Neurorehabilitation - Science topic

Hi Jairo,

I know that MRN projects to PPT, thus I predict that it inhibits it. Similarly to the known MRN inhibition of MS/vDBB, SUM, and other theta promoting, wake-gamma, and awareness promoting regions.

Dear Amirul AB ,

AI can help define specific clinical subtypes and profiles, optimizing pharmacological and neurorehabilitative indications for each patient, increasing their effectiveness. On the therapeutic front, AI has revolutionized how technological devices interact with patients during neurorehabilitation.

https://inrobics.com/en/posibilities-ai-neurorehabilitation/#:~:text=AI%20can%20help%20define%20specific,interact%20with%20patients%20during%20neurorehabilitation.

Regards,

Shafagat

Big principle

Use of progressive strengthening exercises for muscle momory

Dear Amirul AB , this article may be of interest to you.

“I would fall five to six times per day,” says architect and former mayor Marc Gauthier, reflecting on his life before receiving a highly experimental implant that delivers electrical stimulation to his spinal cord. Gauthier has advanced Parkinson’s disease, and the technology enables him to walk fluidly — something no other therapy can do. Researchers say larger studies are needed to assess whether the device will work for others with the disease...

Sorry, I don't know any advanced practice nurse in Germany.

Also check the following very good link:

Task-based interventions are highly effective for gait and ambulation among patients with chronic CVA and TBI provided that a sufficient intensity is maintained.

Dear Dr Monaghan,

I read with interest your answer and I have to admit that your analogy between post-stroke/neuro-rehabilitation and Malcolm Gladwells issues is quite relevant. Indeed, you make here very interesting comments about improving physiotherapy through a psychological approach.

Stroke rehabilitation is a patient-centered approach and should therefore be adapted to each patient regarding his needs. Education about pathology and rehabilitation process is certainly one of the most important things to do when meeting the patient for the first time. I do agree that adding a psychological education would help patients to better recover. Indeed, teaching them to think positive and to develop the habits of working hard would probably lead to improved results.

I would also like to add that patient's motivation could be easily enhanced by giving him the opportunity to self-rehabilitate. In fact, with the development of new technologies such as robot-assisted therapy and virtual reality, self-rehabilitation becomes very interesting. More importantly, thanks to serious games, these technologies offer a good opportunity to enhance patient's adherence to rehabilitation. Indeed, a serious game is an interactive game specifically designed for rehabilitation whose difficulty is constantly adapted to the patient. These games help to make rehabilitation more playful.

Other neurorehabilitation principles described in the review of Maier et al., in 2019

("Effect of Specific Over Nonspecific VR-Based Rehabilitation on Poststroke Motor Recovery: A Systematic Meta-analysis") are also a good way to enhance patient's motivation and outcomes. These principles are: “a massed practice (training with repetitive tasks), dosage (intensive training), a structured practice (training that includes resting times), a task-specific practice (functional training), a variable practice (training that includes different types of task), a multisensory stimulation (training that provides at least two sensorial feedbacks such as visual, auditive or haptic feedback), an increasing difficulty, an explicit feedback (training that provides information about the patient’s task results), an implicit feedback (training that delivers information about the performance such as real time visualization of movement properties), an avatar representation (embodied training), and promoting the use of the paretic limb.”

I also think that stroke rehabilitation could be improved by collaborating between technology developers and the various experts involved in stroke rehabilitation, including physical medicine, neuropsychology, speech and language therapy and occupational therapy. Indeed, neuropsychological disorders are common after stroke and should more often be considered during motor relearning. Cognitive processes are important for the motor function as they spearhead voluntary actions, such as selective attention to select the object for interaction, selection of the response limb effector, planning action to the object and execution, including the inhibition and avoidance of distractors.

Lastly, as described by Stinear et al., in 2020 ("Advances and challenges in stroke rehabilitation"), we also have to improve the way of conducting experimental researches in order to better understand what is efficient or not in stroke motor rehabilitation.

Best regards,

Gauthier

Nice Dear Jonathan A Norton

Nice Contribution Martin Marko

Dear Ardalan,

For example, in the study by Qafarizadeh et al. the Kinesio Taping did not improve the wrist flexors spasticity level.

Qafarizadeh F, Kalantari M, Ansari NN, Baghban AA, Jamebozorgi A. The effect of kinesiotaping on hand function in stroke patients: A pilot study. J Bodyw Mov Ther 2018;22(3):829-831. https://www.researchgate.net/publication/320009712_The_effect_of_kinesiotaping_on_hand_function_in_stroke_patients_A_pilot_study

And here is a recent Brazilian study:

Cavalcante JGT, do Desterro Costae Silva M, da Fonseca Silva JT, dos Anjos CC, Soutinho RSR. Effect of Kinesio Taping on Hand Function in Hemiparetic Patients. World Journal of Neuroscience 2018;8:293--302. https://file.scirp.org/pdf/WJNS_2018052115450211.pdf

The results of this ongoing study "Kinesiotaping Combined With Therapeutic Exercise in Upper Extremity Spasticity and Function in Subacute Stroke Patients" at Chang Gung Memorial Hospital will certainly be interesting: https://clinicaltrials.gov/ct2/show/study/NCT03024190

Best wishes, Martin

The overriding considerations are three-fold: 1. Financial, that is, the ability to pay for the drug in acute stroke. 2. Financial, that is, the ability to pay for the equipment to rule out a bleed as the cause of the stroke because then you would not use a clot-busting drug if there is bleeding in the brain. 3. Expertise, the ability to manage the patient with or without the clot-busting drug.

We have transferred CIMT principles to an autonomous Virtual Reality-based setup, through what we call Reinforcement-Induced Movement Therapy (RIMT):

Ballester, B. R., Maier, M., Mozo, R. M. S. S., Castañeda, V., Duff, A., & Verschure, P. F. (2016). Counteracting learned non-use in chronic stroke patients with reinforcement-induced movement therapy. Journal of neuroengineering and rehabilitation, 13(1), 74. We have also validated the setup at home with hemiparetic stroke patients. If you are interested in integrating our method to merge it with music augmented training please let us know.

Regards,

Samaneh,

Yes! Indeed!

Regards,

Christopher

Hi Kenichi,

if the joint is assisted, the individual is learning to move the joint in an manner that does not activate the sensory and motor systems necessary for normal movement. The individual may learn to move in an assisted manner, but the carry over to normal movement will still require additional training.  As for restoring normal movement, we anticipate roughly 4000 repetitions, however the joint movements are task specific, therefore the carry over to similar movements may require additional training. 

Monica Rivera 

No Julian will try to do so as soon  as possible thanks for your reply

Thank you that is interesting.

Proprioception of the ankle could be better targeted by applying specific unstable destabilisation. You'll maybe find some articles with R.TERRIER and N.Forestier as top author, and the links attached below. For other articulation like knee or hip i'am not sure ! It appears that destabilisation on unstable surface did not target ankle proprioception kiers-brumagne 2012

I think there have been a few studies. See the references below; some may be purely speculative, but some present empirical evidence. How extensive or how high-quality? I don't know. The most active person in the field seems to be Floriana Costanzo, who is in the child neuropsychiatric unit of a Roman hospital. Her lab's director seems to be one Deny Menghini. His contact information is as follows: Menghini, Deny, Bambino Gesu Children Hospital, Department of Neuroscience, Child Neuropsychiatric Unit, Piazza Sant Onofrio 4, I-00165, Rome, Italy, deny.menghini@opbg.net 

Good luck!

Left lateralizing transcranial direct current stimulation improves reading efficiency. (Turkeltaub et al.) Brain Stimulation, Vol 5(3), Jul, 2012 pp. 201-207.

How to improve reading skills in dyslexics: The effect of high frequency rTMS. (Costanzo et al.) Neuropsychologia, Vol 51(14), Dec, 2013 pp. 2953-2959. 

Repetitive Transcranial Magnetic Stimulation (rTMS): A useful tool also for patients suffering from dyslexia? (Niederhofer) Acta Neuropsychologica, Vol7(3), 2009 pp. 193-195. 

Evidence for reading improvement following tDCS treatment in children and adolescents with Dyslexia. (Costanzo et al.) Restorative Neurology and Neuroscience, Vol 34(2), 2016 pp. 215-226. 

Transcranial direct current stimulation: A remediation tool for the treatment of childhood congenital dyslexia? (Vicario et al.) Frontiers in Human Neuroscience, Vol 7, Apr 22, 2013 ArtID: 139. 

Reading changes in children and adolescents with dyslexia after transcranial direct current stimulation. (Costanzo et al.) NeuroReport: For Rapid Communication of Neuroscience Research, Vol 27(5), Mar 23, 2016 pp. 295-300.

As the primary motor cortex is responsible for the initial generation of impulses that will allow for movement -- in this study, they are basing their therapy off of studies done in healthy volunteers where stimulation of healthy tDCS in healthy individuals enhanced motor learning. 

In the abstract, they specifically mention that they'll be only looking at patients whose stroke did not occur in the primary motor cortex -- I assume because, in order to recapitulate the therapy that worked for healthy volunteers, they chose to stimulate the relatively "healthy" ipsilateral motor cortex of these stroke patients, who have damage in other areas.

Patients with primary motor cortex stroke would, therefore, be ineligible for the kind of therapy -- or, at least, need to be studied and evaluated as a completely separate group. 

This is only an educated guess -- if you look at the author list and contact them, I find that investigators are more than happy to answer questions. 

Dear Colleague,

thank you for your interest in my project. With regard to the electical stimulation, I will only record the torques developed at 20Hz and 100Hz. Also I am planning on recording the torque produced during the single shock stimulation of the TMG device.

I hope you find my answer helpful, otherwise please do not hesitate to ask me again.

Best regards,

Georg Langen, M.Sc. (cand.)

clinical neuroanatomy (7th edition)  richard S. snell

Thank you Geert.  I will get in touch with Professor Gosselink.  Good luck with your research project too.

Vicki

Dear Marzena,

As a Chinese medical practitioner, we do not like the western medicine to divide diseases. There are organs, their health is mutual linked and affected. The health is easy to approach: Keep a positive attitude, have Qi and blood freely flow in the body. It's simple and easy.

Different body location blockage, show different symptoms and be named differently in the western medicine. However, in Chinese medicine, we have lots of fewer diseases names. Even though in order to communicate with patients and western medical professionals, we ought to familiar with the western medicine disease names.

The easy way is you tell me what disease that you have a grant or familiar to apply to apply for a grant to see if I can match your needs.

Please also read the linked article. Thanks so much for your interest to support my "Humanity treatments are Patient's right!" movement! If everyone has the basic Chinese medicine concept, there will be no more organ failure.

For years, I saw or hear tragedies among my patients, friends, and relatives, I burn with the desire to help patients. Until seeing my Mom passing away in the front of me and in the way that I am so hard to accept even though his doctors and nurses did their best to help my Mom. I appreciate their efforts toward to my Mom and gave me the convince to take care, my Mom. However, under the western treatment, I could not apply my ability to help my Mom to have a quality life before she left us.

I cannot keep silent any more.

Bring the electrode pair back up the arm onto the wrist extensors ECRB and ECRL.  The Axelgaard website has a very good education section with a video of just what to do.  But basically, place the active (black) electrode over the belly of ECRB and bring the indifferent (red) down the arm.  The more distal you go the more finger involvement you get along with wrist extension. Moving the active electrode further around the arm will produce supination too.  Hope this helps.

Did you see this abnormal correlation in diabetic (or neuropathic) patients ?

Sense and contraction are there normal or decreased in the CES patients ?

Dear Omer:

I have no immediate idea in terms of how to accomodate your request. You may wish to have a look at https://www.srhsb.com/ and contact them for suggestions.

Good luck!

Marc

Dear Jasmin

MSCs during culture expanding undergo some morphological changes .Their diameter increse up to 20 micron and in iv adminestration  the majoraty of them will be entrapmented in the lungs.But that is no problem  for systemic adminestration.

I am a rotating physiotherapist who has some recent experience in spinal cord injury. While working with the more senior experienced physios immediately have often put patients in tilt in space wheelchair as soon as tolerable. This can be as early as week 2 as long as they are haemodymanically stable. While the patient is at intensive care we try to sit them up or tilt bed to start the gradual process early as long as the spin is stable. Abdo binder pass 30 degrees is used to help with coughing and BP. It is important to start the process early so quite often when patients arrive at the acute wards from ICU they can start trialling to sit in wheelchair as mentioned above while monitoring BP, and slowly increasing the sitting time. This really helps with future standing practices.

I have used/implemented mirror therapy along with one of my colleagues on a recent patient. What seems to work is to visualize the unaffected leg, for example right knee and/or ankle dorsiflexion and the pt. looks into the mirror looking as if it is the left leg. 3 sets 5 repetitions. After that then the pt. looks at his left leg and performs knee ext and/or ankle dorsiflexion. This along with utilization of sEMG and patterned electrical stimulation appears to be effective. I hope this helps. 

 Dear Lode,

Impact on Participation and Autonomy Questionnaire (IPA) is a self- report outcome instrument that describes participation and autonomy from the perspective of the participant.  The questionnaire consists of 39 items that measure participation in accordance with the definition to ICF.  The response options in the IPA are: 0=very good, 1=good, 2=fair, 3=poor and 4=very poor. The results can be analyzed both regarding the assessments of the five domains (autonomy outdoors, autonomy indoors, family role, social relations, paid work and education) and the nine areas of different aspects of participation (mobility, self-care, activities in and around the house, looking after our money, leisure, social life and relationship, paid or voluntary work, helping and supporting other people and education/training). 

Cardol, M., de Haan, R.J., van den Bos, G.A., de Jong, B.A. and de Groot, I.J. (1999) The development of a handicap assessment questionnaire: The impact on participation and autonomy (IPA). Clin. Rehabil. 13, 411-419

In the article below we used the IPA which we can recommend.

Factors affecting participation after traumatic brain injury.

Larsson J, Björkdahl A, Esbjörnsson E, Sunnerhagen KS.

J Rehabil Med. 2013 Sep;45(8):765-70. doi: 10.2340/16501977-1184.

ABSTRACT

 Objective: The aim of this work was to explore the extent to which social, cognitive, emotional and physical aspects influence participation after a traumatic brain injury (TBI). Design/subjects: An explorative study of the patient perspective of participation 4 years after TBI. The cohort consisted of all patients (age range 18-65 years), presenting in 1999-2000, admitted to the hospital (n = 129). Sixty-three patients responded; 46 males and 17 females, mean age 41 (range 19-60) years.

Methods: Four years after the injury, the European Brain Injury Questionnaire (EBIQ), EuroQol-5D, Swedish Stroke Register Questionnaire and Impact on Participation and Autonomy (IPA) questionnaire were sent to the sample. Data were analysed with logistic regression.

Results: On the EBIQ, 40% of the sample reported problems in most questions. According to IPA, between 20% and 40% did not perceive that they had a good participation. The analyses gave 5 predictors reflecting emotional and social aspects, which could explain up to 70% of the variation in participation.

Conclusion: It is not easy to find single predictors, as there seems to be a close interaction between several aspects. Motor deficits appear to have smaller significance for participation in this late state, while emotional and social factors play a major role.

Best wishes, Eva

A patient of mine who had TBI years ago from an MVA , with coma , subsequent motor and cognitive deficits and disfigurement, had spent a very long time in various excellent inpatient and outpatient  neuro-rehabilitation programs.

He shared with me a book, written by a U of Penn English Professor's husband. A true story about his experience and hers going thru recovery with top inpatient and outpatient facilities. The Book Title is Where is the Mango Princess.  don't  be dissuaded by the title.

This book I now require residents in GME training to read and perhaps it should be read at Medical Schools and by faculty.  Although written for the lay person, it provides insight and empathy for those who experience TBI and various recovery phases. Realistic STG and LTG enable coping strategies to kick in when despite remarkable or miraculous improvement the subtle cognitive and personality changes may never fully recover and (spoiler alert) preclude to previous employment setting (in this case a high powered Philadelphia law firm)

You will never look at someone with TBI (however minor appearing) the same again- this book can be trans- formative for patient's significant others and to physicians in creating true compassion.

Hi all,  

Just to add to the discussion, there has been some fairly recent work using intracellular recording [1] and optogenetics [2] that strongly suggests that one of the main targets of STN DBS is antidromic activation of cortical neurons projecting to STN . So it is highly possible that motor cortical TMS will activate these neurons orthodromically. The problem is that TMS is unlikely to be selective for one specific type of neuron and the mixed effect of activating these projection neurons, as well as those projecting to both direct and indirect pathway neurons in striatum is unlikely to be collectively helpful. It is possible that appropriate stimulation patterns could induce plasticity at the level of corticostriatal synapses, that may lead to a greater activation of direct pathway neurons, for example, and relieve some of the akinesia, but this stimulation is likely to require concomitant phasic dopamine release [3]. It is possible that strong cortical activation could lead to phasic stratal dopamine release, either by local effects within the striatum driven by strong coordinated activation of glutamatergic inputs to, say, cholinergics [4,5], or possibly by multi synaptic effects between cortex and SN/VTA. But this requires that there is sufficient residual dopamine in still surviving terminals. This would need to be proven using electrochemistry/ human studies using raclopride binding. 

Again we are back to the issue that we don't understand which cortical elements (neurons and/or glia, although the effects I speak of above are all neuronal) are directly activated by rTMS and where any plasticity that results is induced. 

Good discussion!

Thanks Aurélie,

Regards

John

References:

[1] Cortical effects of subthalamic stimulation correlate with behavioral recovery from dopamine antagonist induced akinesia. Dejean C, Hyland B, Arbuthnott G. Cereb Cortex. 2009 May;19(5):1055-63.

[2] Optical deconstruction of parkinsonian neural circuitry. Gradinaru V, Mogri M, Thompson KR, Henderson JM, Deisseroth K. Science. 2009 Apr 17;324(5925):354-9. 

[3] A cellular mechanism of reward-related learning. Reynolds JN, Hyland BI, Wickens JR. Nature. 2001 Sep 6;413(6851):67-70.

[4] Striatal Dopamine Release Is Triggered by Synchronized Activity in Cholinergic Interneurons. Threlfell, S., Lalic, T., Platt, N.J., Jennings, K.A., Deisseroth, K., & Cragg, S.J. Neuron  75: 58-64 (2012).

[5] Modulation of an afterhyperpolarization by the substantia nigra induces pauses in the tonic firing of striatal cholinergic interneurons. Reynolds, J.N.J., Hyland, B.I., & Wickens, J.R. Journal of Neuroscience  24: 9870-7 (2004).

The child needs alot of physiotherapy in addition to what the child is already receiving. The type of physiotherapy that may be needed is task oriented that can be done with due consideration to the main functional skills of self-care, mobility and social function

Once a tattoo has healed, the pigment is stored in dermal fibroblasts. Superficial tape is unlikely to disturb the pigment, unless it were to remove a significant amount of skin (i.e. the entire epidermis and superficial dermis). You'll probably be OK, but it is always better to avoid tattoos if possible because you never know what may happen.

Of the papers you listed, none of them are really relevant to the use of tape. Those papers outline the inflammatory, infectious, and neoplastic complications of tattoos.

Hi Agnieszka, 

It is a good idea to look at what area of stroke you wish to focus on first, Stroke is a complex disability with neuropsychological, visual, speech and motor impairments. A number of people have been working at providing telerehabilitation in each of these fields. From our side we focus on upper-extremity function (as we find that hand function is directly related to independence and quality of life). Something worth looking at is http://www.ebrsr.com/ a great up-to-date review that tried to review all potential approaches. there was also a recent telerehabilitation systematic review as well:

In the upper extremity side of things we first worked with using a commercial web based tool (skype) and an instrumented workstation. But eventually built our own system and called it the ReJoyce ( http://www.rehabtronics.com/) We ended up working on this with the stroke and the SCI population:

The furthest we have ever interacted online with a patients and our system was over 6300 km. others have also worked to deliver various treatments at home:

My personal advice with stroke patients is to make sure you properly assess cognitive function as well as understand their home structure. Also worth noting is to have a fail safe communication method in place including a phone line or a caregiver just in case there are technical difficulties. Surprisingly there are very few difficulties once a stroke patent is familiar with your system. We found the hardest bit is learning to log into a computer - not using any system in particular.

Hope this helps, 

Jan

Dear Georg,

Ok for the Lasègue's sign and the extension, but a lot of patients tend to compensate this test by automatically tilting their pelvis...  

Group sessions were all the rage several years back during the VitalStim hype... Some recent research by Giselle Mann from Florida has shown that a high percentage of therapy session time is wasted on non-treatment talks etc... On this basis, she developped the MDTP, being a high intensity training. Sadly, a lot of her data are only to be founded in conference proceedings. You could always try to contact her.

Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) and the second one from Australia(he University of Queensland)

Thanks Mehdi. Sexual dysfunction / altered sexual functioning in mTBI can occur as a part of the  PCS symptoms and/ or independent  of it. Most of the patients through conventional imaging protocols and hormonal workouts  do not show any sign of hypothalamic-pitutary disturbances. Psychometric and psychiatric evaluation of this patients reveals no significant alteration in mood or behaviour. So, my quest is to find biological basis to this condition post trauma,.

Thank you very much for the excellent information. I've been doing the USD-investigation of venous cerebral blood flow for almost 30 years. Indeed, there are a clear hemodynamic patterns of arterial insufficiency and venous stasis both at extracranial and intracranial levels in patients with multiple sclerosis. With regard to spinal level, I do not yet managed to explore it using ultrasound. Although, the vertebral venous network overload is often the problem in this category of patients. It is not in accordance with the wording of vein stenosis - I regard as it's more functional hypoplasia, which can be neglected in the individually selected treatment approach. Regarding the study of cerebrospinal arteries - the idea is interesting. Perhaps, further research in this area will shed light on the problems of cerebral vascular disorders in patients with lateral amiotrofic  sclerosis, because we  obtained significant improvements swallowing and speech during specific vascular therapy in these patients. 

Hi Emilia,

Here are some references,

Robotic neurorehabilitation: a computational motor learning perspective

Vincent S Huang* and John W Krakauer

Robotics in neuro-rehabilitation.

Pignolo L.

J Rehabil Med 2009; 41: 955–960

European Network on Robotics for NeuroRehabilitation

I believe that Dean et al proved that stroke patients can attain an increase in reaching ability which also carries over to standing up. I'm not sure that the important factor here is whether or not it was through a motor relearning program (at least not the way Sheperd & Carr has defined it). I believe that the important factor here is to take an evidence based approach (which of course also is the cornerstone of Sheperd and Carr's motor learning program.

Nevertheless using a lot of repetitions, pushing the patient to his performance limit and making sure that the augmented feedback is sufficient.

Pretty much as they did in the study by Dean et al.

Dean CM, ChannonEF, Hall JM. Sitting training early after stroke improves sitting ability and quality and carries over to standing up but not to walking: a randomised controlled trial. Australian Journal of Physiotherapy 53: 97–102.

At this time, there is evidence concerning minutes per day, not days per week. More minutes per day of therapy is associated with better outcomes (functional and discharge. Here is a reference:Jette DU, Warren RL, Wirtalla C. The relation between therapy intensity and outcomes of rehabilitation in skilled nursing facilities. Arch Phys Med Rehabil. 2005;86(3):373-379.

You can gather useful information in the international FES society website (http://www.ifess.org). There's an education section that might prove useful for those not familiar with FES concepts. And there's also an open access repository of the IFESS conference proceedings.

I always try to explain this to medical students as thinking of the evolution: anti-gravity activity means to be able stand up (so extension of lower extermities) or to prevent from falling out of a tree, holdong with the arms to a branch (so flexion of the upper extremities). It must be a fylogenitically old reflex pattern which is normally suppresed by newer, cortical systems of movement control.

Hi Mohammad,

what do You mean "completed by this function"? Function of "cubic spline"?

As you can see in the work Zatsiorsky and Duarte (2000) cubic spline function is just one of the steps to obtain from COP a rambling and trembling trajectory.

The cubic spline function allows you to create a rambling trajectory based on the information about the position of the COP in the IEP (at times when the horizontal force is zero).

Best regards,

Grzegorz

I may be biased here, but I believe the fundamental shift is the move towards evidence based neurorehabilitation. One of the major problems I see with this field is that it is guru based. I feel as though about 50% of what is clinically prescribed today has very little evidence or scientific merit supporting it. Furthermore many clinical approaches are loosely based on dated theories that just don't hold up to rigorous scientific scrutiny. I Agree with Emilia in that all of the points she stated will definitely start playing more important roles in clinical practice in the near future as we become more aware of health care costs. Today neurorehabilitation is moving away from wooden blocks and claiming to be high tech, but still has a very long way to go. Many "cool" technologies produce marginal if not poorer than conventional results. In fact, very few RCT's are run in this field because they cost quite a bit. At this stage to see meaningful differences in improvements would require incredible numbers of patients. So even as we move towards evidence based research much of our data is from sub-standard trials with patient as their own controls, that rarely compare one treatment with another.

In the future, I think focus will shift to meaningful combination treatments to optimize cost of recovery with novel means of harnessing patient's motivation. Neurorehabilitation at its core will still depend on repetitive movements and tasks. Even when regenerative medicine steps in to replace and recover damaged / poorly functional neural tissue, Optimizing movement training will still play a large role. But If we hold on to our current guru approach to rehab and don't embrace evidence based neurorehabilitation we might as well be selling fad diets.

Hello Olaf,

Thank you very much for the articles you sent me. I decided to use the 6MPT and the 10M PushTest in my study. The only disadvantage is that some of the participants experience fatigue in their arms because of all the turns during the test. But exempt from that I think that they are clinically very feasible.

Kind Regards,

Kine

Upper limb pronation/supination occurs within the forearm (i.e. radius pivots around the static ulna about the proximal and distal radioulnar joints). Pronation/supination is often misinterpreted as movement at the wrist joint given the visual angular displacement of the hand about its long axis (as in your attached figure).

From clinical neurological reasons, sensory peripheral testing should assess epicritic and protopathic stimuli, as these stimuli are processed by different neuroanatomic pathways to primary and secondary sensory cortical areas. These pathways have also branches to the unspecific ascending reticular activating system. Especially the fine finger movement guidance is dependent on this sensory input.

In neurorehab you can use fine finger movement exercises or a sensory discrimination paradigm to improve and restore sensory hand/finger functions. Such strategies are mainly needed when after an initial sensory loss some functions recover, but in the same time dysaesthesia or neuropathic pain developes.

Maybe you can look for the Chedoke McMaster stroke assessment leg and foot or arm and hand.

You can also visit http://strokengine.ca/assess/ You will find an impressive review of the assessment tools available for stroke and often the links to have access to the tools.

Cheers

Hi I don't know for social communication, but maybye you could be interested to use a questionnaire of social participation. The LIFE-HABIT is a generic questionnaire, validated for pediatric population, and could be used for that purpose. (Noreau et al., 2007).

Thank very much!

When people are soliciting submissions to OA journals, it's important to be up front about the publishing fees, in this case1000 US$.

Transcranial magnetic stimulation (TMS) basically stimulates or inhibits the underlying cortical area. Stimulation or inhibition though depend on the frequency of stimulation used high( above 5 Hz) or low (below 5 Hz). Stimulation areas depend on the CNS condition a patient is suffering from or site or stage of pathology. For e.g in case of parkinson's patient if the patient has more of motor symptoms motor cortical areas may be choosen and if more of depression then frontal cortex may be the area of choice.

This is an FDA approved procedure for treatment of depression but phase III trails are underway for stroke and parkinson's etc.

Molecular studies so far on mice and non-human primates are indicative of changes in the cortical plasticity (short term as well as long term). These results are also seconded by fMRI and PET studies in humans as well as primates.

Dear Pooja I'll sent you some articles in wich there are some answers

Motor performance implies a coordinated activity of several neuronal systems and networks. The word "performance" in this sense reflects a meaningful and clinical relevant activity. A simple muscle twitch or simple focal seizures usually are not regarded as "motor performance". Thus, performance even at a basic level, includes (1) voluntary activation and (2) realization of movements. While the first part is definitely dependent on the cognitive and motivational networks, the second part depends on the integrity of motors systems/networks. In the most extreme form a disturbance of the cognitive motivational part, such as akinetic mutism, can cause absolute cessation of any movements while the motor system is fully intact.

I have had the opportunity of witnessing the icing treatment (lowering extremity into bath/bucket full of water and icecubes) of the spastic hands or feet in adults many years ago. In nearly all cases, patients did not like this at all because it HURTS.

Of course it does not affect the spasticity at a central level.

In my opinion, this type of treatment could even harm the often fragile skin of these patients (vascular system).

I have see it do little except make the extremity extreemly cold and a little less stiff. Mobilising straight afterwards is a little easier but this effect does not last.

Reason why I have never used this measure myself.

Yes, I agree on this plan and I think it is correct to evaluate the situation on the result of a new CT