Posts Tagged therapy

[ARTICLE] Optogenetic Modulation for the Treatment of Traumatic Brain Injury – Full Text

Abstract

Although research involving traumatic brain injury (TBI) has traditionally focused on the acute clinical manifestations, new studies provide evidence for chronic and progressive neurological sequelae associated with TBI, highlighting the risk of persistent, and sometimes life-long, consequences for affected patients. Several treatment modalities to date have demonstrated efficacy in experimental models. However, there is currently no effective treatment to improve neural structure repair and functional recovery of TBI patients. Optogenetics represents a potential molecular tool for neuromodulation and monitoring cellular activity with unprecedented spatial resolution and millisecond temporal precision. In this review, we discuss the conceptual background and preclinical evidence of optogenetics for neuromodulation, and translational applications for TBI treatment are considered.

Introduction

Traumatic brain injury (TBI) is a significant public health issue worldwide and is predicted to be the third largest contributor to the global disease burden by 2020 [1,2]. The multifaceted and heterogeneous pathological aspects of this disease, which occur within days to months postinjury, cause significant neurological sequelae in TBI patients. Current empirical evidence provides new insight into these pathological mechanisms that lead to both focal neurological, as well as cognitive, deficits [3–5].

Recovery following TBI is complex and incompletely understood, yet studies have begun to elucidate important aspects of endogenously activated mechanisms that facilitate the process. Much of this research has been conducted to understand the fundamental concept of plasticity. Although neurogenesis within the mature brain continues, it is limited primarily to the subventricular zone (SVZ) surrounding the lateral ventricles and the subgranular zone (SGZ) of the hippocampal dentate gyrus (DG) [6–8]. A distinct subpopulation of cells from these regions migrate through adult white matter and differentiate into neurons in several cortical locations. Recent evidence suggests these cells may be involved in cell repair or renewal mechanisms [9,10].

Exploitation of this endogenous population of stem cells is of particular interest with regard to TBI. Following both diffuse and focal injury, a significant increase in proliferation within the SVZ and DG has been demonstrated in both mouse and rat TBI models alike [11,12]. Importantly, newly generated and injury-induced granular cells are able to integrate into the existing hippocampal circuitry, a phenomenon thought to facilitate innate cognitive recovery following injury [13,14]. A more recent study of human TBI models found proliferation of cells expressing markers of neural stem cells (NSCs) and neural progenitor cells in the perilesion cortex, thus representing an intrinsic effort by the injured brain to repair and regenerate damaged tissue [15].

This observed endogenous plasticity can be further investigated and manipulated using precise electrical modulation. To date, several methods have been explored to induce or accelerate functional and adaptive recovery in TBI patients, including both invasive (eg, electrical cortical stimulation [ECS]) and noninvasive (eg, transcranial magnetic stimulation [TMS], transcranial direct current stimulation, and pharmacologic) methods, each mediating an upregulation in plasticity following TBI [16–20]. However, animal studies and clinical trials involving the use of these interventions are scarce, and such approaches are often cell type indiscriminate, invasive, and render surrounding tissues susceptible to damage [21,22]. Due to a universal understanding that newer therapeutic approaches must circumvent these limitations, recent developments have successfully incorporated precision and cell type specificity into the treatment modality. Optogenetics builds upon previous research through the use of genetically encoded channels and receptors that serve to selectively activate or inhibit neuronal subpopulations with unprecedented spatial resolution and millisecond temporal precision. In this review, we discuss optogenetics as a means to evaluate and modulate neural circuits in the context of recovery following TBI.

Fundamentals of Optogenetics

Optogenetics is a modern advancement incorporating the fields of bioengineering, optics, and genetics for the purpose of modulating and monitoring cellular activity at the level of molecularly defined neuronal classes. This innovation involves the artificial introduction of light-sensitive proteins (eg, opsins) into cell membranes [23,24]. Neuronal plasma membranes themselves are thus made sensitive to light, permitting direct activation and inhibition of specified, targeted neurons within intact neuronal circuits [25]. In addition, optical monitoring of neuronal activity is achieved using genetically encoded sensors that respond to changes in ion concentration (eg, calcium) or membrane voltage. By utilizing tools with the ability to utilize light energy, neuronal imaging can achieve both high spatial and high temporal resolution [26,27].

While previous approaches typically fall short with respect to temporal and spatial accuracy, optogenetics expands the capability for optical imaging and genetic targeting by simultaneously controlling or monitoring either the activity of many neurons within a circuit or certain regions within a single neuron. Single-cell optogenetics is able to map neural circuits with excellent accuracy and zero-spike crosstalk [28]. Expression of certain light-sensitive proteins can also behave as actuators and switch neurons on and off, inducing either depolarizations or hyperpolarizations for varying periods of time with exquisite precision. This capability allows the opsins to probe neural activity at the resolution of single spikes, raising the possibility that this method can one day mimic natural neural code [29]. Since its inception, optogenetic tools have been developed to further map complex neural circuits and target specific neurons to facilitate behavior modulation, which are significant ambitions of current research in the field of neuroscience.[…]

 

Continue —-> Optogenetic Modulation for the Treatment of Traumatic Brain Injury | Stem Cells and Development

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[WEB PAGE] How to Treat Neurological Conditions with Physical Therapy

PHYSICAL THERAPY HELPS people improve their movement. You may think of physical therapy as something you use after a sports injury or after certain types of surgery. However, physical therapy helps with a variety of health issues. For example, breast cancer patients who have had their lymph nodes removed often get physical therapy to help with lymphedema. Physical therapy can also help with neurological disorders.

(GETTY IMAGES)

Neurological disorders (also called neurological diseases or conditions) affect the brain, spinal cord or nervous system. There are more than 1,000 neurological diseases. Some examples include:

Nearly 100 million Americans were affected by neurological disorders in 2011, according to a report in the Annals of Neurology. This number will likely increase as the population ages. Stroke and Alzheimer’s disease were the fourth- and fifth-highest killers in the U.S. in 2017, according to the Centers for Disease Control and Prevention.

 

Physical therapists are trained, licensed professionals who focus on evaluating and treating problems that affect any type of movement, says Anne Aldrich, a board-certified clinical specialist in pediatric physical therapy at CHOC Children’s, a pediatric health care system in Orange, California.

 

Physical therapists help to improve movement, so people can more easily do the things they want to do, says physical therapist Julie A. Blank, owner of On the Go Therapy Services in Sarasota, Florida.

 

Physical therapy is a good fit for many people with neurological disorders because they may have problems with their movement. These problems are often caused by the disorder. Depending on the type of neurological condition someone has, movement problems can get worse as the disease progresses. This is the case with conditions like Alzheimer’s disease, Parkinson’s disease and ALS.

How Physical Therapy Can Help

“These impairments can be small or large and can have a varying impact on an individual’s ability to move,” Aldrich says. Here are a few examples of how movement problems affect people with neurological disorders – and how physical therapy can help:

  • A man had a stroke eight years earlier. The stroke caused him to walk abnormally. Now his knee hurts due to the way he walks. He wants his knee pain to get better.
  • A child with a neurological disorder may need to learn to walk with a cane. Before doing this, she needs to practice sitting and standing. Then eventually, she can learn to walk with the cane.
  • A woman has a traumatic brain injury. Now her feet and hands aren’t moving together when she walks.
  • A man with ALS wants to learn some simple exercises to help avoid joint pain and stiffness.
  • Caregivers for a woman with Alzheimer’s disease want to help prevent her from falling. A physical therapist practices balance exercises with her to reduce her fall risk.
  • A physical therapist helps a woman with migraines by performing manual therapy, which is a manipulation of the muscles used by physical therapists and other health professionals. These movements help to decrease pain and expand mobility in the head and neck.
  • An older man with Parkinson’s disease has physical therapy to help with repetitive twisting of the foot, which can happen with Parkinson’s. The exercises done in physical therapy help to strengthen his foot.

Physical therapists tailor their care to each patient. They work with patients to create realistic goals. This means the therapy that one person receives will be very different from the therapy someone else gets. For instance, a person who needs a little training with the mobility equipment he or she uses will have very different needs than someone who has just had a stroke and needs to get back to work in a couple of months, says American Physical Therapy Association spokeswoman Alison M. Lichy. She is also the owner of Neurological Physical Therapy in Falls Church, Virginia.

What to Expect

Goals for physical therapy also are tailored for each person, and so are the frequency of physical therapy sessions. A person in the hospital due to a recent stroke or other major neurological injury may receive physical therapy and other types of therapy at the hospital a couple of times a day to help speed up progress.

Other patients may see a physical therapist a couple of times a week at a physical therapist’s office, although some therapists will come to a person’s home.

 

Sessions also can be done:

  • In a gym.
  • At hospice.
  • In a classroom or on a playground, which would be options for children.

It’s important to start physical therapy for neurological conditions as early as possible. Physical therapy can’t stop these conditions or their effects on movement entirely, but it can help slow down their progression, Blank says. “We can help to maintain things like good posture, balance and strength,” Blank notes. It’s harder to get good results if physical therapy starts later on.

Physical therapists help their patients get better with regular, repetitive exercises. Depending on a person’s goals, this can include practice with:

  • Balance.
  • Strengthening.
  • Stretching.

Even if the movements done during those exercises aren’t perfect, they help retrain the muscles and the brain to work together – something they may not have done for a long time.

 

Physical therapy for children with neurological disorders is a little different because sessions can be set up as playtime. For example, a therapist may have a child reach for a toy to help get them to practice rolling over or balance on one foot while playing ring toss in a pool. “This can make pediatric physical therapy both fun and satisfying for children and their parents,” Aldrich says.

 

An important part of physical therapy is the practice done outside of therapy sessions. Lichy says, “(Patients) need to know how to do activities at home and do them safely to maximize what they do outside of physical therapy.”

 

Patients who are motivated to progress tend to do better than those who want to be left alone. Blank says, “Our main job isn’t to provide therapy. It’s to teach and equip you to help you succeed moving forward. We give you the tools to help you get better or maintain what you have.”

Getting the Most Out of Physical Therapy for Neurological Disorders

If you or someone you care for needs physical therapy to help with a neurological condition, there are a few tips to keep in mind to get the best care possible:

 

1. Find out about the therapist’s experience with neurological disorders. There are physical therapists who have a designation called neurologic clinical specialist, or NCS. Although physical therapists all have some knowledge of neurological disorders, those with the NCS designation have passed a special test to expand their expertise in this area. The American Physical Therapy Association can help people find a physical therapist and allows users to specialize if they want someone with neurological expertise.

 

2. Clearly communicate about your problem. If your movement problem isn’t something that can’t be recreated when you first see a physical therapist, then try to take pictures or videos at home, and bring them with you, Aldrich advises.

 

3. Speak up if you need more care. Many patients in today’s health care system feel their care is limited by what their insurance is willing to pay, Blank says. This can leave them feeling frustrated, especially if they still feel they need more care. Let your physical therapist know if that’s your situation. Some will work with you to file additional paperwork for more sessions or to offer additional care, Blank says.

 

4. Practice your assigned exercises at home. This can’t be stressed enough. Doing designated exercises outside of physical therapy sessions can make a big difference in rebuilding your strength or preventing a further loss of movement if you have a worsening condition.

Vanessa Caceres, Contributor

Sources: Anne Aldrich, PT, DPT, PCSJulie A. Blank, PTAlison Lichy, PT, DPT, NCS

via How to Treat Neurological Conditions with Physical Therapy | U.S. News

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[VIDEO] Managing Fatigue After A Brain Injury – YouTube

via Managing Fatigue After A Brain Injury – YouTube

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[Abstract] Robotic-assisted therapy with bilateral practice improves task and motor performance in the upper extremities of chronic stroke patients: A randomised controlled trial.

Abstract

BACKGROUND/AIM:

Task-specific repetitive training, a usual care in occupational therapy practice, and robotic-aided rehabilitation with bilateral practice are used to improve upper limb motor and task performance. The difference in effects of two strategies requires exploration. This study compared the impact of robotic-assisted therapy with bilateral practice (RTBP) and usual task-specific training facilitated by therapists on task and motor performance for stroke survivors.

METHODS:

Forty-three community-dwelling stroke survivors (20 males; 23 females; 53.3 ± 13.1 years; post-stroke duration 14.2 ± 10.9 months) were randomised into RTBP and usual care. All participants received a 10-minute per-protocol sensorimotor stimulation session prior to interventions as part of usual care. Primary outcome was different in the amount of use (AOU) and quality of movement (QOM) on the Motor Activity Log (MAL) scale at endpoint. Secondary outcomes were AOU and QOM scores at follow-up, and pre-post and follow-up score differences on the Fugl-Meyer Assessment (FMA) and surface electromyography (sEMG). Friedman and Mann-Whitney U tests were used to calculate difference.

RESULTS:

There were no baseline differences between groups. Both conditions demonstrated significant within-group improvements in AOU-MAL and FMA scores following treatment (P < 0.05) and improvements in FMA scores at follow-up (P < 0.05). The training-induced improvement in AOU (30.0%) following treatment was greater than the minimal detectable change (16.8%) in the RTBP group. RTBP demonstrated better outcomes in FMA wrist score (P = 0.003) and sEMG of wrist extensor (P = 0.043) following treatment and in AOU (P < 0.001), FMA total score (P = 0.006), FMA wrist score (P < 0.001) and sEMG of wrist extensor (P = 0.017) at follow-up compared to the control group. Control group boost more beneficial effects on FMA hand score (P = 0.049) following treatment.

CONCLUSIONS:

RTBP demonstrated superior upper limb motor and task performance outcomes compared to therapists-facilitated task training when both were preceded by a 10-minute sensorimotor stimulation session.

 

via Robotic-assisted therapy with bilateral practice improves task and motor performance in the upper extremities of chronic stroke patients: A randomi… – PubMed – NCBI

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[Review] Ketogenic Diet and Epilepsy – Full Text PDF

Abstract

Currently available pharmacological treatment of epilepsy has limited effectiveness.
In epileptic patients, pharmacological treatment with available anticonvulsants leads to seizure control in <70% of cases. Surgical intervention can lead to control in a selected subset of patients, but still leaves a significant number of patients with uncontrolled seizures. Therefore, in drug-resistant epilepsy, the ketogenic diet proves to be useful. The purpose of this review was to provide a comprehensive overview of what was published about the benefits of ketogenic diet treatment in patients with epilepsy. Clinical data on the benefits of ketogenic diet treatment in terms of clinical symptoms and adverse reactions in patients with epilepsy have been reviewed. Variables that could have influenced the interpretation of the data were also discussed (e.g., gut microbiota). The data in this review contributes to a better understanding of the potential benefits of a ketogenic diet in the treatment of epilepsy and informs scientists, clinicians, and patients—as well as their families and caregivers—about the possibilities of such treatment. Since 1990, the number of publications on attempts to treat drug-resistant epilepsy with a ketogenic diet has grown so rapidly that it has become a challenge to see the overall trajectory and major milestones achieved in this field. In this review, we hope to provide the latest data from randomized clinical trials, practice guidelines, and new research areas over the past 2 years.

[…]

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[Abstract] Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology

Highlights

  • Virtual reality technology improves cognitive function post-traumatic brain injury.
  • Optimal treatment protocol is; 10–12 sessions, 20–40 min in duration with 2–4 sessions per week.
  • There was weak evidence for positive effect of virtual reality on attention.

Abstract

Background

Traumatic brain injury (TBI) can causes numerous cognitive impairments usually in the aspects of problem-solving, executive function, memory, and attention. Several studies has suggested that rehabilitation treatment interventions can be effective in treating cognitive symptoms of brain injury. Virtual reality (VR) technology potential as a useful tool for the assessment and rehabilitation of cognitive processes.

Objectives

The aims of present systematic review are to examine effects of VR training intervention on cognitive function, and to identify effective VR treatment protocol in patients with TBI.

Methods

PubMed, Scopus, PEDro, REHABDATA, EMBASE, web of science, and MEDLINE were searched for studies investigated effect of VR on cognitive functions post TBI. The methodological quality were evaluated using PEDro scale. The results of selected studies were summarized.

Results

Nine studies were included in present study. Four were randomized clinical trials, case studies (n = 3), prospective study (n = 1), and pilot study (n = 1). The scores on the PEDro ranged from 0 to 7 with a mean score of 3. The results showed improvement in various cognitive function aspects such as; memory, executive function, and attention in patients with TBI after VR training.

Conclusion

Using different VR tools with following treatment protocol; 10–12 sessions, 20–40 min in duration with 2–4 sessions per week may improves cognitive function in patients with TBI. There was weak evidence for effects of VR training on attention post TBI.

via Cognitive rehabilitation post traumatic brain injury: A systematic review for emerging use of virtual reality technology – Journal of Clinical Neuroscience

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[Abstract] Cognitive and Motor Recovery and Predictors of Long-Term Outcome in Patients with Traumatic Brain Injury

Abstract

Objective

To explore the patterns of cognitive and motor recovery at four time points from admission to nine months post-discharge from IR and to investigate the association of therapeutic factors and pre- and post-discharge conditions with long-term outcomes.

Design

Secondary analysis of traumatic brain injury-practice based evidence (TBI-PBE) dataset.

Settings

Inpatient rehabilitation (IR) in Ontario, Canada.

Participants

A total of 85 patients with TBI consecutively admitted for IR between 2008 and 2011 and had data available from admission to nine months follow-up.

Interventions

Not applicable.

Main outcome measure

Functional Independence Measure-Rasch cognitive and motor scores at admission, discharge, three, and nine months post-discharge.

Results

Cognitive and motor recovery showed similar patterns of improvement with recovery up to three months but no significant change from three to nine months. Having fewer post-discharge health conditions was associated with better long-term cognitive scores (95% CI -13.06, -1.2) and added 9.9 % to the explanatory power of the model. More therapy time in complex occupational therapy activities (95% CI .02, .09) and fewer post-discharge health conditions (95% CI -19.5, -3.8) were significant predictors of better long-term motor function and added 14.3% and 7.2% to the explanatory power of the model, respectively.

Conclusion

Results of this study inform health care providers about the influence of the timing of IR on cognitive and motor recovery. In addition, it underlines the importance of making patients and families aware of residual health conditions following discharge from IR.

via Cognitive and Motor Recovery and Predictors of Long-Term Outcome in Patients with Traumatic Brain Injury – Archives of Physical Medicine and Rehabilitation

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[Abstract] Combined transcranial direct current stimulation with virtual reality exposure for posttraumatic stress disorder: Feasibility and pilot results

Abstract

Background

Facilitating neural activity using non-invasive brain stimulation may improve extinction-based treatments for posttraumatic stress disorder (PTSD).

Objective/hypothesis

Here, we examined the feasibility of simultaneous transcranial direct current stimulation (tDCS) application during virtual reality (VR) to reduce psychophysiological arousal and symptoms in Veterans with PTSD.

Methods

Twelve Veterans with PTSD received six combat-related VR exposure sessions during sham-controlled tDCS targeting ventromedial prefrontal cortex. Primary outcome measures were changes in skin conductance-based arousal and self-reported PTSD symptom severity.

Results

tDCS + VR components were combined without technical difficulty. We observed a significant interaction between reduction in arousal across sessions and tDCS group (p = .03), indicating that the decrease in physiological arousal was greater in the tDCS + VR versus sham group. We additionally observed a clinically meaningful reduction in PTSD symptom severity.

Conclusions

This study demonstrates feasibility of applying tDCS during VR. Preliminary data suggest a reduction in psychophysiological arousal and PTSD symptomatology, supporting future studies.

via Combined transcranial direct current stimulation with virtual reality exposure for posttraumatic stress disorder: Feasibility and pilot results – Brain Stimulation: Basic, Translational, and Clinical Research in Neuromodulation

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[ARTICLE] Pilot testing of the spring operated wearable enhancer for arm rehabilitation (SpringWear) – Full Text

Abstract

Background

Robotic devices for neurorehabilitation of movement impairments in persons with stroke have been studied extensively. However, the vast majority of these devices only allow practice of stereotyped components of simulated functional tasks in the clinic. Previously we developed SpringWear, a wearable, spring operated, upper extremity exoskeleton capable of assisting movements during real-life functional activities, potentially in the home. SpringWear assists shoulder flexion, elbow extension and forearm supination/pronation. The assistance profiles were designed to approximate the torque required to move the joint passively through its range. These three assisted DOF are combined with two passive shoulder DOF, allowing complex multi-joint movement patterns.

Methods

We performed a cross-sectional study to assess changes in movement patterns when assisted by SpringWear. Thirteen persons with chronic stroke performed range of motion (ROM) and functional tasks, including pick and place tasks with various objects. Sensors on the device measured rotation at all 5 DOF and a kinematic model calculated position of the wrist relative to the shoulder. Within subject t-tests were used to determine changes with assistance from SpringWear.

Results

Maximum shoulder flexion, elbow extension and forearm pronation/supination angles increased significantly during both ROM and functional tasks (p < 0.002). Elbow flexion/extension ROM also increased significantly (p < 0.001). When the subjects volitionally held up the arm against gravity, extension at the index finger proximal interphalangeal joint increased significantly (p = 0.033) when assisted by SpringWear. The forward reach workspace increased 19% (p = 0.002). Nine subjects could not complete the functional tasks unassisted and only one showed improvement on task completion with SpringWear.

Conclusions

SpringWear increased the usable workspace during reaching movements, but there was no consistent improvement in the ability to complete functional tasks. Assistance levels at the shoulder were increased only until the shoulder could be voluntarily held at 90 degrees of flexion. A higher level of assistance may have yielded better results. Also combining SpringWear with HandSOME, an exoskeleton for assisting hand opening, may yield the most dramatic improvements in functional task performance. These low-cost devices can potentially reduce effort and improve performance during task practice, increasing adherence to home training programs for rehabilitation.

Background

There are 800,000 new strokes in the United States each year [1]. Many survivors experience debilitating motor impairments in the upper extremity that negatively affect functional capacity and quality of life. Impairments can include weakness [2] and lack of coordination between different muscle groups [3]. Fifty percent of stroke survivors older than 64 have persistent hemiparesis at six months post-stroke and 26% are dependent in activities of daily living (ADL) [1]. Unfortunately, a very high level of upper extremity motor control may be needed before the impaired limb is actually incorporated into ADL. Stroke patients often appear to have adequate movement ability when observed in the laboratory, but don’t use the limb with the expected regularity [4].

Neurorehabilitation of these impairments is possible with task-specific repetitive movement practice that incorporates high repetition, volitional effort, and successful completion of tasks to prevent frustration and maintain motivation [5]. Robotics has been studied extensively as a means of assisting movements with forces applied to the limb, allowing completion of movements that would otherwise be impossible to complete unassisted. A recent meta-analysis of 34 studies including 1160 subjects found that robotic devices produced larger gains in arm function, strength and ADL ability than comparison interventions [6]. However, authors concluded the advantages of robotic therapy may not be clinically relevant. The vast majority of these studies involved patients traveling to the clinic on a regimented schedule to practice components of tasks. Home-based approaches may be more effective in increasing the amount of limb use, in particular devices that can assist movements while subjects perform real-world ADL.

Many robotic treatments involve providing partial support of the arm against gravity to enable practice of reaching within a larger workspace [78]. This approach is motivated by research that has shown that many stroke patients have an abnormal synergy whereby elevation of the shoulder against gravity impairs the ability to extend the elbow [91011]. More recently, work has shown an abnormal coupling of proximal and distal arm muscles, such that activation level of proximal muscles and level of arm support can affect control of hand and wrist muscles [1213]. However current robotic approaches that provide gravity compensation do not allow practice of tasks in real-world environments, such as in the home, while standing or when performing bimanual tasks. Also, the provision of gravity support may not completely overcome distal weakness in elbow extension and forearm supination [14]. Additionally, many robotic paradigms rely on repetitive performance of components of functional tasks, for example, planar reaching movements. This contradicts motor learning studies that suggest retention and generalization of skills requires task variability [151617].

In previous work we developed a wearable passively actuated hand exoskeleton (HandSOME) that increases finger ROM and function [1819]. However, some subjects were found to be inappropriate for HandSOME because of proximal weakness, and while the HandSOME enabled adequate range of motion at the fingers, some subjects had difficulty supinating the forearm enough to properly grasp certain objects. Furthermore, finger extension ability would degrade as the arm was lifted against gravity. This motivated the development of a wearable arm exoskeleton called the spring-operated wearable enhancer (SpringWear). Springs apply an angle-dependent torque to the joints, with the goal of increasing ROM, repertoire of possible movements, task variability and success in completing tasks.

Overall, the goal was to enable effective use of the impaired limb in the home environment, thereby allowing patients a highly variable, but meaningful task practice. SpringWear can also reduce effort in task completion promoting greater adherence to home practice schedules. At the shoulder, SpringWear provides partial gravity compensation, which reduces the muscle forces at the shoulder needed to lift the arm. With proper selection of assistance level, the initiation and control of movements are still under patient control but less effort is needed and a larger ROM can be achieved. At the elbow, patients often can flex the joint, but have limited extension, so extension torques are applied to increase elbow extension range. A similar strategy is used to assist forearm supination/pronation. In order to benefit from SpringWear, patients should have some active movement at the joints, but for profoundly weak patients, this approach will not be effective. In these patients, powered exoskeletons may be needed, since they can move the limb throughout a larger workspace than spring powered devices. However, powered devices are much more expensive and complicated to integrate into a wearable device and compact designs are often high impedance, requiring sensors to infer the patient’s intended movement trajectory, which may be difficult in very low level patients.

In this study, chronic stroke patients performed a number of tasks with and without assistance from the SpringWear, and the kinematics of the movements were compared. If successful, SpringWear combined with HandSOME, may provide an inexpensive home-based intervention for a wide range of severe to moderately impaired stroke patients.

Methods

SpringWear design

An upper limb exoskeleton, in general, needs to be adaptable to different segment lengths and have a high number of DOFs in order to allow realistic movement practice with many anatomical joint axes involved [20]. With five DOFs, SpringWear was designed to provide assistance to forearm supination/pronation, elbow extension, shoulder flexion, while providing passive joints for shoulder horizontal abduction/adduction and internal/external rotation to allow realistic upper limb movements (Fig. 1). The design uses rubber bands or bungee cords as springs to provide the assistance. These profiles can be customized for each subject by adjusting the stiffness of the springs, which is dependent on impairment level.

 

Fig. 1 Full Assembly of SpringWear with back splint. Double-headed arrows represents five degrees of freedom. Assistance was applied at shoulder FE, elbow FE, and supination/pronation

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Continue —> Pilot testing of the spring operated wearable enhancer for arm rehabilitation (SpringWear) | Journal of NeuroEngineering and Rehabilitation | Full Text

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[ARTICLE] Classification of Traumatic Brain Injury for Targeted Therapies – Full Text

Abstract

The heterogeneity of traumatic brain injury (TBI) is considered one of the most significant barriers to finding effective therapeutic interventions. In October, 2007, the National Institute of Neurological Disorders and Stroke, with support from the Brain Injury Association of America, the Defense and Veterans Brain Injury Center, and the National Institute of Disability and Rehabilitation Research, convened a workshop to outline the steps needed to develop a reliable, efficient and valid classification system for TBI that could be used to link specific patterns of brain and neurovascular injury with appropriate therapeutic interventions. Currently, the Glasgow Coma Scale (GCS) is the primary selection criterion for inclusion in most TBI clinical trials. While the GCS is extremely useful in the clinical management and prognosis of TBI, it does not provide specific information about the pathophysiologic mechanisms which are responsible for neurological deficits and targeted by interventions. On the premise that brain injuries with similar pathoanatomic features are likely to share common pathophysiologic mechanisms, participants proposed that a new, multidimensional classification system should be developed for TBI clinical trials. It was agreed that preclinical models were vital in establishing pathophysiologic mechanisms relevant to specific pathoanatomic types of TBI and verifying that a given therapeutic approach improves outcome in these targeted TBI types. In a clinical trial, patients with the targeted pathoanatomic injury type would be selected using an initial diagnostic entry criterion, including their severity of injury. Coexisting brain injury types would be identified and multivariate prognostic modeling used for refinement of inclusion/exclusion criteria and patient stratification. Outcome assessment would utilize endpoints relevant to the targeted injury type. Advantages and disadvantages of currently available diagnostic, monitoring, and assessment tools were discussed. Recommendations were made for enhancing the utility of available or emerging tools in order to facilitate implementation of a pathoanatomic classification approach for clinical trials.

Introduction

Traumatic brain injury (TBI) remains a major cause of death and disability. Although much has been learned about the molecular and cellular mechanisms of TBI in the past 20 years, these advances have failed to translate into a successful clinical trial, and thus there has been no significant improvement in treatment. Among the numerous barriers to finding effective interventions to improve outcomes after TBI, the heterogeneity of the injury and identification and classification of patients most likely to benefit from the treatment are considered some of the most significant challenges (Doppenberg et al., 2004; Marshall, 2000; Narayan et al., 2002).

The type of classification one develops depends on the available data and the purpose of the classification system. An etiological classification describes the factors to change in order to prevent the condition. A symptom classificationdescribes the clinical manifestation of the problem to be solved. A prognostic classification describes the factors associated with outcome, and a pathoanatomic classification describes the abnormality to be targeted by the treatment. Most diseases were originally classified on the basis of the clinical picture using a symptom-based classification system. Beginning in the 18th century, autopsies became more routine, and an increasing number of disease conditions were classified by their pathoanatomic lesions. With improvement of diagnostic tools, modern disease classification in most fields of medicine uses a mixture of anatomically, physiologically, metabolically, immunologically, and genetically defined parameters.

Currently, the primary selection criterion for inclusion in a TBI clinical trial is the Glasgow Coma Scale (GCS), a clinical scale that assesses the level of consciousness after TBI. Patients are typically divided into the broad categories of mild, moderate, and severe injury. While the GCS has proved to be extremely useful in the clinical management and prognosis of TBI, it does not provide specific information about the pathophysiologic mechanisms responsible for the neurological deficits. This is clearly demonstrated in Figure 1, in which all six patients are classified as having a severe TBI. Given the heterogeneity of the pathoanatomic features depicted in these computed tomography (CT) scans, it is difficult to see how a therapy targeted simply for severe TBI could effectively treat all of these different types of injury. Many tools such as CT scans and magnetic resonance imaging (MRI) already exist to help differentiate the multiple types of brain injury and variety of host factors and other confounders that might influence the yield of clinical trials. In addition, newer advances in neuroimaging, biomarkers, and bioinformatics may increase the effectiveness of clinical trials by helping to classify patients into groups most likely to benefit from specific treatments.

 

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Heterogeneity of severe traumatic brain injury (TBI). Computed tomography (CT) scans of six different patients with severe TBI, defined as a Glasgow Coma Scale score of <8, highlighting the significant heterogeneity of pathological findings. CT scans represent patients with epidural hematomas (EDH), contusions and parenchymal hematomas (Contusion/Hematoma), diffuse axonal injury (DAI), subdural hematoma (SDH), subarachnoid hemorrhage and intraventricular hemorrhage (SAH/IVH), and diffuse brain swelling (Diffuse Swelling).

Continue —>  Classification of Traumatic Brain Injury for Targeted Therapies

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