Feasibility of integrative games and novel therapeutic game controller for telerehabilitation of individuals chronic post-stroke living in the community.

BACKGROUND: Intensive, adaptable and engaging telerehabilitation is needed to enhance recovery and maximize outcomes. Such services may be provided under early supported discharge, or later for chronic populations. A novel virtual reality game-based telerehabilitation system was designed for individuals post-stroke to enhance their bimanual upper extremity motor function, cognition, and wellbeing. OBJECTIVES: To evaluate the feasibility of novel therapeutic game controller and telerehabilitation system for home use. METHODS: Individuals chronic post-stroke and their caregivers were recruited (n = 8 + 8) for this feasibility study. One was a screen failure and seven completed 4 weeks (20 sessions) of home-based therapy with or without remote monitoring. Standardized clinical outcome measures were taken pre- and post-therapy. Game performance outcomes were sampled at every session, while participant and caregiver subjective evaluations were done weekly. RESULTS: There was a 96% rate of compliance to protocol, resulting in an average of 13,000 total arm repetitions/week/participant. Group analysis showed significant (p <.05) improvements in grasp strength (effect size [ES] = 0.15), depression (Beck Depression Inventory II, ES = 0.75), and cognition (Neuropsychological Assessment Battery for Executive Function, ES = 0.46). Among the 49 outcome variables, 36 variables (73.5%) improved significantly (p = .001, binomial sign test). Technology acceptance was very good with system rating by participants at 3.7/5 and by caregivers at 3.5/5. CONCLUSIONS: These findings indicate the feasibility and efficacy of the system in providing home-based telerehabilitation. The BrightBrainer system needs to be further evaluated in randomized control trials and with individuals early post-stroke.

A Randomized Feasibility Trial of a Novel, Integrative, and Intensive Virtual Rehabilitation Program for Service Members Post-Acquired Brain Injury.

INTRODUCTION: Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the "signature" injury of recent U.S. military conflicts in Iraq and Afghanistan - affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system's clinical effectiveness. MATERIALS AND METHODS: Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards. RESULTS: All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x- = 73-86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x- = -1.07, 95% CI -2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance. CONCLUSION: This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.

Application of Biopharmaceutical and Clinical Metrics in Analyzing Modification of Platelets Aggregation Curves by Calcium Ion.

In context of Evidence Based Medicine concept, Good Clinical Practice rules specify that "data generated should be reliable and robust".Reliability and robustness are further translated in requirements concerning statistical and clinical significance of results. Paper presents main aspectsconnected with comparison of evolutions of endpoints as function of different parameters like time, administered dose, proportion of active components etc., leading to problems of comparison of curves, with direct application to comparison of platelets aggregation curves in presence of different concentrations of ionic calcium. Theoretical part presents comparison of curves in biopharmacyusing f2 metric and area under curve metric, and comparison of survival curves in clinical studies.Platelet aggregation test was performed using Bornturbidimetric light transmission method using Helena PACKS-4 Aggregometer. Blood samples were collected from patients in internal medicine ward of Colentina Clinical Hospital. Platelet rich plasma (PRP) was obtained by centrifugation at 200G. Washed platelets where extracted by centrifugation of PRP at 2700G. The supernatant was replaced with sodium chloride 0.9%. Platelets aggregation was induced by adding different concentrations of calcium gluconate into cuvettes which contained washed platelets. After digitalization, curves were compared using similarity factor f2and areas under curves. Paper puts in evidence that both type of comparison, after mathematical and statistical evaluation, have to define a clinical threshold for clinical significance. In case of f2, in dissolution studies the threshold is 10%, in case of bioequivalence based on area under curves threshold is 20%. Establishment of the threshold for significant clinical difference in comparison of aggregation curves is not only a problem of statistics.Graphical representation of data suggested significant differences between curves obtained with different concentrations of calcium ion. Application of both f2 method and log-rank test let to conclusion that differences were statistical significant. Representation of aria under curves as function of calcium concentration put in evidence an approximate linear dependence. In spite of apparently objective character of mathematical approach, the problem of comparison of aggregation curves remains practically unsolved since we do not know the threshold between clinical significant and non-significant results.

Novel integrative virtual rehabilitation reduces symptomatology of primary progressive aphasia--a case report.

PURPOSE: BrightBrainer™ integrative cognitive rehabilitation system evaluation in an Adult Day Program by a subject with Primary Progressive Aphasia (PPA) assumed to be of the mixed nonfluent/logopenic variant, and for determination of potential benefits. METHODS: The subject was a 51-year-old Caucasian male diagnosed with PPA who had attended an Adult Day Program for 18 months prior to BrightBrainer training. The subject interacted with therapeutic games using a controller that measured 3D hand movements and flexion of both index fingers. The computer simulations adapted difficulty level based on task performance; results were stored on a remote server. The clinical trial consisted of 16 sessions, twice/week for 8 weeks. The subject was evaluated through neuropsychological measures, therapy notes and caregiver feedback forms. RESULTS: Neuropsychological testing indicated no depression (BDI 0) and severe dementia (BIMS 1 and MMSE 3). The 6.5 h of therapy consisted of games targeting Language comprehension; Executive functions; Focusing; Short-term memory; and Immediate/working memory. The subject attained the highest difficulty level in all-but-one game, while averaging 1300-arm task-oriented active movement repetitions and 320 index finger flexion movements per session. While neuropsychological testing showed no benefits, the caregiver reported strong improvements in verbal responses, vocabulary use, speaking in complete sentences, following one-step directions and participating in daily activities. This corroborated well with therapy notes. CONCLUSIONS: Preliminary findings demonstrate a meaningful reduction of PPA symptoms for the subject, suggesting follow-up imaging studies to detail neuronal changes induced by BrightBrainer system and controlled studies with a sufficiently large number of PPA subjects.

Robotics and gaming to improve ankle strength, motor control, and function in children with cerebral palsy--a case study series.

The objective of this study was to investigate the feasibility of game-based robotic training of the ankle in children with cerebral palsy (CP). The design was a case study, 12 weeks intervention, with no follow-up. The setting was a university research laboratory. The participants were a referred sample of three children with cerebral palsy, age 7-12, all male. All completed the intervention. Participants trained on the Rutgers Ankle CP system for 36 rehabilitation sessions (12 weeks, three times/week), playing two custom virtual reality games. The games were played while participants were seated, and trained one ankle at-a-time for strength, motor control, and coordination. The primary study outcome measures were for impairment (DF/PF torques, DF initial contact angle and gait speed), function (GMFM), and quality of life (Peds QL). Secondary outcome measures relate to game performance (game scores as reflective of ankle motor control and endurance). Gait function improved substantially in ankle kinematics, speed and endurance. Overall function (GMFM) indicated improvements that were typical of other ankle strength training programs. Quality of life increased beyond what would be considered a minimal clinical important difference. Game performance improved in both games during the intervention. This feasibility study supports the assumption that game-based robotic training of the ankle benefits gait in children with CP. Game technology is appropriate for the age group and was well accepted by the participants. Additional studies are needed however, to quantify the level of benefit and compare the approach presented here to traditional methods of therapy.

Giant testicular tumor--a case presentation.

BACKGROUND: Testicular cancer is the most common cancer in men 15 to 35 years old. Histological subtypes are seminoma, non-seminoma and mixed tumours (partly seminoma and partly non-seminoma). Seminomas are more sensitive to radiation therapy and are easier to cure than non-seminomas. The surgical treatment is either orchiectomy, either orchiectomy plus lymph node dissection of the involved ganglia. CASE PRESENTATION: We present the case of a 42-year-old man with scrotal pain, important swelling and erythema admitted into our surgical unit. Clinical exam and ultrasound revealed a testicular augmentation of 6/15 cm. Radical orchiectomy was performed and the patient was further referred to the oncology department. CONCLUSIONS: Even though the common causes of scrotal erythema with local swelling and pain are orchiepididimitis and testicular torsion, a careful examination followed by a precise ultrasound can reveal a developing testicular tumor, which was complicated by inflammation. Moreover, a careful anamnesis hints to the development of a tumor as the patient was operated on for cryptorchidism in childhood. Orchiectomy followed by radiotherapy in seminomas, has a cure rate of 70 to 100%.

Integrative rehabilitation of elderly stroke survivors: the design and evaluation of the BrightArm™.

PURPOSE: To describe the development of the BrightArm upper extremity rehabilitation system, and to determine its clinical feasibility with older hemiplegic patients. METHOD: The BrightArm adjusted arm gravity loading through table tilting. Patients wore an arm support that sensed grasp strength and communicated wirelessly with a personal computer. Games were written to improve cognitive, psychosocial and the upper extremity motor function and adapted automatically to each patient. The system underwent feasibility trials spanning 6 weeks. Participants were evaluated pre-therapy, post-therapy, and at 6 weeks follow-up using standardized clinical measures. Computerized measures of supported arm reach and game performance were stored on a remote server. RESULTS: Five participants had clinically significant improvements in their active range of shoulder movement, shoulder strength, grasp strength, and their ability to focus. Several participants demonstrated substantially higher arm function (measured with the Fugl-Meyer test) and two were less-depressed (measured with the Becks Depression Inventory, Second Edition). The BrightArm technology was well-accepted by the participants, who gave it an overall subjective rating of 4.1 on a 5 point Likert scale. CONCLUSIONS: Given these preliminary findings, it will be beneficial to evaluate the BrightArm through controlled clinical trials and to investigate its application to other clinical populations.

Maintained hand function and forearm bone health 14 months after an in-home virtual-reality videogame hand telerehabilitation intervention in an adolescent with hemiplegic cerebral palsy.

Virtual reality videogames can be used to motivate rehabilitation, and telerehabilitation can be used to improve access to rehabilitation. These uses of technology to improve health outcomes are a burgeoning area of rehabilitation research. So far, there is a lack of reports of long-term outcomes of these types of interventions. The authors report a 15-year-old boy with hemiplegic cerebral palsy and epilepsy because of presumed perinatal stroke who improved his plegic hand function and increased his plegic forearm bone health during a 14-month virtual reality videogame hand telerehabilitation intervention. A total of 14 months after the intervention ended, repeat evaluation demonstrated maintenance of both increased hand function and forearm bone health. The implications of this work for the future of rehabilitation in children with neurological disabilities are discussed in this article.

Long-term hand tele-rehabilitation on the PlayStation 3: benefits and challenges.

Rehabilitation interventions for the hand have shown benefits for children with Hemiplegia due to cerebral palsy or traumatic brain injury. Longer interventions are facilitated if training is provided in the patient's home, due to easier access to care and reduced impact on school or work activities. Providing remote rehabilitation over lengthy periods of time has however its own challenges. This paper presents two pediatric patients with hemiplegia, who practiced virtual hand rehabilitation games using a modified PlayStation 3 and 5DT sensing gloves. Despite severe initial hand spasticity, and occasional technology shortcomings, the subjects practiced for about 14 months, and 6 months, respectively. Game performance data for the second patient is presented. Follow-up evaluations 14 months from the removal of the PlayStation 3 from the home of the child with cerebral palsy showed that the patient had good retention in terms of grasp strength, hand function and bone health. Challenges of long-term home tele-rehabilitation are also discussed.

The Rutgers Arm II rehabilitation system--a feasibility study.

The Rutgers Arm II (RA II) is a new system that trains the shoulder/arm motor control, strengthening, arm speed of motion, endurance, and grasp strength in a single rehabilitation session. The system components are a tilted low-friction table, a forearm support with markers and wireless transmitter, a shoulder appendage to detect compensatory leaning, infrared vision tracking, a large display and a PC running custom virtual reality games. Three participants in the chronic stage post-stroke were trained on the RAII for four weeks (12 sessions) and had a follow-up evaluation after three months. The results of this study indicate that the participants were able to use the technology, and preliminary results are encouraging. One participant showed improvement in all timed Jebsen-Taylor test tasks, all participants had a larger shoulder range-of-motion and pinch strength of the affected hand post-training. Computerized measure of supported arm reach area increased in two participants post-training and in all participants at follow-up. Participants reported an improved ability to perform activities of daily living with the affected arm. There was good compliance by the participants, each of whom attended all sessions. The participants accepted the training length, even with some sessions lasting 1 h (excluding rest periods). The participants' subjective evaluation rated the system an average 3.7 out of 5 (see also the accompanying taped video interview of one of the participants).

Pancreatogenic diabetes pacient selection for pancreatic islet transplantation.

BACKGROUND: recently, insulin-dependent diabetes mellitus, can be treated by pancreatic islet allotransplantation. METHODS: This retrospective study involves 137 patients from the Surgery Department of Colentina Clinical Hospital, Bucharest, in the July 2000 - July 2008 period, who underwent pancreatic resections, the number of patients who developed pancreatogenic diabetes and their selection for the pancreatic islet transplantation. RESULTS: After pancreatectomy, 70 patients are diagnosed with diabetes, and 42 with prediabetic stages (IFG and IGT). 61 of these had average glycemic excursions (MAGE) over the normal, and 31 of the 70 patients diagnosed with diabetes, presented hypoglycemic episodes during treatment. CONCLUSION: The present criteria of patient selection for pancreatic islets transplantation are limited and can be applied to a small number of patients.

In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic cerebral palsy.

UNLABELLED: Golomb MR, McDonald BC, Warden SJ, Yonkman J, Saykin AJ, Shirley B, Huber M, Rabin B, AbdelBaky M, Nwosu ME, Barkat-Masih M, Burdea GC. In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic cerebral palsy. OBJECTIVE: To investigate whether in-home remotely monitored virtual reality videogame-based telerehabilitation in adolescents with hemiplegic cerebral palsy can improve hand function and forearm bone health, and demonstrate alterations in motor circuitry activation. DESIGN: A 3-month proof-of-concept pilot study. SETTING: Virtual reality videogame-based rehabilitation systems were installed in the homes of 3 participants and networked via secure Internet connections to the collaborating engineering school and children's hospital. PARTICIPANTS: Adolescents (N=3) with severe hemiplegic cerebral palsy. INTERVENTION: Participants were asked to exercise the plegic hand 30 minutes a day, 5 days a week using a sensor glove fitted to the plegic hand and attached to a remotely monitored videogame console installed in their home. Games were custom developed, focused on finger movement, and included a screen avatar of the hand. MAIN OUTCOME MEASURES: Standardized occupational therapy assessments, remote assessment of finger range of motion (ROM) based on sensor glove readings, assessment of plegic forearm bone health with dual-energy x-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT), and functional magnetic resonance imaging (fMRI) of hand grip task. RESULTS: All 3 adolescents showed improved function of the plegic hand on occupational therapy testing, including increased ability to lift objects, and improved finger ROM based on remote measurements. The 2 adolescents who were most compliant showed improvements in radial bone mineral content and area in the plegic arm. For all 3 adolescents, fMRI during grip task contrasting the plegic and nonplegic hand showed expanded spatial extent of activation at posttreatment relative to baseline in brain motor circuitry (eg, primary motor cortex and cerebellum). CONCLUSIONS: Use of remotely monitored virtual reality videogame telerehabilitation appears to produce improved hand function and forearm bone health (as measured by DXA and pQCT) in adolescents with chronic disability who practice regularly. Improved hand function appears to be reflected in functional brain changes.

Feasibility of modified remotely monitored in-home gaming technology for improving hand function in adolescents with cerebral palsy.

The convergence of game technology, the Internet, and rehabilitation science forms the second-generation virtual rehabilitation framework. This paper presents the first pilot study designed to look at the feasibility of at-home use of gaming technology adapted to address hand impairments in adolescents with hemiplegia due to perinatal stroke or intraventricular hemorrhage. Three participants trained at home for approximately 30 min/day, several days a week, for six to ten months. During therapy, they wore a fifths dimension technologies ultra sensing glove and played custom-developed Java 3D games on a modified PlayStation 3. The games were designed to accommodate the participants' limited range of motion, and to improve finger range and speed of motion. Trials took place in Indiana, while monitoFring/data storage took place at Rutgers Tele-Rehabilitation Institute (New Jersey). Significant improvements in finger range of motion (as measured by the sensing glove) were associated with self- and family-reported improvements in activities of daily living. In online subjective evaluations, participants indicated that they liked the system ease of use, clarity of instructions, and appropriate length of exercising. Other telerehabilitation studies are compared to this study and its technology challenges. Directions for future research are included.

Development and application of virtual reality technology to improve hand use and gait of individuals post-stroke.

Development and application of virtual reality (VR) systems for rehabilitation is an iterative process produced by collaboration of an inter-disciplinary team of engineers, neuroscientists and clinician-scientists. In this paper the use of virtual reality technology for the rehabilitation of individuals post-stroke is described. The development of the hardware is based on principles of motor control. Development of the software uses findings from the enrichment and motor plasticity and training literatures as well as principles of motor learning. Virtual environments are created to afford individuals post-stroke opportunities to practice tasks for which they require rehabilitation. These tasks, related to hand function and gait, are trained both at the impairment and functional level. The training engages users to allow for the repetitive intensive practice required for behavioral motor plasticity. Results from a series of upper and lower extremity studies indicate that use of VR technology to augment rehabilitation of individuals post-stroke merits further study.

Virtual reality-augmented rehabilitation for patients following stroke.

BACKGROUND AND PURPOSE: Recent evidence indicates that intensive massed practice may be necessary to modify neural organization and effect recovery of motor skills in patients following stroke. Virtual reality (VR) technology has the capability of creating an interactive, motivating environment in which practice intensity and feedback can be manipulated to create individualized treatments to retrain movement. CASE DESCRIPTION: Three patients (ML, LE, and DK), who were in the chronic phase following stroke, participated in a 2-week training program (3 1/2 hours a day) including dexterity tasks on real objects and VR exercises. The VR simulations were targeted for range of motion, movement speed, fractionation, and force production. OUTCOMES: ML's function was the most impaired at the beginning of the intervention, but showed improvement in the thumb and fingers in range of motion and speed of movement. LE improved in fractionation and range of motion of his thumb and fingers. DK made the greatest gains, showing improvement in range of motion and strength of the thumb, velocity of the thumb and fingers, and fractionation. Two of the 3 patients improved on the Jebsen Test of Hand Function. DISCUSSION: The outcomes suggest that VR may be useful to augment rehabilitation of the upper limb in patients in the chronic phase following stroke.

Geochemical and biogeochemical features of areas of haematuria in cattle in the Eastern Carpathian Mountains of Romania.

Haematuria-inducing areas in the northern and central parts of the Eastern Carpathian Mountains are characterised by the mesozoic-crystalline, neogene eruptive and transcarpathian flysch zones. The rocks have high concentrations of some metals and radioactive elements, some of them bearing polymetallic sulphides. The soils are strongly or moderately acid and oligomesobasic. They have a deficiency of soluble phosphorus and molybdenum, but up to 4.9 times the background content of metallic elements in non-affected zones. The waters have a pH around 7, a low content of salts (0.09-0.62 g L(-1)), but metal levels in excess of 10 times that of the background level. Pasture vegetation has a low nutritional value, and includes up to 12% of poisonous plant species. It is characterised by low total concentrations of P, Mo, N and K, and high total concentrations of metallic trace elements, including high values of Zn and excessive values of Fe, Mn, Pb, Cr, Ni, Cd and Al. Besides clinical symptoms specific to haematuria, sick animals have abnormal blood and urinary compositions and specific morphopathological features. High concentrations of metallic elements were detected in renal calculi. The correlation of the geochemical and biogeochemical features of the haematuria-inducing areas, together with the results of the epizootological, clinical, paraclinical and morphopathological research emphasises that chronic cattle haematuria is a disease with numerous causes, but is primarily a biogeochemical problem in the area studied, making it an 'ecosystem disease'.