Posts Tagged plateau

[BLOG POST] How to Prevent or Minimize the Plateau Phase After a Stroke – Saebo

The rehabilitation process throughout the first several months of stroke recovery can be confusing and often daunting, with peaks and valleys that either encourage or slow the healing process. Varying levels of paralysis are common, and adjusting to ongoing therapy requires a shift in mindset and a complete lifestyle overhaul.

Yet, some of the most significant improvements often occur during these early days, reflecting the initial plasticity of the brain. Therefore, gaining momentum during this neurologically progressive time is key to facing the often-frustrating period ahead—a stage known as a plateau. During this stage, it may feel as if the initial spike in progress was the end of successful rehabilitation and that no further improvement is possible. But for some, the plateauing phase is quite common and even to be expected, and understanding this will help both the patient and caregivers to avoid losing hope, motivation, and persistence during this difficult time.

Are plateaus real?

Over the past two decades, research has reaffirmed the frequency and common intricacies of plateauing in newer stroke patients. In the past, it was more likely for doctors to assume that patients only regained motor function in the first few months after a stroke, and that once the plateau occurred, ongoing exercises and therapy were ineffective.

However, recently published reports now show that patients can regain motor recovery and function up to 23 years after a stroke. Medical professionals are now finding that this complex recovery period often continues to occur for months and even years after a patient has left rehab—and primarily resumes only if patients and caretakers build a recovery planand have access to evidence-based technology to prevent the plateau phase after leaving traditional rehabilitation. Designing a home-exercise program, often by upgrading the previous inpatient therapeutic regimen, is the key to maintaining progress or restarting growth if the plateau phase has begun.

What causes a plateau?

When a stroke occurs, a specific area of the brain suffers an infarction, obstructing the blood supply and killing the functionality of a section of the brain. Though this specific area is not recoverable, the area directly surrounding the infarction-impacted region still holds potential for rehabilitation. In the moments directly after the stroke, however, the area simply does not work.

During the initial healing phase known as the subacute phase, which is usually the first three to six months after the stroke, the most consistent and encouraging signs of progress occur in these regions. This natural healing stage often takes place when patients are being coached along in rehab; but if the plateau stage occurs towards the end of  the natural healing phase, it’s common for patients to be sent home for a shift in care.

For this group of patients, this is a difficult transition for several reasons: familiar exercises must be altered and adjusted, the home routine requires greater adaptability, and patients face the discouragement of no longer seeing an uptick in progress, often deterring patients and caretakers from pushing on. Progressing through the discouragement is more easily accomplished when patients and caretakers understand the plateau stage. A solid plan of ongoing, managed care is necessary for continuing to bolster the still-developing parts of the mind.

It’s not the patients that have plateaued, rather treatment options have plateaued them.

It is important to keep in mind that traditional therapy that isn’t evidence-based can be ineffective and can actually causea plateau. Sometimes a patient’s recovery is only as good as the therapist, and if the therapist isn’t modifying the treatment to the patient’s specific needs and incorporating the latest proven interventions because they haven’t been trained or educated, the patient will most likely plateau. If the therapist is well educated on the latest advances and interventions in stroke recovery the patient has a much better chance of avoiding the plateau phase. So, a plateau phase may not be an absolute, it’s a possibility.

How can you overcome a plateau?

After reassuring research, the medical community confirms that working with a managed care professional with a series of ongoing exercises does promote improvement in a stroke patient’s long-term recovery. When signs of recovery seem to stall altogether, here are a few common practices for jumpstarting at-home care.

Saebo Rehabilitation Devices

The brain’s cortical plasticity is a key component in this stage of recovery, and Saebo offers several tools for employing this factor. Motor function and utilization of the hands can be continuously developed with the assistance of the SaeboGlove or SaeboFlex, easing therapy at home with minimal assistance and instruction. The SaeboFlex and SaeboGlove include a proprietary tension system that encourages the extension and grasping strength of the hands of healing stroke patients. This action simultaneously supports brain growth and reprogramming, encouraging the plasticity of the mind through task-oriented exercises.

If patients are unable to functionally use their affected hand, they will develop learned non-use and will eventually reach the plateau phase due to avoidance. The SaeboFlex and and SaeboGlove are two tools that may prevent or minimize the plateau phase and allow patients to engage their affected hand in functional tasks that would otherwise be impossible.

Constraint-Induced Movement Therapy

Similar to the SaeboGlove and SaeboFlex’s use of cortical plasticity, Constraint-Induced Movement Therapy (CIMT) encourages the regrowth of neurological pathways damaged during a stroke. This promotes more meticulous use of the affected hand. By keeping the functional hand from taking full responsibility for daily tasks—usually with a mitt—this method involves preference of the developing side of the brain. Though CIMT is an intensive process, which must be guided and supervised for several-hour stretches at a time, positive results may be seen for years to come.

At-Home Exercises

Maintaining a regimen of exercises that both meets the needs of ongoing recovery and the patient’s comfort is essential to progressing past the plateau stage after traditional rehab. The factor of neuroplasticity allows the brain to constantly adapt, but persistence and regularity is key. When followed correctly, an increase in motor function and strength is probable in many patients. Continuing physical exercise assists with many aspects of the healing process, supporting flexibility, coordination, and balance. Though physical activity does not prevent the occurrence of a second stroke, it will keep the body in key health for recovery.

Staying Motivated

During the difficult transition to home care, supportive family and medical professionals are the vital factor in helping patients maintain motivation and feel guided toward success. As a patient is just beginning the rehabilitation process, it is almost solely in the hands of the assistant to set the tone of the session, and this mutual understanding will drive the exercises forward, making it easier to set and meet small goals along the way. Roadblocks and frustrations are common, but with a structured and steady plan, these stages will pass and times of progress will return.

Handling Emotional Changes

When difficult emotions arise, it is crucial to realize that this is completely normal. Stroke recovery is a long, often slow process, and frustration, anger, and depression are understandable obstacles to encounter. Know that these feelings and physical plateaus will pass with time when both patients and caretakers allow themselves self-care and patience. It is also helpful for families to keep this in mind, as maintaining a genuinely flexible and positive atmosphere during rehabilitation will help all parties see these changes and efforts as a long-term process.

Keep Moving Forward

When heading into long-term stroke treatment, awareness of evidence-based treatment interventions may prevent or decrease the plateauing stage. But with consistent at-home tools and exercises, progress will return, even if it feels slower than in previous phases. The recently damaged brain is taking the necessary time to heal and regrow, and this requires setting short-term goals and celebrating small victories. Reaching the plateau stage is an opportunity to reconsider the next best way forward with your therapist—progress is still ahead, even if the methods and system require a new outlook.

Source: How to Prevent or Minimize the Plateau Phase After a Stroke | Saebo



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[BLOG POST] Recovery from stroke after more than 20 years – Motor Impairment


Much can be learned from case studies of individual patients. This has been shown more than once in the field of stroke research.  The observations by the illustrious neuroanatomist Dr. Brodal of his own stroke are an example (Brodal 1973).

A paper recently published in the Journal of Neurophysiology provides another example. It features a case of delayed partial recovery from weakness and paralysis produced by a devastating stroke, with improvements in hand function more than two decades after the initial event (Sörös et al. 2017).



In 1979, when the patient was 15 years old, his cervical rib compressed his subclavian artery, such that thrombosis formed back to the innominate artery. Emboli subsequently entered the carotid and vertebrobasilar circulations. A dense left hemiplegia developed with a large right frontoparietal infarction.

No detail of any initial rehabilitation is given but partial use of the left shoulder and elbow, along with the left leg had been regained about 4 months after the stroke. However, minimal recovery occurred in the left hand: it was spastic and useless for 23 years.

When the patient began regular swimming in 2001, he noted finger movements of his left hand. In 2009, he began extra physiotherapy using a spring-loaded orthosis for his left hand. Currently, the patient can use his left hand to pick up small objects like coins.

Functional MR imaging was performed when the second period of recovery had occurred. When the patient repeatedly opened and closed his left hand there was extensive activation in both hemispheres and bilaterally in the cerebellum. In contrast, movements of comparable size and rate made by the unaffected hand (i.e., the right hand) produced only focal activity in the contralateral sensorimotor cortex, supplementary motor area and cerebellum.



While the case features a rare complication of the thoracic outlet syndrome produced by a cervical rib, it highlights spectacularly the capacity of cortical and cerebellar circuits to be reformed or reactivated in such a way that new functional movements can occur at the distal extremity, i.e. the hand. It is not possible to determine whether the swimming and later rehabilitation caused or even contributed to the surprising improvement. It may have occurred spontaneously.  Nonetheless, the case has important messages for rehabilitation of stroke, especially in young people.  The traditional view in rehabilitation following stroke is that most of the functional improvement occurs within the first 12-18 months.  One widely promoted view is that the initial motor recovery occurs to a fixed proportion of the initial severity of the deficit (70% of recovery occurs in the first three months) (Prabhakaran et al. 2008; Smith et al. 2017).  This case of prolonged paralysis with delayed recovery after a severe ischaemic stroke means that the therapeutic window for improvement can be much longer than traditionally thought.  By implication, many new therapies (potentially cellular, pharmacological or physical ones) could be tested long after stroke.



Sörös P, Teasell R, Hanley DF, Spence JD. Motor recovery beginning 23 years after ischemic stroke. J Neurophysiol 118: 778-781, 2017.



Brodal A. Self-observations and neuro-anatomical considerations after a stroke. Brain 96: 675-694, 1973.

Prabhakaran S, Zarahn E, Riley C, Speizer A, Chong JY, Lazar RM, Marshall RS, and Krakauer JW. Inter-individual variability in the capacity for motor recovery after ischemic stroke. Neurorehabil Neural Repair 22: 64-71, 2008.

Smith MC, Byblow WD, Barber PA, and Stinear CM. Proportional recovery from lower limb motor impairment after stroke. Stroke 48: 1400-1403, 2017.



Simon Gandevia is an NHMRC Senior Principal Research Fellow and Deputy Director of Neuroscience Research Australia (NeuRA). His research investigates the sensorimotor control of human movements. He has special interests in proprioception, muscle, breathing control, and fatigue.  He is Chief investigator of the NHMRC Program grant at NeuRA on Motor Impairment. You can learn more about Simon and his research here. You can also follow him on Twitter @SimonGandevia and @MotorImpairment.

Source: Recovery from stroke after more than 20 years – Motor Impairment

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[BLOG POST] How to Make New Brain Cells and Improve Brain Function

Scientists used to believe that the brain stopped making new brain cells past a certain age. But that believe changed in the late 1990’s as a result of several studies which were performed on mice at the Salk Institute.

After conducting maze tests, neuroscientist Fred H. Gage and his colleagues examined brain samples collected from mice. What they found challenged long standing believes held about neurogenesis, or the creation of new neurons.

To their astonishment, they discovered that the mice were creating new neurons. Their brains were regenerating themselves.

All of the mice showed evidence of neurogenesis but the brains of the athletic mice showed even more.

 These mice, the ones that scampered on running wheels, were producing two to three times as many new neurons as the mice that didn’t exercise.

The difference between the mice who performed well on the maze tests and those that floundered was exercise.

That’s great for the mice, but what about humans?

To find out if neurogensis occurred in adult humans, Gage and his colleagues obtained brain tissue from deceased cancer patients who had donated their bodies to research. While still living, these people were injected with the same type of compound used on Gage’s mice to detect new neuron growth. When Gage dyed their brain samples, he saw new neurons. Like in the mice study, they found evidence of neurogenesis – the growth of new brain cells.

From the mice study, it appears that those who exercise produce even more new brain cells than those who don’t. Several studies on humans seem to suggest the same thing.

Studies performed at both the University of Illinois at Urbana- Champaign and Columbia University in New York City have shown that exercise benefits brain function. The test subjects were given aerobic exercises such as walking for at least one hour three times a week. After 6 months they showed significant improvements in memory as measured by a word-recall test. Using fMRI scans they also showed increases in blood flow to the hippocampus (part of the brain associated with memory and learning). Scientists suspect that the blood pumping into that part of the brain was helping to produce fresh neurons.

Dr. Patricia A. Boyle and her colleagues of Rush Alzheimer’s Disease Center in Chicago found that the greater a person’s muscle strength, the lower their likelihood of being diagnosed with Alzheimer’s. The same was true for the loss of mental function that often precedes full-blown Alzheimer’s.

Neuroscientist Gage, by the way, exercises just about every day, as do most colleagues in his field. As Scott Small a neurologist at Columbia explains,

 I constantly get asked at cocktail parties what someone can do to protect their mental functioning. I tell them, ‘Put down that glass and go for a run.

So if you want to grow some new brain cells and improve your brain function, go get some exercise!

Source: How to Make New Brain Cells and Improve Brain Function | Online Brain Games Blog

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[Abstract] Chronic Stroke Survivors Improve Reaching Accuracy by Reducing Movement Variability at the Trained Movement Speed

Background. Recovery from stroke is often said to have “plateaued” after 6 to 12 months. Yet training can still improve performance even in the chronic phase. Here we investigate the biomechanics of accuracy improvements during a reaching task and test whether they are affected by the speed at which movements are practiced.

Method. We trained 36 chronic stroke survivors (57.5 years, SD ± 11.5; 10 females) over 4 consecutive days to improve endpoint accuracy in an arm-reaching task (420 repetitions/day). Half of the group trained using fast movements and the other half slow movements. The trunk was constrained allowing only shoulder and elbow movement for task performance.

Results. Before training, movements were variable, tended to undershoot the target, and terminated in contralateral workspace (flexion bias). Both groups improved movement accuracy by reducing trial-to-trial variability; however, change in endpoint bias (systematic error) was not significant. Improvements were greatest at the trained movement speed and generalized to other speeds in the fast training group. Small but significant improvements were observed in clinical measures in the fast training group.

Conclusions. The reduction in trial-to-trial variability without an alteration to endpoint bias suggests that improvements are achieved by better control over motor commands within the existing repertoire. Thus, 4 days’ training allows stroke survivors to improve movements that they can already make. Whether new movement patterns can be acquired in the chronic phase will need to be tested in longer term studies. We recommend that training needs to be performed at slow and fast movement speeds to enhance generalization.

Source: Chronic Stroke Survivors Improve Reaching Accuracy by Reducing Movement Variability at the Trained Movement Speed – Feb 01, 2017

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[WEB SITE] 28 Stroke Recovery Tips for Healing & Habits – Flint Rehab

These stroke recovery tips start with the brain and and end with your lifestyle… Why? Because stroke recovery is about more than just the ‘brain thing.’ It’s about the ‘life thing,’ too.

So we’ll start with some basic tips on healing the brain after stroke, and then we’ll cover 3 other important topics:

You can pick and choose which stroke recovery tips you like, but we encourage you to stick around for the full show.

1. Master the Rewiring Process

To rewire your brain after stroke, you need to utilize repetitive practice (repeating an exercise over and over) to trigger neuroplasticity, the mechanism that your brain uses to heal itself after injury.

Neuroplasticity is the #1 thing to focus on during stroke recovery. Become an expert on it and you won’t regret it.

A great book that goes into depth on the subject is called The Brain that Changes Itself by Norman Doidge. It’s one of our top recommended stroke recovery books.

2. Keep Your Nutrition Game Up

We’ll keep this part extremely simple: Eat mostly whole foods, avoid packaged/processed food as much as possible, and supplement where necessary.

If you do these things, then you’ll be consuming a diet that supports your body’s healing.

3. Don’t Fall for the Plateau

The plateau is real – but the word itself is so deceiving! When results slow down after the first few months of recovery, don’t mistake it for a dead end.

Recovery will only stop when you stop.

You can bust through the plateau by keeping your regimen consistent but varied with different exercises.

4. Avoid Permanent Lopsidedness

During stroke recovery, the phrase “use it or lose it” is commonly used by therapists to describe the clinical condition of learned nonuse.

Learned nonuse occurs when you completely stop using your affected limb, and after a while your brain literally forgets how to use it.

The best way to avoid learned nonuse is to move your affected limbs at least a little bit every day.

5. Permanently Treat Pain and Spasticity

Localized pain can be treated with heat packs and medication, which can provide the relief you need to carry out necessary tasks. These treatments, however, are short-term and temporary.

To get long-term relief from painful spastic muscles, you need to relieve the spasticity. How do you get rid of spasticity?

By dutifully performing your rehab exercises so that your brain regains control over your spastic muscles – and they relax. Again, it’s all about neuroplasticity.

6. You Don’t Know What Works…

…Until you’ve tried them all.

Something that worked for a friend might not work for you, or it could be the best thing ever! But you won’t know until you try.

7. Get Tons of Sleep

Sleep helps improve movement recovery after stroke by giving your brain a chance to process and retain all the information it learned from the day’s exercises.

Sleep also helps reduce fatigue, irritability, and toxic buildup in your brain.

It what stroke survivor Jill Bolte Taylor, a neuroscientist who survived a massive stroke, rates sleep as her #1 recommendation for recovery after stroke.

8. Prevent It from Happening Again

Stroke survivors are at higher risk of experiencing another stroke, so prevention is key.

This isn’t the perfect formula, but they’re great guidelines for a generally healthy lifestyle that promotes good health and vitality.

9. Deal with Misbehaving Feet

If you’re suffering from foot drop or curled toes, then AFOs (ankle foot orthosis) can help align your feet and make walking easier and safer.

If you want to regain normal use of your feet without AFOs, then rehab exercises combined with TENS therapy can help get you there.

It’s strongly suggested that you continue to do rehab exercises for your feet and legs because the use of AFOs will make the conditions worse since you won’t be exercising those muscles at all.

Up next is Part 2: Mindset Tips

Source: 28 Stroke Recovery Tips for Healing & Habits – Flint Rehab

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[Abstract] Motor Learning in Stroke. Trained Patients Are Not Equal to Untrained Patients With Less Impairment


Background and Objective: Stroke rehabilitation assumes motor learning contributes to motor recovery, yet motor learning in stroke has received little systematic investigation. Here we aimed to illustrate that despite matching levels of performance on a task, a trained patient should not be considered equal to an untrained patient with less impairment.

Methods: We examined motor learning in healthy control participants and groups of stroke survivors with mild-to-moderate or moderate-to-severe motor impairment. Participants performed a series of isometric contractions of the elbow flexors to navigate an on-screen cursor to different targets, and trained to perform this task over a 4-day period. The speed-accuracy trade-off function (SAF) was assessed for each group, controlling for differences in self-selected movement speeds between individuals.

Results: The initial SAF for each group was proportional to their impairment. All groups were able to improve their performance through skill acquisition. Interestingly, training led the moderate-to-severe group to match the untrained (baseline) performance of the mild-to-moderate group, while the trained mild-to-moderate group matched the untrained (baseline) performance of the controls. Critically, this did not make the two groups equivalent; they differed in their capacity to improve beyond this matched performance level. Specifically, the trained groups had reached a plateau, while the untrained groups had not.

Conclusions: Despite matching levels of performance on a task, a trained patient is not equal to an untrained patient with less impairment. This has important implications for decisions both on the focus of rehabilitation efforts for chronic stroke, as well as for returning to work and other activities.

Source: Motor Learning in Stroke

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[WEB SITE] A New Assistive Glove Can Help People Regain Hand Function After a Stroke – NARIC

About 800,000 Americans have a stroke each year, according to the Centers for Disease Control and Prevention. A stroke occurs when a blood vessel in the brain becomes blocked or bursts, causing brain damage. Sometimes, stroke can lead to long-lasting difficulties with moving one hand or arm due to both muscle weakness and spasms. Therapies are available to help people regain hand mobility after a stroke, but these therapies may not work for people with severely limited hand movement. Research shows that, even with therapy, some people can stall in their recovery (plateau) around three months after experiencing a stroke. A recent NIDILRR-funded study tested a new portable assistive glove to see if it could help people move beyond that plateau and regain hand strength and mobility after a stroke.

Researchers from the Rehabilitation Research and Training Center on Enhancing the Functional and Employment Outcomes of Individuals Who Experience a Stroke tested a new therapy device called the X-Glove. The X-Glove is a modified sports glove with cables running through the back of the glove along the fingers. The cables apply an external source to aid or resist finger movements through a battery-powered system. The glove can be set to one of two modes: passive stretching mode and active training mode. In the passive stretching mode, the glove bends and straightens the user’s finger joints in a repeating cycle. This passive movement provides finger stretching that helps loosen the muscles and reduce spasms. In the active training mode, the glove provides individualized constant tension that maintains the finger joints toward a straight position. The user then bends his or her finger against the tension to build finger strength.

The researchers tested the glove with 13 stroke survivors who were receiving rehabilitation services in a day program, including physical, speech, and occupational therapy. The participants were at least 40 years old and had a stroke in the past 2-6 months. Most had severe limitations in their hand function. The participants completed an additional 15 occupational therapy sessions, 3 per week for 5 weeks, using the X-Glove.

An occupational therapist assists a patient with therapy exercises using the X-glove. The patient is wearing the glove on his right hand and grasping a telephone handset.

Photo: A therapy session with the X-glove.

At the beginning of each session, the participants completed 30 minutes of passive finger stretching with the glove set in the passive stretching mode to help loosen the muscles and reduce spasms. Then they practiced using their hand to complete meaningful tasks for 60 minutes with the glove set in the active training mode to help build strength and skills, while the glove provided resistance. For example, participants practiced grasping, holding, and lifting small objects in their affected hand while pushing against the tension applied by the glove. To find out if the task practice with the X-Glove improved hand function, the researchers first measured participants’ hand mobility and strength three times, once per week over 3 weeks, before the participants started working with the glove. The researchers then took measurements after the participants’ ninth occupational therapy session with the glove, at the end of the fifteenth session, and again one month after the sessions ended.

Although the participants showed little or no improvement in hand strength or function over the course of 3 weeks before working with the glove, they did improve significantly with the help of the X-Glove. For example, the researchers found that participants’ grip was strengthened by about 35% and maintained the strength one month after the treatment ended. The participants also did better on functional tests, such as moving blocks or pouring water from glass to glass. According to the authors, participants showed improvement within the first half of the treatment, and continued to improve throughout the treatment sessions. They suggested that participants could have improved more with more time using the X-Glove.

According to the authors, these findings indicated that with devices like the X-glove, improvements in hand function are possible even for people with severe hand impairment after a stroke. Incorporating both passive stretching of and active practice with the hand during occupational therapy using a device like the X-Glove may help push past the therapy plateau if implemented soon after a stroke. For future research, the authors recommended randomized controlled trials to test the X-Glove with stroke patients in inpatient and outpatient rehabilitation settings, as well as studies with longer treatment and follow-up periods.

To Learn More

The prototype X-Glove and other hand rehabilitation technology are under development at the Rehabilitation Institute of Chicago’s Hand Rehabilitation Laboratory:

To see the X-Glove and other hand rehabilitation technology in action, check out this Prezi from the Hand Rehabilitation Laboratory

Flint Rehabilitation developed the Music Glove, another hand rehabilitation device that was tested under a NIDILRR grant and shown to improve hand function post-stroke:

The American Stroke Association and the National Stroke Association both offer resources for stroke recovery:

To Learn More About This Study

Fischer, H.C., Triandafilou, K.M., Thielbar, K.O., Ochoa, J.M., Lazzaro, E.D.C., Pacholski, K.A., & Kamper, D.G. (2016) Use of a portable assistive glove to facilitate rehabilitation in stroke survivors with severe hand impairment. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 24(3), 344-351. This article is available from the NARIC collection under Accession Number J73926

Date published:


Source: National Rehabilitation Information Center | Information for Independence

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[WEB SITE] Magnifying mistakes boosts motor skills past a performance plateau – Medical News Today

Virtual tetherball shows that reducing neural “noise” could help sharpen motor skills.

Exaggerating the visual appearance of mistakes could help people further improve their motor skills after an initial performance peak, according to a new study published inPLOS Computational Biology.

Previous research has shown that manipulating the perception of mistakes can improve motor skills. Dagmar Sternad, Christopher Hasson and colleagues from Northeastern University in Boston and Hokkaido University in Japan set out to examine whether this strategy could further enhance skills after they plateau.

In the study, 42 healthy participants learned a virtual tetherball-like game in which they tried to hit a target with a ball hanging from a pole. After three days, all players reached a performance plateau. Then, for some players, the researchers secretly manipulated the game so that the distance by which the ball missed the target appeared bigger on screen than it actually was.

Participants whose mistakes appeared at least twice as bad as they really were broke past their plateau and continued sharpening their tetherball skills. A control group that remained undeceived showed negligible improvement.

By analyzing the players’ actions using computational learning models, the researchers found that error exaggeration did not change how they made corrections in their throwing techniques. Instead, it reduced random fluctuations, or noise, in nervous system signals that control muscle movement. These findings challenge existing assumptions that such noise cannot be reduced.

The authors point out that their results could help improve strategies to aid people who have reached a motor skills plateau, including elite athletes, healthy elders, stroke patients, and children with dystonia. Future research could reveal the physiological mechanisms underlying the findings.

This work was supported by the National Institute of Child Health and Human Development (NICHD) R01 HD045639, National Institute on Aging (NIA) 1F32 AR061238, National Science Foundation NSF-DMS 0928587, and the U.S. Army Research Institute for the Behavioral and Social Sciences (W5J9CQ-12-C-0046). DS was also supported by a visiting scientist appointment at the Max-Planck Institute for Intelligent Systems in Tübingen, Germany. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the authors and do not necessarily reflect the views of the funding organizations. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The authors have declared that no competing interests exist.

Article: Neuromotor Noise Is Malleable by Amplifying Perceived Errors, Hasson CJ, Zhang Z, Abe MO, Sternad D, PLOS Computational Biology, doi:10.1371/journal.pcbi.1005044, published 4 August 2016.

Source: Magnifying mistakes boosts motor skills past a performance plateau – Medical News Today

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[ARTICLE] Stroke rehabilitation research needs to be different to make a difference – Full Text HTML


Stroke continues to be a major cause of adult disability. In contrast to progress in stroke prevention and acute medical management, there have been no major breakthroughs in rehabilitation therapies. Most stroke rehabilitation trials are conducted with patients at the chronic stage of recovery and this limits their translation to clinical practice. Encouragingly, several multi-centre rehabilitation trials, conducted during the first few weeks after stroke, have recently been reported; however, all were negative. There is a renewed focus on improving the quality of stroke rehabilitation research through greater harmonisation and standardisation of terminology, trial design, measures, and reporting. However, there is also a need for more pragmatic trials to test interventions in a way that assists their translation to clinical practice. Novel interventions with a strong mechanistic rationale need to be tested in both explanatory and pragmatic trials if we are to make a meaningful difference to stroke rehabilitation practice and outcomes.


Stroke is a leading cause of adult disability worldwide 1. Advances in stroke prevention have led to a decline in stroke incidence, particularly in developed countries 2. There have also been recent advances in acute stroke treatment with thrombolysis and clot retrieval 3. However, the number of people living with the consequences of stroke continues to rise 2. Stroke rehabilitation has steadily evolved with new service delivery models and a greater understanding of the importance of therapy intensity and task specificity. However, the search continues for new therapies that can be widely incorporated into routine clinical practice, despite more than 1000 randomised controlled trials (RCTs) having been conducted 4.

One factor that may limit the translational impact of stroke rehabilitation RCTs is their timing. It is important to conduct rehabilitation trials during the initial days and weeks after stroke because this is when spontaneous biological recovery (SBR) is taking place 5 and when rehabilitation is delivered in the ‘real world’. Testing an intervention at the time of its intended use is crucial for evaluating its efficacy as well as its feasibility in clinical practice. We have found that over half of motor rehabilitation RCTs are conducted with patients who are at least 6 months post-stroke, when rehabilitation services are no longer available to most patients 6. Only 5% of RCTs were of good quality and recruited all patients within 30 days of stroke. Of these, half were negative. Compared with negative trials, the positive trials were more likely to recruit fewer than 40 patients and have no follow-up measures. There is clearly a need for larger trials conducted early after stroke in the real-world clinical setting.

In the last 18 months, six multi-centre rehabilitation RCTs that recruited patients within the first 3 months after stroke have been reported. These trials are summarised below.

1. SIRRACT (Stroke Inpatient Rehabilitation Reinforcement of ACTivity) recruited 135 patients within 45 days after stroke at 16 sites over the course of 15 months 7. Participants were randomly assigned to either standardised verbal feedback about walking speed or augmented feedback based on activity graphs derived from wireless activity sensors. The primary outcomes were average daily time spent walking during inpatient rehabilitation and the fastest safe 15-metre walking speed at discharge from inpatient rehabilitation.

2. CIRCIT (Circuit class therapy or seven-day week therapy for Increasing Rehabilitation Intensity of Therapy after stroke) recruited 283 patients between 5 and 197 days (mean of 28 days) after stroke at five sites in 36 months 8. Participants were randomly assigned to usual care therapy 5 days per week, usual care therapy 7 days per week, or circuit class therapy 5 days per week. The primary outcome was the 6-minute walk test at 4 weeks post-randomisation.

3. AVERT (A Very Early Rehabilitation Trial) recruited 2104 patients within 24 hours of stroke symptom onset at 56 sites over the course of 100 months 9. Participants were randomly assigned to usual care or very early mobilisation, which required at least three additional out-of-bed sessions targeting standing and walking beginning within 24 hours of stroke. The primary outcome was a favourable outcome 3 months after stroke, defined as a modified Rankin Scale score of 0, 1, or 2.

4. A trial of acupuncture recruited 862 patients between 3 and 10 days after stroke at 40 sites in 35 months10. Participants were randomly assigned to either usual care alone or with the addition of acupuncture 5 days per week for 3 weeks. The primary outcome was death or disability at 6 months post-stroke, defined as a Barthel Index score of not more than 60 points.

5. The ICARE (Interdisciplinary Comprehensive Arm Rehabilitation Evaluation) trial recruited 361 patients between 16 and 106 days (mean of 46 days) after stroke at seven sites in 45 months 11. Participants were randomly assigned to usual and customary care, a 30-hour programme of task-oriented motor rehabilitation for the upper limb delivered over 10 weeks, or dose-equivalent usual and customary upper-limb therapy. The primary outcome was the change in the log-transformed time score from the Wolf Motor Function Test, between baseline and 12 months after randomisation.

6. The SWIFT (Soft-Scotch Walking Initial FooT) Cast trial recruited 105 patients between 3 and 42 days (mean of 21 days) after stroke at two sites in 25 months. Participants were randomly assigned to conventional physical therapy with a conventional ankle-foot orthosis or with a customised ankle-foot orthosis 12. The primary outcome was walking speed at the end of the 6-week intervention.

None of these trials found that the intervention was superior to standard care, and one found that the intervention worsened outcomes 9. These are disappointing results for many of the clinicians and researchers who worked on the trials, for the funding bodies, and most importantly for the patients involved and the wider stroke community. Although these trials at least demonstrate that large multi-centre rehabilitation trials can be conducted at the subacute stage of stroke, it should also be noted that two of the larger trials took several years to complete, recruited less than 10% of screened patients, and had recruitment rates less than one patient per month per site 9, 11. A low proportion of patients recruited raises potential concerns about the generalisability of the intervention, whereas a slow recruitment rate raises potential concerns about the feasibility of similar studies in the future.

Low and slow recruitment can be the product of strict inclusion/exclusion criteria, typical of explanatory trials designed to show that a standardised treatment is efficacious in a carefully selected group of patients. Although these are features of a well-designed study, they can also limit the trial’s usefulness to real-world clinical practice. If the treatment is found to be beneficial, the clinician does not know whether to use it for a patient who would have been excluded from the trial or in a setting that cannot provide the precisely defined treatment.

The issue of generalisability has long been recognised 13 and needs to be explicitly addressed in stroke rehabilitation research. As a simple starting point, an intervention’s generalisability could be more easily appreciated if trials reported the proportion of patients for whom an intervention is suitable, even if they cannot participate in research because of factors such as reduced capacity for consent, having contraindications to research measures such as magnetic resonance imaging, or being enrolled in another study. This has been reported by two rehabilitation RCTs that recruited all patients within 30 days of stroke. One reported that the intervention was suitable for 40% of all admitted stroke patients and 9% were eligible for participation in the trial 14. The other reported that the intervention was suitable for 11% of all admitted stroke patients and 3% were eligible for participation in the trial 15. Distinguishing between eligibility for the intervention and eligibility for research provides a clearer picture of the proportion of patients who could potentially benefit from the intervention if it were part of routine clinical practice.

Continue —> Stroke rehabilitation research needs to be different to make a difference

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[Abstract] A review of the progression and future implications of brain-computer interface therapies for restoration of distal upper extremity motor function after stroke.


Stroke is a leading cause of acquired disability resulting in distal upper extremity functional motor impairment. Stroke mortality rates continue to decline with advances in healthcare and medical technology. This has led to an increased demand for advanced, personalized rehabilitation.
Survivors often experience some level of spontaneous recovery shortly after their stroke event, yet reach a functional plateau after which there is exiguous motor recovery. Nevertheless, studies have demonstrated the potential for recovery beyond this plateau.
Non-traditional neurorehabilitation techniques, such as those incorporating the brain-computer interface (BCI), are being investigated for rehabilitation. BCIs may offer a gateway to the brain’s plasticity and revolutionize how humans interact with the world.
Non-invasive BCIs work by closing the proprioceptive feedback loop with real-time, multi-sensory feedback allowing for volitional modulation of brain signals to assist hand function. BCI technology potentially promotes neuroplasticity and Hebbian-based motor recovery by rewarding cortical activity associated with sensory-motor rhythms through use with a variety of self-guided and assistive modalities.

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Source: A review of the progression and future implications of brain-computer interface therapies for restoration of distal upper extremity motor function after stroke – Expert Review of Medical Devices – Volume 13, Issue 5

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