Posts Tagged therapy
As the meteors came down from the sky, my heart thudded in my chest. There was only one way I could save the town below: Reach out into the air, make a fist, and in doing so, set off an explosion. And then another. And another. How else can one be expected to defend a village?
This was the task given to me by Alex Miller, a computer scientist creating virtual realities for the neurology department at the University of Pennsylvania. Under the guidance of Dr. Branch Coslett, Miller’s lab is making programs for stroke victims trying to regain the use of a limb, amputees trying to lose phantom limb pain, and other people with mysterious, hard-to-heal conditions of the body and brain.
But in the meantime, I’m strapped into an Oculus Rift VR headset, with a Leap Motion tracking system attached to the front of it. The Leap Motion is, well, magical: it scans the area in front of it, registers where my hands are, and then projects those hands into the game. The experience is profoundly immersive: when I move my head left or right, the view in the game moves accordingly, and if I open my hand or close my wrist, the same happens in-game, in real-time. There are many possible medical applications: the game is recording all of my movements, creating what would be a hyper-detailed tracking of rehab progress over time, and if Miller so chose, my in-game left hand could be a representation of my real-life right hand—a fun trick for an able-bodied person, but if I had lost my left hand, my brain seeing an intact left hand in game could actually ease phantom limb pain.
Just a few minutes earlier, Miller was strapping sensors to my thighs and knees. I’m in yet another world, and with my virtual feet underneath me. I’m on a platform in a desert, it’s twilight, and I have a puzzle to solve: make it from my spawning point to a glowing goal across the way. There are any number of pits I need to avoid falling into, and in classic game fashion, the solution is to push crates into them. Seated in my chair, I make a slow, dragging step to move forward, and sweep my foot left or right to turn. The sensors strapped to me are set up so that if you had lost your leg below—or above—the knee, the electronic signals sent by the muscles would be detected, and you’d make those same movements in the game. So even for a body that is injured in real life, it can be intact in the game, and neurologically speaking, it doesn’t make that much of a difference.
“That’s the killer use case of virtual reality,” Miller explains. The brain is surprisingly easy to fool, and it will believe that the hands and feet in a game are your own, with potentially huge medical consequences. “It’s really about illusion,” he says: you manipulate what a patient sees in their virtual self and their virtual world, and their brains will literally incorporate these things into the body image. While still early, results indicate that using the Penn neurology games does indeed reduce the intensity of phantom limb pain.
The idea of virtual reality has been around for decades. The French dramatist Antonin Artaud coined “la realite virtuelle” in 1938 to describe the temporary world created by theatre. The 1960s saw the Sensorama, an arcade cabinet that played 3D movies along with stereo sound, wind and smells on head-mounted displays. Movies like Tron, The Lawnmower Man and The Matrix all help make VR a household term. And the 1990s saw a boom in VR arcades, with game console manufacturers making early bids, too—shoutout to Nintendo’s Virtual Boy. The first examples of medical VR started showing up then, too—like a demo of gastrointestinal surgery. But, according to many researchers Thrive Global spoke to, we’ve entered a new era of VR in just the past few years.
With the Oculus, the HTC Vive, and other VR setups becoming available, the price of setting up a VR lab has cratered: Betty Mohler, a researcher at the Max Planck Institute for Biological Cybernetics, tells Thrive Global the cost has fallen a hundredfold. And it’s getting even cheaper, as low-cost options like the Google Daydream start rolling out. “With affordable, high-quality virtual reality devices hitting the market for the first time, the future seems suddenly imminent,” Oxford psychiatrist and VR specialist Daniel Freeman tells Thrive Global. “VR could become the method of choice for psychological treatment — out with the couch, on with the headset.”
It’s a potential that the investors have seen, most famously with Facebook’s $3 billionpurchase of Oculus in 2014. More recently, with the growing hype surrounding MindMaze, a VR startup out of Switzerland with a valuation already north of $1 billion. The company’s stroke rehab treatments were introduced into European hospitals in 2013, and the company announced entry into the US market this year. Since VR is so stimulating, patients are more likely to do their rehab, and according to one company report, a full 100 percent of patients forgot they were in the hospital while doing their VR rehab.
VR is simultaneously neurological and psychological: it has applications with disorders of the body, like phantom limb pain, and conditions of the mind, like PTSD, anxiety, and paranoia. Unlike any other technology before it, VR gives the user a direct sense of embodiment, what University of Barcelona pioneer Mel Slater refers to as “presence.” It’s not just another medium in a long line of media: virtual reality directly accesses people’s sense of self—these hands are mine, my own brain thought, as I pawed at the meteors. Rather than flatly watching, you’re immersed in the virtual world.
The thing about conventional “talk” therapy is that all the therapist and the client can really do is remember and imagine: you might get tips about how to keep your family from driving you crazy the next time Thanksgiving rolls around, but your shrink can’t place you at the dinner table. That all changes with virtual reality: with the right software, a therapist can put you in the places you have come to fear the most. People with arachnophobia get anxious around spiders, those with paranoia are afraid of social situations, and people with PTSD get triggered by cues linked to their trauma.
“Difficulties interacting in the world are at the heart of mental health issues,” Freeman, the Oxford psychiatrist, explains. With VR, you can repeatedly experience those feared situations—at a just-tolerable dose—and learn to overcome them. “The beauty of VR is that individuals know that a computer environment is not real, but their minds and bodies behave as if it is real,” he adds, which allows people to more easily face fearful situations, and then experiment with how to approach them. “This learning then transfers to the real world,” he says.
His lab has done lots of research around paranoia, a condition that affects around 1 or 2 percent of the population. In a 2016 paper in the British Journal of Psychiatry, Freeman and his team dropped people with paranoia into public situations, like standing in an elevator or commuting on a subway car. The subjects wore headsets and could walk around a room, rather than using a controller. Every time the patient entered one of these levels, they’d encounter more people in that space. After doing just 30 minutes of VR, about half of the patients no longer felt severe paranoia at the end of their testing day, and when they went into real social situations, they felt less distressed.[…]
[Abstract+References] XOOM: An End-User Development Tool for Web-Based Wearable Immersive Virtual Tours
XOOM is a novel interactive tool that allows non ICT-specialists to create web-based applications of Wearable Immersive Virtual Reality (WIVR) technology that use 360° realistic videos as interactive virtual tours. These applications are interesting for various domains that range from gaming, entertainment, cultural heritage, and tourism to education, professional training, therapy and rehabilitation. 360° interactive videos are displayed on smart-phones placed on head-mounted VR viewers. Users explore the virtual environment and interact with active elements through head direction and movements. The virtual scenarios can be seen also on external displays (e.g., TV monitors or projections) to enable other users to participate in the experience, and to control the VR space if needed, e.g., for education, training or therapy purposes. XOOM provides the functionality to create applications of this kind, import 360° videos, concatenate them, and superimpose active elements on the virtual scenes, so that the resulting environment is more interactive and is customized to the requirement of a specific domain and user target. XOOM also supports automatic data gathering and visualizations (e.g., through heat-maps) of the users’ experience, which can be inspected for analytics purposes, as well as for user evaluation (e.g., in education, training, or therapy contexts). The paper describes the design and implementation of XOOM, and reports a case study in the therapeutic context.
Stroke causes 5.7 million deaths annually. This ranks stroke as the second most common cause of death and, additionally, it is a major cause of disability. Because of an ageing population, stroke incidence and costs will greatly increase in the future. This makes stroke an ongoing social and economic burden, in contrast to the only very limited therapeutic options.
In the last decade vast sums were spent on translational research focused on neuroprotective strategies in the acute phase of ischaemic stroke. A plethora of candidate agents were tested in experimental models and preclinical studies, but none was proven effective in clinical trials. This gave rise to discussions about the possible reasons for this failure, ending up mainly with criticism of methodological aspects of the preclinical and clinical studies, or of the relevance of animal studies in drug development. Indeed, the question could rather be whether neuroprotection is the right target for successful stroke treatment. In this context, a paradigm change can currently be observed: the focus of experimental and translational stroke research is shifting from early neuroprotection to delayed mechanisms such as stroke-associated comorbidities, regeneration and plasticity.
In this review we highlight a few recently emerging fields in translational stroke research. One such topic is the crosstalk between immunity and the injured brain as key pathomechanism in stroke. On one hand, innate and adaptive immune cells play an important role in the fate of injured brain tissue after stroke; on the other, peripheral immune alterations are critically involved in post-stroke comorbidities.
Another emerging research area is the analysis of mechanisms involved in regeneration and neuronal plasticity after stroke. Here, we discuss the current understanding of basic mechanisms involved after brain injury, clinical imaging approaches and therapeutic strategies to promote regeneration in stroke patients.
Stroke rehabilitation is critical to dealing with a growing burden of stroke-related disability. The most important prognostic factors predicting stroke recovery are stroke severity, age of the stroke survivor, and access to rehabilitation. Neuroplasticity with associated neurological recovery is an important concept which emphasizes the importance of stroke rehabilitation. Optimal rehabilitation outcomes are reported when rehabilitation takes place in specialized interdisciplinary stroke rehabilitation units, when rehab is initiated early and when therapy is of sufficient intensity. Outpatient rehabilitation therapy has been shown to further improve outcomes. In the future, stroke rehabilitation outcomes will improve even further through better adherence to clinical practice guidelines and the increasing use of new technologies. There is a developing evidence base supporting long-term rehabilitation management of stroke, a concept which in the past has received little in the way of resources or attention.
Background. While recent clinical trials involving robot-assisted therapy have failed to show clinically significant improvement versus conventional therapy, it is possible that a broader strategy of intensive therapy—to include robot-assisted rehabilitation—may yield clinically meaningful outcomes.
Objective. To test the immediate and sustained effects of intensive therapy (robot-assisted therapy plus intensive conventional therapy) on outcomes in a chronic stroke population.
Methods. A multivariate mixed-effects model adjusted for important covariates was established to measure the effect of intensive therapy versus usual care. A total of 127 chronic stroke patients from 4 Veterans Affairs medical centers were randomized to either robot-assisted therapy (n = 49), intensive comparison therapy (n = 50), or usual care (n = 28), in the VA-ROBOTICS randomized clinical trial. Patients were at least 6 months poststroke, of moderate-to-severe upper limb impairment. The primary outcome measure was the Fugl-Meyer Assessment at 12 and 36 weeks.
Results. There was significant benefit of intensive therapy over usual care on the Fugl-Meyer Assessment at 12 weeks with a mean difference of 4.0 points (95% CI = 1.3-6.7); P = .005; however, by 36 weeks, the benefit was attenuated (mean difference 3.4; 95% CI = −0.02 to 6.9; P = .05). Subgroup analyses showed significant interactions between treatment and age, treatment and time since stroke.
Conclusions. Motor benefits from intensive therapy compared with usual care were observed at 12 and 36 weeks posttherapy; however, this difference was attenuated at 36 weeks. Subgroups analysis showed that younger age, and a shorter time since stroke were associated with greater immediate and long-term improvement of motor function.
[REVIEW] Post-Stroke Depression | EBRSR – Evidence-Based Review of Stroke Rehabilitation – Full Text PDF
Depression is a common complication post-stroke affecting approximately one-third of patients. The presence of post-stroke depression has been associated with decreases in functional recovery, social activity and cognition. In addition, the presence of mental health disorders following stroke may be associated with increased mortality. The present review discusses the prevalence, natural history and risk factors for post-stroke depression as well as issues around its assessment and impact on rehabilitation outcomes. Strategies for the prevention and management of post-stroke depression are reviewed. Recommendations for assessment and treatment are provided based on current guidelines. A discussion of post-stroke emotionalism, its impact and treatment is also included.
Left neglect, also known as unilateral neglect or hemispatial neglect, is one of the oddest symptoms of a brain injury. It can also be one of the most troublesome symptoms. Left neglect is a deficit that occurs following an injury to the right side of the brain. Due to the injury, the brain has difficulty paying attention to items on the left side. This is generally most apparent in difficulties noticing items visually on the left side. For instance, a survivor with left neglect may bump into frames of doors on the his or her left or miss eating food on the left side of his or her plate. It appears as if he or she is blind to items on the left but this is not a true vision issue. It is an attention issue. The brain is not attending to information on the left. The survivor can have…
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This pilot study tested the effectiveness of an intense, short-term upper-limb robotic therapy for improvement in motor outcomes among chronic stroke patients. We enrolled 30 subjects with upper-limb deficits due to stroke of at least 6 mo duration and with a Motor Power Assessment grade of 3 or less. Over 3 wk, 18 sessions of robot-assisted task-specific therapy were delivered with the use of a robotic exercise device that simulates a conventional therapy known as skateboard therapy.
Primary outcome measures included reliable, validated impairment and disability measures of upper-limb motor function. Statistically significant improvements were observed for severely impaired participants when we compared baseline and posttreatment outcomes (p < 0.05).
These results are important because they indicate that improvement is not limited to those with moderate impairments but is possible among severely impaired chronic stroke patients as well. Moderately and severely impaired patients in our study were able to tolerate a massed-practice therapy paradigm with intensive, frequent, and repetitive treatment. This information is useful in determining the optimal target population, intensity, and duration of robotic therapy and sample size for a planned larger trial.
[ARTICLE] Robotic Therapy Provides a Stimulus for Upper Limb Motor Recovery After Stroke That Is Complementary to and Distinct From Conventional Therapy
Background. Individuals with chronic stroke often have long-lasting upper extremity impairments that impede function during activities of daily living. Rehabilitation robotics have shown promise in improving arm function, but current systems do not allow realistic training of activities of daily living. We have incorporated the ARMin III and HandSOME device into a novel robotic therapy modality that provides functional training of reach and grasp tasks.
Objective. To compare the effects of equal doses of robotic and conventional therapy in individuals with chronic stroke.
Methods. Subjects were randomized to 12 hours of robotic or conventional therapy and then crossed over to the other therapy type after a 1-month washout period. Twelve moderate to severely impaired individuals with chronic stroke were enrolled, and 10 completed the study.
Results. Across the 3-month study period, subjects showed significant improvements in the Fugl-Meyer (P = .013) and Box and Blocks tests (P = .028). The robotic intervention produced significantly greater improvements in the Action Research Arm Test than conventional therapy (P = .033). Gains in the Box and Blocks test from conventional therapy were larger than from robotic therapy in subjects who received conventional therapy after robotic therapy (P = .044).
Conclusions. Data suggest that robotic therapy can elicit improvements in arm function that are distinct from conventional therapy and supplements conventional methods to improve outcomes. Results from this pilot study should be confirmed in a larger study.