Bedside patient engagement monitor for rehabilitation in disorders of consciousness - demonstrative case-reports.

AIM: A chronic disorder of consciousness (DOC) is a devastating condition for the patients and their families. Achieving improved communication with patients in this state is of utmost importance. Over recent years we have seen some progress in the development of rehabilitation protocols for patients with DOC by which the patient's limited actions impact the environment (e.g. activate music) based on the principle of contingent stimulation. However, one of the major factors, which hinders further progress, is the limited overt responsiveness of the patient, which poses a severe limitation on the ability of the therapists to evaluate whether specific interventions have an impact. In this work, we harness a novel electrophysiological marker the Brain Engagement Index (BEI), which enables simple monitoring of patient's engagement during interventions, intending to overcome this limitation. METHODS: We combine the BEI marker with the contingent stimulation principle, to propose a 4-levels protocol for advancing communication with DOC patients. RESULTS: The potential of the evolving protocol is demonstrated with 4 representative case reports. Each case report demonstrates one level of the protocol. CONCLUSIONS: The protocol seems to be both feasible and effective for better clarification of the communication abilities of DOC patients. We recommend its continued evaluation employing a more structured study.IMPLICATIONS FOR REHABILITATIONWe suggest a systematic method for rehabilitation of patients with disorders of consciousnessIt is based upon monitoring patient engagement in real-time and selecting interventions accordingly.

A pilot study on the electrophysiological monitoring of patient's engagement in post-stroke physical rehabilitation.

Introduction: This study discusses the feasibility of an electrophysiological monitor for patient engagement during rehabilitation sessions. While patient engagement has a significant clinical role, it is not obvious how its real-time monitoring could be used.Objective: We designed this study to provide further support for the feasibility of such a tool based on the Brain Engagement Index (BEI), and to discuss clinical usefulness and its evaluation.Methods: The study involved 30 patients during post-stroke rehabilitation. Each patient underwent two sessions with BEI monitoring. In one session the therapist received real-time feedback from the monitor and in the other he did not. The BEI was compared to video-based evaluation of temporary functional change from the session start to its end and with a rater-based evaluation of the level of engagement evoked by the exercises in the session.Results: Irrespective of whether feedback is used, there is association between BEI and temporary functional change as well as with evaluated engagement. Furthermore, the contribution of the BEI monitor to rehabilitation may be demonstrated.Conclusions: It would be challenging to establish directly the monitor's contribution in large-scale studies. Nevertheless, it might be sufficient to demonstrate that the monitor provides important information regarding patient engagement.Implication for RehabilitationThis work presents an easy-to-use electrophysiological index for monitoring patient engagement in real-time.Enhanced engagement is of utmost importance for effective rehabilitation.The ability to identify in real-time barriers to engagement is expected to be of great contributive value.

Changes in mu and beta amplitude of the EEG during upper limb movement correlate with motor impairment and structural damage in subacute stroke.

OBJECTIVE: Mu and beta EEG oscillations show typical desynchronization patterns during movement. The aim of the current study was to assess whether in sub-acute stroke patients the magnitude of movement-related desynchronization reflects the extent of residual motor ability in the paretic upper limb. METHODS: EEG and EMG data were recorded from 14 first-event stroke patients during repeated wrist extension movements of the paretic upper limb. Residual motor ability was assessed by the Fugl Meyer and Box and Blocks standardized clinical tests. Normalized lesion data was analyzed using the MEDx software. RESULTS: The magnitude of event-related de-synchronization (ERD) of the high-mu and low-beta bands of the EEG, measured over the affected hemisphere, correlated significantly with (a) residual motor function in the paretic upper limb as measured by standard clinical tests; (b) the magnitude of EMG recorded from the paretic upper limb during wrist extension; and (c) the total hemispheric volume loss (negative correlation). CONCLUSION: The magnitude of high-mu and low-beta ERD recorded from the lesioned hemisphere of subacute stroke patients correlates with residual motor ability in the paretic upper limb. SIGNIFICANCE: Measures derived from quantitative EEG analysis may play an important role in neurorehabilitation clinical practice.

Lesion location impact on functional recovery of the hemiparetic upper limb.

The effect of stroke topography on the recovery of hemiparetic upper limb (HUL) function is unclear due to limitations in previous studies-examination of lesion effects only in one point of time, or grouping together patients with left and right hemispheric damage (LHD, RHD), or disregard to different lesion impact on proximal and distal operations. Here we used voxel-based lesion symptom mapping (VLSM) to investigate the impact of stroke topography on HUL function taking into consideration the effects of (a) assessment time (subacute, chronic phases), (b) side of damaged hemisphere (left, right), (c) HUL part (proximal, distal). HUL function was examined in 3 groups of patients-Subacute (n = 130), Chronic (n = 66), and Delta (n = 49; patients examined both in the subacute and chronic phases)-using the proximal and distal sub-divisions of the Fugl-Meyer (FM) and the Box and Blocks (B&B) tests. HUL function following LHD tended to be affected in the subacute phase mainly by damage to white matter tracts, the putamen and the insula. In the chronic phase, a similar pattern was shown for B&B performance, whereas FM performance was affected by damage only to the white matter tracts. HUL function following RHD was affected in both phases, mainly by damage to the basal ganglia, white matter tracts and the insula, along with a restricted effect of damage to other cortical structures. In the chronic phase HUL function following RHD was affected also by damage to the thalamus. In the small Delta groups the following trends were found: In LHD patients, delayed motor recovery, captured by the B&B test, was affected by damage to the sensory-motor cortex, white matter association fibers and parts of the perisilvian cortex. In the RHD patients of the Delta group, delayed motor recovery was affected by damage to white matter projection fibers. Proximal and distal HUL functions examined in LHD patients (both in the subacute and chronic phases) tended to be affected by similar structures-mainly white matter projection tracts. In RHD patients, a distinction between proximal and distal HUL functions was found in the subacute but not in the chronic phase, with proximal and distal HUL functions affected by similar subcortical and cortical structures, except for an additional impact of damage to the superior temporal cortex and the retro-lenticular internal capsule only on proximal HUL function. The current study suggests the existence of important differences between the functional neuroanatomy underlying motor recovery following left and right hemisphere damage. A trend for different lesion effects was shown for residual proximal and distal HUL motor control. The study corroborates earlier findings showing an effect of the time after stroke onset (subacute, chronic) on the results of VLSM analyses. Further studies with larger sample size are required for the validation of these results.

[RECRUITMENT PATTERNS OF HOMOLOGOUS MUSCLES DURING UNILATERAL MOVEMENT IN HEMIPARETIC SUBJECTS].

INTRODUCTION: The presence of unintentional muscular activity, with or without overt movement, in the homologue muscle contralateral to the limb being activated voluntarily, has been documented in both healthy and hemi-paretic populations. This activity has been termed contra-lateral motor irradiation (CMI), mirror movement, associated movement, motor overflow or synkinesis. AIMS: To characterize the CMI phenomenon amongst healthy controls and patients with varying degrees of motor ability and also to assess the ability to consciously control this phenomenon. METHODS: A cross-sectional design was used to study sub-acute (within 6 weeks of the insult) stroke patients; assessments were performed within two weeks of commencing rehabilitation and again after 4 weeks. Healthy controls were assessed once. A simple motor task, unilateral extension of wrist and fingers, was examined. Concomitant muscular activity of the homologue muscle on the contralateral upper limb was the focus of interest; EMG activation was monitored on both sides. The Fugl-Meyer test was used to assess the residual motor capacity of the upper limb. RESULTS: CMI was demonstrated only in the non-paretic hand during voluntary activation of the paretic hand. The study group, unlike the control group, was unable to consciously reduce CMI. CONCLUSIONS: Although the mechanisms underlying CMI are poorly understood, they reflect an important aspect of inter-hemispheric relationship in motor control. In stroke patients, CMI monitoring by surface EMG can be used to assess its characteristics following damage to different elements of the motor system.

Neurophysiological effects of mirror visual feedback in stroke patients with unilateral hemispheric damage.

BACKGROUND AND OBJECTIVE: Mirror visual feedback (MVF; the illusory perception of movement in one hand upon viewing the moving opposite hand in a midsagittal mirror) is thought to facilitate restoration of mal-adaptive neurophysiological processes underlying conditions like complex regional pain syndrome and phantom limb pain, and to have a positive effect on brain plasticity processes underlying motor recovery after stroke. However, its exact mode of action remains unclear. The aim of the current study was to explore the immediate neurophysiological effects of MVF in patients with stroke-related hemiparesis. We also investigated how these effects relate to lesion location and extent. METHOD: EEG and EMG data were obtained from 14 first-event sub-acute stroke patients (8 with right-, 6 with left-hemiparesis) during repeated wrist extension movements of the Non-paretic Upper-Limb (NUL), without (NUL/M-) and with (NUL/M+) a midsagittal mirror, as well as during bilateral movements with a mirror (Bil/M+). EEG data was correlated with normalized lesion data obtained from follow-up CT scans. RESULTS: NUL movement was accompanied by an asymmetric event-related de-synchronization (ERD) of low-beta EEG oscillations, with a more conspicuous ERD in the non-affected hemisphere. In the mirror condition, ERD magnitude was attenuated in both hemispheres. Stronger attenuation in the non-affected hemisphere abolished the hemispheric asymmetry. ERD attenuation by the mirror was affected by lesion side, the severity of hemiparesis and by lesion location and extent. CONCLUSION: Following hemispheric stroke, the magnitude of low-beta ERD accompanying unilateral movement of the non-involved upper limb, and its hemispheric asymmetry, are both reduced by MVF. Low-beta ERD dynamics may serve as a marker of neurophysiological response to MVF in research aimed to elucidate the factors influencing patients' clinical gain from this treatment.

An EEG Tool for Monitoring Patient Engagement during Stroke Rehabilitation: A Feasibility Study.

OBJECTIVE: Patient engagement is of major significance in neural rehabilitation. We developed a real-time EEG marker for attention, the Brain Engagement Index (BEI). In this work we investigate the relation between the BEI and temporary functional change during a rehabilitation session. METHODS: First part: 13 unimpaired controls underwent BEI monitoring during motor exercise of varying levels of difficulty. Second part: 18 subacute stroke patients underwent standard motor rehabilitation with and without use of real-time BEI feedback regarding their level of engagement. Single-session temporary functional changes were evaluated based on videos taken before and after training on a given task. Two assessors, blinded to feedback use, assessed the change following single-session treatments. RESULTS: First part: a relation between difficulty of exercise and BEI was identified. Second part: temporary functional change was associated with BEI level regardless of the use of feedback. CONCLUSIONS: This study provides preliminary evidence that when BEI is higher, the temporary functional change induced by the treatment session is better. Further work is required to expand this preliminary study and to evaluate whether such temporary functional change can be harnessed to improve clinical outcome. CLINICAL TRIAL REGISTRATION: Registered with clinicaltrials.gov, unique identifier: NCT02603718 (retrospectively registered 10/14/2015).

Electrophysiological manifestations of mirror visual feedback during manual movement.

OBJECTIVE: To investigate the neurophysiological manifestations of the mechanism underlying the effects of Mirror Visual Feedback (MVF) during manual movement. METHOD: Thirteen healthy right handed individuals were assessed while performing repeated unilateral wrist extension movements with and without MVF. The effect of MVF on EEG oscillations was studied in 3 distinct frequency ranges (low mu, high mu, low beta). RESULTS: Analysis of the low beta range showed that MVF reduces the magnitude of event-related de-synchronization (ERD) in the hemisphere contra-lateral to the moving hand. This effect reached significance when the moving hand was the dominant hand. In the analysis of the low mu range, bi-hemispheric amplification of ERD by the mirror pointed to an added effect of neural recruitment. This effect reached significance when the moving hand was the non-dominant hand. CONCLUSIONS: MVF applied during unilateral manual movement (a) attenuates hemispheric activation asymmetry, and (b) is likely to involve recruitment of the mirror neuron system. SIGNIFICANCE: As each of the above two effects reached significance only in one hand (dominant and non-dominant, respectively), clinical application of MVF might show a different level of efficacy in the treatment of right and left hemiparesis.

Heart rate autonomic regulation system at rest and during paced breathing among patients with CRPS as compared to age-matched healthy controls.

OBJECTIVE: The objective of this study is to assess the autonomic nerve heart rate regulation system at rest and its immediate response to paced breathing among patients with complex regional pain syndrome (CRPS) as compared with age-matched healthy controls. DESIGN: Quasiexperimental. SETTING: Outpatient clinic. SUBJECTS: Ten patients with CRPS and 10 age- and sex-matched controls. METHODS: Participants underwent Holter ECG (NorthEast Monitoring, Inc., Maynard, MA, USA) recording during rest and biofeedback-paced breathing session. Heart rate variability (HRV), time, and frequency measures were assessed. RESULTS: HRV and time domain values were significantly lower at rest among patients with CRPS as compared with controls. A significant association was noted between pain rank and HRV frequency measures at rest and during paced breathing; although both groups reduced breathing rate significantly during paced breathing, HRV time domain parameters increased only among the control group. CONCLUSIONS: The increased heart rate and decreased HRV at rest in patients with CRPS suggest a general autonomic imbalance. The inability of the patients to increase HRV time domain values during paced breathing may suggest that these patients have sustained stress response with minimal changeability in response to slow-paced breathing stimuli.

HandTutor™ enhanced hand rehabilitation after stroke--a pilot study.

BACKGROUND AND PURPOSE: This study assessed the potential therapeutic benefi t of using HandTutor™ in combination with traditional rehabilitation in a post-stroke sub-acute population. The study compares an experimental group receiving traditional therapy combined with HandTutorTM treatment, against a control group receiving only traditional therapy. METHOD: An assessor-blinded, randomized controlled pilot trial, was conducted in the Reuth rehabilitation unit in Israel. Thirty-one stroke patients in the sub-acute phase, were randomly assigned to one of the two groups (experimental or control) in sets of three. The experimental group (n = 16) underwent a hand rehabilitation programme using the HandTutorTM combined with traditional therapy. The control group (n = 15) received only traditional therapy. The treatment schedules for both groups were of similar duration and frequency. Improvements were evaluated using three indicators: 1) The Brunnström-Fugl-Meyer (FM) test, 2) the Box and Blocks (B&B) test and 3) improvement parameters as determined by the HandTutorTM software. RESULTS: Following 15 consecutive treatment sessions, a signifi cant improvement was observed within the experimental group (95% confi dence intervals) compared with the control group: B&B p = 0.015; FM p = 0.041, HandTutor™ performance accuracy on x axis and performance accuracy on y axis p < 0.0003. CONCLUSION: The results from this pilot study support further investigation of the use of the HandTutorTM in combination with traditional occupational therapy and physiotherapy during post stroke hand function rehabilitation.

Does passive leg activity influence oxygen saturation and activity in sedentary elderly adults?

This study aimed to investigate whether any physiological changes might have a clinically significant effect on function in sedentary, institutionalized, older adults treated by a passive training program. A total of 18 subjects (mean age 60.7 +/- 3.4) with intellectual disability (ID) participated. We measured SpO2 (arterial oxygen saturation) before, during, and after passive training, and used Barthel Index to measure daily living activities. The general trend indicated that inactive people with ID evidenced a continual increase in SpO2% levels and some functional gains during passive treatment, with superiority to manual passive treatment compared to mechanical active passive training. For current clinical practice, most sedentary patients who experience clinically significant deconditioning and desaturation can benefit from passive treatment.