by Keyword: Rehabilitation

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Wiers, Reinout W., Verschure, Paul, (2021). Curing the broken brain model of addiction: Neurorehabilitation from a systems perspective Addictive Behaviors 112, 106602

The dominant biomedical perspective on addictions has been that they are chronic brain diseases. While we acknowledge that the brains of people with addictions differ from those without, we argue that the “broken brain” model of addiction has important limitations. We propose that a systems-level perspective more effectively captures the integrated architecture of the embodied and situated human mind and brain in relation to the development of addictions. This more dynamic conceptualization places addiction in the broader context of the addicted brain that drives behavior, where the addicted brain is the substrate of the addicted mind, that in turn is situated in a physical and socio-cultural environment. From this perspective, neurorehabilitation should shift from a “broken-brain” to a systems theoretical framework, which includes high-level concepts related to the physical and social environment, motivation, self-image, and the meaning of alternative activities, which in turn will dynamically influence subsequent brain adaptations. We call this integrated approach system-oriented neurorehabilitation. We illustrate our proposal by showing the link between addiction and the architecture of the embodied brain, including a systems-level perspective on classical conditioning, which has been successfully translated into neurorehabilitation. Central to this example is the notion that the human brain makes predictions on future states as well as expected (or counterfactual) errors, in the context of its goals. We advocate system-oriented neurorehabilitation of addiction where the patients' goals are central in targeted, personalized assessment and intervention.

Keywords: Addiction, Brain disease model, Neurorehabilitation, Systems approach

Grechuta, K., Rubio Ballester, B., Espín Munne, R., Usabiaga Bernal, T., Molina Hervás, B., Mohr, B., Pulvermüller, F., San Segundo, R., Verschure, P., (2019). Augmented dyadic therapy boosts recovery of language function in patients with nonfluent aphasia Stroke 50, (5), 1270-1274

Background and Purpose- Evidence suggests that therapy can be effective in recovering from aphasia, provided that it consists of socially embedded, intensive training of behaviorally relevant tasks. However, the resources of healthcare systems are often too limited to provide such treatment at sufficient dosage. Hence, there is a need for evidence-based, cost-effective rehabilitation methods. Here, we asked whether virtual reality-based treatment grounded in the principles of use-dependent learning, behavioral relevance, and intensity positively impacts recovery from nonfluent aphasia. Methods- Seventeen patients with chronic nonfluent aphasia underwent intensive therapy in a randomized, controlled, parallel-group trial. Participants were assigned to the control group (N=8) receiving standard treatment or to the experimental group (N=9) receiving augmented embodied therapy with the Rehabilitation Gaming System for aphasia. All Rehabilitation Gaming System for aphasia sessions were supervised by an assistant who monitored the patients but did not offer any elements of standard therapy. Both interventions were matched for intensity and materials. Results- Our results revealed that at the end of the treatment both groups significantly improved on the primary outcome measure (Boston Diagnostic Aphasia Examination: control group, P=0.04; experimental group, P=0.01), and the secondary outcome measure (lexical access-vocabulary test: control group, P=0.01; experimental group, P=0.007). However, only the Rehabilitation Gaming System for aphasia group improved on the Communicative Aphasia Log ( P=0.01). The follow-up assessment (week 16) demonstrated that while both groups retained vocabulary-related changes (control group, P=0.01; experimental group, P=0.007), only the Rehabilitation Gaming System for aphasia group showed therapy-induced improvements in language ( P=0.01) and communication ( P=0.05). Conclusions- Our results demonstrate the effectiveness of Rehabilitation Gaming System for aphasia for improving language and communication in patients with chronic aphasia suggesting that current challenges faced by the healthcare system in the treatment of stroke might be effectively addressed by augmenting traditional therapy with computer-based methods. Clinical Trial Registration- URL: . Unique identifier: NCT02928822.

Keywords: Aphasia, Embodied training, Neurological rehabilitation, Virtual reality

Maier, Martina, Rubio Ballester, Belén, Duff, Armin, Duarte Oller, Esther, Verschure, P., (2019). Effect of specific over nonspecific VR-based rehabilitation on poststroke motor recovery: A systematic meta-analysis Neurorehabilitation and Neural Repair 33, (2), 112-129

Background. Despite the rise of virtual reality (VR)-based interventions in stroke rehabilitation over the past decade, no consensus has been reached on its efficacy. This ostensibly puzzling outcome might not be that surprising given that VR is intrinsically neutral to its use—that is, an intervention is effective because of its ability to mobilize recovery mechanisms, not its technology. As VR systems specifically built for rehabilitation might capitalize better on the advantages of technology to implement neuroscientifically grounded protocols, they might be more effective than those designed for recreational gaming. Objective. We evaluate the efficacy of specific VR (SVR) and nonspecific VR (NSVR) systems for rehabilitating upper-limb function and activity after stroke. Methods. We conducted a systematic search for randomized controlled trials with adult stroke patients to analyze the effect of SVR or NSVR systems versus conventional therapy (CT). Results. We identified 30 studies including 1473 patients. SVR showed a significant impact on body function (standardized mean difference [SMD] = 0.23; 95% CI = 0.10 to 0.36; P = .0007) versus CT, whereas NSVR did not (SMD = 0.16; 95% CI = −0.14 to 0.47; P = .30). This result was replicated in activity measures. Conclusions. Our results suggest that SVR systems are more beneficial than CT for upper-limb recovery, whereas NSVR systems are not. Additionally, we identified 6 principles of neurorehabilitation that are shared across SVR systems and are possibly responsible for their positive effect. These findings may disambiguate the contradictory results found in the current literature.

Keywords: Stroke, Paresis, Virtual reality, Rehabilitation, Occupational therapy, Review

Maier, Martina, Ballester, Belén Rubio, Verschure, P., (2019). Principles of neurorehabilitation after stroke based on motor learning and brain plasticity mechanisms Frontiers in Systems Neuroscience 13, 74

What are the principles underlying effective neurorehabilitation? The aim of neurorehabilitation is to exploit interventions based on human and animal studies about learning and adaptation, as well as to show that the activation of experience-dependent neuronal plasticity augments functional recovery after stroke. Instead of teaching compensatory strategies that do not reduce impairment but allow the patient to return home as soon as possible, functional recovery might be more sustainable as it ensures a long-term reduction in impairment and an improvement in quality of life. At the same time, neurorehabilitation permits the scientific community to collect valuable data, which allows inferring about the principles of brain organization. Hence neuroscience sheds light on the mechanisms of learning new functions or relearning lost ones. However, current rehabilitation methods lack the exact operationalization of evidence gained from skill learning literature, leading to an urgent need to bridge motor learning theory and present clinical work in order to identify a set of ingredients and practical applications that could guide future interventions. This work aims to unify the neuroscientific literature relevant to the recovery process and rehabilitation practice in order to provide a synthesis of the principles that constitute an effective neurorehabilitation approach. Previous attempts to achieve this goal either focused on a subset of principles or did not link clinical application to the principles of motor learning and recovery. We identified 15 principles of motor learning based on existing literature: massed practice, spaced practice, dosage, task-specific practice, goal-oriented practice, variable practice, increasing difficulty, multisensory stimulation, rhythmic cueing, explicit feedback/knowledge of results, implicit feedback/knowledge of performance, modulate effector selection, action observation/embodied practice, motor imagery, and social interaction. We comment on trials that successfully implemented these principles and report evidence from experiments with healthy individuals as well as clinical work.

Keywords: Neurorehabilitation, Motor learning, Plasticity, Stroke, Principles

Ballester, B. R., Maier, M., Duff, A., Cameirão, M., Bermúdez, S., Duarte, E., Cuxart, A., Rodríguez, S., San Segundo Mozo, R. M., Verschure, P., (2019). A critical time window for recovery extends beyond one-year post-stroke Journal of neurophysiology Journal of Neurophysiology , 122, (1), 350-357

The impact of rehabilitation on post-stroke motor recovery and its dependency on the patient's chronicity remain unclear. The field has widely accepted the notion of a proportional recovery rule with a "critical window for recovery" within the first 3-6 mo poststroke. This hypothesis justifies the general cessation of physical therapy at chronic stages. However, the limits of this critical window have, so far, been poorly defined. In this analysis, we address this question, and we further explore the temporal structure of motor recovery using individual patient data from a homogeneous sample of 219 individuals with mild to moderate upper-limb hemiparesis. We observed that improvement in body function and structure was possible even at late chronic stages. A bootstrapping analysis revealed a gradient of enhanced sensitivity to treatment that extended beyond 12 mo poststroke. Clinical guidelines for rehabilitation should be revised in the context of this temporal structure. NEW & NOTEWORTHY Previous studies in humans suggest that there is a 3- to 6-mo "critical window" of heightened neuroplasticity poststroke. We analyze the temporal structure of recovery in patients with hemiparesis and uncover a precise gradient of enhanced sensitivity to treatment that expands far beyond the limits of the so-called critical window. These findings highlight the need for providing therapy to patients at the chronic and late chronic stages.

Keywords: Motor recovery, Neuroplasticity, Neurorehabilitation, Stroke recovery, Virtual reality

Rubio Ballester, B., Mura, A., Maier, M., Tobella-Pareja, Laura, Alfayate-Domingo, D., Gimeno-Esteve, M. F., Aguilar, A., Verschure, P., (2019). Adaptive VR-based rehabilitation to prevent deterioration in adults with cerebral palsy Application of VR and Advanced Technology in Pediatric Populations International Conference on Virtual Rehabilitation 2019 (ICVR 2019) , ISVR (Tel Aviv, Israel) , 1-7

Cerebral palsy (CP) is a disabling life-long condition progressively impeding a patient’s independence. Although incident rates are high, a clear understanding of the disease is missing. CP is characterized by several motor disorders and sensory or perceptive comorbidities. This multifaceted nature complicates proper diagnosis and hampers the search for possible treatments. During adolescence and adulthood, individuals with CP experience a drastic deterioration in gross motor control, independence, and quality of life. There is poor evidence that physical therapy promotes the retention of function through aging, and no clinical studies exist that explore the potential of VRbased training to prevent deterioration. In this pilot randomized controlled trial, we expose 14 adults with CP to the Rehabilitation Gaming System (RGS) and examine its usability, effectiveness, and acceptability. Our results show that the RGS difficulty adaptation algorithm automatically matches the patients' impairment level as captured by clinical scales (Barthel and Box & Blocks). The clinical effectiveness and acceptability of the RGS and conventional therapy were comparable. We conclude that VR-based physical therapy as an adjunct to usual treatment may be a promising approach for the prevention of deterioration in adolescents and adults with CP.

Keywords: Cerebral palsy, Virtual realitY, Motor function, Physical therapy, Rehabilitation

Morales, R., Badesa, F. J., Garcia-Aracil, N., Aranda, J., Casals, A., (2015). Autoadaptive neurorehabilitation robotic system assessment with a post-stroke patient Revista Iberoamericana de Automatica e Informatica Industrial , 12, (1), 92-98

This paper presents a new rehabilitation system that is able to adapt its performance to patient's psychophysiological state during the execution of robotic rehabilitation tasks. Using this approach, the motivation and participation of the patient during rehabilitation activity can be maximized. In this paper, the results of the study with healthy subjects presented in (Badesa et al., 2014b) have been extended for using them with patients who have suffered a stroke. In the first part of the article, the different components of the adaptive system are exposed, as well as a comparison of different machine learning techniques to classify the patient's psychophysiological state between three possible states: stressed, average excitation level and relaxed are presented. Finally, the results of the auto-adaptive system which modifies the behavior of the rehabilitation robot and virtual task in function of measured physiological signals are shown for a patient in the chronic phase of stroke.

Keywords: Physiological state multimodal interfaces rehabilitation robotics control

Rajasekaran, V., Aranda, J., Casals, A., (2015). Compliant gait assistance triggered by user intention Engineering in Medicine and Biology Society (EMBC) 37th Annual International Conference of the IEEE , IEEE (Milan, Italy) , 3885-3888

An automatic gait initialization strategy based on user intention sensing in the context of rehabilitation with a lower-limb wearable robot is proposed and evaluated. The proposed strategy involves monitoring the human-orthosis interaction torques and initial position deviation to determine the gait initiation instant and to modify orthosis operation for gait assistance, when needed. During gait, the compliant control algorithm relies on the adaptation of the joints' stiffness in function of their interaction torques and their deviation from the desired trajectories, while maintaining the dynamic stability. As a reference input, the average of a set of recorded gaits obtained from healthy subjects is used. The algorithm has been tested with five healthy subjects showing its efficient behavior in initiating the gait and maintaining the equilibrium while walking in presence of external forces. The work is performed as a preliminary study to assist patients suffering from incomplete Spinal cord injury and Stroke.

Keywords: Biomedical monitoring, Exoskeletons, Joints, Knee, Legged locomotion, Trajectory, Exoskeleton, adaptive control, gait assistance, gait initiation, rehabilitation, wearable robot

Urra, O., Casals, A., Jané, R., (2014). Evaluating spatial characteristics of upper-limb movements from EMG signals IFMBE Proceedings XIII Mediterranean Conference on Medical and Biological Engineering and Computing 2013 (ed. Roa Romero, Laura M.), Springer International Publishing (London, UK) 41, 1795-1798

Stroke is a major cause of disability, usually causing hemiplegic damage on the motor abilities of the patient. Stroke rehabilitation seeks restoring normal motion on the affected limb. However, normality’ of movements is usually assessed by clinical and functional tests, without considering how the motor system responds to therapy. We hypothesized that electromyographic (EMG) recordings could provide useful information for evaluating the outcome of rehabilitation from a neuromuscular perspective. Four healthy subjects were asked to perform 14 different functional movements simulating the action of reaching over a table. Each movement was defined according to the starting and target positions that the subject had to connect using linear trajectories. Bipolar recordings of EMG signals were taken from biceps and triceps muscles, and spectral and temporal characteristics were extracted for each movement. Using pattern recognition techniques we found that only two EMG channels were sufficient to accurately determine the spatial characteristics of motor activity: movement direction, length and execution zone. Our results suggest that muscles may fire in a patterned way depending on the specific characteristics of the movement and that EMG signals may codify such detailed information. These findings may be of great value to quantitatively assess post-stroke rehabilitation and to compare the neuromuscular activity of the affected and unaffected limbs, from a physiological perspective. Furthermore, disturbed movements could be characterized in terms of the muscle function to identify, which is the spatial characteristic that fails, e.g. movement direction, and guide personalized rehabilitation to enhance the training of such characteristic.

Keywords: EMG, Movement spatial characteristics, Pattern recognition, Stroke rehabilitation, Upper-limb

Antelis, J.M., Montesano, L., Giralt, X., Casals, A., Minguez, J., (2012). Detection of movements with attention or distraction to the motor task during robot-assisted passive movements of the upper limb Engineering in Medicine and Biology Society (EMBC) 34th Annual International Conference of the IEEE , IEEE (San Diego, USA) , 6410-6413

Robot-assisted rehabilitation therapies usually focus on physical aspects rather than on cognitive factors. However, cognitive aspects such as attention, motivation, and engagement play a critical role in motor learning and thus influence the long-term success of rehabilitation programs. This paper studies motor-related EEG activity during the execution of robot-assisted passive movements of the upper limb, while participants either: i) focused attention exclusively on the task; or ii) simultaneously performed another task. Six healthy subjects participated in the study and results showed lower desynchronization during passive movements with another task simultaneously being carried out (compared to passive movements with exclusive attention on the task). In addition, it was proved the feasibility to distinguish between the two conditions.

Keywords: Electrodes, Electroencephalography, Induction motors, Medical treatment, Robot sensing systems, Time frequency analysis, Biomechanics, Cognition, Electroencephalography, Medical robotics, Medical signal detection, Medical signal processing, Patient rehabilitation, Attention, Cognitive aspects, Desynchronization, Engagement, Motivation, Motor learning, Motor task, Motor-related EEG activity, Physical aspects, Robot-assisted passive movement detection, Robot-assisted rehabilitation therapies, Upper limb

Amigo, L. E., Fernandez, Q., Giralt, X., Casals, A., Amat, J., (2012). Study of patient-orthosis interaction forces in rehabilitation therapies IEEE Conference Publications 4th IEEE RAS & EMBS International Conference on Biomedical Robotics and Biomechatronics (BioRob) , IEEE (Roma, Italy) , 1098-1103

The design of mechanical joints that kinematically behave as their biological counterparts is a challenge that if not addressed properly can cause inadequate forces transmission between robot and patient. This paper studies the interaction forces in rehabilitation therapies of the elbow joint. To measure the effect of orthosis-patient misalignments, a force sensor with a novel distributed architecture has been designed and used for this study. A test-bed based on an industrial robot acting as a virtual exoskeleton that emulates the action of a therapist has been developed and the interaction forces analyzed.

Keywords: Force, Force measurement, Force sensors, Joints, Medical treatment, Robot sensing systems, Force sensors, Medical robotics, Patient rehabilitation, Biological counterparts, Distributed architecture, Elbow joint, Force sensor, Inadequate forces transmission, Industrial robot, Mechanical joints design, Orthosis-patient misalignments, Patient-orthosis interaction forces, Rehabilitation therapies, Robot, Test-bed, Virtual exoskeleton