Posts Tagged Neurorehabilitation

[Abstract] Brain-Machine Interface in Chronic Stroke: Randomized Trial Long-Term Follow-up

Background. Brain-machine interfaces (BMIs) have been recently proposed as a new tool to induce functional recovery in stroke patients.

Objective. Here we evaluated long-term effects of BMI training and physiotherapy in motor function of severely paralyzed chronic stroke patients 6 months after intervention.

Methods. A total of 30 chronic stroke patients with severe hand paresis from our previous study were invited, and 28 underwent follow-up assessments. BMI training included voluntary desynchronization of ipsilesional EEG-sensorimotor rhythms triggering paretic upper-limb movements via robotic orthoses (experimental group, n = 16) or random orthoses movements (sham group, n = 12). Both groups received identical physiotherapy following BMI sessions and a home-based training program after intervention. Upper-limb motor assessment scores, electromyography (EMG), and functional magnetic resonance imaging (fMRI) were assessed before (Pre), immediately after (Post1), and 6 months after intervention (Post2).

Results. The experimental group presented with upper-limb Fugl-Meyer assessment (cFMA) scores significantly higher in Post2 (13.44 ± 1.96) as compared with the Pre session (11.16 ± 1.73; P = .015) and no significant changes between Post1 and Post2 sessions. The Sham group showed no significant changes on cFMA scores. Ashworth scores and EMG activity in both groups increased from Post1 to Post2. Moreover, fMRI-BOLD laterality index showed no significant difference from Pre or Post1 to Post2 sessions.

Conclusions. BMI-based rehabilitation promotes long-lasting improvements in motor function of chronic stroke patients with severe paresis and represents a promising strategy in severe stroke neurorehabilitation.


via Brain-Machine Interface in Chronic Stroke: Randomized Trial Long-Term Follow-up – Ander Ramos-Murguialday, Marco R. Curado, Doris Broetz, Özge Yilmaz, Fabricio L. Brasil, Giulia Liberati, Eliana Garcia-Cossio, Woosang Cho, Andrea Caria, Leonardo G. Cohen, Niels Birbaumer, 2019

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[ARTICLE] Effect of a four-week virtual reality-based training versus conventional therapy on upper limb motor function after stroke: A multicenter parallel group randomized trial – Full Text



Virtual reality-based training has found increasing use in neurorehabilitation to improve upper limb training and facilitate motor recovery.


The aim of this study was to directly compare virtual reality-based training with conventional therapy.


In a multi-center, parallel-group randomized controlled trial, patients at least 6 months after stroke onset were allocated either to an experimental group (virtual reality-based training) or a control group receiving conventional therapy (16×45 minutes within 4 weeks). The virtual reality-based training system replicated patients´ upper limb movements in real-time to manipulate virtual objects.

Blinded assessors tested patients twice before, once during, and twice after the intervention up to 2-month follow-up for dexterity (primary outcome: Box and Block Test), bimanual upper limb function (Chedoke-McMaster Arm and Hand Activity Inventory), and subjective perceived changes (Stroke Impact Scale).


54 eligible patients (70 screened) participated (15 females, mean age 61.3 years, range 20–81 years, time since stroke 3.0±SD 3 years). 22 patients were allocated to the experimental group and 32 to the control group (3 drop-outs). Patients in the experimental and control group improved: Box and Block Test mean 21.5±SD 16 baseline to mean 24.1±SD 17 follow-up; Chedoke-McMaster Arm and Hand Activity Inventory mean 66.0±SD 21 baseline to mean 70.2±SD 19 follow-up. An intention-to-treat analysis found no between-group differences.


Patients in the experimental and control group showed similar effects, with most improvements occurring in the first two weeks and persisting until the end of the two-month follow-up period. The study population had moderate to severely impaired motor function at entry (Box and Block Test mean 21.5±SD 16). Patients, who were less impaired (Box and Block Test range 18 to 72) showed higher improvements in favor of the experimental group. This result could suggest that virtual reality-based training might be more applicable for such patients than for more severely impaired patients.


Virtual reality-based rehabilitation systems are gaining popularity because of their ease of use, applicability to wide range of patients, and ability to provide patient-personalized training []. Additional reported benefits of virtual reality systems for both patients and health providers include increased therapy efficiency and a high level of attention in patients during training [].

One of the main struggles therapists encounter is keeping patients motivated throughout conventional training sessions. The Yerkes-Dodson Law describes the relationship between arousal or motivation and performance []. At first, an increase in arousal and motivation leads to an increase in performance. But once a certain point is reached, this point can vary based on many factors including the task, the participant, and the context, the relationship becomes inverse and increases in arousal caused decreases in performance. In line with these ideas, previous research has shown that increased performance leads to greater improvement in patients after stroke up to a certain point. Virtual reality-based systems allow manipulation of arousal through training settings to ensure that peak performance is maintained for as large a portion of the therapy time as possible [].

Laver et al. systematically evaluated the literature regarding the efficacy of virtual reality-based training in stroke rehabilitation in 2011 and in its updates in 2015 and 2017 []. Their current meta-analysis of 22 trials including 1038 patients after stroke that focused on upper limb function did not reveal a statistically significant difference between VR-based training and conventional therapy (0.07 standard deviation higher in virtual reality-based compared to conventional therapy. Furthermore, the authors rated the quality of evidence as low, based on the GRADE system. However, for ADL function the experimental groups showed a 0.25 higher standard deviation than the conventional therapy groups based on ten studies, including 466 patients after a stroke with moderate quality of evidence.

Only 10% of the included studies included more than 50 participants, with mean ages between 46 to 76 years. However, due to the different systems used no conclusion could be drawn regarding grip strength, dosage, type or program of the virtual reality-based training. Furthermore, the authors pointed out the low sample sizes and the low methodological quality of the reported trials. In their recommendations for further research, the authors encouraged researchers and clinicians again to conduct larger trials and to increase the detail in reporting to enable more firm conclusions.

YouGrabber (now renamed Bi-Manu Trainer), a game-based virtual reality system designed for upper-limb rehabilitation, has been shown to be effective in children with cerebral palsy. A 2-subject feasibility study indicated that the findings might extend to chronic stroke patients []. Both male subjects, who were trained three years after insult onset, showed increases in scores for the bimanual activities of daily living focused Chedoke McMaster Arm and Hand Activity Inventory (CAHAI) that persisted at the final follow-up, and corresponding cortical changes measured with fMRI.

Based on these findings the present multicenter parallel group randomized single-blinded trial aimed to investigate the efficacy of a virtual reality-based training with the YouGrabber training device (now renamed Bi-Manu Trainer) compared to conventional therapy. The study was designed to test the hypothesis that patients in the chronic stage after stroke in the virtual reality-based training group will show no higher post-intervention performance in the Box and Block Test (BBT) compared to patients receiving an equal training time of physiotherapy or occupational therapy.

For comparison with published and ongoing international studies we selected the Box and Block Test as the primary outcome measure and the CAHAI as the secondary outcome measure.

Methods and materials

Study design

This prospective, multicenter, single-blinded, parallel-group randomized trial was conducted in the outpatient departments of three rehabilitation hospitals in the German and French speaking parts of Switzerland: University hospital Inselspital Bern, Buergerspital Solothurn, and Reha Rheinfelden. In the study plan, each hospital was responsible for the recruitment, assessment, and therapy of 20 patients: 10 patients for the experimental group (EG) and 10 for the control group (CG), respectively.

More details regarding the study methodology can be found in the study flow chart in Fig 1 and the previously published study protocol strictly followed by each center ( []. Ethics approval was warranted by the ethics committee of the Canton Aargau (2012/065) and the Canton Berne (220/12). The study was registered with NCT01774669 before the start of patient recruitment.

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Fig 1
Patient flow chart.BS = Buergerspital Solothurn, IS = Inselspital Bern, Reha Rheinfelden Measurement sessions: twice within one to two weeks before intervention start (BL, T0), once after eight (T1) and after 16 (T2) intervention sessions, and after a two months follow-up period (FU).


Continue —> Effect of a four-week virtual reality-based training versus conventional therapy on upper limb motor function after stroke: A multicenter parallel group randomized trial

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[WEB SITE] FDA Approves MindMotion GO, Mobile Neurorehabilitation Product

The US Food and Drug Administration (FDA) has granted clearance to MindMotion GO, a portable neurorehabilitation product, for launch in the United States.

MindMotion GO utilizes technology that is designed to be used by patients with mild to lightly severe neurological impairments, as well as in the recovery phase of rehabilitation. Produced by the Swiss neurogaming company MindMaze, the mobile rehabilitation product is an outpatient addition to its MindMotion PRO, which received FDA approval in May 2017.

The PRO version differs from the recently approved MindMotion GO in that it is intended for use in patients with severe impairments as well as in early hospital care—in an inpatient setting—with therapeutic activities able to take place within 4 days after a neurological incident.

“Now that both MindMotion products have FDA clearance, MindMaze delivers a full spectrum of neuro-care solutions for both inpatient and outpatient recovery for patients in the United States,” said Tej Tadi, PhD, the CEO and founder of MindMaze, in a statement. “Our unique capability to safely and securely acquire data through our platform is essential for patient recovery and performance, and positions MindMaze as a powerhouse for the future of brain-machine interfaces. Beyond healthcare, this will enable powerful AI-based applications. We are working on a range of brain-tech initiatives at MindMaze to build the infrastructure for innovations to improve patients’ quality of life.”

The mobile MindMotion GO allows for real-time audio and visual feedback, aiding physicians in the assessment of progress and tailoring of therapy to their individual patient’s performance, according to MindMaze. Additionally, it enables the patients to see their progress as well. The set-up and calibration can be done in less than 5 minutes, so patients can begin rehabilitation sessions while physicians facilitate case management.

The program is equipped with a variety of gamified engaging activities which cover motor and task functions and includes a 3D virtual environment. As a result, early findings have suggested that both patient engagement and adherence to therapy have been amplified. Thus far, MindMotion GO has been trialed with upward of 300 patients across therapy centers in the UK, Italy, Germany, and Switzerland.

Neurological impairments are the main cause of long-term disability in the United States, with a recent study estimating direct and indirect costs associated with neurological diseases cost roughly $800 billion annually. For stroke alone, there are almost 800,000 cases each year, with direct annual costs estimated at $22.8 billion.

MindMaze’s Continuum of Care seeks to support earlier, and ongoing, intervention to enable by healthcare providers in the United States to have access to a cost-effective solution for improving neurorehabilitation results.

Even more resources pertaining to stroke prevention and care can be found on MD Magazine‘s new sister site, NeurologyLive.

via FDA Approves MindMotion GO, Mobile Neurorehabilitation Product | MD Magazine

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[Systematic Review] Effects of extracorporeal shock wave therapy on spasticity in post-stroke patients: A systematic review and meta-analysis of randomized controlled trials – Full Text


Objective: To evaluate whether extracorporeal shock wave therapy significantly improves spasticity in post-stroke patients.

Design: Systematic review and meta-analysis.

Data sources: PubMed, EMBASE, EBSCO, Web of Science, Cochrane CENTRAL electronic databases.

Study selection: Randomized controlled trials assessing the effect of extracorporeal shock wave therapy on post-stroke patients with spasticity were selected for inclusion.

Data extraction: Two authors independently screened the literature, extracted data, and assessed the quality of included studies. Primary outcome was modified Ashworth scale (MAS). Secondary outcomes were Modified Tardieu Scale (MTS), H/M ratio and range of motion.

Data synthesis: Eight randomized controlled trial studies (n = 385 patients) were included in the meta-analysis. There was a high level of evidence that extracorporeal shock wave therapy significantly ameliorates spasticity in post-stroke patients according to the 4 parameters: MAS (standard mean difference (SMD) −1.22; 95% confidence interval (95% CI): −1.77 to −0.66); MTS (SMD 0.70; 95% CI 0.42–0.99,); H/M ratio (weighted mean difference (WMD) –0.76; 95% CI –1.19 to –0.33); range of motion (SMD 0.69; 95% CI 0.06–1.32). However, there was no statically significant difference on the MAS at 4 weeks (SMD –1.73; 95% CI –3.99 to 0.54).

Conclusion: Extracorporeal shock wave therapy has a significant effect on spasticity in post-stroke patients.


Lay abstract

The effect of extracorporeal shock wave therapy on spasticity in post-stroke patients has been evaluated in several clinical trials. In addition, a recent meta-analysis suggests that such therapy is effective; however, the measurement of spasticity was based mainly on the modified Ashworth scale, which is insufficient, and a lack of  randomized controlled trials studies in the study design may have biased the results. Therefore, considering the potential limitations of the previous meta-analysis, the aim of the current study was to perform a systematic review and meta-analysis of randomized controlled trials to evaluate the effectiveness of extracorporeal shock wave therapy on spasticity in post-stroke patients. Furthermore, subgroup analysis was performed to identify potential moderators or mediators.


Spasticity is a common complication of various neurological diseases, such as stroke, and is often defined as a velocity-dependent increase in muscle tone, with exaggerated tendon jerks, due to hyperexcitability of the stretch reflex (1). Stroke has a high morbidity and sequelae rate. Approximately 80% of stroke patients have motor dysfunction, and spasticity status is considered to be the main determinant of this (2). Approximately 20-–40% of stroke survivors will develop spasticity (3). Futhermore, only 15.6% of post-stroke patients have a clinically relevant degree of spasticity (MAS ≥ 3) (4), and the prevalence of disabling spasticity 1 year after first-ever stroke is 4% (5). Spasticity after stroke not only limits the subject’s limb movements, but also impacts on their ability in activities of daily living (ADL), and seriously reduces quality of life (QoL). Therefore, improving spasticity post-stroke would reduce the rate of disability.

Various therapeutic interventions can be used to reduce spasticity, including botulinum toxin (BTX) injections, pharmacological treatment, physical therapy (electrical stimulation, thermotherapy), occupational therapy, and chemical neurolysis (6–9). Extracorporeal shock waves have been reported to be a potential therapeutic intervention to improve spasticity (10, 11).

Extracorporeal shock waves are a group of mechanical pulse waves characterized by high peak pressure (100 MPa), fast pressurization speed (< 10 ns) and short cycle time (10 μs) (6). The treatments can be divided into focused extracorporeal shock waves (12) and radial extracorporeal shock waves (rESW) (13). rESW is a relatively new technique that was first applied in 1999. Extracorporeal shock wave therapy (ESWT) has been shown to be a safe, effective, non-invasive treatment for spasticity in patients with cerebral palsy, epicondylitis and multiple sclerosis (13–16). Several studies have shown that ESWT is effective for treating spasticity in post-stroke patients (17, 18). Dymarek et al. (19, 20) indicated that ESWT could effectively improve limb spasticity in post-stroke patients. In addition, a recent meta-analysis demonstrated the effectiveness of ESWT for spasticity in post-stroke patients (21). However, this was not a meta-analysis of randomized controlled trials (RCTs), and the quality of the included studies was not high. Considering the potential limitations of this earlier meta-analysis, the aim of the current study was to perform a systematic review and meta-analysis of RCTs to assess whether ESWT significantly improves spasticity in post-stroke patients. Furthermore, subgroup analysis was carried out to identify potential moderators or mediators.


Data sources

A systematic review and meta-analysis was performed according to the guidelines of the Cochrane Handbook for Systematic Reviews (22) and the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement (23). PubMed, EMBASE, EBSCO, Web of Science, Cochrane CENTRAL electronic databases were searched systematically from the establishment of the database to December 2017, with the key search terms: “extracorporeal shock wave therapy” and “stroke”. The reference lists of the resulting publications and reviews identified in the initial searches were scanned for further references. The literature search was limited to publications in English.

Selection criteria

The inclusion criteria for selection of studies were: (i) double or single-blind RCTs; (ii) participants with a diagnosis of ischaemic stroke or haemorrhagic stroke who had spasticity of the lower or upper limb with a MAS score >1; (iii) experimental groups treated with ESWT alone or ESWT combined with other interventions; (iv) control groups treated with sham ESWT alone or sham ESWT combined with other interventions; (v) English language publications.

The exclusion criteria were: (i) studies that were not RCTs; (ii) studies in which the participants were children or adolescents (aged less than 18 years); (iii) reviews, case reports/series; (iv) non-English articles; (v) duplicated data; (vi) studies in which relevant outcome indexes were not reported.


Data extraction

Two reviewers (WW, WFJ) independently extracted the following data: (i) sample characteristics (sample size, mean age, sex); (ii) clinical features (diagnosis, spasticity at baseline and study end-point); (iii) ESWT therapy protocol (frequency, intensity, site, number of treatment sessions). Study outcome was based on MAS, MTS, H/M ratio and range of motion before and after ESWT.

Risk of bias assessment

The quality of RCTs was assessed independently using the methods recommended by the Cochrane review (24). Two investigators (WW, WFJ) independently assessed the quality of the study, and any disagreements were resolved by discussion and consensus with a third author (QCQ). The quality assessment includes 6 domains: random sequence generation, allocation concealment, blinding of investigators and/or participants, blinding of outcome assessment, degree of incompleteness of outcome data, and selective reporting of study outcomes. Each domain has low, moderate, or high risk.

Statistical analysis

All statistical analyses were conducted using RevMan 5.3 (The Cochrane Collaboration, Software Update, Oxford, UK) and Stata 12.0 (Stata Corp, College Station, TX, USA). All continuous outcomes are expressed as mean differences (standardized and weighted to be determined by available data). Sensitivity analysis was performed to examine the influence of a single study on the overall estimate by omitting 1 study in turn. A p -value <0.05 was considered statistically significant. If p < 0.05 and Ivalue > 50%, the random-effects model was used; otherwise, the fixed effects model was used.[…]


Continue —> Journal of Rehabilitation Medicine – Effects of extracorporeal shock wave therapy on spasticity in post-stroke patients: A systematic review and meta-analysis of randomized controlled trials – HTML

Fig. 1. Flowchart for study selection. RCT: randomized controlled trial.

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[Systematic Review] Trends in robot-assisted and virtual reality-assisted neuromuscular therapy: a systematic review of health-related multiplayer games – Full Text



Multiplayer games have emerged as a promising approach to increase the motivation of patients involved in rehabilitation therapy. In this systematic review, we evaluated recent publications in health-related multiplayer games that involved patients with cognitive and/or motor impairments. The aim was to investigate the effect of multiplayer gaming on game experience and game performance in healthy and non-healthy populations in comparison to individual game play. We further discuss the publications within the context of the theory of flow and the challenge point framework.


A systematic search was conducted through EMBASE, Medline, PubMed, Cochrane, CINAHL and PsycINFO. The search was complemented by recent publications in robot-assisted multiplayer neurorehabilitation. The search was restricted to robot-assisted or virtual reality-based training.


Thirteen articles met the inclusion criteria. Multiplayer modes used in health-related multiplayer games were: competitive, collaborative and co-active multiplayer modes. Multiplayer modes positively affected game experience in nine studies and game performance in six studies. Two articles reported increased game performance in single-player mode when compared to multiplayer mode.


The multiplayer modes of training reviewed improved game experience and game performance compared to single-player modes. However, the methods reviewed were quite heterogeneous and not exhaustive. One important take-away is that adaptation of the game conditions can individualize the difficulty of a game to a player’s skill level in competitive multiplayer games. Robotic assistance and virtual reality can enhance individualization by, for example, adapting the haptic conditions, e.g. by increasing haptic support or by providing haptic resistance. The flow theory and the challenge point framework support these results and are used in this review to frame the idea of adapting players’ game conditions.


Robotic assistance and virtual reality in neuromuscular therapy

Neurological deficits can result in impaired motor function that affect a person’s quality of life. Researchers have been working to restore the nervous system and reduce the neurological deficits of people suffering from stroke, spinal cord injury, or traumatic brain injury [1]. For people with neurological deficits, impaired motor function is among the most prominent factors limiting the quality of life [2]. Motor neurorehabilitation can lead to permanent improvements in motor function [3]. Robotic assistance and virtual reality have the potential to enhance rehabilitation of neuromuscular deficits beyond the levels possible with conventional training strategies [45].

Game experience and task performance in multiplayer games

Robot- and virtual reality-assisted single-player games are well integrated in neurorehabilitation schedules. Recently, multiplayer games have been tested to complement neuromuscular therapy. Multiplayer games are expected to motivate the patients and increase the potential of robot- and virtual reality-assisted neuromuscular therapy.

Multiplayer games incorporate social interaction to promote the enjoyment of the involved players. The additional player adds new possibilities to the game environment, generally missed in single-player gaming against preprogrammed challenges or artificially controlled opponents. The multiplayer environment and related game mechanics can facilitate social interaction, ranging from conversation to haptic interaction. Due to the this added social interaction, the game experience is thought to be better in multiplayer compared to single-player gaming [6].

The mode of the game specifies whether the players compete or cooperate with one another [7]. In line with the flow theory, a competitive mode requires opponents of similar skill level to achieve enjoyment as the task difficulty experienced by one opponent [8]. Comparable skill levels prevent boredom or stress and result in a meaningful challenge level that leads to a flow state when training [9]. In such training conditions the players have a positive game experience.

In positive game experience players increase their game performance [910]. Increased game performance facilitates the general idea of serious games, i.e., playing for a primary purpose other than pure entertainment [11]. If enhanced game performance is achieved by increased physical activity, training intensity is also increased. In neuromuscular therapy, training intensity – alongside early treatment, user-centered, and task-oriented training – is one of the key factors in neurorehabilitation [1213]. Therefore, multiplayer gaming has great potential to further increase the benefits of robot-assisted neuromuscular and virtual reality-assisted therapy [1415].



Continue —> Trends in robot-assisted and virtual reality-assisted neuromuscular therapy: a systematic review of health-related multiplayer games | Journal of NeuroEngineering and Rehabilitation | Full Text


Fig. 4Difficulty adaptation based on individual condition setting in multiplayer games. Game experience (left) can be optimized by balancing the game performance (right). – Left: The initial game experience under nominal conditions relates to the skill level of the opponent and is non-optimal for differently skilled players (squares). Optimal game experience is perceived by the players when the condition adapts the difficulty towards the players’ skill level (circles). – Right: A common initial game performance state consists of a conditional task difficulty and its corresponding player specific game performance (square). Player specific difficulty adaptation can balance the game performances of the two players (circles)

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[Abstract] Evidence for Training-Dependent Structural Neuroplasticity in Brain-Injured Patients: A Critical Review

Acquired brain injury (ABI) is associated with a range of cognitive and motor deficits, and poses a significant personal, societal, and economic burden. Rehabilitation programs are available that target motor skills or cognitive functioning. In this review, we summarize the existing evidence that training may enhance structural neuroplasticity in patients with ABI, as assessed using structural magnetic resonance imaging (MRI)–based techniques that probe microstructure or morphology. Twenty-five research articles met key inclusion criteria. Most trials measured relevant outcomes and had treatment benefits that would justify the risk of potential harm. The rehabilitation program included a variety of task-oriented movement exercises (such as facilitation therapy, postural control training), neurorehabilitation techniques (such as constraint-induced movement therapy) or computer-assisted training programs (eg, Cogmed program). The reviewed studies describe regional alterations in white matter architecture and/or gray matter volume with training. Only weak-to-moderate correlations were observed between improved behavioral function and structural changes. While structural MRI is a powerful tool for detection of longitudinal structural changes, specific measures about the underlying biological mechanisms are lacking. Continued work in this field may potentially see structural MRI metrics used as biomarkers to help guide treatment at the individual patient level.

via Evidence for Training-Dependent Structural Neuroplasticity in Brain-Injured Patients: A Critical Review – Karen Caeyenberghs, Adam Clemente, Phoebe Imms, Gary Egan, Darren R. Hocking, Alexander Leemans, Claudia Metzler-Baddeley, Derek K. Jones, Peter H. Wilson, 2018

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[WEB SITE] Virtual Reality Therapy Designed to Help Stroke Patients Recover

Those recovering from a stroke often face an uphill battle. Rehabilitation typically requires executing continuous, repetitive movements, which can be extremely frustrating and monotonous for the patient.

One company is hoping to change that by incorporating virtual reality-based physical and cognitive exercise games into stroke rehabilitation programs.

The neurotechnology company MindMaze has introduced MindMotion PRO, a 3D virtual environment therapy for upper limb neurorehabilitation for victims of stroke.

As early as one to six weeks post stroke, patients can use this technology to complete customized interactive exercises in a virtual reality environment. The exercises are designed to stimulate the specific area of the brain damaged by the stroke. These training games engage 3D motion tracking cameras, which capture and map patient movements onto 3D avatars in different exercises of the patient’s shoulder, elbow, forearm, and wrist movements. MindMotion is designed for patients starting in the earliest stage of recovery and can be used from a hospital bed if needed.

The technology received FDA clearance in May and is in the process of launching its first U.S. study, which will be based at University of California, San Francisco. The study is expected to launch in fall 2017.

So far, patient responses have been extremely positive, said Andrea Serino, Ph.D., the head of neuroscience at MindMaze.

“Most of the patients are enthusiastic about virtual reality technologies,” said Serino, in an interview with R&D Magazine. “In most clinics, rehabilitation is really boring. But with MindMotion instead of doing one simple, boring repetitive movement over and over, you can have the same movement— because it’s very important that you have the repetition of the same movement—but in a context that is gamified and enjoyable for the patients.”

MindMotion Mask. Credit: MindMaze
Benefits of virtual reality


In addition to making rehabilitation more enjoyable for the patients, virtual reality also has the potential to improve rehabilitation outcomes compared to traditional exercise-based therapies. By using an avatar in a virtual reality environment, healthcare professionals can directly stimulate not only the body of the patient, but their brain.

“We know that if you see another person doing movement, you activate the brain regions that normally activate when you do the same movement,” explained Serino. “By having an avatar in our MindMotion Pro machine which represents the movement of the patients while the patient is moving, we are stimulating both the motor cortex to produce the movement, and an action observation loop to activate the brain regions that have been damaged by the stroke.”

Patients that have no mobility on one side of the body can enter a virtual reality environment and participate in games that require them to move only their working arm. At the same time, their avatar can move the opposite arm, activating the areas that correspond to the damaged part of their cortex.

There is also potential to pair this type of virtual reality technology with robotics technologies that could physically move a paralyzed limb during this exercise.

Utilizing virtual reality for stroke rehabilitation also has benefits for the clinicians that work with these patients. Intensive, repetitive movements continued over a long duration have proven to be the best way for a patient to recover from a stroke. However, this type of treatment requires significant supervision and effort from medical personal.

A virtual reality machine can guide the patient in these repetitive exercises, allowing them to train more often and with increased intensity, while requiring a lower level of supervision and assistance. In addition, the machine monitors each patient’s progress, allowing healthcare providers to track and update their treatment regimen more specifically.

What’s Next

MindMaze is working to expand their MindMotion offerings for stroke rehabilitation virtual reality technology.

“The idea of MindMotion is to take care of patients from the beginning of their disease to the end,” said Serino. “We want to help patients all along the journey of their rehabilitation—from the acute care units, to the rehabilitation units, to the outpatient screenings, and when they go home. This means that you cannot have a single device to do all of these things, because depending on the status of the patient, and the phase of the disease, you will need different approaches and different technologies with different ideas behind them.”

In addition to MindMotion Pro, MindMaze has already developed MindMotion Go, which was created for patients in the later phases of stroke recovery. This is meant to be used in clinics and incorporates more “gamified” types of exercise.

There is also potential to branch out into other neurological diseases, although Serino said MindMaze wants to focus their resources on providing care to stroke patients first. However, he sees future applications for this technology for patients with multiple sclerosis, Parkinson’s disease, or those with dementia and mild cognitive impairment. He also sees potential for these devices to be used in children suffering from attention challenges or other cognitive challenges.

As virtual reality continues to take off within healthcare, and specifically within the neurological space, it is important that new technologies are designed with thought and care to the specific disease they are treating, said Serino.

Virtual reality has such good potential for the rehabilitation field that for sure it will continue to develop, but I think the challenge is how we do that,” he said. “We are now in the moment where we have to define how we are going to use this technology in healthcare. We have to do it in a way that really incorporates the rehabilitation techniques that we already know. We have to use it with a sufficient level of complexity so that we can implement the knowledge we have from the field of neuroscience. That will be the way that we really benefit from this technology.”


via Virtual Reality Therapy Designed to Help Stroke Patients Recover

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[WEB SITE] How Neuro-Physiotherapy Imparts Quality to Life

By Dr. Nayeem U Zia

Since the last decade or so, we have been witnessing an upsurge in neurological problems such as strokes, Parkinson’s disease, diabetic neuropathy, and motor neuron diseases in our society. An alarming concern is that these problems have started affecting people at a younger age. Worldwide, neurological disorders are associated with higher rates of morbidity and mortality which in turn inflict higher cost of rehabilitation upon the sufferers. Given the topography, changing life style and the stressors, Kashmiris , per se, have a strong affinity toward neurological problems.
A belief that still dominates the clinical decision making of most healthcare professionals is that the recovery from neurological disorders is strictly a time bound phenomenon and to expect it happen after a set time frame, is unrealistic. Research has nullified it and suggests that brain can modify itself at any point in time provided the treatment is channelized in a right direction.
Unfortunately, we all come across a chunk of people who have fallen prey to such dogmas and live a lifeless life. Another chunk of the patient population is suffering because of its contentment with regard to the menial and irrelevant improvements. Needless to mention, it is the acumen of a skilled neuro-physiotherapist that determines the potential of rewiring of central nervous system connections essential for recovery. The concept of recovery has changed over a period of time; earlier, recovery was perceived as patients’ ability to achieve nominal and insignificant improvements that would enable them to come out of bed and walk a few steps. On the contrary, recovery now is tantamount to movements with a purpose in order to help patients regain functions, and eventually fulfill their social responsibilities.
Rehabilitation of patients with neurological problems is a high cost affair with huge financial and social costs. Soon after a person gets afflicted with a neurological disorder, besides the patient, the family members start bearing the brunt of the disease. Research reports reveal that the caregivers of neurologically impaired patients are exposed to a high level of stress which affects their productivity and, in turn, compromises the role they play in society. Recovery from neurological disorders, being relatively slower, demands close supervision and assistance from family members. In the meantime family members start dedicating their time and money towards the rehabilitation of the patient. Moreover, with modern family systems, every ailing person does not enjoy the luxury of extended social support and, eventually a number of impediments start emerging in the path of recovery.
In a nutshell, neurological problems not only affect patients but pose a massive challenge to family members too. The best strategy to cope up with the neurological problems is to facilitate patients’ functional independence as rapidly as possible that will eventually offload the family members to a greater extent.
Neurorehabilitation has undergone timely refinements to ensure best possible and evidence based care to patients. Modern day Neurorehabilitation uses approaches that emphasize minimizing compensations to ensure complete functional recovery. Functional independence is its essence and a neuro-physiotherapist proves to be an apt resource to deliver the best in order to achieve the short-term and long-term functional milestones. People in the valley have a limited knowledge of neuro-physiotherapy and the role a neuro-physiotherapist plays. A neuro-Physiotherapist, being a responsible member of healthcare team, plays a vital role right from the onset of a neurological problem to the stage of community rehabilitation of a patient.
Since Physiotherapists are movement science experts, fellow medical professionals and patients’ families can’t afford taking a neuro-Physiotherapist’s consultation and advice for granted. An insignificant problem, if left unaddressed, can have devastating repercussions later. For instance, a trivial fault in the shoulder after stroke/brain injury can affect a patient’s ability to drink and eat with the hand. Therefore, physiotherapy consultation from the outset remains crucial in determining a patient’s functional outcomes and ignoring it is at one’s peril.

Physiotherapists too need to be well versed in the latest developments in the field of neuro-physiotherapy to ensure quality care delivery. A neuro-Physiotherapist can make best use of treatments methods such as Constraint Induced Movement Therapy (CIMT), Virtual Reality (VR), Functional Electrical Stimulation (FES), Proprioceptive Neuromuscular Facilitation (PNF), Neurodevelopmental Treatment (NDT), Motor Relearning Programme (MRP), Task Specific Training, Partial Body Weight Support Treadmill Training (PBWSTT), and Robotics and so on. In order to achieve set functional objectives, neuro-physiotherapists equipped with the magic wand will surely help patients impart quality to their lives.

The author is a Physiotherapist at the J&K Health services, an Ex-Assistant Professor, Hamdard University Delhi and a Certified NDT Therapist , NDTA USA. He can be reached at:


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[Systematic Review] Neural Correlates of Familiarity in Music Listening: A Systematic Review and a Neuroimaging Meta-Analysis – Full Text

Familiarity in music has been reported as an important factor modulating emotional and hedonic responses in the brain. Familiarity and repetition may increase the liking of a piece of music, thus inducing positive emotions. Neuroimaging studies have focused on identifying the brain regions involved in the processing of familiar and unfamiliar musical stimuli. However, the use of different modalities and experimental designs has led to discrepant results and it is not clear which areas of the brain are most reliably engaged when listening to familiar and unfamiliar musical excerpts. In the present study, we conducted a systematic review from three databases (Medline, PsychoINFO, and Embase) using the keywords (recognition OR familiar OR familiarity OR exposure effect OR repetition) AND (music OR song) AND (brain OR brains OR neuroimaging OR functional Magnetic Resonance Imaging OR Position Emission Tomography OR Electroencephalography OR Event Related Potential OR Magnetoencephalography). Of the 704 titles identified, 23 neuroimaging studies met our inclusion criteria for the systematic review. After removing studies providing insufficient information or contrasts, 11 studies (involving 212 participants) qualified for the meta-analysis using the activation likelihood estimation (ALE) approach. Our results did not find significant peak activations consistently across included studies. Using a less conservative approach (p < 0.001, uncorrected for multiple comparisons) we found that the left superior frontal gyrus, the ventral lateral (VL) nucleus of the left thalamus, and the left medial surface of the superior frontal gyrus had the highest likelihood of being activated by familiar music. On the other hand, the left insula, and the right anterior cingulate cortex had the highest likelihood of being activated by unfamiliar music. We had expected limbic structures as top clusters when listening to familiar music. But, instead, music familiarity had a motor pattern of activation. This could reflect an audio-motor synchronization to the rhythm which is more engaging for familiar tunes, and/or a sing-along response in one’s mind, anticipating melodic, harmonic progressions, rhythms, timbres, and lyric events in the familiar songs. These data provide evidence for the need for larger neuroimaging studies to understand the neural correlates of music familiarity.


Music is ubiquitous in human culture and has been present since prehistorical times (Conard et al., 2009). Music does not appear to have a survival value, yet most of the current literature has pinpointed it as a fundamental aspect of human life, describing it as a “universal reward” (Trehub et al., 2005). People often value music for the emotions it generates (Juslin and Laukka, 2004Brattico and Pearce, 2013), and listening to music can help to regulate mood and increase well-being (Hills and Argyle, 1998Kawakami et al., 2014). This might explain the use of music in people’s everyday lives (Schäfer and Sedlmeier, 2010).

Familiarity or repeated exposure in music has been reported as an important factor modulating emotional and hedonic responses in the brain (Pereira et al., 2011). The familiarity principle, also known as the “mere exposure effect,” was first described by Zajonc (1968). It is a psychological phenomenon which suggests that the more exposed we are to someone or something, the more we like it. Repetition in music can be of different types: within a piece, across pieces, or across multiple hearings (Margulis, 2013). Both familiarity and repetition may increase the liking of a piece of music, thus inducing positive emotions (Witviliet and Vrana, 2007Omar Ali and Peynircioglu, 2010).

Long before its description in 1968, the phenomenon of familiarity had been known by social psychologists and applied to the music field (King and Prior, 2013). The first person who documented it was Meyer in 1903. He presented his subjects with a dozen repetitions of unfamiliar music that he had composed. After listening to the last repetition, most subjects asserted that “the aesthetic effect was improved by hearing the music repeatedly” (Meyer, 1903). Moreover, Meyer showed that melodies which ended on the frequency ratio symbol 2 (the Lipps-Meyer Law) was preferred to all other melodies. However, this law was later on disputed by Paul Farnsworth, his student, who argued that interval ending preferences could be altered by training. Therefore, repetition and familiarity with a specific ratio ending could increase preference for that specific ending. This effect, explaining the perception of music closure, was called the “habit principle” (Farnsworth, 1926). Overall, it seems familiarity deepens the understanding of music and engagement with music listening (King and Prior, 2013).

However, according to numerous studies, the relationship between exposure and enjoyment is non-linear, following an inverted-U shape preference response. Repeated exposure to music can increase pleasure (“hedonic value”) for a certain period, but ultimately gives rise to increasing displeasure (Jakobovits, 1966Berlyne, 1971Szpunar et al., 2004Schellenberg, 2008).

There are different explanations for the inverted U-shape preference response. One is the perceptual fluency model (Bornstein and D’Agostino, 1994) which explains that people incorrectly assume that the facilitated processing of a familiar stimulus is associated to some positive attribute of the stimulus itself. However, as the conscious recognition of fluency processing increases, they stop misattributing this effect to the stimulus but to repeated exposure, and therefore pleasure decreases. Another explanation proposed by Berlyne (1971) states that the inverted U reflects the “interaction of two opposing impulses:” the ascending part arises from an evolutionary conditioned preference for the familiar (positive learned safety effect), and the subsequent decline of the U favors for novelty seeking (aversion to boredom). Moreover, the complexity of the stimulus also influences the timescale of satiation effect. According to Szpunar et al. (2004), despite initial increases in liking, after the stimulus complexity has been absorbed, boredom intercedes, and satiation reduces likability.

Peretz et al. reported that familiarity is best conceptualized as an “implicit memory phenomenon,” in which previous experience aids the performance of a task without conscious awareness of these previous episodes (Peretz et al., 1998). The ability to recognize familiar melodies appeared to be dependent on the integrity of pitch and rhythm perception. Of these two factors, pitch is thought to play a more important role (Hébert and Peretz, 1997). The authors noted that “although the mere exposure effect is simple to define and to reproduce experimentally, it is more complicated to explain.”

Familiarity is a complex subject and the neural mechanisms underlying this memory phenomenon toward music listening are still not very clear or consistent. Some authors define familiarity as a semantic memory process, which is a declarative knowledge (e.g., words, colors, faces, or music) acquired over a lifetime. Musical semantic memory is defined as the long-term storage of songs or musical excerpts, which enables us to have a strong feeling of familiarity when we listen to music (Groussard et al., 2010a). Brain lesion studies showed that music semantic memory appears to involve both hemispheres; however, the integrity of the left hemisphere is critical, suggesting functional asymmetry favoring the left hemisphere for semantic memory (Platel et al., 2003). Neuroimaging studies featuring musical semantic memory have reported the involvement of the anterior part of the temporal lobes, either in the left hemisphere or bilaterally, and the activation of the left inferior frontal gyrus (Brodmann area (BA) 47) (Plailly et al., 2007). Groussard and her co-workers also found activation of the superior temporal gyri (BA 22). The right superior temporal gyrus is mostly involved in the retrieval of perceptual memory traces (information about rhythm and pitch), which are useful for deciding whether or not a melody is familiar. The left superior temporal gyrus seems to be involved in distinguishing between familiar and unfamiliar melodies (Groussard et al., 2010a).

Plailly et al. (2007) also addressed the neural correlates of familiarity and its multimodal nature by studying odors and musical excerpts stimuli. These were used to investigate the feeling of familiarity and unfamiliarity. Results for the feeling of familiarity indicated a bimodal activation pattern in the left hemisphere, specifically the superior and inferior frontal gyri, the precuneus, the angular gyrus, the parahippocampal gyrus, and the hippocampus. On the other hand, the feeling of unfamiliarity (impression of novelty) of odors and music was related to the activation of the right anterior insula (Plailly et al., 2007). Janata (2009) studied the neural correlates of music-evoked autobiographical memories in healthy individuals and those with Alzheimer disease. His findings showed that familiar songs from our own past can trigger emotionally salient episodic memories and that this process is mediated by the medial prefrontal cortex (MPFC). In the same study, hearing familiar songs also activated the pre-supplementary motor area (SMA), left inferior frontal gyrus, bilateral thalamus, and the right cerebellar hemisphere (Janata, 2009).

Brain imaging studies in the neurobiology of reward during music listening demonstrated the involvement of mesolimbic striatal areas, especially the nucleus accumbens (NAcc) in the ventral striatum. This structure is connected with subcortical limbic areas such as the amygdala and hippocampus, insula and anterior cingulate cortex, and also integrated with cortical areas including the orbital cortex and ventromedial prefrontal cortex. These limbic and paralimbic structures are considered the core structures of emotional and reward processing (Koelsch, 2010Salimpoor et al., 2013Zatorre and Salimpoor, 2013). Recently, Pereira et al. (2011) investigated familiarity and music preference effects in determining the emotional involvement of the listeners and showed that familiarity with the music contributed more to the recruitment of the limbic and reward centers of the brain.

Electroencephalography (EEG) is another neuroimaging technique that enabled us to address the brain’s response to stimuli. It provides a real-time picture of neural activity, recording how it varies millisecond by millisecond. Time-locked EEG activity or event-related potential (ERP) are small voltages generated in the brain structures in response to specific sensory, cognitive or motor event (Luck, 2005). With regards to auditory stimuli—and, more specifically, to music listening and recognition—the N1, P200, P300, and N400 waves have been found to be particularly important. N1, a negative component found 80–110 ms after stimulus onset, is thought to represent the detection of a sound and its features, as well as detection of change of any kind (pitch, loudness, source location etc.) (Näätänen and Picton, 1987Seppänen et al., 2012). It originates in the temporal lobe, predominantly in or near the primary auditory cortex, suggesting that it is involved in early phases of information processing (Hyde, 1997). Secondly, P2 is a positive component that arises 160–200 ms after the onset of the stimulus (Seppänen et al., 2012) and is localized in the parieto-occipital region (Rozynski and Chen, 2015). It is involved in evaluation and classification of the stimulus (Seppänen et al., 2012) as well as other related cognitive processes, such as working memory and semantic processing (Freunberger et al., 2007). P3, instead, is considered to be more related to selective attention and information processing, such as recognition and memory processes. It is traditionally divided into P3a, arising in the frontal region, and P3b, arising in the temporal and parietal regions; it appears 300–400 ms after the stimulus and lasts 300–600 ms (Patel and Azzam, 2005). However, its timing can vary widely, so it is often described as the late positive complex (LPC), a definition which also includes later deflections, such as P500 and P600 (Finnigan et al., 2002). Finally, N400 arises 200–600 ms after the stimulus, but its anatomical localization has not been well defined since it does not seem to be related to a specific mental operation only. Indeed, it seems to be connected to the processing of meaning at all levels, since it is influenced by factors acting both at lower and at higher levels of these cognitive processes (Kutas and Federmeier, 2011).

Advances in brain imaging techniques have facilitated the examination of music familiarity processing in the human brain. Nevertheless, the use of different modalities and experimental designs has led to differing results. Over the years, studies have used varying music stimuli such as melodies, songs with and without lyrics, with diverse acoustic complexity. Due to this heterogeneity, it is not clear which areas are most reliably engaged when listening to familiar and unfamiliar songs and melodies.

To our knowledge, no systematic review or meta-analysis has been conducted to resolve the inconsistencies in the literature. The present study systematically reviews the existing literature to establish the neural correlates of music familiarity, in healthy population using different neuroimaging methods, including fMRI, PET, EEG, ERP, and MEG. Finally, we used the activation likelihood estimation (ALE) method (Eickhoff et al., 2009) to conduct a series of coordinate-based meta-analyses for fMRI and PET studies. We expected to find brain areas related to emotion or reward as the most active regions when listening to familiar music, as familiarity is positively correlated with likeability and pleasure, at least to a certain number of exposures.[…]


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[Abstract + References] Virtual Reality for Neurorehabilitation: Insights From 3 European Clinics


Virtual reality for the treatment of motor impairment is a burgeoning application of digital technology in neurorehabilitation. Virtual reality systems pose an opportunity for health care providers to augment the dose of task-oriented exercises delivered both in the clinic, and via telerehabilitation models in the home. The technology is almost exclusively applied as an adjunct to traditional approaches and is typically characterized by the use of gamified exergames which feature task-oriented physiotherapy exercises. At present, evidence for the efficacy of this technology is sparse, with some reviews suggesting it is the same or no better than conventional approaches. The purpose of this article is to provide real-world insights on the adoption of a virtual reality by 3 European clinics in 3 different service delivery models. These include an inpatient setting for Parkinson disease, a kiosk model for pediatric neurorehabilitation, and a home-based telerehabilitation model for neurologic patients. Motivations, settings, requirements for the pathology, outcomes, and challenges encountered during this process are reported with the objective of priming clinicians on what to expect when implementing virtual reality in neurorehabilitation.


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