Deans' stroke musings

Changing stroke rehab and research worldwide now.Time is Brain!Just think of all the trillions and trillions of neurons that DIE each day because there are NO effective hyperacute therapies besides tPA(only 12% effective). I have 493 posts on hyperacute therapy, enough for researchers to spend decades proving them out. These are my personal ideas and blog on stroke rehabilitation and stroke research. Do not attempt any of these without checking with your medical provider. Unless you join me in agitating, when you need these therapies they won't be there.

What this blog is for:

Shortly after getting out of the hospital and getting NO information on the process or protocols of stroke rehabilitation and recovery I started searching on the internet and found that no other survivor received useful information. This is an attempt to cover all stroke rehabilitation information that should be readily available to survivors so they can talk with informed knowledge to their medical staff. It's quite disgusting that this information is not available from every stroke association and doctors group.
My back ground story is here:

Monday, April 3, 2017

The visual amplification of goal-oriented movements counteracts acquired non-use in hemiparetic stroke patients

They talk about protocols so demand your doctor get them for you.
  • Belén Rubio BallesterEmail author,
  • Jens Nirme,
  • Esther Duarte,
  • Ampar Cuxart,
  • Susana Rodriguez,
  • Paul Verschure and
  • Armin Duff
Journal of NeuroEngineering and Rehabilitation201512:50
DOI: 10.1186/s12984-015-0039-z
Received: 5 February 2015
Accepted: 13 May 2015
Published: 9 June 2015
The Erratum to this article has been published in Journal of NeuroEngineering and Rehabilitation 2015 12:106



Stroke-induced impairments result from both primary and secondary causes, i.e. damage to the brain and the acquired non-use of the impaired limbs. Indeed, stroke patients often under-utilize their paretic limb despite sufficient residual motor function. We hypothesize that acquired non-use can be overcome by reinforcement-based training strategies.


Hemiparetic stroke patients (n = 20, 11 males, 9 right-sided hemiparesis) were asked to reach targets appearing in either the real world or in a virtual environment. Sessions were divided into 3 phases: baseline, intervention and washout. During the intervention the movement of the virtual representation of the patients’ paretic limb was amplified towards the target.


We found that the probability of using the paretic limb during washout was significantly higher in comparison to baseline. Patients showed generalization of these results by displaying a more substantial workspace in real world task. These gains correlated with changes in effector selection patterns.


The amplification of the movement of the paretic limb in a virtual environment promotes the use of the paretic limb in stroke patients. Our findings indicate that reinforcement-based therapies may be an effective approach for counteracting learned non-use and may modulate motor performance in the real world.


Stroke rehabilitation Hemiparesis Upper extremity Physical therapy Learned non-use Reinforcement-based motor therapy


Following stroke, a loss of neural tissue induces drastic neurophysiological changes that often result in cognitive and motor impairments, such as hemiparesis. In order to counteract these deficits patients often introduce compensatory movements (e.g. overutilizing their non-paretic limb). Although these compensatory strategies may immediately improve functional motor performance in activities of daily living (ADLs) or reduce the burden of using the paretic limb, a long period of non-use of the affected limb can lead to further reversible loss of neural and behavioral function [1]. This so-called learned non-use has been associated with a reduced quality of life. Hence, methods must be found to reduce the impact of acquired non-use.
A possible treatment for learned non-use is Constraint Induced Movement Therapy (CIMT), which forces the patient to use the paretic limb by constraining the movement of the non-paretic limb. This technique has been shown to be effective in mitigating the effects of learned non-use [2, 3, 4]. However, due to the high intensity and long duration of CIMT protocols, which can range from 1 to 6 hours of training per session [5], they may reduce quality of life, affect the patient’s adherence to therapy, be prohibitively expensive and even inconvenient for those patients with severe motor or cognitive deficits [6]. Moreover, it remains unclear whether the standard CIMT protocols are more beneficial than bimanual functional rehabilitation [7]. The success rate of the standard CIMT protocols may depend on the severity of upper limb paresis and latency of intervention post-stroke. Consequently, its application remains restricted to subacute patients, with no severe cognitive impairments, and mild hemiparesis. These very stringent inclusion criteria only account for about 15 % of stroke cases [8]. Hence, in light of these limitations it seems opportune to develop rehabilitation techniques that build on the positive aspects of CIMT, i.e. enhanced use of the paretic limb, while mitigating the negative ones.
CIMT builds on the emergence of compensatory movements post-stroke. Such movements can be acquired and retained through the involvement of the mirror neuron system (MNS) [9]. For instance, it has been proposed that a successful action outcome might reinforce not only the intended action but also any movement that drives the MNS during the course of its execution [10, 11, 12]. Action selection may depend on both the action’s executability and desirability [13]. In this case, the executability of an action is modulated by the MNS and indicates the action’s expected biomechanical error, while the desirability of an action is modulated by its outcome and can be reinforced by accidental success. Desirability of action was demonstrated in a recent study exploring handedness bias, suggesting that performance asymmetries between limbs may influence the choices that individuals make about which hand to use [14]. A recent study on hemiparetic stroke patients proposed that increasing the patient’s confidence in using the paretic arm for a given level of function may be critical for recovering non-pathological hand selection patterns [15]. In this vein, Stoloff and colleagues showed that modulating reward rates during a reaching task can increase the use of the non-dominant hand in healthy subjects [16]. In order to ensure a high performance level the authors used a variable ratio staircase procedure to adjust the size of a virtual target when users selected their non-dominant limb to perform the action. The visual representation of the target remained fixed. Note however, that this reinforcement strategy exposes the user to an incomplete visuomotor feedback of the reaching action when performed using the dominant limb. This is because, due to the changing size of the virtual target, the movements executed with the non-dominant limb were inferior in extent and accuracy when compared to the dominant limb. We hypothesize that exposing a user to the complete visual feedback of an intended action may lead to reinforcement and thus will modulate hand selection patterns.
The approach we take towards stroke rehabilitation is based on the Distributed Adaptive Control (DAC) theory of mind and brain, which proposes that the disruption of the sensorimotor contingencies leads to a reduction of activity in the motor cortical pathways and interconnected sensorimotor areas. This reduction of activity leads to a reduced drive in neural plasticity and thus to an impairment of recovery in case of a lesion to the brain. Consequently, restoring these sensorimotor contingencies through external manipulation of sensory and/or motor modalities during the execution of goal-oriented actions might increase the activation of the MNS and its interconnected motor areas, thus driving plasticity and recovery [17]. On this basis, Virtual Reality (VR)-based protocols have proved beneficial in the clinical context, since they can provide multimodal feedback in safe and ecologically valid training environments. Indeed, we have demonstrated this using the so called Rehabilitation Gaming System (RGS) [18, 19] and provided direct evidence for the involvement of the MNS in these VR-based manipulations [20].
The aim of this study is to explore to what extent goal-oriented movement amplification in VR can induce beneficial changes in a patient’s hand selection patterns, namely, effectively reinforcing the use of the paretic limb, reversing learned non-use, and promoting motor recovery. To realize this, we instructed stroke patients to perform a reaching task in the first person VR RGS environment and a pointing task in the real world. We included in the RGS protocol movement amplification of the paretic limb. Results show that visual amplification of the movement of the virtual counterpart of the paretic limb may induce improvements in use of the affected arm and modulate performance in the real world.

More at link.

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