Posts Tagged Stroke

[ARTICLE] Cell-Based Therapies for Stroke: Are We There Yet? – Full Text

Stroke is the second leading cause of death and physical disability, with a global lifetime incidence rate of 1 in 6. Currently, the only FDA approved treatment for ischemic stroke is the administration of tissue plasminogen activator (tPA). Stem cell clinical trials for stroke have been underway for close to two decades, with data suggesting that cell therapies are safe, feasible, and potentially efficacious. However, clinical trials for stroke account for <1% of all stem cell trials. Nevertheless, the resources devoted to clinical research to identify new treatments for stroke is still significant (53–64 million US$, Phase 1–4). Notably, a quarter of cell therapy clinical trials for stroke have been withdrawn (15.2%) or terminated (6.8%) to date. This review discusses the bottlenecks in delivering a successful cell therapy for stroke, and the cost-to-benefit ratio necessary to justify these expensive trials. Further, this review will critically assess the currently available data from completed stroke trials, the importance of standardization in outcome reporting, and the role of industry-led research in the development of cell therapies for stroke.

Introduction

Background

Stroke has a devastating effect on the society worldwide. In addition to its significant mortality rate of 50% as reported in 5-year survival studies (1), it affects as many as 1 in 6 people in their lifetimes, and is the leading cause of disability worldwide (2). A stroke results in a complex interplay of inflammation and repair with effects on neural, vascular, and connective tissue in and around the affected areas of the brain (3). Therefore, sequelae of stroke such as paralysis, chronic pain, and seizures can persist long term and prevent the patient from fully reintegrating into society. Stroke therefore remains the costliest healthcare burden as a whole (4). In 2012, the total cost of stroke in Australia was estimated to be about $5 billion with direct health care costs attributing to $881 million of the total (5).

Unfortunately, treatment options for stroke are still greatly limited. Intravenous recombinant tissue plasminogen activator (tPA) and endovascular thrombectomy (EVT) are currently the only effective treatments available for acute stroke. However, there is only a brief window of opportunity where they can be successfully applied. EVT is performed until up to 24 h of stroke onset (6), while tPA is applied within 4.5 h of stroke onset. Notably, the recent WAKE-UP (NCT01525290) (7) and EXTEND (NCT01580839) trials have shown that this therapeutic window can be safely extended to 9 h from stroke onset. Furthermore, advancements in acute stroke care and neurorehabilitation have shown to be effective in improving neurological function (8). However, there are no treatments that offer restoration of function and as a result, many patients are left with residual deficits following a stroke. Cell-based therapies have shown promising results in animal models addressing the recovery phase following stroke (9). This is encouraging as currently, there are no approved treatment options addressing the reversal of neurological damages once a stroke has occurred (10).

The majority of data from animal studies and clinical trials demonstrate the therapeutic potential of stem cells in the restoration of central nervous system (CNS) function (1112), applicable to neurodegenerative diseases as well as traumatic brain injury. Transplanted stem cells were reportedly able to differentiate into neurons and glial cells, whilst supporting neural reconstruction and angiogenesis in the ischemic region of the brain (13). Previous work demonstrated the ability of mesenchymal stem cells (MSCs) to differentiate into neurons, astrocytes (14), endothelial cells (1516), and oligodendrocyte lineage cells (17) such as NG2-positive cells (18in vitro, and undergo neuronal or glial differentiation in vivo (19). Bone marrow-derived mesenchymal stem cells (BMSCs) have shown potential to differentiate into endothelial cells in vitro (20). Additionally, both BMSCs and adipose stem cells (ASCs) have been shown to demonstrate neural lineage differentiation potential in vitro (2123). Furthermore, stem cells are able to modulate multiple cell signaling pathways involved in endogenous neurogenesis, angiogenesis, immune modulation and neural plasticity, sometimes in addition to cell replacement (3). The delivery of stem cells from the brain, bone marrow, umbilical cord, and adipose tissue, have been reported to reduce infarct size and improve functional outcomes regardless of tissue source (9). While these were initially exciting reports, they raise the question as to the validity of the findings to date since these preclinical reports are almost uniformly positive. The absence of scientific skepticism and robust debate may in fact have negated progress in this field.

Cell-based therapies have been investigated as a clinical option since the 1990s. The first pilot stroke studies in 2005 investigated the safety of intracranial delivery of stem cells (including porcine neural stem cells) to patients with chronic basal ganglia infarcts or subcortical motor strokes (2425). However, since the publication of these reports, hundreds of preclinical studies have shown that a variety of cell types including those derived from non-neural tissues can enhance structural and functional recovery in stroke. Cell therapy trials, mainly targeted at small cohorts of patients with chronic stroke, completed in the 2000s, showed satisfactory safety profiles and suggestions of efficacy (10). Current treatments such as tPA and EVT only have a narrow therapeutic window, limited efficacy in severe stroke and may be accompanied by severe side effects. Specifically, the side effects of EVT include intracranial hemorrhage, vessel dissection, emboli to new vascular territories, and vasospasm (26). The benefit of tPA for patients with a severe stroke with a large artery occlusion can vary significantly (27). This is mainly due to the failure (<30%) of early recanalisation of the occlusion. Thus, despite the treatment options stroke is still a major cause of mortality and morbidity, and there is need for new and improved therapies.

Stem cells have been postulated to significantly extend the period of intervention and target subacute as well as the chronic phase of stroke. Numerous neurological disorders such as Parkinson’s disease (1228), Alzheimer’s disease (29), age-related macular degeneration (30), traumatic brain injury (31), and malignant gliomas (32) have been investigated for the applicability of stem cell therapy. These studies have partly influenced the investigation of stem cell therapies for stroke. A small fraction of stem cell research has been successfully translated to clinical trials. As detailed in Table 1, most currently active trials use neuronal stem cells (NSCs), MSCs or BMSCs (3537), including conditionally immortalized neural stem-cell line (CTX-DP) CTX0E03 (38), neural stem/progenitor cells (NSCs/NPSCs) (e.g., NCT03296618), umbilical cord blood (CoBis2, NCT03004976), adipose (NCT02813512), or amnion epithelial cells (hAECs, ACTRN 1261800076279) (39).

Table 1. Challenges and bottlenecks of stem cell therapy and clinical trials using stem cells (3334).

[…]

 

Continue —>  Frontiers | Cell-Based Therapies for Stroke: Are We There Yet? | Neurology

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[ARTICLE] A review of transcranial electrical stimulation methods in stroke rehabilitation – Full Text

 

Abstract

Transcranial electrical stimulation (TES) uses direct or alternating current to non-invasively stimulate the brain. Neuronal activity in the brain is modulated by the electrical field according to the polarity of the current being applied. TES includes transcranial direct current stimulation (tDCS), transcranial random noise stimulation, and transcranial alternating current stimulation (tACS). tDCS and tACS are the two non-invasive brain stimulation techniques that have been used alone or in combination with other rehabilitative therapies for the improvement of motor control in hemiparesis. Increasing research in these methods is being carried out to improvise on the existing technology because they have proven to exhibit a lasting effect, thereby contributing to brain plasticity and motor re-learning. Artificial stimulation of the lesioned or non-lesioned hemisphere induces participation of its cells when a movement is being performed. The devices are portable, stimulation is easy to deliver, and they are not known to cause any major side effects which are the foremost reasons for their trials in stroke rehabilitation. Recent research is focused on maximizing the outcome of stroke rehabilitation by combining them with other modalities. This review focuses on stimulation protocols, parameters, and the results obtained by these techniques and their combinations.

Key Message: Motor recovery and control poses a great challenge in stroke rehabilitation. Transcranial electrical stimulation methods look promising in this regard as they have been shown to augment long-term and short-term potentiation in the brain which may have a role in motor re-learning. This review discusses transcranial direct current stimulation and transcranial alternating current stimulation in stroke rehabilitation.

According to World Health Organization (WHO) statistics on 2016, cardiovascular diseases (CVD) are the foremost cause of death and adult disability worldwide.[1],[2] Stroke statistics in India show that the incidence of stroke was 435/100,000 population and only one in three stroke survivors are hospitalized and given further rehabilitation because treatment is expensive.[3]

Stroke survivors are faced with paralysis of one side of the body, that is, the side contra-lateral to the affected side in the brain. Rehabilitation aims at strengthening these muscles to prevent wastage and bring back function to the maximum possible extent. Taking the upper extremity into consideration, a combination of muscle over-activity (spastic muscle) in certain groups and weakening in other groups causes poor motor control leading to deformities and inability to reach, grasp, and release objects.

Various therapies such as splinting, stretching exercises, functional electrical stimulation (FES), and mirror therapy are being used to treat this condition, with varying degrees of success. In an ideal situation, the aim of stroke rehabilitation is to recover the paralyzed limb to an extent that it is functionally useful. In this context, recent research is being conducted in neuroplasticity or motor-relearning. Neuroplasticity refers to the brain being able to adapt to changes in response to its external environment and stimulation. TES and transcranial magnetic stimulation (TMS) are the non-invasive brain stimulation (NIBS) methods that invoke this type of re-learning.[4],[5]

NIBS methods include TMS and TES since they non-invasively stimulate the cortex. These methods are still under research for medical applications and were first introduced to treat psychiatric conditions such as insomnia, chronic anxiety, mild depression and post stroke aphasia.[6],[7],[8] Recently, tDCS has also been tried on normal individuals and was shown to improve cognition, working memory, and performance.[9],[10],[11] These methods are now gaining importance in stroke rehabilitation because they provide motor relearning probably through cortical reorganization, which occurs because the neural continuity between the brain and the periphery is intact.[12]

This article attempts to review the stimulation protocols used for TES by various research groups and the results obtained. The first section begins with an introduction to non-invasive methods of brain stimulation followed by a brief summary on the history that led to the use of TES for stroke rehabilitation. Later sections deal with tDCS and tACS. The section on tDCS is further subdivided into tDCS alone and tDCS with adjuvant therapy. The tables give a list of the studies that have been carried out for neurorehabilitation, although it is not meant to be an exhaustive list.[…]

Continue —> A review of transcranial electrical stimulation methods in stroke rehabilitation Solomons CD, Shanmugasundaram V Neurol India

Figure 1: Placement of electrodes for a-tDCS and c-tDCS

Figure 1: Placement of electrodes for a-tDCS and c-tDCS

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[WEB SITE] Telerehab Program Works as Well as Clinic-Based Program for Improved Arm Function Poststroke – JAMA Neurology

It’s probably not news to physical therapists (PTs) when research backs up the idea that patients who experience arm impairments poststroke will tend to make greater functional improvements with larger and longer doses of rehabilitation. Unfortunately, PTs are also familiar with the fact that what’s optimal isn’t necessarily what’s typical, with challenges such as payment systems, logistics, and clinic access making it difficult to achieve the best possible results. That’s where telerehabilitation could make a big difference, say authors of a new study that found an entirely remotely delivered rehab program to be as effective as an equal amount of clinic-based sessions.

The findings lend further support to the ideas behind APTA’s efforts to increase telehealth opportunities for PTs and their patients—a significant component of the association’s current public policy priorities. In addition, APTA provides multiple telehealth resources on a webpage devoted to the topic, and has created the Frontiers in Research, Science, and Technology Council that provides interested members and other stakeholders with an online community to discuss technology’s role in physical therapy.

The study, published in JAMA Neurology (abstract only available for free), involved 124 participants who experienced arm motor deficits poststroke. All participants were enrolled in a rehabilitation therapy program that included 36 70-minute treatment sessions, half of which were supervised, over a 6- to 8-week period. The only major difference: one group’s supervised sessions were face-to-face with a physical therapist (PT) or occupational therapist (OT), while the other group received telerehab from a PT or OT via a computer with video capabilities, accompanied by the use of a gaming system.

Researchers were interested in finding out how patients fared in each approach, using scores from the Fugl Meyer (FM) assessment of motor recovery poststroke as their primary measure. Authors of the study also measured patient adherence with therapy as well as levels of patient motivation related to how well they liked the therapy they were receiving and their degree of dedication to treatment goals.

Using a treatment approach “based on an upper-extremity task-specific training manual and Accelerated Skill Acquisition Program,” researchers set up matched programs that included at least 15 minutes per session of arm exercises from a common set of 88 possible exercises, at least 15 minutes of functional training, and 5 minutes of stroke education. The clinic-based participants received in-person instruction on the exercises and used “standard exercise hardware”; the telerehab patients received instructions via video link and engaged in functional exercise via a videogame interface. Here’s what the researchers found:

  • Both groups improved at about the same rate, with the telerehab participants averaging a 7.86 FM gain, compared with an average gain of 8.36 points for the clinic-based group.
  • Improvements were also about the same for the subgroup of participants who entered rehabilitation more than 90 days poststroke, with these “late” participants averaging a 6.6-point gain for the telerehab group and a 7.4-point increase for the clinic-based group.
  • While both groups reported high levels of dedication to treatment goals, the clinic-based group tended to report better levels of motivation and satisfaction. Adherence was also high for both groups, with a 93.4% adherence rate for the clinic-based group and a rate of 98.3% for the telerehab group.
  • Both groups increased their knowledge of stroke at similar rates.

As for the technical details of the telerehab sessions, the system included a computer linked to the internet, a table, a chair, and 12 “gaming input devices.” Keyboards were not necessary. The supervised sessions began with a 30-minute videoconference between the patient and therapist, and the functional training games used were designed to match the functional task work being done with the clinic-based participants. Unsupervised sessions adhered to the same content but didn’t include contact with the therapist.

“In an era when prescribed doses of poststroke rehabilitation therapy are declining, adversely affecting patient outcomes, these and prior findings suggest that outcomes could be improved for many patients…if larger doses of rehabilitation therapy were prescribed,” authors write. “Our study found that a 6-week course of daily home-based [telerehab] is safe, is rated favorably by patients, is associated with excellent treatment adherence, and produces substantial gains in arm function that were not inferior to dose-matched interventions delivered in the clinic.”

Authors acknowledged that patient satisfaction with telerehab might be improved by increasing the amount of time spent with the therapist—providing that therapist is properly trained. “Current results underscore the importance of maintaining a licensed therapist’s involvement during [telerehab],” they write.

Ultimately, it’s still too early to determine just how generalizable the findings are to other populations and conditions, the researchers say, but all indicators seem to point to the need for increasing the availability of telerehab and its inclusion in health plans.

“The US Bipartisan Budget Act of 2018 expanded telehealth benefits,” authors write. “Eventually, home-based [telerehab] may plan an ascendant role for improving patient outcomes.”

Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association’s PTNow website.

via JAMA Neurology: Telerehab Program Works as Well as Clinic-Based Program for Improved Arm Function Poststroke

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[ARTICLE] Virtual rehabilitation of upper extremity function and independence for stoke: a meta-analysis – Full Text

Abstract

We aimed to conduct a systematic literature review with a meta-analysis to investigate whether virtual reality (VR) approaches have beneficial effects on the upper extremity function and independent activities of stroke survivors. Experimental studies published between 2007 and 2017 were searched from two databases (EBSCOhost and PubMed). This study reviewed abstracts and assessed full articles to obtain evidence on qualitative studies. For the meta-analysis, the studies that estimated the standardized mean between the two groups analyzed the statistical values necessary for calculating the effect size. The present study also evaluated the statistical heterogeneity. In total, 34 studies with 1,604 participants were included, and the number of participants in each study ranged from 10 to 376. Nine studies were assessed to evaluate the quantitative statistical analysis for 698 patients with hemiparetic stroke. The results of the meta-analysis were as follows: The overall effect size was moderate (0.41, P<0.001). The 95% confidence interval ranged from 0.25 to 0.57. However, no significant heterogeneity and publication bias were observed. The results of this study showed that VR approaches are effective in improving upper extremity function and independent activities in stroke survivors.

 

INTRODUCTION

Stroke has varying severity and subsequent functional impact, which depends on the recovery process of an individual and the extent of neurological damage (Chollet et al., 1991). Several stroke survivors experience physical, cognitive, perceptual, and mental impairments that require a period of intensive rehabilitation and may develop permanent disabilities (Teasell et al., 2005). Some stroke survivors can undergo a short period of inpatient rehabilitation program for recovery of function, and others continue to recover for a long period or throughout their lifetimes (Cramer, 2011). Therefore, in the intensive rehabilitation of individuals with neurological diseases, extremely important considerations must be made because of the reintegration of family and social roles and recreational activities (French et al., 2016West and Bernhardt, 2012).
In rehabilitation settings, functional and task-specific trainings are the key elements of therapy and designed to assist stroke survivors in restoring their motor control to attain more-normal functional movement patterns (Teasell et al., 2005). Stroke survivors must have significant changes in the motor control and strength of the trunk and limbs, with an emphasis on the more-affected side and bilateral symmetric movement; these may be achieved using specific reeducation strategies (Veerbeek et al., 2014West and Bernhardt, 2012). In terms of stroke rehabilitation settings, most previous studies were performed in laboratory or clinical settings that are less complex than the outdoor environment (Cho and Lee, 2013). Laboratory and clinical settings are not appropriate for establishing some complex personal space and community surroundings to meet the demands of multiple tasks for stroke survivors (Demain et al., 2013Fung et al., 2012).
Virtual reality (VR) is a computer-generated environment that simulates a realistic experience for practicing functional tasks at intensities higher than those in traditional rehabilitation programs for stroke survivors (Chen et al., 2016). VR may help engage stroke survivors in a repetitive, intensive, and goal-oriented therapy to improve their functional disabilities, activity limitations, and participation restrictions, without considering the cost and burden associated with increasing the number of therapeutic sessions (Merians et al., 2002). Furthermore, VR provides real-time visual feedback for movements, thereby increasing engagement in enjoyable rehabilitation tasks. VR provides rehabilitative clinicians with new and effective therapeutic tools that can help treat various disabilities and enables remote therapy. VR-based interventions lead to clinical improvement and cortical reorganization through repetitive, adaptive, task-oriented, meaningful, and challenging exercises for stroke survivors (Laver et al., 2012).
As mentioned earlier, several virtual realities in rehabilitation interventions have been applied in the stroke population. However, the efficacy of VR rehabilitation interventions remains to be fully elucidated. In particular, studies on the qualitative and quantitative beneficial effects of VR on upper extremity function and independence in performing activities of daily living among patients with stroke are limited. The objectives of the present study were as follows: (a) to investigate the effectiveness of VR-based interventions in rehabilitation programs for restoring the upper extremity function of stroke survivors through a systematic review and (b) to examine the efficacy of VR-based interventions as part of a therapeutic rehabilitation program to improve upper limb function and independence in performing activities of daily living in stroke survivors by conducting a meta-analysis. Then, the VR-based interventions that are effective for improving upper limb function and independence in performing activities of daily living in stroke survivors were identified.[…]

Continue —> Virtual rehabilitation of upper extremity function and independence for stoke: a meta-analysis

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[WEB SITE] How to help patients recover after a stroke

stroke
Credit: CC0 Public Domain

The existing approach to brain stimulation for rehabilitation after a stroke does not take into account the diversity of lesions and the individual characteristics of patients’ brains. This was the conclusion made by researchers of the Higher School of Economics (HSE University) and the Max Planck Institute of Cognitive Sciences in their article, “Predicting the Response to Non-Invasive Brain Stimulation in Stroke.”

Among the most common causes of death worldwide,  ranks second only to myocardial infarction (heart attack). In addition, a stroke is also a chronic disease that leaves patients disabled for many years.

In , non-invasive neuromodulation methods such as electric and magnetic stimulation of various parts of the nervous system have been increasingly used to rehabilitate patients after a stroke. Stimulation selectively affects different parts of the , which allows you to functionally enhance activity in some areas while suppressing unwanted processes in others that impede the restoration of brain functions. This is a promising mean of rehabilitation after a stroke. However, its results in patients remain highly variable.

The study authors argue that the main reason for the lack of effectiveness in neuromodulation approaches after a stroke is an inadequate selection of patients for the application of a particular brain stimulation technique.

According to the authors, the existing approach does not take into account the diversity of lesions after a stroke and the variability of individual responses to brain stimulation as a whole. Researchers propose two criteria for selecting the optimal brain  strategy. The first is an analysis of the interactions between the hemispheres. Now, all patients, regardless of the severity of injury after a stroke, are offered a relatively standard treatment regimen. This approach relies on the idea of interhemispheric competition.

“For a long time, it was believed that when one hemisphere is bad, the second, instead of helping it, suppresses it even more,” explains Maria Nazarova, one of the authors of the article and a researcher at the HSE Institute of Cognitive Neurosciences. “In this regard, the suppression of the activity of the “unaffected” hemisphere should help restore the affected side of the brain. However, the fact is that this particular scheme does not work in many  after a stroke. Each time it is necessary to check what the impact of the unaffected hemisphere is—whether it is suppressive or activating.”

The second criterion, scientists call the neuronal phenotype. This is an individual characteristic of the activity of the brain, which is “as unique to each person as their fingerprints.” Such a phenotype is determined, firstly, by the ability of the brain to build effective structural and functional connections between different areas (connectivity). And, secondly, the individual characteristics of neuronal dynamics, including its ability to reach a . This is the state of the neuronal system in which it is the most plastic and capable of change.

Only by taking these criteria into account, the authors posit, can neuromodulation methods be brought to a new level and be effectively used in clinical practice. To do this, it is necessary to change the paradigm of the universal approach and select methods based on the individual characteristics of the brain of a particular person and the course of his or her disease.


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How electrical stimulation reorganizes the brain

 

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[ARTICLE] What is the impact of user affect on motor learning in virtual environments after stroke? A scoping review – Full Text

Abstract

Purpose

The purported affective impact of virtual reality (VR) and active video gaming (AVG) systems is a key marketing strategy underlying their use in stroke rehabilitation, yet little is known as to how affective constructs are measured or linked to intervention outcomes. The purpose of this scoping review is to 1) explore how motivation, enjoyment, engagement, immersion and presence are measured or described in VR/AVG interventions for patients with stroke; 2) identify directional relationships between these constructs; and 3) evaluate their impact on motor learning outcomes.

Methods

A literature search was undertaken of VR/AVG interventional studies for adults post-stroke published in Medline, PEDro and CINAHL databases between 2007 and 2017. Following screening, reviewers used an iterative charting framework to extract data about construct measurement and description. A numerical and thematic analytical approach adhered to established scoping review guidelines.

Results

One hundred fifty-five studies were included in the review. Although the majority (89%; N = 138) of studies described at least one of the five constructs within their text, construct measurement took place in only 32% (N = 50) of studies. The most frequently described construct was motivation (79%, N = 123) while the most frequently measured construct was enjoyment (27%, N = 42). A summative content analysis of the 50 studies in which a construct was measured revealed that constructs were described either as a rationale for the use of VR/AVGs in rehabilitation (76%, N = 38) or as an explanation for intervention results (56%, N = 29). 38 (76%) of the studies proposed relational links between two or more constructs and/or between any construct and motor learning. No study used statistical analyses to examine these links.

Conclusions

Results indicate a clear discrepancy between the theoretical importance of affective constructs within VR/AVG interventions and actual construct measurement. Standardized terminology and outcome measures are required to better understand how enjoyment, engagement, motivation, immersion and presence contribute individually or in interaction to VR/AVG intervention effectiveness.

Introduction

An increasing evidence base supports the use of virtual reality (VR) and active video gaming (AVG) systems to promote motor learning in stroke rehabilitation [1234]. However, practical and logistical barriers to VR/AVG implementation in clinical sites have been well described [567]. To support their use, researchers and developers often emphasize the potential advantages of VR/AVG systems over conventional interventions, including that these technologies may enhance a patient’s affective experience in therapy for the purpose of facilitating recovery [891011]. Examining the role of affective factors for motor learning is an emerging area of emphasis in rehabilitation [212131415].

VR/AVG use may enhance patients’ motivation to participate in rehabilitation as well as their engagement in therapeutic tasks. Motivation encourages action toward a goal by eliciting and/or sustaining goal-directed behavior [16]. Motivation can be intrinsic (derived from personal curiosity, importance or relevance of the goal) or extrinsic (elicited via external reward) [17]. Engagement is a cognitive and affective quality or experience of a user during an activity [16]. Many characteristics of VR/AVG play can contribute to user motivation and engagement, such as novelty, salient audiovisual graphics, interactivity, feedback, socialization, optimal challenge [14], extrinsic rewards, intrinsic curiosity or desire to improve in the game, goal-oriented tasks, and meaningful play [18].

Motivation and engagement are hypothesized to support motor learning either indirectly, through increased practice dosage leading to increased repetitive practice, or directly, via enhanced dopaminergic mechanisms influencing motor learning processes [1516]. Yet evidence is required to support these claims. A logical first step is to understand how these constructs are being measured within VR/AVG intervention studies. Several studies have used practice dosage or intensity as an indicator of motivation or engagement [192021]. To the authors’ knowledge, few have specifically evaluated the indirect mechanistic pathway by correlating measurement of patient motivation or engagement in VR/AVGs with practice dosage or intensity. While participants in VR/AVG studies report higher motivation as compared to conventional interventions [222324], conclusions regarding the relationship between motivation and intervention outcomes are limited by lack of consistency and rigour in measurement, including the use of instruments with poor psychometric properties [2223].

The body of research exploring the direct effects of engagement or motivation on motor learning is still in its infancy. Lohse et al. [16] were the first to evaluate whether a more audiovisually enriched as compared to more sterile version of a novel AVG task contributed to skill acquisition and retention in typically developing young adults, finding that participants who played under the enriching condition had greater generalized learning and complex skill retention. Self-reported engagement (User Engagement Scale; UES) was higher in the enriched group, but the only difference in self-reported motivation was in the Effort subscale of the Intrinsic Motivation Inventory (IMI), where the enriched group reported less effort as compared to the sterile group. The authors did not find a significant correlation between engagement, motivation and retention scores. A follow-up study using electroencephalography did not replicate the finding that the more enriched practice condition enhanced learning, it did show that more engaged learners had increased information processing, as measured by reduced attentional reserve [25].

Enjoyment, defined as ‘the state or process of taking pleasure in something’ [26], has less frequently been the subject of study in motor learning research, but has become popular as a way of describing patient interaction with VR/AVGs. Enjoyment may be hypothesized to be a precursor to both motivation and engagement. Given that the prevailing marketing of VR/AVGs is that they are ‘fun’ and ‘enjoyable’ [131427], it is important to evaluate its measurement in the context of other constructs.

Motivation, engagement and enjoyment in VR/AVGs may be influenced by the additional constructs of immersion and presence. Immersion is defined as “the extent to which the VR system succeeds in delivering an environment which refocuses a user’s sensations from the real world to a virtual world” [1328]. Immersion is considered as an objective construct referring to how the computational properties of the technology can deliver an illusion of reality through hardware, software, viewing displays and tracking capabilities [2930]. A recent systematic review [13] could not conclusively state effect of immersion on user performance. Immersion is distinct from presence, defined as the “psychological product of technological immersion” [31]. Presence is influenced by many factors, including the characteristics of the user, the VR/AVG task, and the VR/AVG system [28]. While presence is thought to be related to enhanced motivation and performance [32], relationships between this and other constructs of interest require exploration. Table 1 outlines definitions of constructs of interest to this scoping review.

Table 1

Construct definitions

Construct

Definition

Reference

Motivation

Motivation encourages action toward a goal by eliciting and/or sustaining goal-directed behavior.

[16]

Engagement

Engagement is a cognitive and affective quality or experience of a user during an activity.

[16]

Enjoyment

The state or process of taking pleasure in something.

[26]

Immersion

The extent to which the VR system succeeds in delivering an environment which refocuses a user’s sensations from the real world to a virtual world.

[1328]

Presence

The psychological product of technological immersion.

[31]

The purpose of this scoping review is to explore the impact of these affective constructs on motor learning after stroke. This greater understanding will enhance the clinical rationale for VR/AVG use and inform directions for subsequent research. Specifically, our objectives were to:

  1. 1.

    Describe how VR/AVG studies measure or report client enjoyment, motivation, engagement, immersion and presence.

  2. 2.

    Evaluate the extent to which motivation, enjoyment, engagement, immersion, and presence impact motor learning.

  3. 3.

    Propose directional relationships between enjoyment, motivation, engagement, immersion, presence and motor learning.

[…]

 

Continue —> What is the impact of user affect on motor learning in virtual environments after stroke? A scoping review | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 2Proposed relationships between the five constructs and motor learning

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[Abstract] Virtual Reality Environment for the Cognitive Rehabilitation of Stroke Patients

Abstract

We present ongoing work to develop a virtual reality environment for the cognitive rehabilitation of patients as a part of their recovery from a stroke. A stroke causes damage to the brain and problem solving, memory and task sequencing are commonly affected. The brain can recover to some extent, however, and stroke patients have to relearn to carry out activities of daily learning. We have created an application called VIRTUE to enable such activities to be practiced using immersive virtual reality. Gamification techniques enhance the motivation of patients such as by making the level of difficulty of a task increase over time. The design and implementation of VIRTUE is presented together with the results of a small acceptability study.

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[WEB SITE] Neuromodulation helps rehabilitate patients after a stroke

How neuromodulation helps patients recover after a stroke.

The neuromodulation methods can be brought to a new level and be effectively used in clinical practice only by taking these criteria into account. (Photo: Representational/Pixabay)

 The neuromodulation methods can be brought to a new level and be effectively used in clinical practice only by taking these criteria into account. (Photo: Representational/Pixabay)

Washington: The current approach used for brain stimulation to rehabilitate patients after a stroke does not look into the diversity of lesions and the individual characteristics of the brains of patients, finds a recent study.

The study was published in the journal ‘Frontiers in Neurology’. In recent decades, non-invasive neuromodulation methods such as electric and magnetic stimulation of various parts of the nervous system have been increasingly used to rehabilitate patients after a stroke.

Stimulation selectively affects different parts of the brain, which allows you to functionally enhance activity in some areas while suppressing unwanted processes in others that impede the restoration of brain functions.

This is a promising mean of rehabilitation after a stroke. However, its results in patients remain highly variable. The study authors argued that the main reason for the lack of effectiveness in neuromodulation approaches after a stroke is an inadequate selection of patients for the application of a particular brain stimulation technique.

According to the authors, the existing approach does not take into account the diversity of lesions after a stroke and the variability of individual responses to brain stimulation as a whole. Researchers proposed two criteria for selecting the optimal brain stimulation strategy. The first is an analysis of the interactions between the hemispheres.

Now, all patients, regardless of the severity of injury after a stroke, are offered a relatively standard treatment regimen. This approach relied on the idea of inter-hemispheric competition.

“For a long time, it was believed that when one hemisphere is bad, the second, instead of helping it, suppress it even more,’ explained Maria Nazarova, one of the authors of the article.

“In this regard, the suppression of the activity of the ‘unaffected’ hemisphere should help restore the affected side of the brain. However, the fact is that this particular scheme does not work in many patients after a stroke. Each time it is necessary to check what the impact of the unaffected hemisphere is, whether it is suppressive or activating,” said Nazarova.

The second criterion is the neuronal phenotype. This is an individual characteristic of the activity of the brain, which is ‘unique to each person like their fingerprints’. Such a phenotype is determined, firstly, by the ability of the brain to build effective structural and functional connections between different areas (connectivity).

Secondly, the individual characteristics of neuronal dynamics. This is the state of the neuronal system in which it is the most plastic and capable of change. The neuromodulation methods can be brought to a new level and be effectively used in clinical practice only by taking these criteria into account.

 

via Neuromodulation helps rehabilitate patients after a stroke

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[NEWS] Researchers propose new approach for post-stroke rehabilitation

The existing approach for brain stimulation to rehabilitate patients after a stroke does not take into account the diversity of lesions and the individual characteristics of patients’ brains, a study has found.

In recent decades, non-invasive neuromodulation methods such as electric and magnetic stimulation of various parts of the nervous system have been increasingly used to rehabilitate patients after a stroke.

Stimulation selectively affects different parts of the brain, which allows you to functionally enhance activity in some areas while suppressing unwanted processes in others that impede the restoration of brain functions.

This is a promising mean of rehabilitation after a stroke. However, its results in patients remain highly variable.

Authors of the study, which was published in the journal ‘Frontiers in Neurology’, argued that the main reason for the lack of effectiveness in neuromodulation approaches after a stroke is an inadequate selection of patients for the application of a particular brain stimulation technique.

They said the existing approach does not take into account the diversity of lesions after a stroke and the variability of individual responses to brain stimulation as a whole.

The researchers have proposed two criteria for selecting the optimal brain stimulation strategy.

The first is an analysis of the interactions between the hemispheres. Now, all patients, regardless of the severity of injury after a stroke, are offered a relatively standard treatment regimen. This approach relies on the idea of interhemispheric competition.

“For a long time, it was believed that when one hemisphere is bad, the second, instead of helping it, suppresses it even more,” said

Maria Nazarova, researcher at the HSE Institute of Cognitive Neurosciences.

“In this regard, the suppression of the activity of the “unaffected” hemisphere should help restore the affected side of the brain. However, the fact is that this particular scheme does not work in many patients after a stroke. Each time it is necessary to check what the impact of the unaffected hemisphere is — whether it is suppressive or activating,” she said.

According to the researchers, the second criterion is the neuronal phenotype.

This is an individual characteristic of the activity of the brain, which is ‘unique to each person like their fingerprints’.

Such a phenotype is determined, firstly, by the ability of the brain to build effective structural and functional connections between different areas (connectivity).

Secondly, the individual characteristics of neuronal dynamics, including its ability to reach a critical state. This is the state of the neuronal system in which it is the most plastic and capable of change.

(This story has not been edited by Business Standard staff and is auto-generated from a syndicated feed.

First Published: Fri, June 28 2019. 15:20 IST

 

via Researchers propose new approach for post-stroke rehabilitation | Business Standard News

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[WEB SITE] Best gripping aid for me? – The Active Hands Company

Best gripping aid for me?

Active Hands now sells a wide range of gripping aids for a wide variety of activities. To help you decide which gripping aid is right for you, please read the guide below.

 

How does your disability affect you? What do you want to grip? Which aid is right for you?
Reduced hand functionPoor finger strength

Tremors or involuntary movement

(This may include people with
Spinal Cord Injury, MS, cerebral palsy,
Guillan-Barré Syndrome, muscular dystrophy,
spina bifia, stroke survivors and other
similar disabilities).

 

Gym Equipment General Purpose gripping aid
D-ring gripping aids
Looped exercise aids
Hook aids
Gym pack/Gym pack deluxe
DIY tools General Purpose gripping aid
Kitchen implements General Purpose gripping aid
Sports equipment; rowing, kayaking etc General Purpose gripping aid
Looped Exercise aids
Hook aids
Gardening tools General Purpose gripping aid
Winter sports equipment such as adaptive skiing Winter Sports aid
Small diameter item: pen, make-up, toothbrush Small Item gripping aid
Adaptive tricycle/children’s walking frame General Purpose Mini aid (for children under 5) or General Purpose gripping aid
Missing fingersMissing parts of hands

This may include people with
dysmelia (conditions from birth), or amputation, illness or injury
later in life.

Gym equipment General Purpose gripping aid
D-ring gripping aids
Looped exercise aids
DIY tools Limb Difference gripping aid
Kitchen implements Limb Difference gripping aid
Sports equipment; rowing, kayaking etc Limb Difference gripping aid
Looped exercise aids
Gardening tools Limb Difference gripping aid

Find the product that best suits you…

Visit Site —> Best gripping aid for me? – The Active Hands Company

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