild traumatic brain injury patients, where music training in the form of eight weeks of piano tuition resulted in significantly improved results in executive functions related to attention, learning strategies and memory retrieval.17 Thus, music interventions have demonstrated positive effects across the spectrum of brain damage.

Of all behavioural domains with neurological populations, the strongest evidence for music interventions is with motor disorders. Motor regions within the cortex are sensitive to and driven by auditory stimuli as the auditory system processes temporal information rapidly and precisely, creating entrainment between a rhythmic signal and movement.18 In healthy subjects, movement to music results in superior physical performance: running for longer, lower perceived exertion, and slower exhaustion.19 These beneficial effects are increased when agency is incorporated into a workout, that is, that the physical movements result in musical sounds.20 These observations support the growing body of research examining the influence of music with a strong beat on gait disorders and upper limb function in adults with stroke and acquired brain injury. A Cochrane Review examined the effects of rhythmic auditory stimulation (RAS) on gait velocity, cadence, stride length, stride symmetry, gait and balance.2 RAS is a therapeutic intervention using rhythmic pulse to improve gait or gait related aspects of movement. Using live music, the therapist can embed the rhythmic pulse into the music for the patient to move to, or a metronome alone can be used. Based on 10 randomised controlled studies (n=298) the meta-analysis found beneficial effects for RAS on gait velocity, stride length, gait cadence and general gait in people with stroke, although the degree of improvement across studies was inconsistent.2 Subgroup analyses indicated that RAS interventions using live music with the beat embedded in the music may be more effective than using a metronome alone in addressing gait velocity and cadence. These findings highlight that although RAS can be implemented within interdisciplinary rehabilitation by non-music professionals using a metronome, the inclusion of a music therapist in the rehabilitation team using live music may enhance the intervention’s benefits. Music provides an intrinsic motivational reward, and using live music enables components (such as tempo, dynamic tension, harmonic tension and resolution, melodic direction) to be adapted in the moment to the patient’s movements, driving these movements to goal attainment.

Music interventions are used to rehabilitate upper limb function following stroke, measuring outcomes such as timing of movement, strength, hand function, manual dexterity, range of motion and elbow extension angle2 and often in co-treatment with occupational therapists. Interventions typically involve the patient playing strategically placed musical instruments in live music making: the therapist commonly manipulates rhythm and tempo in the accompanying music to guide the patient’s movements, but harmonic and melodic tensions are also used. A number of studies have examined neural reorganisation during these interventions, noting coupling between the motor and auditory cortices.11 The benefits for involving music therapy in team treatment include motivation and adherence to treatment of motor disorders.21

Communication outcomes are frequently targeted with music following stroke and traumatic brain injury, as it has long been noted that people with severe non-fluent aphasia have greater success when singing lyrics than speaking the same words.10 Although speech and music are neurologically distinct, they share pitch, timing and timbre cues to convey information at an acoustic level and at a cognitive level both demand complex cognitive skills: memory, attention, and the ability to integrate acoustic events and perceive these according to rules of syntax are required by both.22 Music, like language, has structural rules for production suggesting a deep connection between the two within the brain. Intensive music interventions to address language production with people with severe non-fluent aphasia have resulted in neuroplastic changes to connections across brain regions.10 The acts of speech and singing additionally share musculature for respiration, phonation, articulation and resonance.23 Music therapy interventions address communication goals through singing and vocalising, often in co-treatment with speech and language therapists. Singing interventions address non-fluent aphasia, dysarthria, dyspraxia, dysprosody and dysphonia measuring outcomes such as words produced, speech intensity, naturalness and intelligibility, rate control, articulation, phonation and prosody.2,24 Melodic intonation therapy is an intervention frequently used to target language production in expressive aphasia, engaging right-hemispheric structures through tapping of the left hand and intoning words in a melodic contour that imitates speech prosody.10 Numerous case reports describe the benefits of a number of music interventions to improve communication, supported to some extent in research suggesting benefits to overall communication, naming and repetition.2 Further research would consolidate these findings and improve the widely varying protocols that have been reported.

Lastly, music therapy interventions are reported to improve psychosocial functions such as behavioural outcomes, emotional needs, mood, well-being, social skills and quality of life.2 Psychosocial sequelae are integrally related following brain injury: communication or behavioural difficulties impact upon social relationships, risking feelings of isolation and depressed mood, reducing quality of life. Music therapy can reduce agitation in patients with post-traumatic amnesia.16 The intersectional nature of psychosocial subdomains can be addressed through therapeutic music-making as a meaningful social experience that enhances social bonding3 and stimulates emotional experiences. Music therapy will typically use active music interventions such as song-writing, improvisation and song-singing to address mood, identity reconstruction and emotional expression in neuro-rehabilitation.2 These can be powerful interventions when delivered in groups and may also incorporate members of the patient’s social support network. Individually tailored music listening programmes in the acute recovery phase post-stroke have resulted in less depressed and confused mood states than standard rehabilitation.8 More research is needed examining the effects of music interventions on all aspects of psychosocial functioning.

Conclusions

Music provides a familiar salient stimulus that activates widespread neural activity and has the potential to be harnessed to improve functioning across all the behavioural domains, including motor, cognition, communication and psychosocial. Thus, music therapy is well-placed as an intervention in neuro-rehabilitation. Music is also ubiquitous and easily accessible with the swipe of a screen, but its use is not without risk, particularly the possibility of triggering strong emotional reactions. The application of music interventions in neuro-rehabilitation thus requires planned and careful application with vulnerable populations by professionals trained in its use.

References

  1. American Music Therapy Association. Definition and Quotes about Music Therapy [Internet]. Silver Spring MD: American Music Therapy Association; n.d. [cited 2019 July 15]. Available from https://www.musictherapy.org/about/quotes/https://www.musictherapy.org/about/quotes/ .
  2. Magee WL, Clark I, Tamplin J, Bradt J. Music interventions for acquired brain injury. Cochrane Database of Systematic Reviews. 2017(1). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006787.pub3/abstract
  3. Trehub SE, Becker J, Morley I. Cross-cultural perspectives on music and musicality. Philosophical Transactions of the Royal Society B: Biological Sciences. 2015 Mar 19;370(1664):20140096. https://royalsocietypublishing.org/doi/full/10.1098/rstb.2014.0096
  4. Dissanayake E. An ethological view of music and its relevance to music therapy. Nordic Journal of Music Therapy. 2001 Jul 1;10(2):159-75. https://www.tandfonline.com/doi/abs/10.1080/08098130109478029
  5. Keeler JR., Roth EA, Neuser BL, Spitsbergen JM, Waters DJM, Vianney JM. (2015). The neurochemistry and social flow of singing: bonding and oxytocin. Frontiers in human neuroscience. 2015;9:18.
  6. Fancourt D, Aufegger L, Williamon A. Low-stress and high-stress singing have contrasting effects on glucocorticoid response. Frontiers in psychology. 2015:6;1242.
  7. Blood AJ, Zatorre RJ. Intensely pleasurable responses to music correlate with activity in brain regions implicated in reward and emotion. Proceedings of the National Academy of Sciences. 2001 Sep 25;98(20):11818-23.
  8. Särkämö T, Tervaniemi M, Laitinen S, Forsblom A, Soinila S, Mikkonen M, Autti T, Silvennoinen HM, Erkkilä J, Laine M, Peretz I. Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain. 2008 Feb 20;131(3):866-76. https://academic.oup.com/brain/article/131/3/866/318687
  9. Särkämö T, Tervaniemi M, Huotilainen M. Music perception and cognition: development, neural basis, and rehabilitative use of music. Wiley Interdisciplinary Reviews: Cognitive Science. 2013 Jul;4(4):441-51.
  10. Schlaug G, Norton A, Marchina S, Zipse L, Wan CY. From singing to speaking: facilitating recovery from nonfluent aphasia. Future neurology. 2010;5(5):657-65.
  11. Street AJ, Magee WL, Odell-Miller H, Bateman A, Fachner JC. Home-based neurologic music therapy for upper limb rehabilitation with stroke patients at community rehabilitation stage—a feasibility study protocol. Frontiers in human neuroscience. 2015;23;9:480. https://www.frontiersin.org/articles/10.3389/fnhum.2015.00480/full
  12. O’Kelly J, James L, Palaniappan R, Fachner J, Taborin J, Magee WL. Neurophysiological and behavioral responses to music therapy in vegetative and minimally conscious states. Frontiers in Human Neuroscience. 2013;25:7:884.
  13. Castro M, Tillmann B, Luauté J, Corneyllie A, Dailler F, André-Obadia N, Perrin F. Boosting cognition with music in patients with disorders of consciousness. Neurorehabilitation and neural repair. 2015;29;(8):734-42.
  14. Verger J, Ruiz S, Tillmann B, Ben MR, De MQ, Castro M, Tell L, Luauté J, Perrin F. Beneficial effect of preferred music on cognitive functions in minimally conscious state patients. Revue neurologique. 2014;170(11):693-9.
  15. Magee WL. Music in the diagnosis, treatment and prognosis of people with prolonged disorders of consciousness. Neuropsychological rehabilitation. 2018;17;28(8):1331-9.
  16. Baker F. The effects of live, taped, and no music on people experiencing posttraumatic amnesia. Journal of Music Therapy. 2001;38(3):170-92.
  17. Vik BM, Skeie GO, Vikane E, Specht K. Effects of music production on cortical plasticity within cognitive rehabilitation of patients with mild traumatic brain injury. Brain injury. 2018;16;32(5):634-43. https://www.tandfonline.com/doi/full/10.1080/02699052.2018.1431842
  18. Thaut MH, Abiru M. Rhythmic auditory stimulation in rehabilitation of movement disorders: a review of current research. Music Perception: An Interdisciplinary Journal. 2010;1;27(4):263-9.
  19. Terry PC, Karageorghis CI, Saha AM, D’Auria S. Effects of synchronous music on treadmill running among elite triathletes. Journal of Science and Medicine in Sport. 2012;1;15(1):52-7.
  20. Fritz TH, Hardikar S, Demoucron M, Niessen M, Demey M, Giot O, Li Y, Haynes JD, Villringer A, Leman M. Musical agency reduces perceived exertion during strenuous physical performance. Proceedings of the National Academy of Sciences. 2013;29;110(44):17784-9.
  21. Street AJ, Magee WL, Bateman A, Parker M, Odell-Miller H, Fachner J. Home-based neurologic music therapy for arm hemiparesis following stroke: results from a pilot, feasibility randomized controlled trial. Clinical rehabilitation. 2018;32(1):18. https://journals.sagepub.com/doi/full/10.1177/0269215517717060
  22. Kraus N, Chandrasekaran B. Music training for the development of auditory skills. Nature reviews neuroscience. 2010;11(8):599.
  23. Wan CY, Rüüber T, Hohmann A, Schlaug G. The therapeutic effects of singing in neurological disorders. Music perception: An interdisciplinary journal. 2010;1;27(4):287-95.
  24. Tamplin J, Baker FA. Therapeutic singing protocols for addressing acquired and degenerative speech disorders in adults. Music Therapy Perspectives. 2017;17;35(2):113-23.

Wendy L Magee, PhD, is a Music Therapist Clinician and Researcher, working with adults with complex needs from acquired brain injury and neuro-degenerative disorders since 1988. Her published research covers: evidence-based music interventions in neuro-rehabilitation including a Cochrane Review; measurement; Disorders of Consciousness; identity following disability; and new and emerging music technologies in healthcare.

via Why include music therapy in a neuro-rehabilitation team? | ACNR | Online Neurology Journal

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[REVIEW] Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls – Full Text

Acute brain ischemia causes changes in several neural networks and related cortico-subcortical excitability, both in the affected area and in the apparently spared contralateral hemisphere. The modulation of these processes through modern techniques of noninvasive brain stimulation, namely repetitive transcranial magnetic stimulation (rTMS), has been proposed as a viable intervention that could promote post-stroke clinical recovery and functional independence. This review provides a comprehensive summary of the current evidence from the literature on the efficacy of rTMS applied to different clinical and rehabilitative aspects of stroke patients. A total of 32 meta-analyses published until July 2019 were selected, focusing on the effects on motor function, manual dexterity, walking and balance, spasticity, dysphagia, aphasia, unilateral neglect, depression, and cognitive function after a stroke. Only conventional rTMS protocols were considered in this review, and meta-analyses focusing on theta burst stimulation only were excluded. Overall, both HF-rTMS and LF-rTMS have been shown to be safe and well-tolerated. In addition, the current literature converges on the positive effect of rTMS in the rehabilitation of all clinical manifestations of stroke, except for spasticity and cognitive impairment, where definitive evidence of efficacy cannot be drawn. However, routine use of a specific paradigm of stimulation cannot be recommended yet due to a significant level of heterogeneity of the studies in terms of protocols to be set and outcome measures that have to be used. Future studies need to preliminarily evaluate the most promising protocols before going on to multicenter studies with large cohorts of patients in order to achieve a definitive translation into daily clinical practice.

Background

Stroke is a common acute neurovascular disorder that causes disabling long-term limitations to daily living activities. The most common consequence of a stroke is motor deficit of variable degree,1 although nonmotor symptoms are also relevant and often equally disabling.2 To date, to the best of the authors’ knowledge, there is no validated treatment that is able to restore the impaired functions by a complete recovery of the damaged tissue. Indeed, stroke management basically consists of reducing the initial ischemia in the penumbra, preventing future complications, and promoting a functional recovery using physiotherapy, speech therapy, occupational therapy, and other conventional treatments.3,4

Ischemic damage is associated with significant metabolic and electrophysiological changes in cells and neural networks involved in the affected area. From a pure electrophysiological perspective, however, beyond the affected area, there is a local shift in the balance between the inhibition and excitation of both the affected and contralateral hemisphere, consisting of increased excitability and disinhibition (reduced activity of the inhibitory circuits).3,5 In addition, subcortical areas and spinal regions may be altered.3,5 In particular, the role of the uninjured hemisphere seems to be of utmost significance in post-stroke clinical and functional recovery.

Different theoretical models have been proposed to explain the adaptive response of the brain to acute vascular damage. According to the vicariation model, the activity of the unaffected hemisphere contributes to the functional recovery after a stroke through the replacement of the lost functions of the affected areas. The interhemispheric competition model considers the presence of mutual inhibition between the hemispheres, and the damage caused by a stroke disrupts this balance, thus producing a reduced inhibition of the unaffected hemisphere by the affected side. This results in increased inhibition of the affected hemisphere by the unaffected side. More recently, a new model, called bimodal balance recovery, has been proposed.3,5 It introduces the concept of a structural reserve, which describes the extent to which the nondamaged neural pathways contribute to the clinical recovery. The structural reserve determines the prevalence of the interhemispheric imbalance over vicariation. When the structural reserve is high, the interhemispheric competition model can predict the recovery better than the vicariation model, and vice versa.3

Repetitive transcranial magnetic stimulation

One of the proposed interventions to improve stroke recovery, by the induction of neuromodulation phenomena, is based on methods of noninvasive brain stimulation. Among them, transcranial magnetic stimulation (TMS) is a feasible and painless neurophysiological technique widely used for diagnostic, prognostic, research, and, when applied repetitively, therapeutic purposes.69 By electromagnetic induction, TMS generates sub or suprathreshold currents in the human cortex in vivo and in real time.10,11

The most common stimulation site is the primary motor cortex (M1), that generates motor evoked potentials (MEPs) recorded from the contralateral muscles through surface electromyography electrodes.11 The intensity of TMS, measured as a percentage of the maximal output of the stimulator, is tailored to each patient based on the motor threshold (MT) of excitability. Resting MT (rMT) is found when the target muscle is at rest, it is defined as the minimal intensity of M1 stimulation required to elicit an electromyography response with a peak-to-peak amplitude > 50 µV in at least 5 out of 10 consecutive trials.11 Alternatively TMS MTAT 2.0 software (http://www.clinicalresearcher.org/software.htm) is a free tool for TMS researchers and practitioners. It provides four adaptive methods based on threshold-tracking algorithms with the parameter estimation by sequential testing, using the maximum-likelihood strategy for estimating MTs. Active MT (aMT) is obtained during a tonic contraction of the target muscle at approximately 20% of the maximal muscular strength.11

The rMT is considered a basic parameter in providing the global excitation state of a central core of M1 neurons.11 Accordingly, rMT is increased by drugs blocking the voltage-gated sodium channels, where the same drugs may not have an effect on the gamma-aminobutyric acid (GABA)-ergic functions. In contrast, rMT is reduced by drugs increasing glutamatergic transmission not mediated by the N-methyl-D-aspartate (NMDA) receptors, suggesting that rMT reflects both neuronal membrane excitability and non-NMDA receptor glutamatergic neurotransmission.12 Finally, the MT increases, being often undetectable, when a substantial portion of M1 or the cortico-spinal tract is damaged (i.e. by stroke or motor neuron disease), and decreases when the motor pathway is hyperexcitable (such as epilepsy).13

Repetitive (rTMS) is a specific stimulation paradigm characterized by the administration of a sequence of consecutive stimuli on the same cortical region, at different frequencies and inter sequence intervals. As known, rTMS can transiently modulate the excitability of the stimulated cortex, with both local and remote effects outlasting the stimulation period. Conventional rTMS modalities include high-frequency (HF-rTMS) stimulation (>1 Hz) and low-frequency (LF-rTMS) stimulation (⩽1 Hz).11 High-frequency stimulation typically increases motor cortex excitability of the stimulated area, whereas low-frequency stimulation usually produces a decrease in excitability.14 The mechanisms by which rTMS modulates the brain are rather complex, although they seem to be related to the phenomena of long-term potentiation (LTP) and long-term depression (LTD).15

When applied after a stroke, rTMS should ideally be able to suppress the so called ‘maladaptive plasticity’16,17 or to enhance the adaptive plasticity during rehabilitation. These goals can be achieved by modulating the local cortical excitability or modifying connectivity within the neuronal networks.10

rTMS in stroke rehabilitation: an overview

According to the latest International Federation of Clinical Neurophysiology (IFCN) guidelines on the therapeutic use of rTMS,10 there is a possible effect of LF-rTMS of the contralesional motor cortex in post-acute motor stroke, and a probable effect in chronic motor stroke. An effect of HF-rTMS on the ipsilesional motor cortex in post-acute and chronic motor stroke is also possible.

The potential role of rTMS in gross motor function recovery after a stroke has been assessed in a recent comprehensive systematic review of 70 studies by Dionisio and colleagues.18 The majority of the publications reviewed report a role of rTMS in improving motor function, although some randomized controlled trials (RCTs) were not able to confirm this result,1923 as shown by a recent large randomized, sham-controlled, clinical trial of navigated LF-rTMS.24 It has also been suggested that rTMS can specifically improve manual dexterity,10 which is defined as the ability to coordinate the fingers and efficiently manipulate objects, and is of crucial importance for daily living activities.25 Notably, most of the studies focused on motor impairment in the upper limbs, whereas limited data is available on the lower limbs.18 Walking and balance are frequently impaired in stroke patients and significantly affect the quality of life (QoL),26,27 and rTMS might represent a valid aid in the recovery of these functions.28,29 Spasticity is another common complication after a stroke, consisting of a velocity-dependent increase of muscular tone,30 and for which rTMS has been proposed as a rehabilitation tool.31

Dysphagia is highly common in stroke patients, it impairs the global clinical recovery, and predisposes to complications.32 It has been pointed out that rTMS targeting the M1 area representing the muscles involved in swallowing may contribute to the treatment of post-stroke dysphagia.33

Nonmotor deficit is also a relevant post-stroke disability that negatively impacts the QoL. Aphasia is a very common consequence of stroke, affecting approximately 30% of stroke survivors and significantly limiting rehabilitation.34 According to the IFCN guidelines, to date, there is no recommendation for LF-rTMS of the contralesional right inferior frontal gyrus (IFG). Similarly, no recommendation for HF-rTMS or intermittent theta burst stimulation (TBS) of the ipsilesional left IFG or dorsolateral prefrontal cortex (DLPFC) in Broca’s aphasia has been currently approved.10 The same is true for LF-rTMS of the right superior temporal gyrus in Wernicke’s aphasia.10

Neglect is the incapacity to respond to tactile or visual contralateral stimuli that are not caused by a sensory-motor deficit.35 Although hard to treat, rTMS has been proposed as a tool for neglect rehabilitation.36 However, the IFCN guidelines state that currently there is no recommendation for LF-rTMS of the contralesional left posterior parietal cortex, or for HF-rTMS of the ipsilesional right posterior parietal cortex.10 In a recent systematic review, most of the included studies supported the use of TMS for the rehabilitation of aphasia, dysphagia, and neglect, although the heterogeneity of stimulation protocols did not allow definitive conclusions to be drawn.37

Post-stroke depression is a relevant complication of cerebrovascular diseases.38 The role of rTMS in the management of major depressive disorders is well documented,39,40 and currently, rTMS is internationally approved and indicated for the treatment of major depression in adults with antidepressant medication resistance, and in those with a recurrent course of illness, or in cases of moderate-to-severe disease severity.39 In major depression disorders, according to the IFCN guidelines, there is a clear antidepressant effect of HF-rTMS over the left DLPFC, a probable antidepressant effect of LF-rTMS on the right DLPFC, and probably no differential antidepressant effect between right LF-rTMS and left HF-rTMS. Moreover, there is currently no recommendation for bilateral stimulation combining HF-rTMS of the left DLPFC and LF-rTMS of the right DLPFC. The mentioned guidelines also state that the antidepressant effect when stimulating DLPFC is probably additive, and possibly potentiating, to the efficacy of antidepressant drugs.10 However, no specific recommendation currently addresses the use of rTMS in post-stroke depression. Recently, rTMS has been proposed as a treatment option for the late-life depression associated with chronic subcortical ischemic vascular disease, the so called ‘vascular depression’.4144 Three studies tested rTMS efficacy in vascular depression (one was a follow-up study with citalopram). Although presenting positive findings, further trials should refine clinical and diagnostic criteria to assess its impact on antidepressant efficacy.45

Approximately 25–30% of stroke patients develop an immediate or delayed cognitive impairment or an overt picture of vascular dementia.46 There is evidence of an overall positive effect on cognitive function for both LF-rTMS47 and HF-rTMS,48 supported by studies on experimental models of vascular dementia.4952 Nonetheless, the few trials examining the effect on stroke-related cognitive deficit produced mixed results.5356 In particular, two studies found no effect on cognition when stimulating the left DLPFC at 1 Hz and 10 Hz,53,54 whereas a pilot study found a positive effect on the Stroop interference test with HF-rTMS over the left DLPFC in patients with vascular cognitive impairment without dementia.55 However, this finding was not replicated in a follow-up study.56 To summarize, rTMS can induce beneficial effects on specific cognitive domains, although data are limited and their clinical significance needs to be further validated. Major challenges exist in terms of appropriate patient selection and optimization of the stimulation protocols.57

Central post-stroke pain (CPSP) is the pain resulting from an ischemic lesion of the central nervous system.58 It represents a relatively common complication after a stroke, although it is often under-recognized and, therefore, undertreated.59 According to the IFCN guidelines for the use of rTMS in the treatment of neuropathic pain, there is a definite analgesic effect of HF-rTMS of contralateral M1 to the pain side, and LF-rTMS of contralateral M1 to the pain side is probably ineffective. In addition, there is currently no recommendation for cortical targets other than contralateral M1 to the pain side.10 Notably, rTMS might be effective in drug-resistant CPSP patients.58 A recent systematic review that included nine HF-rTMS studies suggested an effect on CPSP relief, but also underlined the insufficient quality of the studies considered.60

Study objective

In this article, we aim to provide an up-to-date overview of the most recent evidence on the efficacy of rTMS in the rehabilitation of stroke patients. Although several studies have been published, a conclusive statement supporting a systematic use of rTMS in the multifaceted clinical aspects of stroke rehabilitation is still lacking.

[…]

 

Continue —> Repetitive transcranial magnetic stimulation in stroke rehabilitation: review of the current evidence and pitfalls – Francesco Fisicaro, Giuseppe Lanza, Alfio Antonio Grasso, Giovanni Pennisi, Rita Bella, Walter Paulus, Manuela Pennisi, 2019

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[WEB PAGE] Ekso Bionics Unveils the EksoNR Neurorehabilitation Device

EksoNR, the latest exoskeleton from Ekso Bionics, features EksoView, a new touchscreen controller that allows therapists to intuitively adapt assistance to challenge patients using real-time feedback. (Photo courtesy of Ekso Bionics Holdings Inc)

EksoNR, the latest exoskeleton from Ekso Bionics, features EksoView, a new touchscreen controller that allows therapists to intuitively adapt assistance to challenge patients using real-time feedback. (Photo courtesy of Ekso Bionics Holdings Inc)

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The EksoNR is a next-generation EksoGT exoskeleton device developed by Ekso Bionics Holdings Inc to aid the neurorehabilitation of patients recovering from stroke and spinal cord injury, and to help them learn to walk again with a more natural gait.

Among the EksoNR’s new features and enhancements is EksoView, a new touchscreen controller that allows therapists to intuitively adapt assistance to challenge patients using real-time feedback and perform outcome measures during use.

Held in the palm of a therapists’ hand, EksoView provides visualization of various exercises beyond gait training, such as balancing, squatting from sit-to-stand positioning, lifting one leg, or standing in place, to actively engage patients and enhance the use of these beneficial features.

Another feature is the optimized SmartAssist software, developed to enable EksoNR to have a smoother and more natural gait path when transitioning between steps.

SmartAssist also gives gait symmetry and posture feedback and allows therapists to track patient progress with the upgraded EksoPulse, a cloud-based analytics solution. EksoPulse now uses rehabilitation data to generate insightful metrics and graphs for therapists and administrators to monitor patient progress and outcomes, Ekso Bionics notes in a media release.

“Ekso Bionics is committed to developing the latest exoskeleton advances for rehabilitation. We continue to innovate to ensure physical therapists have access to the latest tools to deliver better patient outcomes and superior care in neurorehabilitation,” says Jack Peurach, chief executive officer and president of Ekso Bionics, in the release.

“EksoNR is a full neurorehabilitation tool that is effective, intuitive, and differentiating. There is an increasing demand for adoption, as our technology sets rehabilitation centers apart,” he adds.

EksoNR is cleared by the US Federal Drug Administration for stroke and spinal cord injury rehabilitation. The device is also CE-marked and available in Europe.

Ekso Bionics will begin taking orders for EksoNR immediately. Existing customers will have the option to upgrade, the release continues.

[Source: Ekso Bionics]

 

via Ekso Bionics Unveils the EksoNR Neurorehabilitation Device – Rehab Managment

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