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Hand Dexterity Improves in Patients with Progressive Multiple Sclerosis (MS) with Telerehabilitation Using Transcranial Direct Current Stimulation (tDCS) [Meeting Abstract]

Charvet, L; Pilloni, G; Lustberg, M; Malik, M; Feinberg, C; Gutman, J; Krupp, L; Raghavan, P
Abstract Background: Loss of hand dexterity is disabling and reduces quality of life. People living with progressive forms of MS have marked neurologic disabilities but limited rehabilitation options. Transcranial direct current stimulation (tDCS) is a method of noninvasive brain stimulation in which stimulation delivered during motor training can strengthen outcomes. We have established a remotely supervised tDCS (RS-tDCS) protocol that delivers multiple stimulation sessions paired with training to participants at home.
Objective(s): To evaluate a blinded randomized sham-controlled clinical trial of active vs. sham tDCS paired with manual dexterity training for people with progressive MS.
Method(s): We recruited right-hand dominant individuals with progressive MS and hand dexterity impairment. Participants completed 20 sessions of daily (M-F) manual dexterity and were randomized to either active (2.0 mA) or sham primary motor cortex (M1-SO) tDCS. Manual dexterity was measured with the Nine-Hole Peg Test (9HPT) and Dellon-Modified Moberg Pick-Up test (MMPUT) at baseline and study end and transformed to normative z-scores for comparison.
Result(s): Participants were n=60 with primary (32%) or secondary (68%) progressive MS (52% female, ages 37-72 years, and a median Expanded Disability Status Scale (EDSS) score of 5.0 [1.5-7.5]). The intervention was safe and well tolerated, with n=59/60 (98%) completing 18/20 daily sessions. Combining hands and tasks, the full group improved following the manual dexterity training (mean z-score improvement 1.64+/-9.53, p=0.016). Active tDCS led to greater improvement (mean z-score improvement 4.51+/-8.78, p=0.001). Analyzing those with right- or left-hand impairment at baseline, the active tDCS group had significant improvement on the 9HPT (Right: p=0.036, Left: p=0.028) and trended towards significant improvement for the MMPUT (Right: p=0.071, Left: p=0.079).
Conclusion(s): At-home manual dexterity training paired with tDCS is a safe, tolerable, and feasible intervention for people with progressive MS and hand impairment. Training outcomes are augmented with simultaneous M1-SO tDCS. Research Category and Technology and Methods Clinical Research: 9. Transcranial Direct Current Stimulation (tDCS) Keywords: tDCS, motor training, multiple sclerosis, teleintervention
Copyright
EMBASE:2022769993
ISSN: 1876-4754
CID: 5511542

Hyaluronan Homeostasis and its Role in Pain and Muscle Stiffness

Amir, Adam; Kim, Soo; Stecco, Antonio; Jankowski, Michael P; Raghavan, Preeti
PMID: 35077007
ISSN: 1934-1563
CID: 5154382

Music Upper Limb Therapy-Integrated (MULT-I) Provides a Feasible Enriched Environment and Reduces Post Stroke Depression: A Pilot Randomized Controlled Trial

Palumbo, Anna; Aluru, Viswanath; Battaglia, Jessica; Geller, Daniel; Turry, Alan; Ross, Marc; Cristian, Adrian; Balagula, Caitlin; Ogedegbe, Gbenga; Khatri, Latika; Chao, Moses V; Froemke, Robert C; Urbanek, Jacek K; Raghavan, Preeti
OBJECTIVE:This study aims to refine Music Upper Limb Therapy - Integrated (MULT-I) to create a feasible enriched environment for stroke rehabilitation and compare its biological and behavioral effects to that of a home exercise program (HEP). DESIGN/METHODS:Randomized mixed-methods study of 30 adults with post-stroke hemiparesis. Serum brain derived neurotrophic factor (BDNF) and oxytocin levels measured biologic effects, and upper limb function, disability, quality of life and emotional well-being were assessed as behavioral outcomes. Participant experiences were explored using semi-structured interviews. RESULTS:MULT-I participants showed reduced depression from pre- to post- intervention as compared to HEP participants. BDNF levels significantly increased for MULT-I participants, but decreased for HEP participants, with a significant difference between groups after excluding those with post-stroke depression. MULT-I participants additionally improved quality of life and self-perceived physical strength, mobility, activity, participation, and recovery from pre- to post-intervention. HEP participants improved upper limb function. Qualitatively, MULT-I provided psychosocial support and enjoyment while HEP supported self-management of rehabilitation. CONCLUSIONS:Implementation of a music enriched environment is feasible, reduces post-stroke depression, and may enhance the neural environment for recovery via increases in BDNF levels. Self-management of rehabilitation through a home exercise program may further improve upper limb function.
PMID: 34864768
ISSN: 1537-7385
CID: 5080352

Nonlinear functional muscle network based on information theory tracks sensorimotor integration post stroke

O'Keeffe, Rory; Shirazi, Seyed Yahya; Bilaloglu, Seda; Jahed, Shayan; Bighamian, Ramin; Raghavan, Preeti; Atashzar, S Farokh
Sensory information is critical for motor coordination. However, understanding sensorimotor integration is complicated, especially in individuals with impairment due to injury to the central nervous system. This research presents a novel functional biomarker, based on a nonlinear network graph of muscle connectivity, called InfoMuNet, to quantify the role of sensory information on motor performance. Thirty-two individuals with post-stroke hemiparesis performed a grasp-and-lift task, while their muscle activity from 8 muscles in each arm was measured using surface electromyography. Subjects performed the task with their affected hand before and after sensory exposure to the task performed with the less-affected hand. For the first time, this work shows that InfoMuNet robustly quantifies changes in functional muscle connectivity in the affected hand after exposure to sensory information from the less-affected side. > 90% of the subjects conformed with the improvement resulting from this sensory exposure. InfoMuNet also shows high sensitivity to tactile, kinesthetic, and visual input alterations at the subject level, highlighting its potential use in precision rehabilitation interventions.
PMCID:9338017
PMID: 35906239
ISSN: 2045-2322
CID: 5277062

Evidence-Based Medicine Training in US-based Physiatry Residency Programs

Annaswamy, Thiru M; Rizzo, John-Ross; Schnappinger, Amy; Morgenroth, David C; Engkasan, Julia Patrick; Ilieva, Elena; Arnold, W David; Boninger, Mike; Bean, Allison C; Cirstea, Carmen M; Dicianno, Brad E; Fredericson, Michael; Jayabalan, Prakash; Raghavan, Preeti; Sawaki, Lumy; Suri, Pradeep; Suskauer, Stacy J; Wang, Qing Mei; Hosseini, Maryam; Case, Christina; Whyte, John; Paganoni, Sabrina
ABSTRACT/UNASSIGNED:While the physiatric community increasingly embraces Evidence-Based Medicine (EBM), the current state of EBM training for trainees in physiatry is unclear. The purpose of this article is to report the results of the Association of Academic Physiatrists (AAP)'s surveys of physiatry residency programs in the United States (US), to discuss the implications of their findings, and to better delineate the 'baseline' upon which sound and clear recommendations for systematic EBM training can be made. The two AAP surveys of US physiatry residency programs reveal that most survey respondents report that they include EBM training in their programs that covers the five recommended steps of EBM core competencies. However, while most respondents reported using traditional pedagogical methods of training such as journal club, very few reported that their EBM training used a structured and systematic approach. Future work is needed to support and facilitate physiatry residency programs interested in adopting structured EBM training curricula that include recommended EBM core-competencies and the evaluation of their impact.
PMID: 33852491
ISSN: 1537-7385
CID: 4871172

Densification: Hyaluronan Aggregation in Different Human Organs

Stecco, Antonio; Cowman, Mary; Pirri, Nina; Raghavan, Preeti; Pirri, Carmelo
Hyaluronan (HA) has complex biological roles that have catalyzed clinical interest in several fields of medicine. In this narrative review, we provide an overview of HA aggregation, also called densification, in human organs. The literature suggests that HA aggregation can occur in the liver, eye, lung, kidney, blood vessel, muscle, fascia, skin, pancreatic cancer and malignant melanoma. In all these organs, aggregation of HA leads to an increase in extracellular matrix viscosity, causing stiffness and organ dysfunction. Fibrosis, in some of these organs, may also occur as a direct consequence of densification in the long term. Specific imaging evaluation, such dynamic ultrasonography, elasto-sonography, elasto-MRI and T1ρ MRI can permit early diagnosis to enable the clinician to organize the treatment plan and avoid further progression of the pathology and dysfunction.
PMCID:9028708
PMID: 35447719
ISSN: 2306-5354
CID: 5218542

Data-Driven Classification of Human Movements in Virtual Reality-Based Serious Games: Preclinical Rehabilitation Study in Citizen Science

Barak Ventura, Roni; Stewart Hughes, Kora; Nov, Oded; Raghavan, Preeti; Ruiz Marín, Manuel; Porfiri, Maurizio
BACKGROUND:Sustained engagement is essential for the success of telerehabilitation programs. However, patients' lack of motivation and adherence could undermine these goals. To overcome this challenge, physical exercises have often been gamified. Building on the advantages of serious games, we propose a citizen science-based approach in which patients perform scientific tasks by using interactive interfaces and help advance scientific causes of their choice. This approach capitalizes on human intellect and benevolence while promoting learning. To further enhance engagement, we propose performing citizen science activities in immersive media, such as virtual reality (VR). OBJECTIVE:This study aims to present a novel methodology to facilitate the remote identification and classification of human movements for the automatic assessment of motor performance in telerehabilitation. The data-driven approach is presented in the context of a citizen science software dedicated to bimanual training in VR. Specifically, users interact with the interface and make contributions to an environmental citizen science project while moving both arms in concert. METHODS:In all, 9 healthy individuals interacted with the citizen science software by using a commercial VR gaming device. The software included a calibration phase to evaluate the users' range of motion along the 3 anatomical planes of motion and to adapt the sensitivity of the software's response to their movements. During calibration, the time series of the users' movements were recorded by the sensors embedded in the device. We performed principal component analysis to identify salient features of movements and then applied a bagged trees ensemble classifier to classify the movements. RESULTS:The classification achieved high performance, reaching 99.9% accuracy. Among the movements, elbow flexion was the most accurately classified movement (99.2%), and horizontal shoulder abduction to the right side of the body was the most misclassified movement (98.8%). CONCLUSIONS:Coordinated bimanual movements in VR can be classified with high accuracy. Our findings lay the foundation for the development of motion analysis algorithms in VR-mediated telerehabilitation.
PMID: 35142629
ISSN: 2291-9279
CID: 5167632

Developing a Framework for Designing and Deploying Technology-Assisted Rehabilitation After Stroke: A Qualitative Study

Jayasree-Krishnan, Veena; Ghosh, Shramana; Palumbo, Anna; Kapila, Vikram; Raghavan, Preeti
OBJECTIVE:Many unmet rehabilitation needs of patients with stroke can be addressed effectively using technology. However, technological solutions have not yet been seamlessly incorporated into clinical care. The purpose of this pilot study was to examine how to bridge the gaps between the recovery process, technology, and clinical practice to impact stroke rehabilitation meaningfully. DESIGN:Semistructured interviews were performed using a grounded theory approach with purposive sampling of 17 diverse expert providers in acute care, inpatient, and outpatient stroke rehabilitation settings. Common themes were identified from qualitative analyses of the transcribed conversations to develop a guiding framework from the emerging concepts. RESULTS:Four core themes emerged that addressed major barriers in stroke rehabilitation and technology-assisted solutions to overcome these barriers: (1) accessibility to quality rehabilitation, (2) adaptability to patient differences, (3) accountability or compliance with rehabilitation, and (4) engagement with rehabilitation. CONCLUSIONS:The results suggest a four-pronged framework, the A3E framework that stands for Accessibility, Adaptability, Accountability, and Engagement, to comprehensively address existing barriers in providing rehabilitation services. This framework can guide technology developers and clinicians in designing and deploying technology-assisted rehabilitation solutions for poststroke rehabilitation, particularly using telerehabilitation.
PMID: 33141773
ISSN: 1537-7385
CID: 4989532

Pilot study quantifying muscle glycosaminoglycan using bi-exponential T1ρ mapping in patients with muscle stiffness after stroke

Menon, Rajiv G; Raghavan, Preeti; Regatte, Ravinder R
Post stroke muscle stiffness is a common problem, which left untreated can lead to disabling muscle contractures. The purpose of this pilot study was to evaluate the feasibility of bi-exponential T1ρ mapping in patients with arm muscle stiffness after stroke and its ability to measure treatment related changes in muscle glycosaminoglycans (GAGs). Five patients with muscle stiffness after stroke and 5 healthy controls were recruited for imaging of the upper arm with 3D-T1ρ mapping. Patients were scanned before and after treatment with hyaluronidase injections, whereas the controls were scanned once. Wilcoxon Mann-Whitney tests compared patients vs. controls and patients pre-treatment vs. post-treatment. With bi-exponential modeling, the long component, T1ρl was significantly longer in the patients (biceps P = 0.01; triceps P = 0.004) compared to controls. There was also a significant difference in the signal fractions of the long and short components (biceps P = 0.03, triceps P = 0.04). The results suggest that muscle stiffness is characterized by increased muscle free water and GAG content. Post-treatment, the T1ρ parameters shifted toward control values. This pilot study demonstrates the application of bi-exponential T1ρ mapping as a marker for GAG content in muscle and as a potential treatment monitoring tool for patients with muscle stiffness after stroke.
PMCID:8260636
PMID: 34230600
ISSN: 2045-2322
CID: 4991232

Telerehabilitation for Geriatrics

Oh-Park, Mooyeon; Lew, Henry L; Raghavan, Preeti
Advancements in medical science and technology, along with global increases in life expectancy, are changing the way health care services are delivered to the aging society. Telerehabilitation refers to rehabilitation services involving evaluation and treatment. It is an attractive option for older adults who may have multiple comorbidities. Limited access to in-person services and the concern about potential exposure to severe acute respiratory syndrome coronavirus-2 during this pandemic accelerated the implementation of telerehabilitation. This article review the scope, need, and implementation of telehealth and telerehabilitation in the aging population from the perspective of clinicians, patients, and caregivers.
PMID: 33814059
ISSN: 1558-1381
CID: 4838802