Caloric vestibular stimulation in aphasic syndrome

Caloric vestibular stimulation (CVS) is commonly used to diagnose brainstem disorder but its therapeutic application is much less established. Based on the finding that CVS increases blood flow to brain structures associated with language and communication, we assessed whether the procedure has potential to relieve symptoms of post-stroke aphasia. Three participants, each presenting with chronic, unilateral lesions to the left hemisphere, were administered daily CVS for 4 consecutive weeks. Relative to their pre-treatment baseline scores, two of the three participants showed significant improvement on both picture and responsive naming at immediate and one-week follow-up. One of these participants also showed improved sentence repetition, and another showed improved auditory word discrimination. No adverse reactions were reported. These data provide the first, albeit tentative, evidence that CVS may relieve expressive and receptive symptoms of aphasia. A larger, sham-controlled study is now needed to further assess efficacy

Low Cost Inertial Sensors for the Motion Track-ing and Orientation Estimation of Human Upper Limbs in Neurological Rehabilitation

This paper presents the feasibility of utilizing low cost inertial sensors such as those found in Sony Move, Nintendo Wii (Wii Remote with Wii MotionPlus) and smartphones for upper limb motion mon-itoring in neurorehabilitation. Kalman and complementary filters based on data fusion are used to estimate sensor 3D orientation. Furthermore, a two-segment kinematic model was developed to estimate limb segment position tracking. Performance has been compared with a high-accuracy measurement system using the Xsens MTx. The experimental results show that Sony Move, Wii and smartphones can be used for measuring upper limb orientation, while Sony Move and smartphones can also be used for specific applications of upper limb segment joint orientation and position tracking during neurorehabilitation. Sony Move’s accuracy is within 1.5° for Roll and Pitch and 2.5° for Yaw and position tracking to within 0.5 cm over a 10 cm movement. This accuracy in measurement is thought to be adequate for upper limb orientation and position tracking. Low cost inertial sensors can be used for the accurate assessment/measurement of upper limb movement of patients with neurological disorders and also makes it a low cost replacement for upper limb motion measurements. The low cost inertial sensing systems were shown to be able to accurately measure upper limb joint orienta-tion and position during neurorehabilitation

Inertial Sensor based Quantitative Assessment of Upper Limb Range of Motion and Functionality before and after Botulinum Toxin: A Pilot Study

Botulinum toxin (BTX) treatment of upper limb is considered effective for upper limb spasticity following stroke and brain injury. Traditional method - Modified Ashworth Scale (MAS) is widely used for assessment of spasticity, however, it suffers from limitations including the lack of objective outcome measures and ignorance of the active movements. This pilot study is to develop a quantitative assessment utilizing inertial sensors tool for upper limb movement measurement and to investigate an objective measure of upper limb function for neurological patients before and after BTX treatment of spasticity. The system we proposed provides kinematic measurements of upper limb segment and joint motion data. In this study, four stroke patients were assessed by our proposed inertial sensing system immediately before and one week after BTX injection. In addition, patients were assessed using clinical assessment scales e.g. MAS, Disability Assessment Scale (DAS) and Motor Assessment Scale. The results showed that elbow Active Range of Motion (AROM) increased by 19 degrees on average and MAS and Motor Assessment Scale scores did not show significant change. The changes of the kinematic measures for patients 1-3 e.g. AROM, Rate of change of elbow joint angle, NJS, MUN and S-ratio all show that the inertial system is able to identify improvement in performance. This inertial sensing system provides additional and novel dynamic motion data for a sensitive and quantitative assessment of response to treatment and the efficacy of post-injection physiotherapy

Neuropsychiatric Outcomes in UK Military Veterans with Mild Traumatic Brain Injury and Vestibular Dysfunction

Objective: To estimate the frequency of vestibular dysfunction following blunt, blast, and blunt & blast mild traumatic brain injury (mTBI) and thereon assess the long-term impact of vestibular dysfunction on neurobehavioral function and disability independently of co-morbid psychiatric symptoms. Setting: Combat Stress residential and Veterans’ Outreach drop-in centres for psychological support. Participants: 162 help-seeking UK military veterans. Main measures: Self-reported frequency and severity of mTBI (using the Ohio State Identification Method), Vertigo Symptom Scale, PTSD checklist for DSM5, Kessler Psychological Distress Scale, Neurobehavioral Symptom Inventory, HIT6, Memory Complaints Inventory, WHO Disability Assessment Scale 2.0. Results: 72% of the sample reported one or more mTBI over their lifetime. Chi-square analyses indicated that vestibular disturbance, which affected 69% of participants, was equally prevalent following blunt (59%) or blast (47%) injury and most prevalent following blunt and blast combined (83%). Mediation analysis indicated that when PTSD, depression and anxiety were taken into account, vestibular dysfunction in participants with mTBI was directly and independently associated with increased postconcussive symptoms and functional disability. Conclusion: Vestibular dysfunction is common after combined blunt and blast mTBI and singularly predictive of poor long-term mental health. From a treatment perspective, vestibular rehabilitation may provide relief from postconcussive symptoms other than dizziness and imbalance

A durable gain in motor and non-motor symptoms of Parkinson’s Disease following repeated caloric vestibular stimulation: A single-case study

Objective: To gain ‘first-in-man’ evidence that repeated caloric vestibular stimulation (CVS), a non-invasive form of neuro-modulation, can induce a lasting and clinically-relevant reduction in Parkinson’s Disease (PD) symptoms. Methods: A 70yr old male, diagnosed with PD 7 years prior to study enrolment, self-administered CVS at home 2x20 minutes per day for three months using a solid-state portable device. Standardised neuropsychological assessments of motor, cognitive, affective and independent function were carried out prior to stimulation, at the start and end of the sham (month 1) and active (months 2-3) phases, and 5 months post-stimulation. Results: Relative to the pre-stimulation baseline, behavioural improvements that exceeded the minimal detectable change were observed on the EQ5D, Unified Parkinson’s Disease Rating Scale, Schwab and England scale, 2 minute walk, Timed up and go, Non-motor symptom assessment scale for PD, Montreal cognitive assessment, Hospital depression scale and Epworth sleepiness scale. The level of change exceeded the threshold for a minimal clinically important difference on all scales for which a threshold has been published. By contrast, little improvement was seen during the sham (i.e. placebo) phase. Conclusion: Caloric vestibular stimulation may offer a novel, home-based method of relieving everyday symptoms of PD, and merits further evaluative study

Behavioural Improvement in Minimally Conscious State After Caloric Vestibular Stimulation: Evidence from two single case studies.

Objective: To investigate whether caloric vestibular stimulation, a non-invasive form of neuro-modulation, alters level of awareness in people residing in minimally conscious state. Design: Single-case (n=2), prospective, controlled (ABAB) efficacy study. Setting: Tertiary, neuro-rehabilitation in-patient ward within a university hospital Participants: Two individuals in minimally conscious state Intervention: Left ear caloric vestibular stimulation was performed in two four/five-week blocks interleaved with two four/five-week blocks of sham stimulation. Session duration and frequency gradually increased within each block from once per day for 10 minutes (week 1) to once per day for 20 minutes (week 2) to 20 minutes twice per day in the remaining weeks. Measures: Wessex Head Injury Matrix, JFK Coma Recovery Scale – Revised. Results: Both participants’ Wessex Head Injury Matrix scores indicated a transition from involuntary (i.e. mechanical vocalization) to voluntary (i.e. gesture making, selective responses to family members) behaviour that was time-locked to the onset of active stimulation. In one participant, this improvement persisted for at least 4 weeks after active stimulation while in the other it diminished 2 weeks after stimulation. Allied, although less dramatic, changes were seen on the arousal and auditory subscales of the JFK Coma Recovery Scale – Revised. Conclusion: The data provide the first evidence that vestibular stimulation may help improve outcome in low awareness state although further studies are needed to replicate effect and determine longer-term benefit

Quantitative Assessment of Upper Limb Motion in Neurorehabilitation Utilizing Inertial Sensors

Two inertial sensor systems were developed for 3-D tracking of upper limb movement. One utilizes four sensors and a kinematic model to track the positions of all four upper limb segments/joints and the other uses one sensor and a dead reckoning algorithm to track a single upper limb segment/joint. Initial evaluation indicates that the system using the kinematic model is able to track orientation to 1 degree and position to within 0.1 cm over a distance of 10 cm. The dead reckoning system combined with the “zero velocity update” correction can reduce errors introduced through double integration of errors in the estimate in offsets of the acceleration from several meters to 0.8% of the total movement distance. Preliminary evaluation of the systems has been carried out on ten healthy volunteers and the kinematic system has also been evaluated on one patient undergoing neurorehabilitation over a period of ten weeks. The initial evaluation of the two systems also shows that they can monitor dynamic information of joint rotation and position and assess rehabilitation process in an objective way, providing additional clinical insight into the rehabilitation process

Co‐creating system‐wide improvement for people with traumatic brain injury across one integrated care system in the United Kingdom to initiate a transformation journey through co‐production

Background and Objective: There is a need for better integration of services across communities and sectors for people living with traumatic brain injury (TBI) to meet their complex needs. Building on insights gained from earlier pilot work, here we report the outcomes of a participatory workshop that sought to better understand the challenges, barriers and opportunities that currently exist within the care pathway for survivors of TBI. Methods: A diverse range of stakeholders from the acute and rehabilitation care pathway and the health and social care system were invited to participate in a 3‐h workshop. The participants worked in four mixed subgroups using practice development methodology, which promotes person‐centred, inclusive and participatory action. Results: Thematic analysis identified shared purposes and values that were used to produce a detailed implementation and impact framework for application at both the level of the care interface and the overarching integrated care system. A variety of enablers were identified that related to collective values and behaviours, case management, team leadership and integrated team working, workforce capability, evidence‐based practice and resourcing. The clinical, economic, cultural and social outcomes associated with these enablers were also identified, and included patient safety, independence and well‐being, reduced waiting times, re‐admission rates, staff retention and professional development. Conclusion: The co‐produced recommendations made within the implementation and impact framework described here provide a means by which the culture and delivery of health and social care services can be better tailored to meet the needs of people living with TBI. We believe that the recommendations will help shape the formation of new services as well as the development of existing ones. Patient or Public Contribution: Patient and public involvement have been established over a 10‐year history of relationship building through a joint forum and events involving three charities representing people with TBI, carers, family members, clinicians, service users, researchers and commissioners, culminating in a politically supported event that identified concerns about the needs of people following TBI. These relationships formed the foundation for the interactive workshop, the focus of this publication

Feasibility and safety of a powered exoskeleton for balance training for people living with multiple sclerosis: A single-group preliminary study (Rapper III)

Objective: To evaluate the feasibility, usability, safety, and potential health benefits of using an exoskeleton device for rehabilitation of people living with multiple sclerosis.Design:Single-group preliminary study.Subjects: Eleven adults living with multiple sclerosis, with Expanded Disability Status Scores that ranged from 6 to 7.5 (mean age (standard deviation; SD) 54.2 (11.8) years), were recruited. Methods: Individual participants undertook a balance rehabilitation exercise programme using the Rex Rehab robotic exoskeleton device. Each participant undertook 4 × 45–60 min supervised, balance exercise sessions. Primary outcomes were: (i) the number of participants who completed the trial protocol safely, and (ii) the number and nature of adverse events reported. Secondary outcomes were: mobility; balance; spasticity; sleep; functional independence; quality of life; and device satisfaction. Results: Ten out of 11 participants completed the trial protocol safely. Four adverse events were recorded (1 serious), all of which were deemed unrelated to the trial. Secondary outcomes showed allied improvements in balance, joint mobility, spasticity and quality of life. All participants found the device acceptable to use. Conclusion: These results suggest that it is feasible and safe to use the Rex Rehab exoskeleton device to assist with balance rehabilitation for people living with multiple sclerosis. Conclusion: These results suggest that it is feasible and safe to use the Rex Rehab exoskeleton device to assist with balance rehabilitation for people living with multiple sclerosis