Why Avocado Is The One Fruit You Don't Need To Pair With Protein by mindbodygreen

 Why your competent? doctor needs to have the dietician create a protocol on this for you. Will it become part of your diet protocol? Oh NO, you HAVE NO DIET PROTOCOL, DO YOU? Oh well, your doctors' incompetence prevailed, not wanting to do the work of creating that protocol! Good luck recovering with such crapola backing you have!

• avocados? (12 posts to January 2015)

Why Avocado Is The One Fruit You Don't Need To Pair With Protein

One Blood Marker Is Tied to Cognition and Mortality in People Who Live Past 100

 Is this one of the common tests post stroke so your doctor can identify the EXACT REHAB PROTOCOLS  to fix this? Oh NO, your competent? doctor has no protocols at all for anything in stroke! S/he prefers guessing on what needs to be done for your recovery! Good luck with that!

One Blood Marker Is Tied to Cognition and Mortality in People Who Live Past 100

Elevated NfL levels tracked with poorer cognitive scores and higher death risk in centenarians

Key Takeaways

• Neurofilament light chain (NfL) is a measure of neuronal injury.
• Higher blood NfL levels in centenarians correlated with lower cognitive scores and increased mortality rates.
• NfL may reflect complex systemic interactions that influence mortality, researchers suggested.

Neurofilament light chain (NfL), a measure of neuronal injury, emerged as a key blood-based biomarker associated with both cognitive function and survival in centenarians, a Japanese cohort study showed.

Higher plasma NfL levels correlated with lower cognitive scores on the Mini-Mental Status Examination (MMSE) after adjusting for potential confounders (β = -0.92, 95% CI -1.62 to -0.23), reported Yasumichi Arai, MD, PhD, of Keio University School of Medicine in Tokyo, and co-authors.

Elevated NfL was also tied to increased mortality (HR 1.36, 95% CI 1.17-1.57), the researchers wrote in JAMA Network Open. Meanwhile, a lower level of plasma amyloid-beta 42/40, an Alzheimer's disease biomarker, was linked to worse cognitive scores (β = 0.99, 95% CI 0.46-1.52). However, neither that measure, nor plasma phosphorylated tau 181 (p-tau181), had a significant relationship with mortality after adjustment. Unlike amyloid and tau biomarkers, "NfL appeared to be a more generalizable marker of neurodegeneration that reflected the complex interactions between the nervous system and physiological systems such as immunity and vascular function," Arai and colleagues wrote. "These findings suggest that NfL could serve as a valuable biomarker for assessing the health trajectory of extremely old adults and provide critical insights into the mechanisms underlying cognitive aging at the limits of human life," they added. NfL is a structural component of nerve cells; when damaged, it is released in the blood and cerebrospinal fluid (CSF). The biomarker is assessed in a number of disorders, including vascular brain injury, multiple sclerosis, amyotrophic lateral sclerosis (ALS), traumatic brain injury, and Huntington's disease. Higher blood or CSF levels of NfL are considered markers of neurodegeneration.

The Japanese study results mirror a key finding from earlier research that showed plasma NfL was associated with mortality in the oldest old.

"I'm delighted that our findings from the Danish nonagenarian and centenarian cohorts have now been replicated in a Japanese cohort," noted Mathias Jucker, PhD, of the German Center for Neurodegenerative Diseases in Tübingen. "This independent validation across distinct populations strongly supports the robustness of the findings," he told MedPage Today.

Other population-based studies have reported that NfL blood levels also may predict mortality in younger cohorts, Jucker added.

"In light of the growing interest in NfL as a biomarker for human neurological health and mortality, we have recently extended our analysis to include animals," he said. "Our findings suggest that NfL may serve as a cross-species blood biomarker for assessing aging interventions and predicting mortality."

Arai and colleagues studied a cohort of 495 Japanese centenarians recruited from 2000 to 2021 with a mean baseline age of 104.1 years; most (80.4%) were women. Participants had baseline cognitive tests and blood sampling, and were followed up to 17 years for mortality.

The MMSE evaluated cognitive function; scores can range from 30, indicating normal cognition, to 0, indicating severe impairment. The researchers assessed dementia severity with the Clinical Dementia Rating (CDR) scale, which ranges from 0 for no impairment to 3 for severe dementia.

Overall, 419 participants took the MMSE; the mean score was 13.7. Among 436 participants with a CDR assessment, 83 people had a score of 0; 59 people had a score of 0.5; and 129 people had a score of 1.

The mean NfL level was 114.6 pg/mL, but values ranged widely from 12.5 to 1,239.5 pg/mL. During the follow-up period, 466 participants (95.5%) died.

"While amyloid-beta deposition has long been considered a hallmark of Alzheimer's disease, and p-tau181 is a related protein to amyloid-beta, they appear to be less strongly associated with mortality in centenarians compared with neurodegeneration-associated biomarkers such as NfL," Arai and co-authors observed.

"This suggests that nonamyloid-beta pathology or systemic pathology affecting neurodegeneration rather than amyloid-beta pathology itself may play a more significant role in the morbidity and mortality of centenarians, which is compatible with recent findings showing a distinct pattern of cognitive decline in centenarians compared with patients with Alzheimer's disease," the researchers pointed out.

"The role of physical system decline in chronic inflammation, worsening nutritional status, and declining kidney function as reflected in NfL levels underscores the complex systemic interactions that likely influence mortality in this population," they added.

The study had several limitations, Arai and co-authors noted. It did not account for a formal diagnosis of dementia or incorporate imaging measures like cerebrovascular lesions. The cohort was also limited to a Japanese population.

"Replication in other ethnic groups and regions will be essential to evaluate the generalizability of these findings and to examine potential cultural or genetic influences on NfL as a biomarker of aging," the researchers wrote.

Judy George covers neurology and neuroscience news for MedPage Today, writing about brain aging, Alzheimer’s, dementia, MS, rare diseases, epilepsy, autism, headache, stroke, Parkinson’s, ALS, concussion, CTE, sleep, pain, and more. Connect:

Disclosures

This study was supported by a grant from the Japan Agency for Medical Research and Development; the Ministry of Health, Welfare, and Labour for the Scientific Research Project for Longevity; a Grant-in-Aid for Scientific Research from the Japan Society for the Promotion of Science; and the Program for Initiative Research Projects from Keio University and the Keio University Global Research Institute.

Arai reported receiving grants from Ezaki Glico, Johnson & Johnson, and Tuning Fork Bio. Co-authors reported relationships with Eisai, Otsuka, Kowa, K Pharma, and SanBio.

Jucker had no conflicts of interest.

Primary Source

JAMA Network Open

Source Reference: Shikimoto R, et al "Biomarkers, cognitive function, and mortality in centenarians" JAMA Netw Open 2026; DOI: 10.1001/jamanetworkopen.2026.11335.

Three ways to improve arm function in the chronic phase after stroke by robotic priming combined with mirror therapy, arm training, and movement-oriented therapy

Good luck mimicking this for your recovery with no protocol provided.

 Three ways to improve arm function in the chronic phase after stroke by robotic priming combined with mirror therapy, arm training, and movement-oriented therapy

Archives of Physical Medicine and Rehabilitation. Volume 104(8), Pgs. 1195-1202.

NARIC Accession Number: J92709. What's this?
Author(s): Li, Yi-chun, Lin, Keh-chung, Chen, Chia-ling, Yao, Grace, Chang, Ya-ju, Lee, Ya-yun, Liu, Chien-ting, Chen, Wen-Shiang.
Publication Year: 2023.
Abstract: Study examined the effects of bilateral robotic priming combined with mirror therapy (R-mirr) vs bilateral robotic priming combined with bilateral arm training (R-bilat), relative to the control approach of bilateral robotic priming combined with movement-oriented training (R-mov)(What's this?) in patients with stroke. In a single-blind randomized controlled trial, 63 outpatients with stroke and mild-to-moderate motor impairment received 6 weeks of clinic-based R-mirr, R-bilat, or R-mov for 90 minutes a day, 3 days a week, plus a transfer package at home for 5 days a week. Outcomes included the Fugl-Meyer Assessment Upper Extremity subscale (FMA-UE), ABILHAND, and Stroke Impact Scale v3.0 scores obtained before, immediately after, and 3 months after treatment as well as lateral pinch strength and accelerometry before and immediately after treatment. The posttest results favored R-mirr over R-bilat and R-mov on the FMA-UE score. Follow-up analysis revealed that significant improvement in FMA-UE score was retained at the 3-month follow-up in the R-mirr over R-bilat or R-mov. Significant improvements were not observed in the R-mirr over R-bilat and R-mov on other outcomes. Between-group differences were only detected for the primary outcome, FMA-UE. R-mirr was more effective at enhancing upper-limb motor improvement, and the effect has the potential to be maintained at 3 months of follow-up.
Descriptor Terms: EXERCISE, LIMBS, MOTOR SKILLS, PHYSICAL THERAPY, REHABILITATION TECHNOLOGY, ROBOTICS, STROKE, THERAPEUTIC TRAINING.


Can this document be ordered through NARIC's document delivery service*?: Request Information.

Citation: Li, Yi-chun, Lin, Keh-chung, Chen, Chia-ling, Yao, Grace, Chang, Ya-ju, Lee, Ya-yun, Liu, Chien-ting, Chen, Wen-Shiang. (2023.) Three ways to improve arm function in the chronic phase after stroke by robotic priming combined with mirror therapy, arm training, and movement-oriented therapy. Archives of Physical Medicine and Rehabilitation., 104(8), Pgs. 1195-1202. Retrieved 11/30/2023, from REHABDATA database.

Combination therapy using robotics to treat finger and upper-extremity function for a stroke patients with severe upper-extremity paresis

Good luck getting any robotics in your stroke hospital. They don't read or implement research proving they are an incompetent hospital.

Combination therapy using robotics to treat finger and upper-extremity function for a stroke patients with severe upper-extremity paresis

重度の上肢麻痺のある脳卒中患者の指と上肢の機能を治療するためのロボット工学を使用した併用療法.  Japanese Occupational Therapy Research , Volume 38(1) , Pgs. 78-86.

NARIC Accession Number: I247496.  What's this?
Author(s): Takashi TAKEBAYASHI; Arisa Matsushima; Kenta Takeuchi; Shinichi Shimad.
Publication Year: 2019.

Abstract: 

This paper presents treatment consisting of robotic therapy for severe upper-extremity paresis related to inactive finger extension one month after stroke onset. Previous research indicates that poor finger mobility one month after stroke onset may indicate poor upper-extremity function. After improving upper-extremity function, the researchers used the brief version of transfer package of constraint-induced movement therapy to transfer functional gain in training into real-world use. Consequently, upper-extremity and real-world functions improved. These results suggest that combination therapy incorporating robotic therapy may be an effective treatment for stroke patients with severe upper-extremity paresis.
Descriptor Terms: Orientation, Statistics, Treatment, Brain.
Language: Japanese
Geographic Location(s): Japan, East & Southeast Asia.

Can this document be ordered through NARIC's document delivery service*?: Request Information.
Get this Document: https://www.jstage.jst.go.jp/article/jotr/38/1/38_78/_pdf/-char/en.

Citation: Takashi TAKEBAYASHI, Arisa Matsushima, Kenta Takeuchi, Shinichi Shimad. (2019). Combination therapy using robotics to treat finger and upper-extremity function for a stroke patients with severe upper-extremity paresis.  重度の上肢麻痺のある脳卒中患者の指と上肢の機能を治療するためのロボット工学を使用した併用療法.  Japanese Occupational Therapy Research , 38(1), Pgs. 78-86. Retrieved 6/23/2022, from REHABDATA database.

A Case Report: Effect of Robotic Exoskeleton Based Therapy on Neurological and Functional Recovery of a Patient With Chronic Stroke

Good luck getting your insurance to pay for chronic therapy.

A Case Report: Effect of Robotic Exoskeleton Based Therapy on Neurological and Functional Recovery of a Patient With Chronic Stroke

Neha Singh¹, Megha Saini¹, Nand Kumar², M. V. Padma Srivastava³, S. Senthil Kumaran⁴ and Amit Mehndiratta^1,5*

• ¹Centre for Biomedical Engineering, Indian Institute of Technology Delhi (IITD), New Delhi, India
• ²Department of Psychiatry, All India Institute of Medical Sciences (AIIMS), New Delhi, India
• ³Department of Neurology, All India Institute of Medical Sciences (AIIMS), New Delhi, India
• ⁴Department of Nuclear Medicine and Resonance, All India Institute of Medical Sciences (AIIMS), New Delhi, India
• ⁵Department of Biomedical Engineering, All India Institute of Medical Sciences (AIIMS), New Delhi, India

Background: In this study, a novel electromechanical robotic exoskeleton was developed for the rehabilitation of distal joints. The objective was to explore the functional MRI and the neurophysiological changes in cortical-excitability in response to exoskeleton training for a 9-year chronic stroke patient.

Case-Report: The study involved a 52-year old female patient with a 9-year chronic stroke of the right hemisphere, who underwent 20 therapy sessions of 45 min each. Cortical-excitability and clinical-scales: Fugl-Mayer (FM), Modified Ashworth Scale (MAS), Brunnstrom-Stage (BS), Barthel-Index (BI), Range of Motion (ROM), were assessed pre-and post-therapy to quantitatively assess the motor recovery.

Clinical Rehabilitation Impact: Increase in FM wrist/hand by 6, BI by 10, and decrease in MAS by 1 were reported. Ipsilesional Motor Evoked Potential (MEP) (obtained using Transcranial Magnetic Stimulation) was increased by 98 μV with a decrease in RMT by 6% and contralesional MEP was increased by 43 μV with a decrease in RMT by 4%. Laterality Index of Sensorimotor Cortex (SMC) reduced in precentral- gyrus (from 0.152 to −0.707) and in postcentral-gyrus (from 0.203 to −0.632).

Conclusion: The novel exoskeleton-based training showed improved motor outcomes, cortical excitability, and neuronal activation. The research encourages the further investigation of the potential of exoskeleton training.

Introduction

Post-stroke motor recovery follows a non-linear trajectory (1). Although, there is a period of enhanced plasticity or spontaneous recovery of motor function following a stroke, it is insufficient and often negligible in patients with chronic-stroke. Intensive therapeutic and rehabilitative interventions primarily lead to functional restoration in chronic-stroke survivors (2). While research studies have explored neuronal and motor recovery, patients with chronic-stroke often manifest long-term disability and limitations in the activities of daily living (3). The exact behavior of neurophysiological aspects at a neuronal level showing enhanced responsiveness to treatment in chronic-stroke is not clear yet (1).

Robotic-training for physical therapy is now becoming a new normal for the rehabilitation community (4). It might share a good amount of the clinical load of the therapist and can substantially facilitate the phenomenon of functional neuro-rehabilitation and recovery. An electro-mechanical robotic-exoskeleton was developed for distal joints that synchronize wrist-extension with Metacarpophalangeal (MCP) flexion and wrist-flexion with MCP-extension (4). The exoskeleton targets spasticity through a synergy-based rehabilitation approach while also maintaining patient-initiated therapy through residual muscle activity using Electromyogram (EMG) for maximizing voluntary effort. Here, we present the case of a 52-year old female with late chronic-stroke of 9 years, who had a partial recovery, and its convergent association of potential brain reorganization in response to the novel exoskeleton. The objective of this case study was to explore the neurophysiological repertoire of behavior behind motor recovery in response to the goal-directed treatment using exoskeleton for a patient with chronic-stroke.

More at link.

 

A Comparative Efficacy Study of Robotic Priming of Bilateral Approach in Stroke Rehabilitation

Good luck in trying to get your hospital to have this robotic priming device. When you ask for it all you are going to get is the deer in the headlights look. 

A Comparative Efficacy Study of Robotic Priming of Bilateral Approach in Stroke Rehabilitation

Yi-chun Li¹, Keh-chung Lin^1,2*, Chia-ling Chen^3,4, Grace Yao⁵, Ya-ju Chang^6,7,8, Ya-yun Lee⁹ and Chien-ting Liu¹⁰

• ¹School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
• ²Division of Occupational Therapy, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
• ³Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
• ⁴Graduate Institute of Early Intervention, College of Medicine, Chang Gung University, Taoyuan, Taiwan
• ⁵Department of Psychology, National Taiwan University, Taipei, Taiwan
• ⁶Neuroscience Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
• ⁷School of Physical Therapy and Graduate Institute of Rehabilitation Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
• ⁸Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan
• ⁹School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
• ¹⁰Department of Physical Medicine and Rehabilitation, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taipei, Taiwan

Background: Stroke survivors can remain impaired in body functions, activity, and participation. A novel rehabilitation regimen is required to obtain scientific evidence and to help clinicians determine effective interventions for stroke. Mirror therapy (MT) and bilateral upper limb training (BULT) are based on the tenet of bilateral movement practice; however, the additional effect of bilateral robotic priming combined with these two therapies is unclear.

Objectives: This study examined the effects of two hybrid therapies, robotic priming combined with MT and robotic priming combined with BULT, in stroke survivors.

Methodology: The study randomized 31 participants to groups that received robotic priming combined with MT (n = 15) or robotic priming combined with BULT (n = 16). Outcome measures included the Fugl–Meyer Assessment (FMA), the revised Nottingham Sensory Assessment (rNSA), the Chedoke Arm and Hand Activity Inventory (CAHAI), and accelerometer data.

Results: Both groups showed statistically significant within-group improvements in most outcome measures. Significant between-group differences and medium-to-large effect sizes were found in favor of the group that received robotic priming combined with MT based on the FMA distal part subscale scores, FMA total scores, and accelerometer data.

Conclusion: Robotic priming combined with MT may have beneficial effects for patients in the improvements of overall and distal arm motor impairment as well as affected arm use in real life. Additional follow-up, a larger sample size, and consideration of the effect of lesion location or different levels of cognitive impairment are warranted to validate our findings in future studies.

Clinical trial registration: www.ClinicalTrials.gov, identifier NCT03773653.

Introduction

Rehabilitation of stroke patients is a long process that takes several months or even years. More than 30% of stroke patients admitted to the hospital remain impaired in autonomy, engagement, and fulfillment of societal roles (1). Rehabilitation methods are needed to allow individuals to continue to maximize gains in arm impairment and function more than 3 months after stroke. Priming, an implicit learning technique, can be used to prepare the brain for a more plastic response before task-based rehabilitative therapy, thereby leading to improved functional outcomes (2). Bilateral robotic priming, an extended application of robotic therapy involving bimanual, repetitive, mirror-symmetric movement practice, is a type of movement-based priming with a low-tech robot device (3). It can normalize cortical inhibition, prepare the brain for subsequent rehabilitative therapies, and facilitate recovery through a task-oriented approach (2, 4, 5).

In recent years, reports on task-oriented approaches have increased. Mirror therapy (MT) and bilateral upper limb training (BULT) are bimanual strategies for stroke recovery and can be applied as task-oriented approaches (3, 6). BULT is performed intensively and simultaneously with both arms in a symmetrical or alternating pattern. According to the classical definition, BULT is typically symmetrical, both temporally and spatially, and can exploit the coupling effect of both arms to improve movement of the affected arm, for example, in simultaneously lifting two soft drink bottles (3, 7–11). Asymmetrical movement with different temporal and spatial relationships for the achievement of common goals, such as opening a jar of coffee or drying one's own back with a towel, has also been viewed as a kind of BULT in recent studies. BULT focuses on facilitating the coordination of a variety of different real-world tasks (12–14). For comprehensive effects, rehabilitation regimens should include not only classical definitive bilateral arm training but also the bilateral synergy framework.

MT is a promising approach in which a mirror is positioned vertically between the two arms so that the reflected image of the less affected arm gives the appearance of normal movement in the affected arm (15). The possible mechanism for the success of this therapy is that it could induce primary motor cortex cortical activations (16). Compared with BULT, MT has been proposed to provide significant benefits to distal hand function and superior improvements in sensory deficits, quality of life, and the amount of use of the affected arm (6, 17). A previous study found that BULT integrated with bilateral robotic priming was more effective than unilateral hybrid therapy for improving motor function. The efficacy was believed to result from inter limb coupling and the priming effects of bilateral symmetric practice (18). MT and BULT are both bimanual strategies for stroke; however, the distinct effect of bilateral robotic priming combined with MT and BULT is unclear.

In summary, bilateral robotic priming, MT, and BULT have been considered to be types of bilateral approaches (3, 6) and are based on the tenet of bilateral movement practice. MT and BULT can be provided as task-oriented approaches involving both arms. When combined with bilateral robotic priming, the effects of MT and BULT may be increased and differentiated. Bilateral hybrid therapy (bilateral robotic priming plus BULT) yielded a better effect on motor improvement (18). However, if bilateral robotic priming is followed by MT, which is also a type of bilateral approach but involves mirror visual feedback, the regimen may enhance the recovery effect.

This study compared the efficacy of these two different hybrid approaches that are both based on the tenet of bilateral movement practice. We hypothesized that within-group differences in the robotic primed MT (RMT) and robotic primed BULT (RBULT) groups would be found after the intervention. Furthermore, we hypothesized that sensorimotor function recovery would be better in the RMT group than in the RBULT group.

More at link.

 

Transcranial electrostimulation with special waveforms enhances upper-limb motor function in patients with chronic stroke: a pilot randomized controlled trial

 If you're chronic, good luck getting your insurance to pay for this.

Transcranial electrostimulation with special waveforms enhances upper-limb motor function in patients with chronic stroke: a pilot randomized controlled trial

• Shih-Ching Chen,
• Ling-Yu Yang,
• Muhammad Adeel,
• Chien-Hung Lai &
• Chih-Wei Peng 

Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 106 (2021) Cite this article

Abstract

Background

Transcranial direct current stimulation (tDCS) and intermittent theta burst stimulation (iTBS) were both demonstrated to have therapeutic potentials to rapidly induce neuroplastic effects in various rehabilitation training regimens. Recently, we developed a novel transcranial electrostimulation device that can flexibly output an electrical current with combined tDCS and iTBS waveforms. However, limited studies have determined the therapeutic effects of this special waveform combination on clinical rehabilitation. Herein, we investigated brain stimulation effects of tDCS-iTBS on upper-limb motor function in chronic stroke patients.

Methods

Twenty-four subjects with a chronic stroke were randomly assigned to a real non-invasive brain stimulation (NIBS; who received the real tDCS + iTBS output) group or a sham NIBS (who received sham tDCS + iTBS output) group. All subjects underwent 18 treatment sessions of 1 h of a conventional rehabilitation program (3 days a week for 6 weeks), where a 20-min NIBS intervention was simultaneously applied during conventional rehabilitation. Outcome measures were assessed before and immediately after the intervention period: Fugl-Meyer Assessment-Upper Extremity (FMA-UE), Jebsen-Taylor Hand Function Test (JTT), and Finger-to-Nose Test (FNT).

Results

Both groups showed improvements in FMA-UE, JTT, and FNT scores after the 6-week rehabilitation program. Notably, the real NIBS group had greater improvements in the JTT (p = 0. 016) and FNT (p = 0. 037) scores than the sham NIBS group, as determined by the Mann–Whitney rank-sum test.

Conclusions

Patients who underwent the combined ipsilesional tDCS-iTBS stimulation with conventional rehabilitation exhibited greater impacts than did patients who underwent sham stimulation-conventional rehabilitation in statistically significant clinical responses of the total JTT time and FNT after the stroke. Preliminary results of upper-limb functional recovery suggest that tDCS-iTBS combined with a conventional rehabilitation intervention may be a promising strategy to enhance therapeutic benefits in future clinical settings.

Trial registration: ClinicalTrials.gov Identifier: NCT04369235. Registered on 30 April 2020.

Introduction

Neuromodulation is an evolving therapy for rehabilitation after a stroke and is also used to improve motor function in the lesioned cortex. Recently, studies indicated that neuromodulation could enhance neuroplasticity, the ability of the brain to reorganize or relearn in response to a new stimulus, resulting in facilitation of motor sensory recovery in stroke patients [1,2,3]. Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation (NIBS) technique, is contemporarily important as it can modulate neuroplasticity in advanced rehabilitation medicine, such as pain, depression and, addictive diseases [4,5,6]. tDCS can selectively change the excitability of the regional cortex non-invasively and safely [7]. In addition, tDCS has been explored as a treatment option for stroke, particularly for upper/lower-limb motor function [8,9,10,11]. However, studies reported only 10% ~ 30% improvement in forearm motor function after stroke rehabilitation. Optimal stimulation strategies of tDCS to improve plasticity and enhance motor learning need to be determined.

Recovery as a result of traditional stroke rehabilitation often has poor outcomes and long rehabilitation times. Therefore, developing a more-effective therapeutic device is an important issue for stroke rehabilitation. To develop an optimal tDCS protocol to improve motor function, we designed and implemented a prototype of a novel transcranial electrostimulation device that can flexibly output an electrical current waveform by combining DC and theta burst waveforms [12]. Theta burst stimulation (TBS) was originally a novel waveform of repetitive transcranial magnetic stimulation (rTMS) that is more rapid and efficacious than rTMS [13]. Numerous studies determined that TBS has more advantages than other traditional waveforms of rTMS, such as long-lasting effects on motor-evoked potentials (MEPs) and neuronal excitability after a shorter stimulation duration [14,15,16], and it was associated with fewer adverse events [17]. It is well known that the most widely used TBS patterns are intermittent (i)TBS and continuous (c)TBS. iTBS consists of a 2-s train of TBS repeated every 10 s for a total of 190 s which produces long-term potentiation (LTP)-like effects, whereas cTBS consists of three-pulse bursts at 50 Hz repeated every 200 ms for 40 s, which induces long-term depression (LTD)-like cortical plasticity [14, 18,19,20].

Use of an rTMS protocol with iTBS in chronic stroke patients was shown to significantly increase ipsilesional M₁ excitability, enhanced MEP amplitudes, and improve upper-limb motor functions [15, 21,22,23]. One recent meta-analysis showed that the standardized mean difference (SMD) of iTBS was 0.60 (p = 0.018), whereas that for cTBS was 0.35 (p = 0.138) for the recovery of upper-limb motor outcomes in stroke patients, indicating that iTBS was more beneficial than cTBS in motor recovery after a stroke [24]. Therefore, modulation of cortical plasticity induced by iTBS may have therapeutic potential for patients with post-stroke motor disorders.

Both rTMS and tDCS can cause physiological effects and indirectly modulate deep-brain locations via neural circuits [25, 26]. In general, rTMS therapy is usually applied before undertaking occupational therapy for patients with motor function deficits, due to the bulky size of the rTMS device. On the contrary, the lightweight, portable tDCS device can be directly worn on a patient's head during active rehabilitation exercises, which was associated with augmentation of synaptic plasticity [27,28,29]. However, most traditional transcranial stimulators have only a DC waveform mode at present. Thus, our novel transcranial burst electrostimulator was designed to develop an effective and optimal therapeutic system for patients who need rehabilitation therapy. We previously demonstrated that compared to conventional anodal tDCS, the combined DC-iTBS electrostimulator induced LTP-like plasticity as evident from significantly enhanced MEP amplitudes for at least 30 min in animal experiments [12].

With the excellent efficacy of previously combined stimulation, we report a pilot randomized controlled study to examine the combined effects of DC-iTBS and conventional rehabilitation (CR) on upper-limb motor function as measured by the Fugl-Meyer Assessment upper extremity (FMA-UE), Finger-to-Nose test (FNT), and Jebsen-Taylor hand function test (JTT) in patients with chronic stroke compared to a sham intervention. To our knowledge, this is the first randomized controlled trial (RCT) to apply tDCS with iTBS to facilitate upper-limb motor function in chronic stroke patients. We also expected that the novel DC-iTBS stimulation combined with rehabilitation of the upper extremities would result in greater improvements and have potential to become a routine treatment strategy for stroke patients at hospitals and residential rehabilitation facilities.

More at link.

 

Targeted engagement of a dorsal premotor circuit in the treatment of post-stroke paresis

Good luck figuring out what a premotor therapy is and you need robotics besides. I believe most of my premotor cortex was destroyed so nothing here will help me even if I could figure it out. 

Targeted engagement of a dorsal premotor circuit in the treatment of post-stroke paresis

2013, NeuroRehabilitation
 Lucy Dodakian a, 

Kelli G. Sharp a, 

Jill See a, 

Neil S. Abidi a, 

Khoa Mai a, 

Brett W. Fling a, 

Vu H. Le a

and Steven C. Cramer a,b,∗
a  Department of Anatomy & Neurobiology, University of California, Irvine, CA, USA
b  Department of Neurology, University of California, Irvine, CA, USA

*  Address for correspondence: Steven C. Cramer, MD, University of California, Irvine Medical Center, 200S. Manchester Ave. Suite206, Orange, CA 92868, USA. Tel.: +1 714 456 6876; Fax: +1 714456 8805; E-mail: scramer@uci.edu

Abstract

.
BACKGROUND:
 Good motor outcome after stroke has been found to correlate with increased activity in a dorsal premotor(PMd) brain circuit, suggesting that therapeutic strategies targeting this circuit might have a favorable, causal influence on motor status.
OBJECTIVE:
This study addressed the hypothesis that a Premotor Therapy that exercises normal PMd functions would providegreater behavioral gains than would standard Motor Therapy; and that Premotor Therapy benefits would be greatest in patients with greater preservation of PMd circuit elements.
METHODS:
 Patients with chronic hemiparetic stroke (n=15) were randomized to 2-weeks of  Premotor Therapy
 or Motor Therapy, implemented through a robotic device.
RESULTS:
 Overall, gains were modest but significant (change in FM score, 2.1±2.8 points, p<0.02) and did not differ by treatment assignment. However, a difference between Therapies was apparent when injury to the PMd circuit was considered, as the interaction between treatment assignment and degree of corticospinal tract injury was significantly related to the change inFM score (p=0.018): the more the corticospinal tract was spared, the greater the gains provided by Premotor Therapy. Similar results were obtained when looking at the interaction between treatment assignment and PMd function (p=0.03).
CONCLUSIONS:
 Targeted engagement of a brain circuit is a feasible strategy for stroke rehabilitation. This approach has maximum impact when there is less stroke injury to key elements of the targeted circuit.Keywords: Stroke, premotor cortex, robot, motor recovery, corticospinal tract
1. Introduction
Motor deficits are among the most common forms of impairment after stroke, present in>80% of patients acutely (Rathore, Hinn, Cooper, Tyroler, & Rosamond,2002). Most patients show spontaneous improvement in motor status during the weeks following stroke. Several forms of brain plasticity that contribute to this recovery have been identified (S. C. Cramer, 2008;Nudo, 2011). In particular, anatomical and functional evidence support a role for dorsal premotor cortex in support of return of motor function (Alagona et al.,2001; S. Cramer et al., 1997; Denny-Brown, 1950;Fries, Danek, Scheidtmann, & Hamburger, 1993; Gau-thier, Taub, Mark, Barghi, & Uswatte, 2012; Laplane,Talairach, Meininger, Bancaud, & Bouchareine, 1977;Seitz et al., 1998; Weiller, Chollet, Friston, Wise, &Frackowiak, 1992). Activity within ipsilesional dorsal premotor cortex (PMd) has been associated withachieving spontaneous recovery (Fridman et al., 2004;Platz et al., 2000; Rehme, Eickhoff, Wang, Fink, &Grefkes, 2011; Sharma, Baron, & Rowe, 2009; Wardet al., 2006) as well as treatment-induced recovery(Careyetal.,2002;Johansen-Berg,Dawes,etal.,2002;
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 L. Dodakian et al. / Targeted dorsal premotor engagement
Page,Szaflarski,Eliassen,Pan,&Cramer,2009;Strup-pler et al., 2007) after stroke. Evidence suggests that contralesional PMd might contribute to recovery, too,particularly in patients with more severe stroke (Bute-fisch et al., 2005; Kantak, Stinear, Buch, & Cohen,2012; Lotze et al., 2011; Rehme, Fink, von Cramon,&Grefkes,2011).Changes in PMd activity are thought to support behavioral gains through connections with ipsilesional primary motor cortex (M1), contralesional brain areas, spinal cord targets, and possibly reticulospinal brain stem neurons (Fregni & Pascual-Leone,2006; Fridman, et al., 2004; James et al., 2009; Kantak, et al., 2012). Together, these findings suggest that therapies that increase PMd activity could improve motor status after stroke. This idea was examined in the current study by testing two main hypotheses. The first is that practicing a motor behavior known to engage PMd circuitry will improve motor status after stroke to a greater extent than will practicing a repetitive motor behavior unrelated to PMd. These cond is that the extent to which such a PMd-based therapy provides superior gains in motor status will vary with the availability of PMd anatomically, and perhaps functionally–a therapy can not provide benefit if its biological target is excessively injured by stroke(Nouri & Cramer, 2011). These two hypotheses were examined in the cur-rent study, with a focus on the distal upper extremity. A Premotor Therapy
 was designed, the features of which emphasized normal functions of a PMd circuit.Key anatomical components of the PMd circuit include PMd, which processes novel external cues in order to guide the timing and the choice of voluntary movements(Askim,Indredavik,&Haberg,2010;Chouinard&Paus,2006;Geyer,Matelli,Luppino,&Zilles,2000;Koch et al., 2006; Kurata & Hoffman, 1994; O’Shea,Johansen-Berg,Trief,Gobel,&Rushworth,2007;Pass-ingham, 1993; Rushworth, Johansen-Berg, Gobel, &Devlin, 2003; Schluter, Rushworth, Passingham, &Mills, 1998), as well as M1 and the corticospinaltract, important for expressing the output of corticalcomponents of the circuit. A study of healthy control subjects (described below) confirmed that performing the timed movement tasks that constitute Premotor Therapy
 was associated with increased activity within a dorsal premotor circuit. A robotic device (Takahashi,Der-Yeghiaian, Le, Motiwala, & Cramer, 2008), found to improve post-stroke arm motor function in a prior study, served as an ideal vehicle for implementing the timed cues central to
 Premotor Therapy, and furthermore allowed inclusion of therapy in a gaming context, an approach useful to modulating the function of selected brain circuits (Bavelier, Levi, Li, Dan, &Hensch, 2010; Colzato, van den Wildenberg, Zmigrod,& Hommel, 2012). In the current study, this Premotor Therapy
 was contrasted with Motor Therapy
, in which subjects performed the same distal arm movements as with
 Premotor Therapy but without cues or novelty. Patients with chronic stroke underwent a baseline example plus MRI for assessing anatomical and functional features of a PMd circuit, were randomized to two weeks of Motor Therapy vs. Premotor Therapy via the robotic device, and then had their motor outcome assessed 1 month after completion of therapy. These data were used to address the above two hypotheses.