Science topic

Neurorehabilitation - Science topic

Research related to improving outcomes after neurologic injury, such as stroke, traumatic brain injury or spinal cord injury.
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I`m looking for colleagues in my setting.
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Sorry, I don't know any advanced practice nurse in Germany.
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Parkinson Disease (PD) is a degenerative disease that affects motor function and sequential.
At which level of H&Y stages will this improve?
Short term or long term effect?
Any evidence to help patient and client?
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According to your clinical experience, which approach you prefer in clinic and do you think that it is better than other one approach? (For Stroke patients only)
A top-down approach such as using task-specific interventions.
A bottom-up approach, using weight bearing, PNF, and NDT techniques
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Patient with neurological problems have different problems. This will impaired their physical, cognitive and even social interaction and so forth.
So, which approach and why that approach is used?
Look into more discussion and information.
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Task-based interventions are highly effective for gait and ambulation among patients with chronic CVA and TBI provided that a sufficient intensity is maintained.
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Hi everyone,
I was wondering if there was an optimal time for performing the follow up assessment when evaluating the long term effect of a rehabilitation technology (such as VR, robot assisted therapy,...) in a stroke population. Especially for upper limb function, activity and participation. Is there any paper supporting the fact that stroke patients’ long term retention should be assessed a certain time after the intervention ?
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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
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This study will be relatively small-scale, and will form part of my doctoral thesis. I am hoping to bilaterally stimulate the DLPFC in a group of cannabis users for a short duration, in order to assess whether craving can be temporarily modulated.
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Nice Dear Jonathan A Norton
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I work in a neurorehabilitation center and I am interested in incorporating tDCS for patients with disorders of consciousness, cerebral palsy, spinal cord injuries, neurodegenerative diseases...
I would like to know what is the maximum recommended number of sessions (number of days/weeks/months) and if there is any colleague who has a protocolized number of sessions.
I have seen many articles but they are very heterogeneous so I would like to know the opinion of experts. In fact I even read a case report of a patient with disorders of consciousness treated for 6 months.
I would also like to know if once stimulation has been applied how long the «rest period» would a patient have before resuming electrostimulation.
Thanks in advance.
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Nice Contribution Martin Marko
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When treating patients with abnormal tone, I often find recurrent inhibition using a range of sensory modalities from cooling to electrical stimulation at low levels is very effective in some patients. Others respond best to reciprocal activity. Clearly, spasticity results from an inbalance of inhibitory and excitatory activity, but can we deduct or identify which? If so, does that have a direct influence on central or peripheral management of tone? While Botox and other end organ interventions work, I am looking for ways to alter the central activity related to the abnormal tone.
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There are some evidences about the positive effects of Kinesio taping among patients post stroke.
I want to know, if it could be useful to decrease the level of spasticity or if it was just as a supporter for their limbs.
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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
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Overall, stroke is one of the devastating condition that cause individual lost their ability and so forth.
Even economic burden because leads to more medical treatments, modification of certain activity daily work and so on.
How far the hospital and clinical staff know about it in terms of their knowledge, attitude, perception or even more practice pattern or treatment options in certain country.
There are many Clinical Practical Guideline from different country.
Apart from FAST campaign to increase awareness, what are alternative that being applied across the country in this world? What are other factors that contribute to increase awareness?
Looking for more depth discussion about this issue.
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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.
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Is it possible to show the recovery of motor function of upper limbs or elbows of individuals with stroke by observing simple elbow flexion and changes in the EMG pattern of the extension muscles?
In addition to simply increasing the potential, please tell me the detail relationship between the phase pattern change of the flexor muscle and extensor muscle, the degree of synchronization with the joint motion or smoothness of the joint movement.
Are there papers showing evidence?
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The feasibility study results can be found in clinical rehabilitation and the protocol in Fromtiers in human neuroscience: just search 'home-based neurological music therapy for arm rehabilitation......'
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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,
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Biofeedback is a method that uses the mind to control a body function that the body normally regulates automatically, such as muscle tension, heart rate, pain perception or stability... The biofeedback therapist will then teach physical and mental exercises that can help patient control the function. Can these exercises also be effective for involuntary actions such as stress? If yes, By which method?
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For people with central nervous system disorders, how much joint assistance or individual's effort is required for joint movement to restore motor function or better motor learning? What factor that defines The optimum assistance for reorganization of CNS is? Please tell me the papers or information on these.
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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 
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Doining a sistimatic review on the eficicy of AAT compared to traditional therapy on adult patients with motor deficit and came across this article which is important and would like to read it but don't know how it's from Bottger S Early neurological rehabilitation of function and emotion using animal supported therapy..
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No Julian will try to do so as soon  as possible thanks for your reply
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Is there been any published research or do you know of any outcome studies with stem cell injections for nerve injuries from radiation.  Specifically Radiation Induced Brachial Plexopathy
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Thank you that is interesting.
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Exercises on unstable surface are very useful on the rehabilitation of prorpioceptive impairments, but i want to know if we can concentrate the work on a specific part of the lower limb
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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
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I'm looking for studies that have investigated the impacts of transcranial direct stimulation and repeated magnetic transcranial stimulation on reading processes. Can they help dyslexic people?  
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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.
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I was wondering how why in the Materials and Methods : primary motor cortex stroke was exclusion criteria ?
about Science translational medicine in march 2016 "Ipsilesional anodal tDCS enhances the functional benefits of rehabilitation in patients after stroke"
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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. 
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I would like to know if you have studied also neuromuscular transmission at electrical stimulation of the nerve with the frequencies of 1Hz,3Hz,10H,25Hz and so on,with the recording of the evoked potentials in the respective muscles.
Thank you,
Constantin Vasilescu,MD.,PhD.
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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.)
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I am writing a case study as part of my degree. the case study looks at a patient with a left sided CVA with right sided hemiplegia. I have to try and include in the case study why injuries on one side of the brain affects the opposite side, but I am struggling to find much solid information.
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clinical neuroanatomy (7th edition)  richard S. snell
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I am a physical therapist preparing an "evidence-based" mind-body workshop called "The ABCs of Prevention and Fitness," Alignment, Breathing and Centering.  I am looking for research establishing the benefits of good posture (Alignment) on physical function; "conscious" and "prolonged exhalation" breathing for reduced stress and improved pulmonary function.  I also welcome research related to "mindfulness" especially as it relates to physical function. 
Thank you.
C. Vicki Gold, PT, MA
Pres. Thera-Fitness, Inc.
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Thank you Geert.  I will get in touch with Professor Gosselink.  Good luck with your research project too.
Vicki
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The current Alzheimer disease treatments are using electrical shock or brain pacemaker. There is a potential risk for the patient and the cost is high. However, if applied Chinese medicine theory and use a magnet or magnet to treat, can cut down the cost, eliminate the injury.
If anyone has the grant application experience and would like to collaborate with me to do the research, will be highly appreciated. Please, contact me. Thanks.
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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.
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The pt has full range of motion in wrist extension.  When placing the electrodes on the flexors (Carmick approach) the wrist flexors kick in as expected. 
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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.
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  • spine
  • spinal cord injury
  • electrodiagnosis
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Did you see this abnormal correlation in diabetic (or neuropathic) patients ?
Sense and contraction are there normal or decreased in the CES patients ?
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Achieving optimal adjustment is a sensitive and difficult process which hopefully leads to significant cure. At this stage it is important to consolidate a clear plan
1) to avoid the dangerous over drainage, 
2) to avoid brain degenerations,
3) rehabilitations
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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
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Dear researchers, 
What is your opinion, is it better to use small or large stem cells for therapeutic use, in theory and practice?
Previous findings indicate that i.v. application of MSCs with a diameter ˃25 um resulted in microinfarctions. Does anyone think that the application of large cells is better, for example, for local application, and small cells for systematic application?
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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.
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Hi, we work in a acute neurorehabilitation clinic admitting SCIs in the first 8 weeks of the injury onset and we have difficulties with the tetraplegic patients during upright positioning trials. Nonpharmachologic(ie: corset,pneumotic compression, fluid intake, meal,  urinary and GI tract  precautions) and pharmachologic (ie: midodrine up to 30mg) management strategies usually do not work in the first months. For example many patients do not tolerate upright positioning although they can be positioned 60 degree on the tilt table for 15-20 minutes or ortostatic hypotension problems do not resolve in complete tetraplegics up to 4-6 months. Can anyone have experience about ideal timing for upright positioning of tetraplegics and ideal pharmachologic (forexample fluidrocortisone?) treament strategies for ortostatic hypotension during the acute phase rehabilitation process?
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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.
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Has anyone implemented mirror therapy (MT) based on the unilateral approach (ie, practice by the un affected upper limb)? If there is pertinent literature on this unilateral approach to mirror therapy that you know, please kindly let me know.
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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. 
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We are working with primary care physiotherapy teams to evaluate exercise in thecommunity programmes that are in conjunciton with local gyms. We are looking for an ICF Participation level measure that is validated for use with stroke, PD and MS and that considers either impact of the condition or quality of life, or participation in everyday activities/interaction with family and community. Would be grateful for any suggestions of suitable measures.
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 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
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One aspect we lag behind in management is the timely rehabilitation in patients with TBI. Can anyone advise on the rational approach for the same in the resource restrained setup ?????
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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.
Where Is the Mango Princess?: A Journey Back From Brain Injury Kindle Edition
by Cathy Crimmins (Author)
4.8 out of 5 stars 103 customer reviews
"5.0 out of 5 stars What an Amazing Book !!, October 15, 2000
By
BeachReader
This review is from: Where Is the Mango Princess? (Hardcover)
Cathy Crimmins has taught us all a lesson in this book.....that life isn't always as we had thought it would be and that we must be proactive in order to change it.
When her husband, Alan, a successful bank attorney in Philadelphia, suffers a Traumatic Brain Injury (TBI) in an accident, his life and his family's lives change forever. Crimmins takes us through the extensive rehab process which she handles with both tears and laughter. As a reader, I found myself experiencing feelings of anger, hope, sadness, and joy at the smallest improvement in her husband's condition and at the smallest victory over the system.
I could not believe how much I learned from this book. It should be "must reading" for everyone who works with brain-injured patients and also for all of those insurance company "voices on the phone" who make life and death decisions based on very little information, and with very little empathy. I learned about something called "perseveration" which is when a brain-injured person repeats an action or phrase over and over and over again. I also learned that with brain injuries such as this, inhibitions disappear, which means that socially inappropriate behaviors are often displayed. Crimmins also made the reader understand why these patients and their families become so frustrated. I could fill pages with what I learned.......
I read this book in one day and a friend who was visiting me read it the next. I then passed it on to my daughter who also read it in one day and then recommended it to her neurobiology professor who thought it was outstanding. If I had the power to make this book a bestseller, I would!"
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.
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Transcranial Magnetic Stimulation has brought a lot of hope in the field of non-invasive treatment of Neurological disorders.
As it has picked my interest in the case of Parkinson's Disease, I can't help but wonder how we hope such a specific effect of TMS on PD's motor symptoms. Indeed the basal ganglia circuits is a very complex one and each structure will affect several others in an activating or inhibiting way. So how can we really hope for a specific effect, when we are merely activating a superficial region (that will of course, in turn, activate others, but still, how specific can such an intervention be) ?
There has been some effect I have seen, but, as of now (and I know it is still a young field of investigation), results are mitigated (see Benninger and Hallet review in NeuroRehabilitation, 2015 for a recent comparison of results)
Or maybe will it be more useful in combination with medication ?
Any thoughts ?
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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).
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I have a girl who is already 6 years old, going to attend Kindergarten 2 next year, together with once a week speech therapy support. She started with us when she was about 5 years old, and have attended Kindergarten 1, with twice a week speech therapy and once a week occupational therapy support in the past year. She is not diagnosed and did not attend any therapy previously.
The teachers are all worried about her because she is really SLOW. Prior to her intervention program with us, she was observed to be unaware of lip closure and she used to drool because of this. Now after 1 year of ST + OT support, she no longer drools. She is also quite talkative (but her speech lacks variety and details), and has all the foundation learning skills (e.g., writing, phonics, etc.). However, she always looks absent-minded, and does not do anything if not pushed or reminded by the teacher. Since she does not speak up in the class at all, the teacher does not know if she understands certain concepts.
She is also naturally anxious, according to our ST, even if she knows something, she has to get absolute assurance that she is correct, she refuses to say it out loud if no assurance is given.
She is able to write well, but her major concern is the speed of doing things. She usually takes more than 1 hour to complete one meal, be it individually or in a group (individual performance is slightly better). We tried to condition her but it did not work, she does not initiate any reaction even if she is hungry and deprived (and of course parents would not allow that to happen). She starts to cry badly if she is scolded or forced, and only babbles one thing when crying "I want mama". She is not yet off diaper, because she cannot control the bowl and bladder movement well, and still does not spontaneously indicate the needs to toilet. Even after a long-winded toilet training, she still passes urine in class occasionally. She is able to mingle with friends but refuses most gross motor activities or games by keeping telling us that she "cannot do".
I think she is within the average intellectually, but we are all worried that she can no longer keep up with the pace of the class if the academic learning gets heavier. Given her anxious nature, we are also worried that she might "shut down" even more in the future, when she notice the difference between herself and the peers.
Any experts or experienced professional could please give some advice on what exactly is her problem, and how to better help her? Thank you for your help.
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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
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I would like to hear everyone's opinion on the use of Elastic Therapeutic (Kinesio / Kinesiology) Tape OR NMES on tattoos. I wonder, as both activate the superficial circulation, if we are doing harm when applying tape or electrodes on top of tattoos. Could the chemicals and inkt be 'enticed' to enter the body further?
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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.
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Do you have any knowledge about researches about using remote methods of rehabilitation in stroke?
Do you know any technologies that can be used to control excercises performed by patient himself?
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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
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Also, is there a relation with the degree of hip flexion? 
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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...  
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I'm involved in a short term research project comparing outcomes of individual vs. group dysphagia exercise programs in medical settings. Also wondering if anyone has examined using SLPAs in hospitals to carry out prescribed dysphagia exercises. Any information would be much appreciated!
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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.
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I want to write a paper and have looked through endless journals which i feel are not that appropriate. Hoping someone has read something that will help me. Thank you 
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Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) and the second one from Australia(he University of Queensland)
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Changes in sexual behavior, loss of libido or in some cases hypersexuality has been noted in patients with mild head injury. However this changes are not seen all mTBI patients, a selected few. What could be the possible explanation to it besides hormonal or morphological changes?
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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,.
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I'm agree with their opinion towards vascular factor disorders in the MS lesions. Why do explore only venous vascular net? As for my experience, majority of MS-patients have a multivascular reasons in patogenesis of MS-focuses. I believe, that adequate vascular correction of the cerebral arterio-venous balance leads to the decreasing of neurological deficits. In our practice we have some no-walking MS- patients, which began realized their self serving program slowly step-by-step due to our long-term combine courses with vascular therapy and individual neurorehabilitation approach. There are nearly 5-6 etipatogenetical hemodynamical patterns of MS-arterio-venous disorders at extra- and intracranial levels.
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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. 
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My collaborators and I have published several articles with preliminary results of the research concerning role of toys in neurorehabilitation of children (including both traditional toys, therapeutic toys, therapeutic robots, etc.) - mainly in the clinical practice of physiotherapist (including NDT-Bobath method). Research concerns infants and younger children, where video games and Virtual Reality may be not applicable. Please let me know about similar studies.
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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
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Effectiveness of motor relearning program against convention therapy.
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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.
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Does anyone have good article to support the reason?
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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.
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I am trying to understand the concept of FES. Since I'm not an expert in rehab research, is there any good link or maybe good review paper that I can read that clarifies the research direction of this FES? For those who are experts, is there any issue or gap that can be filled if I'm interested in getting involved in this area of research? Thanks.
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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.
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1. Spasticity in UMN lesions is seen predominantly in "ANTI-GRAVITY" muscles (Susan B O'Sullivan, Physical rehabilitation). What is the rationale behind this?
2. Why are shoulder adductors and ankle plantar flexors spastic in the same case as their action is not evidently against gravity? How can this be explained?
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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.
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COP decomposition has been made by some MATLAB codes such as "Cubic spline function" to obtain an estimate of rambling trajectory. Trembling is the deviation of COP from rambling trajectory. I was wondering if the whole process can be completed by this function?
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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
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The change or advances in the rehabilitation of stroke is enormous: from Biofeedback, Brunnstrom, Bobath (NDT) approaches to Carr and Shephard MRP, task specific training, strength training (beyond the controversies), CIMT, FES, TMS to robotic therapy and so on. But none proves to be the most effective. Cost effectiveness of the rehab protocol is also another major concern.
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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.
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Anyone who have validated the 6min walk test for wheelchair shuttle ride? Or does anyone know of a good, clinical tool for measuring cardiorespiratory fitness in wheelchair users? Primarily for young adults with disabilities (CP, TBI, SCI).
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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
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In a review on robot assisted neuro-rehabilitation I realised that the group had defined pronation and supination as part of wrist movement, however, to me it seems as if it is rather part of the movements of the forearm. Please see the attached image.
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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).
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Observationally providing sensory input via cutaneous or sensory nerve stimulation improves task performance in some individuals, yet the sensory contribution is rarely evaluated or measured. Motor components of task performance are much easier to measure and quantify. Therapists frequently focus on strengthening as a primary intervention and outcome measure. Yet we see some very weak individuals with good timing and coordination be very functional while conversely there are very strong patients by traditional muscle testing who are very functionally deficient. How is somatic, schematic awareness and proprioception involved in motor learning and task performance and how might we measure? Has this been done? Any references?
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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.
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How can we assess VMC when there is spasticity (say MAS more than 1+)? Or would you prefer manual muscle testing when there is spasticity?
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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
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I am interested in assessment of social communication of children with autism, but I would like develop alternative assessment methods from questionnaires.
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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).
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Which is the best way to measure joint range of motion in clinical practice. I´m now using goniometry, but i don't know who is the reference author.
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Thank very much!
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Stroke Research and Treatment
Special Issue on
Stroke in Developing Countries
Call for Papers
Stroke is a major health burden around the world, with general mean yearly rates of 120 per 100’000 inhabitants. It is commonly accepted that stroke is a disease of the elderly in developed countries, with a strong association with risk factors, such as hypertension, diabetes mellitus, cigarette smoking and increased cholesterol. Gender also bears an association, with male predominance, except in the youngest and eldest patients. However, epidemiological data suggest that stroke is also a major issue in emerging and developing countries, including in much younger patients, in association with similar or different risk factors.
We invite authors to submit original research and review articles addressing epidemiological, diagnostic issues, and management in developing countries around the world. This will allow gathering a series of data which will help to understand better this complex problem with critical impact on population health.
Potential topics may include, but without being limited to:
 Prevalence and incidence changes
 Stroke subtyping
 Political medical issues in specific countries
 Diagnostic facilities
 Acute phase therapy
 Stroke prevention strategy and implementation
 Rehabilitation after stroke
 Cultural aspects dealing with mood disorders after stroke
Before submission, authors should carefully read over the journal’s Author Guidelines, which are located at http://www.hindawi.com/journals/srt/guidelines. Prospective authors should submit an electronic copy of their complete manuscript through the journal Manuscript Tracking System at http://mts.hindawi.com/ according to the following timetable:
Manuscript Due November 29, 2013 First Round of Reviews February 21, 2014 Publication Date April 18, 2014
Lead Guest Editor
Julien Bogousslavsky, GSMN Neurocenter, Switzerland; JBOGOUSSLAVSKY@cliniquevalmont.ch
Guest Editors
Bartlomjej Piechowski-Jozwiak, Imperial College London, UK; bpiechowski@gazeta.pl
Alexander Tsiskaridze, University of Tbilisi, Georgia; tsisk@gol.ge
Jacques Joubert, University of Notre Dame Australia, Melbourne, Australia; jacques.joubert@me.com
Abderramane Chahidi, Beni Mellal, Morocco; chahidi12@yahoo.fr
Jorge Moncayo, University of Quito, Ecuador; jmgaete@panchonet.net
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When people are soliciting submissions to OA journals, it's important to be up front about the publishing fees, in this case1000 US$.
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Example: Stroke
What are the stimulation parameters and how do patients respond to this treatment?
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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.
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although one reason may be TVR and reciprocal inhibition bt that would affect antagonist not agonist.
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Dear Pooja I'll sent you some articles in wich there are some answers
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Neuronal activity is responsible for movements to be performed, but does all motor performance need a neuronal network?
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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.
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Cryotherapy has its own controversies on its application on muscle activation or inhibition. So what could be the effect of cryotherapy in spasticity which is a common problem in neurological patients?
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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.
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Anyone who has recommendations for if and how physical activity should be limited after traumatic carotid artery dissection? Or references to evidence-based recommendations?
We now treat a 45 year old female patient with bilateral traumatic carotid dissection after a cycling accident. Furthermore bifrontal brain damage. Some cognitive, but almost no motor impairment. As she is used to a lot of physical activity, she is quite eager to start with high intensity training.
Thanks for any suggestions
- Frank Becker MD PhD
Sunnaas Rehabilitation Hospital, Norway
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Yes, I agree on this plan and I think it is correct to evaluate the situation on the result of a new CT