[WEB] A smart glove to improve stroke rehabilitation

by University of Southampton

The stroke glove prototype on a lab model. Credit: University of Southampton

An electronic glove that enables movement in the paralyzed hand of stroke survivors to support their rehabilitation has been invented by a team from the University of Southampton.

The glove has electrodes printed on the sleeve that make contact with the skin. The electrodes send electronic impulses to stimulate the nerves and muscles to produce an artificial movement. It enables stroke survivors to achieve movement in their weak side, helping them to regain muscle strength and function.

The glove has been designed and made by Kai Yang, Professor of E-textiles in Healthcare, and her team based at the university’s Winchester School of Art. Professor Yang explained, “I wanted to develop something easy for stroke survivors to use at home. People who have suffered a stroke get fatigued easily, so engaging in long rehabilitation sessions is very challenging. This glove enables them to work on their rehab in small blocks of time when it suits them. With stroke rehabilitation, the more you practice movement, the more you regain muscle strength and mobility.”

The prototype glove has been developed and made at Winchester School of Art, using the school’s industrial knitting machines. The electrodes are printed inside the sleeve and connected to an electronic control unit, allowing the user to vary the level of stimulation as required.

Professor Yang has worked with Different Strokes Southampton, a charity run by stroke survivors for stroke survivors, to develop the glove.

Through the charity, she has worked with stroke survivor Dave Lea, from Chandler’s Ford. He suffered a major stroke in 2015, at the age of 54, that has left him largely paralyzed on his right-hand side. The glove enables him to move his paralyzed right hand. “It’s life changing,” he said. “It means I can move my hand—something I’ve been unable to do for eight years.”

Mr. Lea’s wife, Sarah, added, “It was really emotional seeing Dave test run the glove for the first time—it’s incredible that it enables him to move his hand. It really could change the lives of stroke survivors.”

Ranj Parmar, Group Coordinator at Different Strokes Southampton and a stroke survivor himself, added, “The benefits of the stroke rehabilitation sleeve are extremely impactful. It allows stroke survivors to be able to continue their rehab many weeks and months after their stroke. It enables a stroke survivor to open their affected hand and when performed repeatedly it should enable the opening and closing of the hand more easily.”

Professor Yang is now looking to refine the design of the prototype glove by working with more stroke survivors, and then conduct a home usability test with stroke survivors using the glove multiple times every day. Following this, she intends to seek regulatory approval and then work with a manufacturer to scale-up the production of the glove.

“We are delighted with the prototype and would like to see this become a product that’s available to all stroke survivors, to help improve their recovery and their quality of life,” she said.

Provided by University of Southampton 

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Playing video games helps stroke recovery

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[ARTICLE] Increasing the delivery of upper limb constraint-induced movement therapy programs for stroke and brain injury survivors: evaluation of the ACTIveARM project – Full Text

Abstract

Purpose

To increase the number of constraint-induced movement therapy (CIMT) programs provided by rehabilitation services.

Methods

A before-and-after implementation study involving nine rehabilitation services. The implementation package to help change practice included file audit–feedback cycles, 2-day workshops, poster reminders, a community-of-practice and drop-in support. File audits were conducted at baseline, every three months for 1.5 years, and once after support ceased to evaluate maintenance of change. CIMT participant outcomes were collected to evaluate CIMT effectiveness and maintenance (Action Research Arm Test and Motor Activity Log). Staff focus groups explored factors influencing CIMT delivery.

Results

CIMT adoption improved from baseline where only 2% of eligible people were offered and/or received CIMT (n = 408 files) to more than 50% over 1.5 years post-implementation (n = 792 files, 52% to 73% offered CIMT, 27%–46% received CIMT). Changes were maintained at 6-month follow-up (n = 172 files, 56% offered CIMT, 40% received CIMT). CIMT participants (n = 74) demonstrated clinically significant improvements in arm function and occupational performance. Factors influencing adoption included interdisciplinary collaboration, patient support needs, intervention adaptations, a need for continued training, and clinician support.

Conclusions

The implementation package helped therapists overcome an evidence-practice gap and deliver CIMT more routinely.

IMPLICATIONS FOR REHABILITATION

• Constraint induced movement therapy (CIMT) is a highly effective intervention for arm recovery after acquired brain injury, recommended in multiple clinical practice guidelines yet delivery of CIMT in practice remains rare.
• A multifaceted implementation package including clinician training workshops, a community of practice, drop in support and regular audit and feedback cycles improved delivery of CIMT programs in practice by neurorehabilitation teams.
• Stroke survivors and people with brain injury who received a CIMT program in usual practice demonstrated clinically important improvements in arm function, dexterity and occupational performance.

Introduction

Constraint-induced movement therapy (CIMT) is a recommended intervention for arm recovery after stroke and acquired brain injury in multiple clinical practice guidelines [Citation1–4]. A systematic review of 44 randomised controlled trials reported positive effects on arm motor function, arm-hand activities, self-reported amount of arm-hand use and quality of arm-hand movement in daily life (effect sizes from <0.2 to 0.8) [Citation5], yet delivery of CIMT in practice remains limited [Citation6]. An international survey of therapists who reported using CIMT, found CIMT programs were being offered but not always delivered with fidelity, and most therapists offered CIMT programs only once or twice annually (n = 99, 58.6%) [Citation7]. Therapists who routinely deliver CIMT report factors such as organisational support and access to resources and training enable implementation and sustainability [Citation8].

Adoption of CIMT into routine practice (i.e., where CIMT is offered and delivered to all eligible and consenting patients) remains a significant evidence–practice gap. Only 11% of eligible stroke survivors received CIMT in 2020 during their rehabilitation in Australia [Citation6]. Strategies that support implementation include CIMT education and training, written resources, ongoing coaching, mentoring, and modelling from a senior therapist [Citation9,Citation10]. This highlights a need for active support beyond initial education and training to facilitate CIMT implementation and maintenance in routine practice. Thus, effective strategies are needed to help therapists adopt, offer, and routinely deliver CIMT to eligible patients. To address this evidence-practice gap, we developed a staff behaviour change intervention as part of the Australian Constraint Therapy Implementation study of the Arm (ACTIveARM), described in detail elsewhere [Citation11].

There is a need to evaluate the impact of behaviour change interventions, such as ACTIveARM, on the delivery of evidence-based interventions, in this case, CIMT programs. The impact can be measured via patient outcomes and clinician behaviour change [Citation12]. Comprehensive evaluation can also identify additional team and organisational factors that may influence outcomes if the behaviour change intervention was to be scaled up to other organisations.

RE-AIM is an evaluative framework that identifies the essential elements needed for sustained adoption and implementation of evidence-based interventions [Citation13]. The framework comprises five key dimensions: Reach to the target population; Effectiveness of the evidence-based intervention; Adoption of the intervention by staff, settings or institutions; Implementation of the intervention including program adaptations, fidelity, costs, and consistency of program delivery; and Maintenance of the intervention effects, both maintenance of patient outcomes (individual level) and routine delivery of the intervention in practice over time (setting level) [Citation13]. The RE-AIM framework can be used to evaluate the effectiveness of implementation strategies, and the scale-up of such strategies and interventions to other settings [Citation14], and was used in the ACTIveARM study.

The aim of this study was to evaluate whether the ACTIveARM implementation package, a theoretically-informed behaviour change intervention, could change therapist behaviour and increase the number of CIMT programs offered and delivered to eligible stroke and brain injury patients.

The primary research question related to RE-AIM dimensions of Adoption and Maintenance (setting level):

Q1. Is there an increase in the number and proportion of eligible patients who are offered a CIMT program after therapists receive the ACTIveARM implementation package (Adoption), and is this practice change sustained (Maintenance – setting level)?

Secondary research questions related to the Reach, Effectiveness, Implementation, and Maintenance (individual and setting levels) of CIMT programs in practice were:

Q2. Is there an increase in the number and proportion of eligible patients who are provided with a CIMT program after therapists receive the ACTIveARM implementation package (Reach), and is this practice change sustained (Maintenance – setting level)?

Q3. Do patients with stroke and traumatic brain injury who complete a CIMT program achieve upper limb outcomes consistent with published outcomes (Effectiveness), and are these effects sustained (Maintenance – individual level)?

Q4. How consistently is CIMT delivered across settings and staff, including adaptations to improve feasibility in public health settings? (Implementation)

Q5. What supports are needed by therapy teams to sustain changes in their practice, and continue to offer and deliver CIMT programs as part of routine care (Maintenance – setting level)? […]

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[NEWS] ChatGPT and rehab: a mystery that requires further investigation

Now that ChatGPT can “see” and “hear,” could it be useful for people with mobility, sensory or cognitive disabilities?

Whether it’s a question of analyzing medical images, detecting drug interactions, or creating brain-computer interfaces, it seems like the potential applications of artificial intelligence (AI) in the healthcare industry are endless.

Could an AI chatbot like ChatGPT be a useful tool for healthcare professionals?

More specifically, could ChatGPT’s new features, which can decipher images and speak fluently with others, allow it to be used in rehab?

Already part of our lives

These technologies are already part of our lives and could help people overcome various disabilities in several ways, according to Dahlia Kairy and Joseph Omer Dyer, physiotherapy professors at Université de Montréal’s School of Rehabilitation.

They believe that ChatGPT’s voice-command feature could make it easier for people with mobility or sensory impairments to communicate and access information. Individuals recovering from a brain injury or stroke could also use these technologies’ vocal and linguistic abilities to have a conversation.

According to Dyer, ChatGPT could be used for to plan agendas, book appointmens and figure out when different kinds of medication should be taken. Similarly, Kairy thinks ChatGPT could suggest exercises that suit each patient’s unique needs (socioeconomic situation, age, and physical, mental and neurological condition)  and explain how and why they should be performed.

“In short, patients could use ChatGPT to free them from some of the restrictions imposed by their condition, as well as to find information they need,” said Dyer. “But anyone who uses this software needs to think critically, in addition to understanding the nitty-gritty of how it works and any risks it may pose.”

Need to be cautious

Both professors agree that we still need to be cautious and make sure ChatGPT doesn’t have any unexpected repercussions. “We’re flying blind, said Dyer. We don’t have any conclusive data to show that ChatGPT can help or at least prove that it’s harmless,” added Kairy.

As a physiotherapist and researcher at UdeM’s Groupe interdisciplinaire de recherche sur la cognition et raisonnement professionnel, Dyer is concerned about the ethical and professional issues raised by ChatGPT.

“If I share personal information with it to make a diagnosis or a decision, am I violating my patient’s confidentiality?” he asked. “And if I suggest a patient use it to overcome their disability, I don’t have any scientific data that confirms it will actually be useful. I also don’t know what the side effects could be.”

Kairy, a researcher with the Centre for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), wonders whether ChatGPT could keep patients from progressing with their rehab because they would no longer be forced to gradually develop their physical skills.

“Since the AI ultimately ends up doing certain things for us, we could permanently lose the ability to do them ourselves,” suggested Kairy, who’s also an expert in telerehabilitation. “We still don’t have any evidence, but we have reasonable grounds to believe that, at least neurologically speaking, it really is a question of use it or lose it.”

The professors also warned that using ChatGPT for rehab could lead to issues such as digital addiction or social isolation.

More research needed

Before using ChatGPT in a clinical setting, Kairy and Dyer want to be sure that regulations are in place to protect privacy and ensure that the software is used ethically. They also want scientific evidence that it is in fact useful.

They’re counting on universities to research these questions, dig deeper and eventually answer them. And they hope colleagues from other fields will work on the issue.

“As academics, our role is to put our tools and resources to good use in our respective fields to move science and society forward,” said Dyer.

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[WEB] Could virtual reality be the answer to post-stroke rehabilitation?

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• By Neha Mathur ,Sep 19 2023, Reviewed by Sophia Coveney

In a recent article published in eClinicalMedicine, researchers evaluated the effectiveness and safety of virtual reality (VR), an innovative neurorehabilitation modality, in people diagnosed with cerebral stroke.

Study: Effectiveness and safety of virtual reality rehabilitation after stroke: an overview of systematic reviews. Image Credit: Motortion Films/Shutterstock.com

Background

Over 12 million new strokes occur each year globally. However, by 2050, the global stroke burden may double.

According to the World Health Organisation (WHO) estimates, upper limb impairment, decreased ability to self-care, and social inactivity are common in stroke survivors, which can cause a deterioration in quality of life.

Given the continuous expansion in the number of stroke survivors, there is a need for more engaging, interactive, patient-centered, and relatively inexpensive modalities to enhance functional recovery.

One can access VR via personal computers, mobile devices, VR glasses, and head-mounted displays. It allows a patient to immerse in environments similar to real-world events and objects.

Moreover, they provide real-time feedback through their sensory channels. Furthermore, VR can be non-, semi-, or fully immersive based on the extent of a user’s perceived presence and interaction with the virtual environment.

Systems that utilize concave surface projection, head-mounted displays, or video capture are immersive, while single-screen projection or desktop displays where users can interact with a computer-generated avatar are non-immersive. VR glasses that enable users to navigate by a visual stimulus are semi-immersive VR.

VR appears to have the potential to maximize motor learning after a stroke. Many previous systematic reviews uncovered the discordances of VR use on upper limb function (arm and hands) and activity compared to conventional therapy, emphasizing the need for an overview of reviews in accordance with the Cochrane guidelines.

About the study

In the present study, researchers searched 11 databases, e.g., SCOPUS and grey literature, from inception to January 17, 2023, and identified systematic reviews published in English that covered adult patients with a clinical diagnosis of stroke undergoing VR intervention with/without conventional therapy vs. conventional therapy only. 

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Eligible systematic reviews with and without meta-analysis of randomized controlled trials (RCTs) or both RCTs and non-randomized studies of interventions (NRSI) involved adult patients with a clinical diagnosis of acute or chronic stroke who had motor impairments and were undergoing non-, semi-, or non-immersive VR interventions.

The primary study outcome was upper limb function and activity, and secondary outcomes were measures of gait, activities of daily living (ADL), participation restriction and quality of life, cognitive function, and other adverse events.

Results

The current overview of multiple (n=58) systematic reviews summarized the evidence from 42 meta-analyses, including 345 primary studies on VR intervention used for stroke.

Almost 40% of the trials were published in the last five years, suggesting the need for new evidence to update the available evidence.

Multiple meta-analyses using the Fugl Meyer Assessment scale (FMA-UE) to measure upper limb function and activity found that VR with or without conventional therapy was superior to conventional therapy, with low to moderate certainty of evidence (CoE) and probable to definite clinical relevance.

On the contrary, VR motor rehabilitation did not affect arm activity assessed with the Box and Block Test (BBT), Wolf Motor Function Test (WMFT), and Action Research Arm Test (ARAT).

Some reviews reported equal effects of VR and conventional therapy between study groups. VR might be useful for patients who need to perform a cognitive task but also refine the quality of movement during task execution. Further, VR might have a beneficial effect on mobility, balance, and ADL.

Thus, overall, VR could be considered a safe neurorehabilitation intervention with few mild adverse events. However, there is a need to minimize the risk of falling during balance training.

Conclusions

Clinicians should evaluate ways to incorporate VR into post-stroke rehabilitation interventions for patient’s motor recovery.

Depending on a patient’s training aims, they could introduce tailored exercises with visual, auditory, and tactile feedback, which might help patients improve performance and personal capacity.

Given the current expansion of knowledge regarding gender medicine and individualized therapy, clinicians should incorporate this research into VR rehabilitation.

For example, higher stress levels might increase female susceptibility to simulator sickness and discomfort during VR. Clinicians should be ready to handle this by defining the type of technology and intervention dose appropriate for each patient.

According to the authors, this is the broadest overview of systematic reviews examining VR as a stroke rehabilitation intervention yet. However, since many of the reviews included in this overview used poor methodological quality, its findings must be interpreted with caution.

Journal reference:

• Bargeri S, Scalea S, Agosta F, et al. (2023). Effectiveness and safety of virtual reality rehabilitation after stroke: an overview of systematic reviews, eClinicalMedicine. doi:10.1016/j.eclinm.2023.102220. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(23)00397-8/fulltext

Source: https://www.news-medical.net/news/20230919/Effectiveness-and-safety-of-virtual-reality-rehabilitation-post-stroke.aspx

[NEWS] New AI-based system aims to facilitate the rehabilitation process for stroke patients

Reviewed by Lily Ramsey, LLM Jul 24 2023

Statistics indicate that globally 1 in 4 adults over the age of 25 will have a stroke in their lifetime. One of the most serious consequences of this disease is disability. The joint study by Rytis Maskeliūnas, a researcher at Kaunas University of Technology, Faculty of Informatics (KTU IF), and Lithuanian researchers is focused on creating an artificial intelligence (AI)-based system that aims to facilitate the rehabilitation process.

More recently, a team of researchers presented BiomacVR, an innovation that aims to help stroke victims get back on their feet as quickly as possible. Shortly afterwards, a third component of this technology was developed: BiomacEMG.

According to Maskeliūnas, the new system is a part of the Biomac project’s solutions, for monitoring the arm. This system will be useful for those patients who need to monitor the movements of the hand or the whole arm during rehabilitation exercises.

The KTU researcher believes that the integration of motion recognition technology into physical therapy is an innovation that will allow patients to focus on the task at hand and perform it correctly. The software enables the patient to study and adjust the exercises, which ensures an efficient healing and rehabilitation process.

Motion is measured by a bracelet

According to the researcher, the new system essentially measures muscle movements: “Our study evaluated the technical feasibility of measuring and recognizing the arm movements of the participants in the experiment, and thus monitoring the rehabilitation or other medical process”.

At this stage, in order to check the accuracy, it was chosen to measure not only the movements of the whole arm or another large part of the body but also more precise scenarios, i.e. to investigate the movements made by the fingers.

The wearable equipment, more specifically, a bracelet measuring the state of the nerves, muscles and the nerve cells that control them, is placed on the forearm and used to measure different types of muscle groups in real-time. According to Maskeliūnas, the process is simple – you put the bracelet on your arm and try to make the gestures shown in the picture. The system (or a doctor online) informs you whether you are doing the exercises correctly or incorrectly.

Our team was responsible for the system, and the colleagues from other Lithuanian universities developed the biomechanics model (a model of the muscles and their movements) and carried out the testing.”

Rytis Maskeliūnas, Researcher, Kaunas University of Technology

The system benefits not only the patient but also the professional

“Our new methodology with electromyography (EMG) elements is particularly important for proper exercise design during a rehabilitation programme. With this new technology, you can see exactly which muscle is working and at what capacity, how it reacts to the load and how quickly it recovers. This information allows the specialist to work with the patient not blindly, but knowing exactly which muscles are working well, which are overworked, or which are not even tired,” says Aušra Adomavičienė, a researcher at the Faculty of Medicine at Vilnius University (VU MF).

In her opinion, such technology is not only a great help to the rehabilitation specialist, but it is equally essential for the patient, who, with such technology, can continue the exercises at home, see the progress, and feel safe and secure, without doubts about whether they are doing it right, or whether they are harming themselves, etc.

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“This system is important for patients with musculoskeletal disorders or diseases that require the restoration of lost movement and mobility function, which is directly caused by reduced or lost muscle function. These are the patients who have suffered a cerebral infarction, various traumas, fractures, soft tissue or nerve damage, systemic diseases such as Multiple Sclerosis or Parkinson’s Disease,” says Adomavičienė.

The researcher points out that this innovative technology can also be used for wellness purposes. For example, people who, due to irregular, poor working posture, or repetitive movements at work that strain one segment of the body, have muscular imbalances in their bodies, and often experience chronic pain (back, shoulder or wrist) or fatigue. According to Adomavičienė, the simple, user-friendly and easy-to-use technology is suitable for people of any age, whether child or adult.

These technologies are our future

“I think that after 20 years, patients and professionals involved in rehabilitation will not even be able to imagine that during functional assessment, testing and program execution, they were guided by the subjective, hand-held instruments that we now use on a daily basis,” says Adomavičienė.

According to her, computerized and intelligent systems based on artificial intelligence strategies will not only be able to identify in detail the problems experienced by the patient, but after the assessment, they will be able to analyze, systematize and provide feedback, i.e. to provide information and recommendations during the live sessions on how to adjust the rehabilitation programme individually according to the patient’s situation to increase tolerance to physical load, activate recovery mechanisms and the healing process.

KTU researcher Maskeliūnas agrees with his colleague: “Future research should also look at the development of individualised treatment plans and the adaptation of the algorithm to respond to a wider range of possible actions, taking into account the individual needs of the patient.”

Although the study evaluated the accuracy of the system in measuring hand movement patterns, the long-term impact on functional recovery in stroke patients needs to be further investigated, including the integration of this approach with other therapies such as occupational and physical therapy, according to Maskeliūnas.

Source: Kaunas University of Technology (KTU)

[ARTICLE] Research Status and Emerging Trends in Virtual Reality Rehabilitation: Bibliometric and Knowledge Graph Study – Full Text

Abstract

Background:Virtual reality (VR) technology has been widely used in rehabilitation training because of its immersive, interactive, and imaginative features. A comprehensive bibliometric review is required to help researchers focus on future directions based on the new definitions of VR technologies in rehabilitation, which reveal new situations and requirements.

Objective:Herein, we aimed to summarize effective research methods for and potential innovative approaches to VR rehabilitation by evaluating publications from various countries to encourage research on efficient strategies to improve VR rehabilitation.

Methods:The SCIE (Science Citation Index Expanded) database was searched on January 20, 2022, for publications related to the application of VR technology in rehabilitation research. We found 1617 papers, and we created a clustered network, using the 46,116 references cited in the papers. CiteSpace V (Drexel University) and VOSviewer (Leiden University) were used to identify countries, institutions, journals, keywords, cocited references, and research hot spots.

Results:A total of 63 countries and 1921 institutes have contributed publications. The United States of America has taken the leading position in this field; it has the highest number of publications; the highest h-index; and the largest collaborative network, which includes other countries. The reference clusters of SCIE papers were divided into the following nine categories: kinematics, neurorehabilitation, brain injury, exergames, aging, motor rehabilitation, mobility, cerebral palsy, and exercise intensity. The research frontiers were represented by the following keywords: video games (2017-2021), and young adults (2018-2021).

Conclusions:Our study comprehensively assesses the current research state of VR rehabilitation and analyzes the current research hot spots and future trends in the field, with the aims of providing resources for more intensive investigation and encouraging more researchers to further develop VR rehabilitation.

Introduction

In recent years, the number of people with rehabilitation needs has increased, particularly among groups of older patients, patients with disabilities, patients with chronic diseases, and patients with functional and cognitive impairments. The loss of movement, sensation, balance, and cognition, as well as other aspects, seriously affects patients’ quality of life, work, study, and social life [1,2]. Such patients require long-term, consistent rehabilitation training and guidance [3]. However, traditional rehabilitation training has a number of problems, including fixed rehabilitation centers, a lack of rehabilitation resources, uninteresting training processes, high treatment costs, and a lack of automatic guidance and incentive mechanisms. These result in a lack of confidence in the rehabilitation process, which in turn affects the outcomes of rehabilitation treatments [4,5].

With the gradual popularization of virtual reality (VR) technology, rehabilitation training systems based on VR technology have been gradually applied in sports, exercise, and functional rehabilitation for various diseases and have achieved positive effect results [6,7]. The combination of VR technology and rehabilitation medicine can enable more patients to train regularly at home or in the community, as VR rehabilitation systems provide an immersive experience that stimulates patients’ interest and improves their participation, thus overcoming the disadvantages of fixed centers and the lack of resources [8]. Furthermore, VR rehabilitation systems can sense and record a patient’s movement and biological data via sensors to further improve existing rehabilitation programs [9]. This rehabilitation technology is a useful supplement to traditional rehabilitation and is a promising new research direction in the field of rehabilitation medicine.

A comprehensive bibliometric review is required to help researchers focus on future directions based on the new definitions of VR technologies in rehabilitation, which reveal new situations and requirements. Although bibliometric methods have yielded positive results in a variety of fields, we found that there is still a significant gap in the research on VR rehabilitation and its development trends by using bibliometric methods.

We used bibliometric methods to analyze SCIE (Science Citation Index Expanded) papers on studies related to VR rehabilitation research. Articles from different countries, regions, and research institutions were included. We identified papers in journals, gathered the top 10 citations, and enumerated how many times these citations were used. The VR rehabilitation knowledge base was analyzed by grouping authors’ co-occurring keyword networks. Burst citations were used to identify research hot spots on this topic, which could provide a useful reference for future research [10,11]. These analyses will provide rehabilitation specialists with a macroscopic understanding of the knowledge domain as a whole, as well as a microscopic characterization. Compared to other reviews, our study is timely and visual and provides an impartial approach to developing and exploring particular knowledge domains. Our findings may encourage more researchers to conduct additional research in this field to further develop VR rehabilitation methods. The following basic information was gathered from studies: titles, abstracts, author information, institutions, countries, regions, keywords, and citations.[…]

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Figure 6. The dual map overlay of journals that contributed to publications on virtual reality rehabilitation.

[WEB] Scientists develop new tool to monitor brain plasticity

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Reviewed by Emily Henderson, B.Sc. Oct 19 2022

Scientists at Scripps Research have developed a new tool to monitor brain plasticity-;the way our brains remodel and physically adapt as we learn and experience things, from watching a movie to learning a new song or language. Their approach, which measures the proteins produced by individual types of brain cells, has the potential to both answer basic questions about how the brain works, and shed light on numerous brain diseases in which plasticity goes awry.

Prior experiments in several labs have already revealed how brain activity spurs changes in the gene expression in neurons, an early step in plasticity. The team’s experiments, described in Journal of Neuroscience on September 7, focus on the next essential step in plasticity, translation of the genetic code into proteins.

We still don’t understand all the mechanisms underlying how cells in our brain change in response to experiences, but this approach gives us a new window into the process.”

Hollis Cline, PhD, the Hahn Professor and Chair of Neuroscience at Scripps Research and Senior Author  

When you learn something new, two things happen: First, neurons immediately pass electrical signals along new routes in your brain. Then, over time, this leads to changes in the physical structure of cells and their connections in the brain. But scientists have long wondered what happens in between these two steps. How does this electrical activity in neurons ultimately coax the brain to change in more lasting ways? Even further, how and why does this plasticity decrease with age and certain diseases?

Previously, researchers have studied how genes in neurons turn on and off in response to brain activity, hoping to get insight into plasticity. With the advent of high-throughput gene sequencing technologies, tracking genes in this way has become relatively easy. But most of those genes encode proteins-;the real workhorses of cells, the levels of which are more difficult to monitor. But Cline, in close collaboration with Scripps professor John Yates III, PhD, and associate professor Anton Maximov, PhD, wanted to look directly at how proteins in the brain change.

“We wanted to jump into the deep end of the pool and see what proteins are important to brain plasticity,” says Cline.

The team designed a system in which they could introduce a specially tagged amino acid-;one of the building blocks of proteins-;into one type of neuron at a time. As the cells produced new proteins, they would incorporate this amino acid, azidonorleucine, into their structures. By tracking which proteins contained the azidonorleucine over time, the researchers could monitor newly made proteins and distinguish them from pre-existing proteins.

Cline’s group used the azidonorleucine to track which proteins were made after mice experienced a large and widespread spike in brain activity, mimicking what happens at a smaller scale when we experience the world around us. The team focused on cortical glutamatergic neurons, a major class of brain cell responsible for processing sensory information.

After the increase in neural activity, the researchers discovered levels of 300 different proteins changed in the neurons. While two-thirds increased during the spike in brain activity, the synthesis of the remaining third decreased. By analyzing the roles of these so-called “candidate plasticity proteins”, Cline and her colleagues were able to gain general insight into how they might impact plasticity. Many of the proteins related to the structure and shape of neurons, for instance, as well as how they communicate with other cells. These proteins suggested ways in which brain activity can immediately begin to impact connections between cells.

Additionally, a number of the proteins were related to how DNA is packaged inside cells; changing this packaging can change which genes a cell can access and use over a long time period. This suggests ways that a very short spike in brain activity can lead to more sustained remodeling within the brain.

“This is a clear mechanism by which a change in brain activity can lead to waves of gene expression for many days,” says Cline.

The researchers hope to use this method to discover and study additional candidate plasticity proteins, for instance those that might change in different types of brain cells after animals see a new visual stimulus. Cline says their tool also could offer insight into brain diseases and aging, through comparisons of how brain activity impacts protein production in young versus old and healthy versus diseased brains.

Source: Scripps Research Institute

Journal reference: Schiapparelli, L.M., et al. (2022) Activity-Induced Cortical Glutamatergic Neuron Nascent Proteins. JNeurosci. doi.org/10.1523/JNEUROSCI.0707-22.2022.

[WEB] Researchers receive fresh $11M to continue cracking post-TBI epilepsy

Dave Pearson, May 13, 2022

NIH has granted $11 million to study post-traumatic epilepsy (PTE) over the next five years, and structural brain abnormalities detected by MRI are among the risk factors the funded researchers will identify as novel biomarkers.

Albert Einstein College of Medicine in Bronx, New York, announced the award May 12.

Einstein’s Aristea Galanopoulou, MD, PhD, will lead the work, collaborating with colleagues at several institutions in the U.S. and one in Australia.

Uniformed Services University of the Health Sciences is among the collaborating institutions. War veterans are believed develop PTE at substantially higher rates than members of the general population owing to battlefield blasts, although years may pass between returning home and suffering a first seizure, according to the Epilepsy Foundation.

The Einstein-led project’s brain MRI component will be part of a study arm concentrating on establishing biomarker panels for patients at risk for PTE—and likely to respond to treatment—following a traumatic brain injury (TBI).

Other tests contributing to these panels include blood tests to detect and measure TBI-associated tau proteins and EEGs to record oscillations in the electrical activity of the brain seen in epilepsy.

Epilepsy of the post-TBI type is “characterized by recurring seizures that begin a week or more after [a traumatic] brain injury, and there is currently no way to identify those at risk for developing PTE or to prevent its onset,” according to the announcement.

To this Galanopoulou adds:

Traumatic brain injuries are one of the most common causes of epilepsy, particularly among people aged 15 to 24 and the elderly. For that reason, PTE requires specialized attention. Our fruitful research collaboration over the past five years laid the groundwork for this grant, and we look forward to translating our findings to the clinic in the coming years, so we can provide hope for patients.”

The groundwork to which she refers was PTE research funded by the NIH in 2017 to the tune of $21 million.

Galanopoulou and colleagues also have received two two-year grants from the U.S. Department of Defense totaling nearly $1.95 million to “develop more realistic animal models of traumatic brain injury and to study how inflammation and the gut microbiome influence the onset of PTE,” according to the May 12 announcement.

More coverage of epilepsy imaging:

Real-world fast brain MRI in outpatient setting offers ‘substantial’ business benefits

7T MRI scans improve care for patients with focal epilepsy

Unenhanced CT a wise first choice when treating adult patients with new-onset seizure

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[ARTICLE] Why we need an internationally shared rehabilitation definition for clinical research purposes – Full Text

Abstract

Purpose:

Responding to a recent editorial arguing against defining rehabilitation, we discuss the reasons for developing a classification of rehabilitation for research purposes, its philosophical background and some of the possible risks.

Why define:

Science requires the definition and classification of phenomena to allow replication of experiments and studies, and to allow interpretation and use of the findings. As understanding increases, the definitions can be refined. Defining rehabilitation does run the risk of excluding some interventions or practices that are either considered rehabilitation (perhaps wrongly) or are rehabilitation interventions; when identified, these errors in definition can be remedied. Defining rehabilitation for research purposes should not inhibit but could (possibly) orient research.

Risk of not:

Without a definition, rehabilitation will remain in a permanent limbo. Experts will (apparently) know what it is, while others are left guessing or failing to comprehend or recognise it. This uncertainty may reassure some people, because all possible interventions are included; we argue that it downgrades the understanding of our field because interventions that are not rehabilitation are, nonetheless, called rehabilitation. In an era of international collaboration, and of undertaking systematic reviews with metanalysis, we need a shared definition.

Conclusion:

Terminology is often controversial, but definition enables progress in understanding such that terms themselves can evolve over time.

A recent, fascinating (as usual) editorial by Wade¹ raised the issue of the impossible task of defining rehabilitation – a task that Cochrane Rehabilitation embarked on, with the ambition of achieving the first operational definition for research purposes.² In this editorial, we discuss the reasons for this effort, some of the philosophical and scientific background, some limitations (and criticisms received), and how much previous experiences with debating the meaning of key terminology have already contributed to shaping the world of rehabilitation.

Several definitions and conceptual descriptions of rehabilitation exist.³ Some are popular among consumers,⁴ others among professionals³ and researchers,⁵ who mainly refer to the most important international agencies, like the World Health Organization (WHO).⁶ Some are synthetic and simple,⁴ others comprehensive but also complicated.^1,3 However, they do not allow what research needs: classifying what is and what is not rehabilitation.^2–5,7 For this reason, in 2019, Cochrane Rehabilitation launched its ‘rehabilitation definition for research purposes’ project² that is now coming to an end.

Science is based on simplifications to understand fundamental phenomena that often become progressively more complicated as understanding grows. Science usually follows a process beginning with initial theories or hypotheses that have been developed from qualitative or explorative research or from ideas arising from clinical practice. These theories and hypotheses are then tested to generate evidence to support or refute them or provide further exploration avenues.

This is precisely the process that Cochrane Rehabilitation decided to follow to improve the current situation around the definition of rehabilitation. We began with some basic research^3–5,7 followed by a qualitative consensus development process¹ to achieve the first version of a definition of rehabilitation for research purposes, which can now be taken forward for testing by scientists worldwide.

From a philosophical standpoint, we argue that we will not have any growth without a clear definition as a first attempt to understand what is and what is not rehabilitation. Koyré⁸ discussed the progress from the medieval age (the ‘Closed World’) to the modern, scientific world (the ‘Infinite Universe’) through the ‘invention’ of the watch. In the Middle Ages, time was a never-ending continuum, conceptually impossible to divide into discrete elements. Consequently, people imprecisely met at ‘dawn’, or ‘sunset’, or ‘when the sun is high in the sky’.

The arbitrary decision to divide time into segments of a specific length gradually led to the current precision: today we meet at 2:05 pm sharp, and we know that the fastest man in the world runs 100 m in 9.58 seconds. In this way, humans did not negate the never-ending continuum of time. Still, they developed some (always perfectible) instruments to understand it. Similarly, an operational definition of rehabilitation should provide an instrument for improving understanding without limiting further debate on the topic and, most of all, without pretending to be exhaustive or not perfectible.

We disagree that it is unfeasible to define rehabilitation because it is impossible to include all its parts in the definition. We could debate the mereological fallacy,⁹ which warns against inferring the meaning of a ‘whole’ from a study of its part. Alternatively, we could take an ethnosemantic perspective,¹⁰ which encourages analysing the meaning of terms from its component parts.

There are centuries of philosophical debate on the meaning of words; we are interested in more practical problems. In our view, the concept of rehabilitation cannot be harmed by inclusion and exclusion criteria more than the never-ending continuum of time by a watch. We broke up the definition into single words/concepts (with relative meanings) to make it operational, to offer scientists clear elements to make decisions. Nevertheless, the definition is valid only if taken as a whole: any intervention respecting one or several parts, but not all of them, does not respect the definition.

Wade¹ proposes a solution in complex or high-stake cases using the judgement of a group of people. This process is precisely what Cochrane Rehabilitation proved failing.^7,11 We found that solely having a system of people making judgements about what is and what is not rehabilitation resulted in increasingly arbitrary decisions that were difficult to track. This meant we need to create better criteria for making these decisions, and a definition is one way to start.

Providing a definition runs the risk of expelling some interventions or practices that are either considered rehabilitation (perhaps wrongly) or, even worse, that effectively are rehabilitation. One of these expulsions refers to single interventions provided by single rehabilitation professionals: this decision came to avoid the circular argument we previously used – ‘rehabilitation is what rehabilitation professionals do’.^7,11

This prior approach to defining rehabilitation was problematic for two reasons: (1) rehabilitation professionals can provide interventions that are not rehabilitation, and (2) rehabilitation includes interventions that rehabilitation professionals do not provide. While the second statement is widely accepted, stakeholders tend to reject the first for professional reasons. It was one of the most significant criticisms we received. Still, we decided to use a conceptual line of argument not necessarily interwoven with professional interests.

Another criticism we received about the exclusion criteria is that they could inhibit research on specific interventions. We cannot disagree more. The current definition can only (possibly) orient research. During its development, we better understood that rehabilitation is a whole (process). In contrast, single, stand-alone interventions are not rehabilitation but can be part (or not) of a rehabilitation process. This interpretation will be submitted to research evaluation.

There will also be research on our definition and practices that could be (momentarily) considered ‘not rehabilitation’ because of the definition. All this research will improve the overall understanding of rehabilitation and possibly drive to a new version of this definition.

Wade¹ raised the argument that instances of misclassification, requiring systems for handling misclassification, are evidence that a definition is faulty or has failed to achieve its purpose. We argue that definitions of words are inevitably imperfect, while explorations of misclassifications provide opportunities to refine and improve shared understanding of a definition. Misclassifications describe the boundaries of definitions. They allow research, refinements and debate to better understand the words and their meaning.

We recognise that this is a first effort with its consequent inherent limitations. Nevertheless, we affirm the importance of this attempt, without which clinical rehabilitation will remain in a permanent limbo for experts who know ‘the thing’ while all the others are left guessing or fail to comprehend or recognising it. We argue that, while this limbo can seem reassuring to some (we include everything that is rehabilitation, at the cost of not excluding interventions that are not rehabilitation), in the end, it downgrades the overall understanding of our field (not excluding what is not rehabilitation means being confused with it).

In addition, the more we turn to international collaboration, or we try to summarise and metanalyse the evidence for worldwide use, the more we need a shared understanding. Socio-cultural and historical conditions considerably drive our understanding of rehabilitation and make it local and particular.¹² This confusion is the enemy of research and understanding, and ultimately of the growth called by all international agencies for rehabilitation.¹³ In the end, the current lack of a good definition limited our ability to define evidence-based practice in rehabilitation and, therefore, ultimately undermines quality service delivery for patients.

In the world of rehabilitation, we already experienced a cultural breakthrough when the WHO defined the words ‘impairments’, ‘disability’ and ‘handicap’.¹⁴ We also experienced how their application increased understanding, leading 20 years later, together with society changes, to their upgrade within the overall framework of ‘functioning’,¹⁵ including the terms ‘capacity’ and ‘performance’. We are not stating that this process was uncontroversial or that a complete international agreement on these concepts and terminology was ever fully achieved. Still, the fact is that these terms offer a reference framework that nobody can ignore, even when personally not accepting it. More than anything, applying these terms according to their established definition reduces the risk of ambiguity. Most of the rehabilitation students learn this terminology and its respective definitions. They are part of our evolving world and will continue to evolve (with all the words in our dictionaries) through time and use.

We agree with Wade¹ that definitions of words can be (or perhaps are always) incomplete representations of the concept they refer to and that one word can have many different definitions depending on the context. However, in our view, missing a clear definition of the term for research purposes impairs rehabilitation internally (research and reciprocal understanding) and externally (inappropriate attribution of interventions, or use of inappropriate terms like ‘conservative’, ‘non-pharmacological’, ‘(re)enablement’, ‘resettlement’, ‘restorative care’, etc.). For these many reasons, Cochrane Rehabilitation is developing the first rehabilitation definition for research purposes.

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[WEB] On-demand brain stimulation alleviates severe depression

Reviewed by Emily Henderson, B.Sc.

The study, which appears in the Oct. 4, 2021, issue of Nature Medicine, represents a landmark success in the years-long effort to apply advances in neuroscience to the treatment of psychiatric disorders.

This study points the way to a new paradigm that is desperately needed in psychiatry. We’ve developed a precision-medicine approach that has successfully managed our patient’s treatment-resistant depression by identifying and modulating the circuit in her brain that’s uniquely associated with her symptoms.”

Andrew Krystal, PhD, professor of psychiatry and member of the UCSF Weill Institute for Neurosciences

Previous clinical trials have shown limited success for treating depression with traditional deep brain stimulation (DBS), in part because most devices can only deliver constant electrical stimulation, usually only in one area of the brain. A major challenge for the field is that depression may involve different brain areas in different people.

What made this proof-of-principle trial successful was the discovery of a neural biomarker – a specific pattern of brain activity that indicates the onset of symptoms – and the team’s ability to customize a new DBS device to respond only when it recognizes that pattern. The device then stimulates a different area of the brain circuit, creating on-demand, immediate therapy that is unique to both the patient’s brain and the neural circuit causing her illness.

This customized approach alleviated the patient’s depression symptoms almost immediately, Krystal said, in contrast to the four- to eight-week delay of standard treatment models and has lasted over the 15 months she has had the implanted device. For patients with long-term, treatment-resistant depression, that result could be transformative.

“I was at the end of the line,” said the patient, who asked to be known by her first name, Sarah. “I was severely depressed. I could not see myself continuing if this was all I’d be able to do, if I could never move beyond this. It was not a life worth living.”

Applying proven advances in neuroscience to mental health

The path to this project at UCSF began with a large, multicenter effort sponsored under President Obama’s BRAIN (Brain Research through Advancing Innovative Neurotechnologies) Initiative in 2014.

Through that initiative, UCSF neurosurgeon Edward Chang, MD, and colleagues conducted studies to understand depression and anxiety in patients undergoing surgical treatment for epilepsy, for whom mood disorders are also common. The research teamdiscovered patterns of electrical brain activity that correlated with mood states and identified new brain regions that could be stimulated to relieve depressed mood.

With results from the previous research as a guide, Chang, Krystal, and first author Katherine Scangos, MD, PhD, all members of the Weill Institute, developed a strategy relying on two steps that had never been used in psychiatric research: mapping a patient’s depression circuit and characterizing her neural biomarker.

“This new study puts nearly all the critical findings of our previous research together into one complete treatment aimed at alleviating depression,” said Chang, who is co-senior author with Krystal on the paper and the Joan and Sanford Weill Chair of Neurological Surgery.

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The team evaluated the new approach in June 2020 under an FDA investigational device exemption, when Chang implanted a responsive neurostimulation device that he has successfully used in treating epilepsy.

“We were able to deliver this customized treatment to a patient with depression, and it alleviated her symptoms,” said Scangos. “We haven’t been able to do this the kind of personalized therapy previously in psychiatry.”

To personalize the therapy, Chang put one of the device’s electrode leads in the brain area where the team had found the biomarker and the other lead in the region of Sarah’s depression circuit where stimulation best relieved her mood symptoms. The first lead constantly monitored activity; when it detected the biomarker, the device signaled the other lead to deliver a tiny (1mA) dose of electricity for 6 seconds, which caused the neural activity to change.

“The effectiveness of this therapy showed that not only did we identify the correct brain circuit and biomarker, but we were able to replicate it at an entirely different, later phase in the trial using the implanted device,” said Scangos. “This success in itself is an incredible advancement in our knowledge of the brain function that underlies mental illness.”

Translating neural circuits into new insights

For Sarah, the past year has offered an opportunity for real progress after years of failed therapies.

“In the early few months, the lessening of the depression was so abrupt, and I wasn’t sure if it would last,” she said. “But it has lasted. And I’ve come to realize that the device really augments the therapy and self-care I’ve learned while being a patient here at UCSF.”

The combination has given her perspective on emotional triggers and irrational thoughts on which she used to obsess. “Now,” she said, “those thoughts still come up, but it’s just…poof…the cycle stops.”

While the approach appears promising, the team cautions that this is just the first patient in the first trial.

“There’s still a lot of work to do,” said Scangos, who has enrolled two other patients in the trial and hopes to add nine more. “We need to look at how these circuits vary across patients and repeat this work multiple times. And we need to see whether an individual’s biomarker or brain circuit changes over time as the treatment continues.”

FDA approval for this treatment is still far down the road, but the study points toward new paths for treating severe depression. Krystal said that understanding the brain circuits underlying depression is likely to guide future non-invasive treatments that can modulate those circuits.

Added Scangos, “The idea that we can treat symptoms in the moment, as they arise, is a whole new way of addressing the most difficult-to-treat cases of depression.”

Source: University of California – San Francisco

Journal reference: Scangos, K.W., et al. (2021) Closed-loop neuromodulation in an individual with treatment-resistant depression. Nature Medicine. doi.org/10.1038/s41591-021-01480-w.

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