Stroke awareness

Medium f*cking whoopee.
This is what well meaning people do and think this is really helping solve the stroke problem. It does  nothing for survivors and takes money away from research that can actually solve all the problems in stroke.  This is precisely why the World Stroke Day is such a waste of effort.

Static splinting after stroke: Are therapists overlooking the evidence?

Pretty much precisely what Peter Levine wrote about here:

Splinting after stroke? Why?

 Static splinting after stroke: Are therapists overlooking the evidence?

 

Occupational therapy as a field is striving to be known for being “science driven and evidence based”. I’m currently in my 3rd semester pursuing a Master of Science in Occupational Therapy at Brenau University and I feel proud to be in an OT program that answers this call. During my first semester, I took a course called Evidence Based Practice. Thanks to my exceptional instructors, I felt this was one of the most important courses I’ve ever taken in school…ever! Now that I’ve started my field work and I’m learning more about different interventions, I’ve made a habit of ‘asking for the evidence’. However, I’ve discovered that many common interventions have little or poor evidence to justify their widespread use. So I’d like to take this opportunity to reach out to other students and therapists, and to explore an example about arm and hand splinting and stretching for stroke rehabilitation. These interventions are still in use to prevent or treat contractures after stroke, but is there good evidence to support this practice?

So does splinting help with contractures?

While there’s anecdotal evidence and a few older non-randomized studies that suggest stretching from static splinting is effective for preventing and treating contractures, when subjected to more rigorous testing, positive results simply have not materialized. For example, a randomized controlled trial (RCT) involving 63 post stroke patients studied the effects of either neutral static splint or extended static splint worn overnight for 4 weeks, as compared to a control group wearing no splint (Lannin, 2007). The study found that splinting the wrist in either the neutral or extended wrist position for 4 weeks did not reduce wrist contracture after stroke. Citing the above RCT, the Scottish Intercollegiate Guidelines Network (SIGN) guideline on stroke management and rehabilitation says that splinting is not recommended for improving upper limb function or for reducing spasticity in the wrist and finger flexors following stroke. Other medical stroke guidelines that were written before this study say that splinting should be “considered” while acknowledging that the evidence was poor.
A few years later, the same RCT was included in a Cochrane systematic review (Katalinic, 2010), along with 34 other studies, with 1,391 participants. This review went even further and investigated if stretching, whether it was administered from splints, manual stretching, or even positioning programs, help prevent or treated contractures caused by several neurological conditions (stroke, traumatic brain injury, spinal cord injury, and cerebral palsy) as well as non-neurological conditions.
The authors concluded that there is moderate to high quality evidence to show that there is little or no effect of stretching/splinting on joint mobility, if this treatment is used for up to seven months (no study explored the use of stretch for longer periods). The effects of stretch on quality of life and activity limitation haven’t been well investigated, but in the few studies where this was evaluated there was no benefit from stretching. Stretch did not decrease pain or spasticity and was found to cause an immediate increase in pain in people with neurological conditions.
Since the Cochrane review was published, we can add another RCT (Basaran, 2012). This time, in 2012, a group of 39 patients post-stroke were divided into dorsal splint, volar hand splint, and a control group (no splint). The results were in line with the Cochrane Review’s and again failed to demonstrate any clinically significant differences in spasticity or in wrist passive range of motion of both the volar and dorsal splint groups.

Ok, so what?

Well, despite this evidence, static hand splints are still used by occupational therapists (OTs) to treat patients post-stroke. In 2011, a fascinating cross-sectional survey of hand-splinting practice among inpatient OTs in Ireland examined the perceived hand splinting efficacy and splint prescription pattern after stroke (Adrienne, 2011). The study found almost two-thirds of the respondents, 38 (61.3%) out of 62 OTs surveyed, believe splinting to be effective or very effective for rehabilitation after a stroke. Now granted, that’s a relatively small study, but it seems that OTs perceive hand splints to be effective and continue to prescribe splints regularly to their clients, despite inadequate evidence to support their continued use. All this comes at a time when healthcare systems are trying to reduce their costs while improving patient care. Reducing the use of less efficient interventions would help lower costs and improve outcomes.

So what does this mean for therapists?

I may have oversimplified the full picture of stretching and splinting for spasticity and contractures after stroke, as splints can be used for many reasons. It just seems that static splinting to prevent or treat contractures shouldn’t be one of these reasons.
The most important message here is that a treatment is in use which can be painful for patients and offer them no benefit in the short term, while the long-term effects are unknown. Similar examples can be found in other areas of healthcare too. It’s a reminder that we therapists must frequently review the best available evidence to see if it supports our interventions. Perhaps we are all at risk of falling into patterns of treatment that could even develop into a discipline’s “tradition” of practice. Sure, we could blame outdated medical guidelines based on much weaker evidence, but we shouldn’t be afraid to challenge health science’s guidelines or status quo with the best available evidence.
What do you think? Do you know of other widely used interventions that are not as effective as people believe? What can we do to encourage better use of available evidence?

Links:

Lannin, N. A., Cusick, A., McCluskey, A., & Herbert, R. D. (2007). Effects of Splinting on Wrist Contracture After Stroke A Randomized Controlled Trial. Stroke, 38(1), 111–116. doi:10.1161/01.STR.0000251722.77088.12
Katalinic OM, Harvey LA, Herbert RD, Moseley AM, Lannin NA, Schurr K. Stretch for the treatment and prevention of contractures. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD007455. DOI: 10.1002/14651858.CD007455.pub2.
Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning. Edinburgh: SIGN; 2010. (SIGN publication no. 118). [cited June 2010]. Available from URL: http://www.sign.ac.uk/guidelines/fulltext/118/index.html
Basaran, A., Emre, U., Karadavut, K. I., Balbaloglu, O., & Bulmus, N. (2012). Hand splinting for poststroke spasticity: a randomized controlled trial. Topics in Stroke Rehabilitation, 19(4), 329–337. doi:10.1310/tsr1904-329
Adrienne, C., & Manigandan, C. (2011). Inpatient occupational therapists hand-splinting practice for clients with stroke: A cross-sectional survey from Ireland. Journal of Neurosciences in Rural Practice, 2(2), 141–149. doi:10.4103/0976-3147.83579

(a) In patients with atrial fibrillation, 2 tools are best for predicting risk for stroke; a third tool is best for predicting risk for bleeding

I'll soon find out if this applies to me.
http://www.mcmasteroptimalaging.org/full-article/07bd6b405cc395b2de8727fbab083fb7

Lopes RD, Crowley MJ, Shah BR, et al. Stroke Prevention in Atrial Fibrillation AHRQ Comparative Effectiveness Review. Rockville, MD: Agency for Healthcare Research and Quality; 2013 Aug. Report No 13-EHC113-EF.

Review question

How effective are tools for predicting stroke and bleeding risk in patients with atrial fibrillation?

Background

Atrial fibrillation is an abnormal heart rhythm that can cause small clots to form in the heart. These clots can travel to the brain, causing a stroke.

Anticoagulant (or blood thinning) treatment is the therapy of choice for preventing stroke in non-valvular atrial fibrillation. However, anticoagulants can cause bleeding. People with atrial fibrillation vary a lot in their risk of stroke from AF, and in their risk of bleeding.

Prediction tools assess which people are most likely to benefit from treatment and which are most likely to be harmed.

How the review was done

This summary is based on a systematic review of 37 studies on predicting stroke risk and 17 studies on predicting bleeding in people with atrial fibrillation. Average age of participants ranged from 53 to 81 years. Publication period was 2000 to 2012.

What the researchers found

Scores from the CHADS2 and CHA2DS2-VASc are best for predicting risk for stroke. Their average prediction value is 0.70 (ranging from 0.66 to 0.75).

A value of 0.50 means that the tool is no better than chance in predicting an outcome. A value of 1.0 means that the tool predicts an event with certainty.

The strength of the evidence for these 2 tools is low.

The HAS-BLED score is best for predicting bleeding risk. Strength of the evidence is moderate.

Conclusions

The CHADS2 and CHA2DS2-VASc scores are best for predicting stroke in people with atrial fibrillation.

HAS-BLED scores are best for predicting bleeding risk.

---

Tools for predicting stroke or bleeding

Tool	Description
CHADS2	Congestive heart failure; Hypertension; Age 75 or older; Diabetes; prior Stroke [2 points]
CHA2DS2-VASC	Congestive heart failure; Hypertension; Age 75 or older [2 points]; Diabetes; prior Stroke [2 points]; Vascular disease; Age 65 to 74; Sex = female
HAS-BLED	1 point for each of Hypertension; Abnormal kidney or liver function; Stroke; Bleeding history or predisposition; Labile international normalized ratio; Elderly [older than 65]; Drugs/alcohol concomitantly

After stroke: The Cinderella of falls prevention research

What is your doctors stroke fall prevention protocol? Any protocol at all? If not that doctor needs to be fired.
http://www.mcmasteroptimalaging.org/full-article/5df379aeabac190455b1378e1857c94e

Summary - The message of this resource is:

Vitamin D appears to help reduce falls after stroke, as does the medicine alendronate. More research is needed about falls prevention approaches for people who have had a stroke, especially for people in the weeks following a stroke.

Key message: There is a lack of evidence on interventions which aim to prevent falls in people after they have had a stroke. This is in contrast to good evidence on some effective  preventive measures for older people living in the community.
It’s Age UK’s annual Falls Awareness Week this week, with an emphasis this year on healthy feet. The excellent review from the Cochrane Bone, Joint and Muscle Trauma Group on preventing falls in older people living in the community, which we blogged about when it was updated last autumn, has useful evidence on a range of strategies to prevent falls, including some relating to feet! Using an anti-slip shoe device reduced falls in icy conditions, while adding foot and ankle exercises to regular podiatry for people with disabling foot pain also reduced falls. Another review, also updated last autumn, found less clear evidence on how to prevent falls in older people in care homes and hospitals but did find that vitamin D supplements reduced falls in care homes, probably because the residents had low levels of vitamin D to start with. You can read the story of these reviews, which started as one, in an editorial by author Lesley Gillespie.
This month saw the publication of a new review from the Cochrane Stroke Group on strategies which aim to prevent falls in people who have had a stroke. Falls are a common problem in this population but it is unclear how much research has been done on the effects of interventions to prevent them falling. The reviewers searched for randomized controlled trials (RCTs) of any intervention which aimed to prevent falls in people at any of three stages after having a stroke: the acute stage (in a stroke unit or hospital ward), subacute stage (in a rehabilitation ward or clinic after discharge from an acute ward, or receiving intensive support at home) or chronic stage (after discharge from rehabilitation). Like the reviews looking at falls prevention in a more general population, this review looked at the effect of interventions on the rate of falls (number of falls divided by length of follow-up) and the number of fallers. Ten RCTs with 1004 people were included. One involved people in the acute and subacute stages while the rest involved those in the chronic stage. The interventions looked at were:

• exercise (7 studies involving different types of exercise including walking, balance and strengthening exercises, stair climbing, upper limb exercises and whole-body vibration)
• medicine (2 studies, vitamin D compared with placebo and alendronate compared with alphacalcidol)
• single lens distance vision glasses compared with multifocal glasses (1 study)

What did they find?

• Exercise did not reduce the rate of falls or the number of fallers either in the chronic stage (combined results of 4 studies with 412 people and 6 studies with 616 people respectively) or the acute/subacute stage
• Quality of life was measured in different ways in all of the exercise trials and three reported a significant improvement in favour of the intervention group
• Vitamin D was associated with significantly reduced rate of falls and number of fallers in hospitalised women as was alendronate when compared to alphacalcidol in hospitalised people after stroke
• No differences were seen between people wearing single lens or multifocal lens glasses after discharge from rehabilitation

How good was the evidence?

Most studies were judged to be at low risk of bias on all items assessed apart from blinding, where they were at high risk of bias. Falls were not defined in three studies and definitions varied in the other studies.
There were very few trials to include with a small number of people, in contrast to the 159 trials and over 79,000 people in the review of falls prevention for older people living in the community. Sample sizes were small and may have lacked power to detect differences. Some of the included trials had missing information.
What does this mean in practice?
Regrettably, the evidence on falls prevention after stroke is insufficient to guide those working in this area. There is much to be done in terms of future research. The reviewers note that even the positive findings for vitamin D and alendronate need to be replicated before this influences clinical practice. Exercise programmes, especially with balance and strength training elements, have been shown to reduce falls in the general population of older people and more research is needed on its potential benefits for people after stroke. Only one study included people in the acute and subacute phase yet around 7% of people fall in the first week after stroke.
Meanwhile, a brand new NICE guideline on Stroke has been published this month, with evidence from five Cochrane reviews and a Falls guideline has also been issued to replace an earlier one, still with five Cochrane reviews included and the addition of new data for falls in hospital patients.
For more information about Falls Awareness Week and a selection of fact sheets about falls, here’s the link to the Age UK website.

Links:

Verheyden GSAF, Weerdesteyn V, Pickering RM, Kunkel D, Lennon S, Geurts ACH, Ashburn A. Interventions for preventing falls in people after stroke. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD008728. DOI: 10.1002/14651858.CD008728.pub2.
Cochrane summary http://summaries.cochrane.org/CD008728/interventions-for-preventing-falls-in-people-after-stroke
Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146. DOI: 10.1002/14651858.CD007146.pub3.
Cochrane summary and podcast http://summaries.cochrane.org/CD007146/interventions-for-preventing-falls-in-older-people-living-in-the-community
Evidently Cochrane blog Keeping the over-65s on their feet: new review evidence tells us how. October 15th 2012.
Cameron ID, Gillespie LD, Robertson MC, Murray GR, Hill KD, Cumming RG, Kerse N. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD005465. DOI: 10.1002/14651858.CD005465.pub3
Cochrane summary and podcast http://summaries.cochrane.org/CD005465/interventions-for-preventing-falls-in-older-people-in-care-facilities-and-hospitals
Gillespie LD. Preventing falls in older people: the story of a Cochrane Review [editorial]. Cochrane Database of Systematic Reviews 2013 28 Feb;2:ED000053. DOI:10.1002/14651858.ED000053.
National Clinical Guideline Centre; National Institute for Health and Care Excellence (commissioner). Stroke rehabilitation: long term rehabilitation after stroke. London: National Clinical Guideline Centre, Royal College of Physicians; 2013 (NICE CG162). [Issued June 2013]. Available from URL: http://guidance.nice.org.uk/CG162/Guidance/pdf/English
Centre for Clinical Practice, National Institute for Health and Care Excellence. Falls: assessment and prevention of falls in older people. Manchester: Centre for Clinical Practice, National Institute for Health and Care Excellence; 2013 (NICE CG161). [Issued June 2013]. Available from URL: http://guidance.nice.org.uk/CG161/NICEGuidance/pdf/English

Direct admission to specialist stroke centres has no clear benefit over initial treatment at a local hospital

This pretty much contradicts everything about initial stroke treatment that is currently accepted as fact. So ask your doctor where you should be delivered if you have a stroke.  This is mortality rates not disability so maybe you do want to be delivered to a stroke center. If only we had a great stroke association to ask such a simple question. But no, we have totally craptastic stroke associations doing nothing but fucking press releases. What a waste of resources that could be used to fund research into solving all the problems in stroke.  http://www.mcmasteroptimalaging.org/full-article/faeb6e43e1810e2eaa1ce3dae07ebcb5

Pickering A, Harnan S, Cooper K, et al.  Acute ischaemic stroke patients - direct admission to a specialist centre or initial treatment in a local hospital? A systematic review Journal of Health Services Research & Policy. 2015 May.

Review question

Are mortality rates decreased when stroke patients bypass local, non-specialist hospitals in favour of specialist stroke centres?

Background

Treating patients with a suspected stroke is a time-critical concern, and there is uncertainty regarding the benefit of directly transferring patients to a specialist stroke centre rather than beginning therapy at a local, non-specialist hospital.

Current guidelines recommend that stroke patients be admitted directly to stroke centres, but therapy can begin in a local, non-specialist hospital under appropriately trained staff before transfer to a specialist centre.

Due to the time-sensitive nature of treating someone who has had a stroke, the best treatment option may be at the closest, local hospital.

How the review was done

A detailed search of a number of electronic databases for studies published from 1988 to 2012 was conducted. Studies that compared direct admission of stroke patients to a specialist centre with admission of stroke patients to a non-specialist centre (with the potential to transfer), were included in the review.

A total of 14 studies were included in the review after assessment for eligibility.

This review was funded by the National Institute for Health Research Service Delivery and Organization Programme.

What the researchers found

The review found that stroke mortality rates were no different when patients began therapy at local hospitals and then transferred to stroke centres, as compared to direct admission to a stroke centre.

When patients were assessed for complications after discharge from the hospital, outcomes were the same for those who transferred directly to a stroke centre and those who transferred from a local hospital.

The included studies showed that there is uncertainty as to whether time to therapy is longer when patients were admitted directly to a stroke centre compared to receiving treatment first at a non-specialist local hospital.

Conclusion

This review found that health outcomes are the same for patients who are transferred directly to a specialist centre and those who are treated at a non-specialist local hospital before being transferred to a specialist centre. However, the authors cite poor data and study quality as major limitations to the generalizability of these findings, and more evidence is needed to support the current guidelines of transferring all stroke patients to specialist stroke centres for treatment.

MyPhysioRehab

In case you don't think you are getting correct rehab exercises from your OTs and PTs. This is only to be used to consult with your therapists to make sure they have a plan to get you to 100% recovery. If they don't have such a plan then they need to be fired. Well nevermind, no search results for stroke, so physios do not rehabilitate stroke survivors.
MyPhysioRehab

MyPhysioRehab allows you as a health professional to provide your patients with an injury profile and a rehabilitation programme to aid rapid recovery

• Our Search allows to you to select the injury and exercises quickly
• Update exercises in real time online
• Video demonstrations of exercises for your clients
• Patients can download template to any device - a physio in your pocket!
• 'Suggestions' gives you the most popular exercises for a particular condition

 

Oxidative theory of atherosclerosis and antioxidants

How is your doctor going to use this to stop and reverse your atherosclerosis?
http://www.sciencedirect.com/science/article/pii/S0300908415004289

Dedicated to the memory of L. Douste-Blazy (MD, DrSc, Professor of Biochemistry, Faculty of Medicine, University of Toulouse, France).

• R. Salvayre^{a, b, c, ,} ,
• Negre -Salvayre^a, ,
• C. Camaré^{a, b, c}

 Show more

Choose an option to locate/access this article:

Check if you have access through your login credentials or your institution

Check access

Purchase $35.95

• 

doi:10.1016/j.biochi.2015.12.014

Get rights and content

---

Highlights

•

Atherosclerosis is a universal process in humans. Brief picture of Atherogenesis.

•

The 'Lipid theory of atherosclerosis'. From early discoveries to modern era: cholesterol, LDL receptor and scavenger receptor pathways.

•

The 'oxidative theory of atherosclerosis'. Free radicals, Reactive oxygen species, LDL oxidation, biological properties and potential role of oxidized LDLs in atherogenesis.

•

Antioxidants are effective to prevent LDL oxidation and delay atherogenesis in animal models, but do not prevent myocardial infarction and coronary heart disease death in humans.

•

The 'Mediterranean diet' seems to be protective against cardiovascular events and death.

---

Abstract

Atherosclerosis is a multifactorial process that begins early in infancy and affects all the humans. Early steps of atherogenesis and the evolution towards complex atherosclerotic plaques are briefly described. After a brief history of the 'Lipid theory of atherosclerosis', we report the most prominent discoveries on lipoproteins, their receptors and metabolism, and their role in atherogenesis. The main focus is the 'oxidative theory of atherosclerosis', with emphasis on free radicals and reactive oxygen species, lipid peroxidation and LDL oxidation, biological properties of oxidized LDL and their potential role in atherogenesis. Then, we report the properties of antioxidants and antioxidant systems and their effects in vitro, on cultured cells, in animal models and in humans. The surprising discrepancy between the efficacy of antioxidants in vitro and in animal model of atherosclerosis and the lack of protective effect against cardiovascular events and death in epidemiological study and clinical trials are discussed. In contrast, epidemiological studies seem to indicate that the Mediterranean diet may protect (in part) against atherosclerosis complications (myocardial infarction and cardiovascular death).

Graph from here:

 

Can we prevent and slow down neurodegeneration with diet and exercise?

A book your doctor should be consulting for your dementia prevention protocol.
Or you could ask your doctor about my ideas:
Dementia prevention 19 ways
 Can we prevent and slow down neurodegeneration with diet and exercise?

Brain Recovery after a Plane Crash: Treatment with Growth Hormone (GH) and Neurorehabilitation: A Case Report

What use of this is applicable to stroke recovery? We'll never know because we have NO stroke strategy or stroke leadership in any part of stroke.

Brain Recovery after a Plane Crash: Treatment with Growth Hormone (GH) and Neurorehabilitation: A Case Report

Jesús Devesa ^1,2,*, Gustavo Díaz-Getino ¹, Pablo Rey ¹, José García-Cancela ¹, Iria Loures ¹, Sonia Nogueiras ¹, Alba Hurtado de Mendoza ¹, Lucía Salgado ¹, Mónica González ¹, Tamara Pablos ¹ and Pablo Devesa ¹

¹

Scientific Direction Medical Centre Foltra, Teo 15886, Spain

²

Department of Physiology, School of Medicine, University of Santiago de Compostela, Santiago de Compostela 15710, Spain

*

Correspondence: Tel.: +34-981-802-928; Fax: +34-981-807-650

Academic Editor: Katalin Prokai-Tatrai

Received: 28 November 2015 / Accepted: 16 December 2015 / Published: 21 December 2015

Abstract

: The aim of this study is to describe the results obtained after growth hormone (GH) treatment and neurorehabilitation in a young man that suffered a very grave traumatic brain injury (TBI) after a plane crash. Methods: Fifteen months after the accident, the patient was treated with GH, 1 mg/day, at three-month intervals, followed by one-month resting, together with daily neurorehabilitation. Blood analysis at admission showed that no pituitary deficits existed. At admission, the patient presented: spastic tetraplegia, dysarthria, dysphagia, very severe cognitive deficits and joint deformities. Computerized tomography scanners (CT-Scans) revealed the practical loss of the right brain hemisphere and important injuries in the left one. Clinical and blood analysis assessments were performed every three months for three years. Feet surgery was needed because of irreducible equinovarus. Results: Clinical and kinesitherapy assessments revealed a prompt improvement in cognitive functions, dysarthria and dysphagia disappeared and three years later the patient was able to live a practically normal life, walking alone and coming back to his studies. No adverse effects were observed during and after GH administration. Conclusions: These results, together with previous results from our group, indicate that GH treatment is safe and effective for helping neurorehabilitation in TBI patients, once the acute phase is resolved, regardless of whether or not they have GH-deficiency (GHD). 

 

Much more at link.

Resveratrol Directly Binds to Mitochondrial Complex I and Increases Oxidative Stress in Brain Mitochondria of Aged Mice

So our fucking failures of stroke associations should be running research to determine the exact dose of resveratrol needed for best benefits.  And calculate that to the amount of red wine needing to be consumed. Based upon the style of red wine; Cabernet Sauvignon, Chianti, Malbec, Merlot, Nebbiolo, Pinot Noir, Syrah, Tempranillo, Zinfandel? What does aged mean?
http://www.ncbi.nlm.nih.gov/pubmed/26684010

Gueguen N^1,2,3, Desquiret-Dumas V^1,2,3, Leman G^1,3, Chupin S^1,2,3, Baron S⁴, Nivet-Antoine V⁴, Vessières E^1,3, Ayer A^1,3, Henrion D^1,3, Lenaers G^1,3, Reynier P^1,2,3, Procaccio V^1,2,3.

Author information

Abstract

Resveratrol is often described as a promising therapeutic molecule for numerous diseases, especially in metabolic and neurodegenerative disorders. While the mechanism of action is still debated, an increasing literature reports that resveratrol regulates the mitochondrial respiratory chain function. In a recent study we have identified mitochondrial complex I as a direct target of this molecule. Nevertheless, the mechanisms and consequences of such an interaction still require further investigation. In this study, we identified in silico by docking study a binding site for resveratrol at the nucleotide pocket of complex I. In vitro, using solubilized complex I, we demonstrated a competition between NAD+ and resveratrol. At low doses (<5μM), resveratrol stimulated complex I activity, whereas at high dose (50 μM) it rather decreased it. In vivo, in brain mitochondria from resveratrol treated young mice, we showed that complex I activity was increased, whereas the respiration rate was not improved. Moreover, in old mice with low antioxidant defenses, we demonstrated that complex I activation by resveratrol led to oxidative stress. These results bring new insights into the mechanism of action of resveratrol on mitochondria and highlight the importance of the balance between pro- and antioxidant effects of resveratrol depending on its dose and age. These parameters should be taken into account when clinical trials using resveratrol or analogues have to be designed.

PMID:

26684010

[PubMed - in process]

Free full text

Exercise Effects on the Brain and Sensorimotor Function in Bed Rest

For all purposes stroke patients are getting excessive bed rest due to lack of therapy so this research is very relevant.
http://ntrs.nasa.gov/search.jsp?R=20150023268

NTRS Full-Text:	Click to View  [PDF Size: 14 KB]
Author and Affiliation:	Koppelmans, V. (Michigan Univ., School of Kinesiology, Ann Arbor, MI, United States); Cassady, K. (Michigan Univ., Dept. of Psychology, Ann Arbor, MI, United States); De Dios, Y. E. (Wyle Science, Technology and Engineering Group, Houston, TX, United States); Szecsy, D. (Bastion Technologies, Inc., Huntsville, AL, United States); Gadd, N. (Wyle Science, Technology and Engineering Group, Houston, TX, United States); Wood, S. J. (Azusa Pacific University, Dept. of Psychology, Azusa, CA, United States); Reuter-Lorenz, R. A. (Universities Space Research Association, Houston, TX, United States); Kofman, I. (Wyle Science, Technology and Engineering Group, Houston, TX, United States); Bloomberg, J. J. (NASA Johnson Space Center, Houston, TX, United States); Mulavara, A. P. (Michigan Univ., Dept. of Psychology, Ann Arbor, MI, United States); Ploutz-Snyder, L. (Universities Space Research Association, Houston, TX, United States); Seidler, R. D. (Michigan Univ., School of Kinesiology, Ann Arbor, MI, United States)
Abstract:	Long duration spaceflight microgravity results in cephalad fluid shifts and deficits in posture control and locomotion. Effects of microgravity on sensorimotor function have been investigated on Earth using head down tilt bed rest (HDBR). HDBR serves as a spaceflight analogue because it mimics microgravity in body unloading and bodily fluid shifts. Preliminary results from our prior 70 days HDBR studies showed that HDBR is associated with focal gray matter (GM) changes and gait and balance deficits, as well as changes in brain functional connectivity. In consideration of the health and performance of crewmembers we investigated whether exercise reduces the effects of HDBR on GM, functional connectivity, and motor performance. Numerous studies have shown beneficial effects of exercise on brain health. We therefore hypothesized that an exercise intervention during HDBR could potentially mitigate the effects of HDBR on the central nervous system. Eighteen subjects were assessed before (12 and 7 days), during (7, 30, and ~70 days) and after (8 and 12 days) 70 days of 6-degrees HDBR at the NASA HDBR facility in UTMB, Galveston, TX, US. Each subject was randomly assigned to a control group or one of two exercise groups. Exercise consisted of daily supine exercise which started 20 days before the start of HDBR. The exercise subjects participated either in regular aerobic and resistance exercise (e.g. squat, heel raise, leg press, cycling and treadmill running), or aerobic and resistance exercise using a flywheel apparatus (rowing). Aerobic and resistance exercise intensity in both groups was similar, which is why we collapsed the two exercise groups for the current experiment. During each time point T1-weighted MRI scans and resting state functional connectivity scans were obtained using a 3T Siemens scanner. Focal changes over time in GM density were assessed using voxel based morphometry (VBM8) under SPM. Changes in resting state functional connectivity was assessed using both a region of interest (ROI, or seed-to-voxel) approach as well as a whole brain intrinsic connectivity (i.e., voxel-to-voxel) analysis. For the ROI analysis we selected 11 ROIs of brain regions that are involved in sensorimotor function (i.e., L. Insular C., L. Putamen, R. Premotor C., L.+R. Primary Motor C., R. Vestibular C., L. Posterior Cingulate G., R. Cerebellum Lobule V + VIIIb + Crus I, and the R. Superior Parietal G.) and correlated their time course of brain activation during rest with all other voxels in the brain. The whole brain connectivity analysis tests changes in the strength of the global connectivity pattern between each voxel and the rest of the brain. Functional mobility was assessed using an obstacle course. Vestibular contribution to balance was measured using Neurocom Sensory Organization Test 5. Behavioral measures were assessed pre-HDBR, and 0, 8 and 12 days post-HDBR. Linear mixed models were used to test for effects of time, group, and group-by-time interactions. Family-wise error corrected VBM revealed significantly larger increases in GM volume in the right primary motor cortex in bed rest control subjects than in bed rest exercise subjects. No other significant group by time interactions in gray matter changes with bed rest were observed. Functional connectivity MRI revealed that the increase in connectivity during bed rest of the left putamen with the bilateral midsagittal precunes and the right cingulate gyrus was larger in bed rest control subjects than in bed rest exercise subjects. Furthermore, the increase in functional connectivity with bed rest of the right premotor cortex with the right inferior frontal gyrus and the right primary motor cortex with the bilateral premotor cortex was smaller in bed rest control subjects than in bed rest exercise subjects. Functional mobility performance was less affected by HDBR in exercise subjects than in control subjects and post HDBR exercise subjects recovered faster than control subjects. The group performance differences and GM changes were not related. Exercise in HDBR partially mitigates the adverse effect of HDBR on functional mobility, particularly during the post-bed rest recovery phase. In addition, exercise appears to result in differential brain structural and functional changes in motor regions such as the primary motor cortex, the premotor cortex and the putamen. Whether these central nervous system changes are related to motor behavioral changes including gait and balance warrants further research.
Publication Date:	Feb 08, 2016
Document ID:	20150023268 (Acquired Dec 21, 2015)
Subject Category:	AEROSPACE MEDICINE
Report/Patent Number:	JSC-CN-35042

Cognitive remediation for depressed inpatients: Results of a pilot randomized controlled trial

Will your doctor be following this up with changes to your stroke depression protocol? Oh you don't have a depression protocol? FUCKING HEY, START SCREAMING AT YOUR DOCTOR FOR BEING USELESS.  Don't allow any deflection because this wasn't tested in stroke patients. 

Cognitive remediation for depressed inpatients: Results of a pilot randomized controlled trial

1. Wolfgang Trapp1⇑
2. Sinha Engel1
3. Goeran Hajak1
4. Stefan Lautenbacher2
5. Bernd Gallhofer3

1. ¹Department of Psychiatry, Sozialstiftung Bamberg, Bamberg, Germany
2. ²Department of Physiological Psychology, Otto-Friedrich-Universität Bamberg, Bamberg, Germany
3. ³Centre for Psychiatry, Justus Liebig University School of Medicine Gießen, Gießen, Germany

1. Wolfgang Trapp, Department of Psychiatry, Sozialstiftung Bamberg, St-.Getreu-Straße 18, 96049 Bamberg, Germany. Email: wolfgang.trapp@sozialstiftung-bamberg.de

Abstract

Objective: Neurocognitive deficits that persist despite antidepressive treatment and affect social and vocational functioning are well documented in major depressive disorder. Cognitive training approaches have proven successful in ameliorating these deficits in other psychiatric groups, but very few studies have been conducted in unipolar depressive patients by now. In contrast to previous studies solely including outpatients, effects of a cognitive remediation intervention on neurocognitive functioning of depressed inpatients were assessed by the present study.

Method: A randomized controlled trial was carried out with 46 depressed inpatients of a psychiatric hospital. Patients were randomly assigned to either a control group that received standard drug and non-drug (cognitive behavioural, occupational, sports, relaxation and music therapy) antidepressive treatment or a remediation group that additionally received 12 sessions of cognitive training for a total of 4 weeks (three sessions per week). An intent to treat analysis and a last observation carried forward method was used for data analyses.

Results: Patients of the remediation group demonstrated greater improvements in neurocognitive measures of verbal and nonverbal memory, working memory and executive function (Cohen’s d effect sizes between .52 and .98).

Conclusions: These results provide preliminary evidence that cognitive remediation interventions can be successfully applied also in psychiatric inpatients experiencing an acute depressive episode.

Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation

So I'm now drinking cranberry-pomegranate juice instead of OJ. You doctor can do the hard work of contacting these researchers to see what the daily amounts were. Hell this is only 7 years old, is your doctor so fucking incompetent that they haven't come up with a dietary protocol for this yet? They'd rather just prescribe pills instead of solving the problem the correct way?

Cranberry juice consumption may protect against cardiovascular disease

Drinking low-calorie cranberry juice may help lower risk of heart disease, diabetes and stroke

 

Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation

Aviram M¹, Rosenblat M, Gaitini D, Nitecki S, Hoffman A, Dornfeld L, Volkova N, Presser D, Attias J, Liker H, Hayek T.

Author information

Erratum in

• Clin Nutr. 2008 Aug;27(4):671.

Abstract

Dietary supplementation with polyphenolic antioxidants to animals was shown to be associated with inhibition of LDL oxidation and macrophage foam cell formation, and attenuation of atherosclerosis development. We investigated the effects of pomegranate juice (PJ, which contains potent tannins and anthocyanins) consumption by atherosclerotic patients with carotid artery stenosis (CAS) on the progression of carotid lesions and changes in oxidative stress and blood pressure. Ten patients were supplemented with PJ for 1 year and five of them continued for up to 3 years. Blood samples were collected before treatment and during PJ consumption. In the control group that did not consume PJ, common carotid intima-media thickness (IMT) increased by 9% during 1 year, whereas, PJ consumption resulted in a significant IMT reduction, by up to 30%, after 1 year. The patients' serum paraoxonase 1 (PON 1) activity was increased by 83%, whereas serum LDL basal oxidative state and LDL susceptibility to copper ion-induced oxidation were both significantly reduced, by 90% and 59%, respectively, after 12 months of PJ consumption, compared to values obtained before PJ consumption. Furthermore, serum levels of antibodies against oxidized LDL were decreased by 19%, and in parallel serum total antioxidant status (TAS) was increased by 130% after 1 year of PJ consumption. Systolic blood pressure was reduced after 1 year of PJ consumption by 12% [corrected] and was not further reduced along 3 years of PJ consumption. For all studied parameters, the maximal effects were observed after 1 year of PJ consumption. Further consumption of PJ, for up to 3 years, had no additional beneficial effects on IMT and serum PON1 activity, whereas serum lipid peroxidation was further reduced by up to 16% after 3 years of PJ consumption. The results of the present study thus suggest that PJ consumption by patients with CAS decreases carotid IMT and systolic blood pressure and these effects could be related to the potent antioxidant characteristics of PJ polyphenols.

PMID:

15158307

[PubMed - indexed for MEDLINE]

Home-based telesurveillance and rehabilitation after stroke: a real-life study

I really don't trust this paper, it seems to be most useful for reducing hospital costs by kicking patients out early. And that could easily be proven by cherry picking the correct patients to enroll. 

Home-based telesurveillance and rehabilitation after stroke: a real-life study

PreviewFull text HTML

PDF

Access options

DOI:

10.1080/10749357.2015.1120453

Palmira Bernocchi^a*, Fabio Vanoglio^b, Doriana Baratti^a, Roberta Morini^b, Silvana Rocchi^c, Alberto Luisa^b & Simonetta Scalvini^a

Publishing models and article dates explained

• Received: 8 Jun 2015
• Accepted: 23 Aug 2015
• Published online: 14 Dec 2015

Alert me

Abstract

Background: After discharge from in-hospital rehabilitation, post-stroke patients should have the opportunity to continue the rehabilitation through structured programs to maintain the benefits acquired during intensive rehabilitation treatment.

Objective: The primary objective was to evaluate the feasibility of implementing an home-based telesurveillance and rehabilitation (HBTR) program to optimize the patient's recovery by reducing dependency degree.
Method: Post-stroke patients were consecutively screened. Data were expressed as mean ±  standard deviation (SD). 26 patients enrolled: 15 were sub-acute (time since stroke: 112 ± 39 days) and 11 were chronic (time since stroke: 470 ± 145 days). For 3 months patients were followed at home by a nurse-tutor, who provided structured phone support and vital signs telemonitoring, and by a physiotherapist (PT) who monitored rehabilitation sessions by videoconferencing.
Results: 23 patients completed the program; 16.7 ± 5.2 phone contacts/patient were initiated by the nurse and 0.9 ± 1.8 by the patients. Eight episodes of atrial fibrillation that required a change in therapy were recorded in two patients. Physiotherapists performed 1.2 ± 0.4 home visits, 1.6 ± 0.9 phone calls and 4.5 ± 2.8 videoconference-sessions per patient. At least three sessions/week of home exercises were performed by 31% of patients, two sessions by 54%. At the end of the program, global functional capacity improved significantly (P < 0.001), in particular, static (P < 0.001) and dynamic (P = 0.0004) postural balance, upper limb dexterity of the paretic side (P = 0.01), and physical performance (P = 0.002). Symptoms of depression and caregiver strain also improved.

Conclusion: The home-based program was feasible and effective in both sub-acute and chronic post-stroke patients, improving their recovery, and maintaining the benefits reached during inpatient rehabilitation

• Full text HTML
• PDF

Do falls experienced during in-patient stroke rehabilitation affect length of stay, functional status, and discharge destination?

I was one of those fallers during my hospital stay, Got the dreaded yellow wrist band for that. My first night in the hospital proper, not the first three days spent in the ER and step-down units, I woke up in the middle of the night needing to go pee. I swung my legs over the side, took one step and fell over. Probably didn't help that my doctor never told me I had a stroke and what my deficits were. I'm not sure I even knew I was in a hospital at that point. That got me a catheter, wondered why they didn't install one immediately.
http://www.sciencedirect.com/science/article/pii/S0003999315015014

• Jennifer S. Wong, BSc^{1, 2, ,} ,
• Dina Brooks, PhD^{1, 2, 3, 4},
• Avril Mansfield, PhD^{1, 2, 3, 4}

 Show more

Choose an option to locate/access this article:

Check if you have access through your login credentials or your institution

Check access

Purchase $35.95

• 

doi:10.1016/j.apmr.2015.12.005

Get rights and content

---

Abstract

Objective

To compare length of stay, functional status, and discharge destination between individuals who fell during in-patient stroke rehabilitation and those who did not fall. We hypothesized that individuals who fell would have poorer recovery compared to those who did not fall.

Design

Retrospective cohort study.

Setting

Rehabilitation hospital.

Participants

106 individuals who fell during in-patient stroke rehabilitation (‘fallers’; mean age=67.8 years, SD =12.9; mean time post-stroke=26.4 days, SD=28.3) were matched to 106 individuals who did not fall (‘non-fallers’; mean age=67.3 years, SD=13.6; mean time post-stroke=21.9 days, SD=28.8) on age and functional status.

Interventions

Not applicable.

Main outcome measures

Total length of stay, Functional Independence Measure (FIM) assessed at discharge, and discharge destination.

Results

The mean length of stay for fallers was 11 days longer than non-fallers (p=0.0017). Non-fallers and fallers did not differ on discharge total FIM scores (p=0.19), and both groups were discharged home after in-patient rehabilitation (non-fallers: 77%; fallers: 74%; p=0.52)

Conclusions

This study suggests that falls experienced during in-patient stroke rehabilitation may have contributed to a longer length of stay; however, falls did not impact discharge functional status or discharge destination.

Can a 3D Touch app help stroke rehab patients recover dexterity and strength in their hands?

We'll never know because we have NO stroke strategy or stroke leadership in any part of stroke. A great stroke association would be working this like mad to create rehab applications to be sold to survivors and use the proceeds to fund stroke research. But we don't have anyone in stroke with enough brains to do something so fuckingly simple. And the boards of directors must be ok with such incompetency.
http://www.theverge.com/2015/12/23/10656592/apple-3d-touch-johns-hopkins-medical-games-new-ios-apps

Heart Age* Predictor Using BMI

With high blood pressure I'm going to die damn soon.
Bizarre calculations Heart age = 86 if blood pressure is treated and at 180
                                 Heart age = 80 if blood pressure is not treated and at 195                              
                                 heart age = 76 if blood pressure is not treated at 180
                                 heart age = 73 if blood pressure is 140 and treated
                                 heart age = 65 if blood pressure is 140 and not treated



                         getting down to a BMI of 25 only gets me one extra year or nothing at all. I'll find out in January what my real blood pressure is. The only way I get to my real age is a blood pressure of 120.

Heart Age* Predictor Using BMI

UC San Diego's Comprehensive Stroke Center receives Gold Plus Award

These are NOT result awards so they don't tell you anything about how good the program is. Call that hospital president(

Patty Maysent, MPH, MBA

 

Interim CEO and Chief Strategy Officer

) 

Main telephone number: 858-657-7000

  and demand to know what the RESULTS are; 30 day deaths, 100% recovery, tPA efficacy?
There is absolutely nothing in here that tells me that the RESULTS are better in this hospital than other hospitals. I don't give a crap about how well you do processes.
Big f*cking whoopee.
Guidelines here: You can see how this is nothing to be impressed about. This is all indirect action, not results.
http://www.heart.org/HEARTORG/HealthcareResearch/GetWithTheGuidelinesHFStrokeResus/GetWithTheGuidelinesStrokeHomePage/Get-With-The-Guidelines-Stroke-Overview_UCM_308021_Article.jsp

    
The puffery article here: 
http://www.news-medical.net/news/20151211/UC-San-Diegos-Comprehensive-Stroke-Center-receives-Gold-Plus-Award.aspx 

When someone experiences a major stroke, almost two million nerve cells in the brain die each minute, emphasizing the need for rapid treatment. Stroke patients who receive life-saving interventions more quickly have a higher chance of recovery. A recent data analysis showed the Comprehensive Stroke Center at UC San Diego Medical Center exceeded national average treatment times, and as a result, has received a "Get With The Guidelines-Stroke Gold Plus Quality Achievement Award" from The American Heart Association and American Stroke Association (AHA/ASA).
UC San Diego Health is part of a group of hospitals recognized for their commitment and success in implementing a higher standard of stroke care by ensuring that patients receive the most appropriate treatment according to nationally recognized, research-based guidelines and recommendations.
"Our success as a Comprehensive Stroke Center is a team product, including neurologists, radiologists and pharmacists all working together with one goal: to provide the fastest and most effective treatments using the highest level of imaging and diagnostic tools,(Why not best results?)" said Thomas Hemmen, MD, PhD, professor in the Department of Neurosciences at UC San Diego School of Medicine and clinical services chief of neurology at UC San Diego Health. "Receiving this award validates our ongoing efforts to turn guidelines into lifelines."
To receive a Gold Plus Award, a hospital must achieve 85 percent or higher compliance to core standard levels of care as outlined by the AHA/ASA for two or more 12-month consecutive periods and achieve 75 percent or higher compliance with five of eight "Get With The Guidelines-Stroke Quality Measures."
According to the AHA/ASA, on average, someone suffers from a stroke every 40 seconds. The neurological event is the fifth-leading cause of death in the United States.

"We are pleased to recognize UC San Diego Health for its commitment to stroke care," said Deepak L. Bhatt, MD, MPH, national chairman of the Get With The Guidelines steering committee, executive director of interventional cardiovascular programs at Brigham and Women's Hospital and professor of medicine at Harvard Medical School. "Studies have shown that hospitals that consistently follow Get With The Guidelines quality improvement measures can reduce length of stay and 30-day readmission rates and reduce disparities in care."
UC San Diego Medical Center was the first to receive Comprehensive Stroke Center certification in San Diego County in 2012 and has pioneered endovascular approaches using state-of-the-art devices for procedures, such as embolectomies - the surgical removal of blood clots.
"This honor not only reflects the life-saving technologies used when every minute counts, but it also recognizes the high quality of elective care our center provides to patients diagnosed with conditions such as brain bleeds and aneurysms or who have suffered from a previous stroke," said Alexander Khalessi, MD, vice chairman of clinical affairs for neurosurgery and director of endovascular neurosurgery at UC San Diego Health.
The center also brings instant expertise to other organizations and saves lives beyond San Diego County with the stroke telemedicine program, which transports stroke specialists virtually via computer desktop or laptop to the patient's bedside using highly sophisticated video, audio and Internet technologies.
"Time is brain during a stroke, so it is paramount we continue to use innovative approaches that lead the way in stroke care," said Khalessi, who also played a critical role in working with the AHA/ASA to write new guidelines on early management of acute ischemic stroke.

Source:

University of California, San Diego Health Sciences

Fit Body, Fit Brain and Other Fitness Trends

Your doctor should be providing you with protocols and reasons for exercising both your body and your brain. If not you have an incompetent doctor.
http://well.blogs.nytimes.com/2015/12/23/fit-body-fit-brain-and-other-fitness-trends/
I really liked the article at the bottom;
The Close Ties Between Exercise and Beer

Using a brain-machine interface to control a hybrid upper limb exoskeleton during rehabilitation of patients with neurological conditions

Maybe your grandchildren will be able to use this. With NO stroke strategy or stroke leadership this will take at least 50 years to get to clinical use. Unless you are rich and can pay for your own research.
http://jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-015-0082-9

• Enrique Hortal†Email author,
• Daniel Planelles†,
• Francisco Resquin,
• José M. Climent,
• José M. Azorín and
• José L. Pons

†Contributed equally

Journal of NeuroEngineering and Rehabilitation201512:92

DOI: 10.1186/s12984-015-0082-9

©  Hortal et al. 2015

Received: 31 March 2015

Accepted: 8 October 2015

Published: 17 October 2015

Abstract

Background

As a consequence of the increase of cerebro-vascular accidents, the number of people suffering from motor disabilities is raising. Exoskeletons, Functional Electrical Stimulation (FES) devices and Brain-Machine Interfaces (BMIs) could be combined for rehabilitation purposes in order to improve therapy outcomes.

Methods

In this work, a system based on a hybrid upper limb exoskeleton is used for neurological rehabilitation. Reaching movements are supported by the passive exoskeleton ArmeoSpring and FES. The movement execution is triggered by an EEG-based BMI. The BMI uses two different methods to interact with the exoskeleton from the user’s brain activity. The first method relies on motor imagery tasks classification, whilst the second one is based on movement intention detection.

Results

Three healthy users and five patients with neurological conditions participated in the experiments to verify the usability of the system. Using the BMI based on motor imagery, healthy volunteers obtained an average accuracy of 82.9 ± 14.5 %, and patients obtained an accuracy of 65.3 ± 9.0 %, with a low False Positives rate (FP) (19.2 ± 10.4 % and 15.0 ± 8.4 %, respectively). On the other hand, by using the BMI based on detecting the arm movement intention, the average accuracy was 76.7 ± 13.2 % for healthy users and 71.6 ± 15.8 % for patients, with 28.7 ± 19.9 % and 21.2 ± 13.3 % of FP rate (healthy users and patients, respectively).

Conclusions

The accuracy of the results shows that the combined use of a hybrid upper limb exoskeleton and a BMI could be used for rehabilitation therapies. The advantage of this system is that the user is an active part of the rehabilitation procedure. The next step will be to verify what are the clinical benefits for the patients using this new rehabilitation procedure.

Keywords

BMI EEG Rehabilitation Neurological condition Exoskeleton Functional electrical stimulation Motor imagery Arm movement intention detection

Background

Currently, the number of people suffering from motor disabilities or reduced mobility is increasing. Cerebro-Vascular Accidents (CVAs), i.e. strokes, are ones of the main causes of these problems. The number of people with probability of suffering a CVA is growing worldwide mainly due to the aging population [1]. This value is expected to reach in 2030 an increase of 24.9 % compared to 2010 levels [2]. According to the Spanish Society of Neurology, the number of stroke patients at Spanish hospitals has increased by 40 % over the last 15 years [3]. As reported by the World Health Organization (WHO), 15 million people suffer stroke worldwide each year, and around 5 million of them are permanently disabled [4]. All these facts evidence the necessity of improving not only prevention mechanisms but also rehabilitation procedures for people with these conditions.

Due to certain shortcomings of conventional therapy, rehabilitation systems applied after a CVA have experimented an important improvement in recent years. After conventional therapies, motor impairments as paralysis persist in a large percentage of stroke population. Recovery of motor skills is commonly very low after stroke [5] and, compared to lower limb, improvements of upper limb motor function are even lower [6]. By these facts, novel rehabilitation approach, as robot-aided rehabilitation and functional electrical stimulation (FES) were introduced, with the aim to improve effectiveness of therapy.

Several publications have showed improvements in upper limb motor function after rehabilitation therapies based on robotic devices [7, 8] and FES [9, 10]. Furthermore, the combined use of both technologies has shown promising results in terms of motor recovery after stroke [11, 12]. The main advantage of using the hybrid approach is that, individual limitations are overcome, generating in this way a more robust concept [13]. Robotic devices generally apply external mechanical forces to drive joint movements, while FES-based therapy facilitates exercise execution leaded by the participant’s own muscles. This last approach yields several benefits considering motor recovery, such as muscle strength [14] and cortical excitability [15]. Further, even when stroke participant does not contribute to voluntary movement these advantages are still present. However, the use of FES elicits the fast occurrence of muscle fatigue due to non-physiological recruitment (unnatural) of the motor units. Muscle fatigue decreases the efficacy of therapy and also entails other drawbacks, that is why, effort are always targeted to prolong the appearance of its effects. Moreover, the nonlinear and time variant behavior of the muscles during FES generate a less accurate motor control response. This problem can be addressed by using an exoskeleton, in order to cooperatively aid the movements. The inclusion of robotic device avoids stimulate arm’s muscles to overcome gravity effects, and hence, release the system from patients discomfort generated when arm muscles are constantly stimulated for this purpose. So, the main idea begins the hybrid approach based on reaching movement rehabilitation is that the exoskeleton compensate again gravity and FES assists the patient for movements execution.

Besides physical rehabilitation [16], an important question arises from the neurological level due to the neuroplasticity [17]. In this regard, multiple works focused on this kind of rehabilitation are being developed [18–20]. Brain-Machine Interfaces (BMIs) are conceived as a powerful tool for rehabilitation of CVA patients. By using these interfaces, patients are an active part of the process because the control commands are generated directly from their brain activity. Thus, not only would the rehabilitation improve from the physical point of view, but also from the neurological perspective [21]. With this system, patients are actively involved in their rehabilitation process.

To achieve a greater involvement of the patients, the use of a BMI can represent an important improvement. Several studies based on BMIs have demonstrated that people with disabilities are able to control properly systems such as a wheelchair [22], robots [23] or other devices such as a PC mouse [24] or a web browser [25]. The main objective in these works was to provide a new way to interact with the environment and facilitate daily life activities. However, these systems were not designed to restore the affected capacities of the users. Other works used brain signals to command systems that provide aid in physical and neurological rehabilitation as in [26].

Thanks to neuroscience, it is well known that many brain cognitive processes are located around the cortex. When BMIs are used in motor rehabilitation, parietal and frontal lobes are more interesting than others because they take part in intention, planning and decision of making a movement [27]. Therefore, signals acquired from these lobes can provide more information about the will to imagine or perform a movement. By using their brain signals, patients in rehabilitation could command a device to provide them some voluntary mobility. It is demonstrated that a FES therapy triggered by Electromyography (EMG) has advantages as it integrates the concept of sensorimotor feedback [9]. Using electroencephalography (EEG), follows the same approach, FES simulates normal operation of neural connections, taking the cortical level signals instead of peripheral signals (EMG) to trigger the execution of the task.

In this paper, a BMI allows, through two different methods, the control of a hybrid upper limb exoskeleton. Both methods are based in the analysis of EEG signals. EEG techniques are a non-invasive method which provides a higher patient acceptance, eliminates the health risks of operations and reduces impediments related to ethical issues. The exoskeleton is used to assist the upper limb rehabilitation process by performing extension and flexion elbow movements of the arm applying FES. The methods used in the BMI are based on motor imagery and movement intention detection through the Event-Related Desynchronization (ERD) and Event-Related Synchronization (ERS) detection. The accuracy of both methods are analyzed to demonstrate their usability and to determine which of them is better to be used in the rehabilitation therapy.

More at link