This study investigated the effects of intensive neuromuscular electrical stimulation (NMES) treatment at home over 3 weeks on functional improvements and cortical changes in subjects with chronic stroke. 16 subjects were randomly assigned to either a true NMES treatment group or a sham treatment group. Both groups underwent testing before and after treatment, and the sham group was also tested after crossing over to the true treatment. The true NMES group showed improvements in measures of hand function and strength, while the sham group did not improve initially but did improve after crossing over. Functional MRI revealed increased cortical activation in the ipsilateral somatosensory cortex following true NMES treatment. The findings suggest NMES may stimulate cortical sensory areas to enable improved motor function in subjects
Application of Pstim in Clinical Practice MaxiMedRx
The P-Stim and ANSiStim™ miniaturized device is designed to administer auricular point stimulation treatment over several days. The ear provides numerous points for stimulation within a small area. Stimulation is performed by electrical pulses emitted through strategically positioned needles. The ANSiscope device monitors the pain condition of the patient before, during and after the treatment.
The P-Stim and ANSiStim™ point stimulation therapy is mainly used to treat pain. Use of the device is recommended for pre-operative, intra-operative and post-operative pain therapy as well as for the treatment of chronic pain. DyAnsys is researching the possibilities of using this concept for the treatment of depression, addiction and allergy.
P-Stim and ANSiStim™ therapy allows continuous point stimulation over a period of several days while offering the patient a high degree of comfort and mobility. Use of the P-Stim and ANSiStim™ therapy provides advantages over drug therapy by minimizing possible side-effects caused by pain medications (i.e. opioid). In most cases, the patient continues to lead a normal life without side effects or any loss of quality of life.
Application of Pstim in Clinical Practice MaxiMedRx
The P-Stim and ANSiStim™ miniaturized device is designed to administer auricular point stimulation treatment over several days. The ear provides numerous points for stimulation within a small area. Stimulation is performed by electrical pulses emitted through strategically positioned needles. The ANSiscope device monitors the pain condition of the patient before, during and after the treatment.
The P-Stim and ANSiStim™ point stimulation therapy is mainly used to treat pain. Use of the device is recommended for pre-operative, intra-operative and post-operative pain therapy as well as for the treatment of chronic pain. DyAnsys is researching the possibilities of using this concept for the treatment of depression, addiction and allergy.
P-Stim and ANSiStim™ therapy allows continuous point stimulation over a period of several days while offering the patient a high degree of comfort and mobility. Use of the P-Stim and ANSiStim™ therapy provides advantages over drug therapy by minimizing possible side-effects caused by pain medications (i.e. opioid). In most cases, the patient continues to lead a normal life without side effects or any loss of quality of life.
To Compare the Effect of Muscle Energy Technique and Ultrasound on Jaw Range ...ijtsrd
Introduction Temporomandibular joint is a horse shaped bone that articulates with the temporomandibular bone. When TM joint is not working properly, the condition is known as temporomandibular joint dysfunction joint. The TMJ is positioned Right in front of ear canals. Objective The aim and objective of this study was to compare the effectiveness of Muscle Energy Technique MET and Ultrasound in patient with Temporomandibular Joint Dysfunction. Methods 20 subjects with Temporomandibular Joint Dysfunction were divided conveniently into two groups Group A was receiving Muscle Energy Technique MET and Group B was receiving Ultrasound. The treatment was continued for 5 days and readings were taken 1st and 5th day. Result The study showed non significant improvements in R.O.M following 5 sessions of treatment within both groups. Conclusion Muscle Energy Technique MET and Ultrasound both are effective in Temporomandibular Joint Dysfunction. Dr Jaspinder Kaur | Dr Shilpy Jetly ""To Compare the Effect of Muscle Energy Technique and Ultrasound on Jaw Range of Motion in Subjects with Temporomandibular Joint Dysfunction"" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-4 , June 2019, URL: https://www.ijtsrd.com/papers/ijtsrd23579.pdf
Paper URL: https://www.ijtsrd.com/other-scientific-research-area/other/23579/to-compare-the-effect-of-muscle-energy-technique-and-ultrasound-on-jaw-range-of-motion-in-subjects-with-temporomandibular-joint-dysfunction/dr-jaspinder-kaur
Recent advances in Manipulative MedicineSoniya Lohana
What new techniques are been used in manipulative medicine and physical therapy that help the patients to recover better and address their condition by various approaches where surgery is not required.
Acupuncture is one of the oldest types of therapy known to us for about five thousand years. It originated in Asia, specifically in China, was developed further and constituted a very essential part of medicine in that part of the world. In the West, acupuncture was virtually unknown until the year 1972. Professor Bischko was able to prove its mode of action using scientifically recognized methods of Western medicine.
Electro-acupuncture is already used on a word-wide scale at present, but has found only limited application in auricular acupuncture, due to the currently relatively large sized equipment. For this reason, a miniature form of electro- acupuncture has been developed, in order to permit carrying out long term auricular acupuncture. The main component of the device is a micro controller (in further sequence a microchip), which allows continuous stimulation in conjunction with an integrated acupuncture needle.
Intro to Transcranial Direct Curent Stimulation (tDCS)Daniel Stevenson
A comprehensive introduction to tDCS with a main focus on research utilizing motor-evoked potentials (MEPs) to uncover the physiological mechanism of therapeutic and enhancing effects of tDCS application. Regulation and FDA guidelines are also thoroughly covered. Provides a good source of relevant academic citations (on each slide).
The focus of this White Paper will be on defining trigger points and their role in pathology. Myofascial
pain may be categorized in many ways, but the majority of cases are associated with trigger points. It is
important to continue to consider other sources, such as, muscle spasm, muscle tension, and muscle deficiency
STRATEGY FOR ELECTROMYOGRAPHY BASED DIAGNOSIS OF NEUROMUSCULAR DISEASES FOR A...ijbbjournal
Assistive Rehabilitation aims at developing procedures and therapies which reinstate lost body functions
for individuals with disabilities. Researchers have monitored electrophysiological activity of muscles using
biofeedback obtained from Electromyogram signals collected at appropriate innervation points. In this
paper, we present a comprehensive technique for detection of neuromuscular disease in a subject and a
strategy for continuous therapeutic assessment using the Rehabilitation Assessment Matrix. The decision
making tool has been trained using a wide spectrum of synthetic physiological data incorporating varying
degrees of myopathy and neuropathy from beginning stages to acute. The statistical, spectral and cepstral
features extracted from EMG have been used to train a Cascade Correlation Neural Network Classifier
for disease assessment. The diagnostic yield of the classifier is 91.2% accuracy, 85.3% specificity and
91.35% sensitivity. The strategy has also been extended to include isotonic contractions in addition to
static isometric contractions. This comprehensive strategy is proposed to aid physicians plan and schedule
treatment procedures to maximize the therapeutic value of the rehabilitation process.
Reduced Short- and Long-Latency Afferent Inhibition Following Acute Muscle Pa...Antonio Martinez
Corticomotor output is reduced in re-
sponse to acute muscle pain, yet the mechanisms
that underpin this effect remain unclear. Here the au-
thors investigate the effect of acute muscle pain on
short-latency afferent inhibition, long-latency afferent
inhibition, and long-interval intra-cortical inhibition to
determine whether these mechanisms could plausibly
contribute to reduced motor output in pain.
To Compare the Effect of Muscle Energy Technique and Ultrasound on Jaw Range ...ijtsrd
Introduction Temporomandibular joint is a horse shaped bone that articulates with the temporomandibular bone. When TM joint is not working properly, the condition is known as temporomandibular joint dysfunction joint. The TMJ is positioned Right in front of ear canals. Objective The aim and objective of this study was to compare the effectiveness of Muscle Energy Technique MET and Ultrasound in patient with Temporomandibular Joint Dysfunction. Methods 20 subjects with Temporomandibular Joint Dysfunction were divided conveniently into two groups Group A was receiving Muscle Energy Technique MET and Group B was receiving Ultrasound. The treatment was continued for 5 days and readings were taken 1st and 5th day. Result The study showed non significant improvements in R.O.M following 5 sessions of treatment within both groups. Conclusion Muscle Energy Technique MET and Ultrasound both are effective in Temporomandibular Joint Dysfunction. Dr Jaspinder Kaur | Dr Shilpy Jetly ""To Compare the Effect of Muscle Energy Technique and Ultrasound on Jaw Range of Motion in Subjects with Temporomandibular Joint Dysfunction"" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Volume-3 | Issue-4 , June 2019, URL: https://www.ijtsrd.com/papers/ijtsrd23579.pdf
Paper URL: https://www.ijtsrd.com/other-scientific-research-area/other/23579/to-compare-the-effect-of-muscle-energy-technique-and-ultrasound-on-jaw-range-of-motion-in-subjects-with-temporomandibular-joint-dysfunction/dr-jaspinder-kaur
Recent advances in Manipulative MedicineSoniya Lohana
What new techniques are been used in manipulative medicine and physical therapy that help the patients to recover better and address their condition by various approaches where surgery is not required.
Acupuncture is one of the oldest types of therapy known to us for about five thousand years. It originated in Asia, specifically in China, was developed further and constituted a very essential part of medicine in that part of the world. In the West, acupuncture was virtually unknown until the year 1972. Professor Bischko was able to prove its mode of action using scientifically recognized methods of Western medicine.
Electro-acupuncture is already used on a word-wide scale at present, but has found only limited application in auricular acupuncture, due to the currently relatively large sized equipment. For this reason, a miniature form of electro- acupuncture has been developed, in order to permit carrying out long term auricular acupuncture. The main component of the device is a micro controller (in further sequence a microchip), which allows continuous stimulation in conjunction with an integrated acupuncture needle.
Intro to Transcranial Direct Curent Stimulation (tDCS)Daniel Stevenson
A comprehensive introduction to tDCS with a main focus on research utilizing motor-evoked potentials (MEPs) to uncover the physiological mechanism of therapeutic and enhancing effects of tDCS application. Regulation and FDA guidelines are also thoroughly covered. Provides a good source of relevant academic citations (on each slide).
The focus of this White Paper will be on defining trigger points and their role in pathology. Myofascial
pain may be categorized in many ways, but the majority of cases are associated with trigger points. It is
important to continue to consider other sources, such as, muscle spasm, muscle tension, and muscle deficiency
STRATEGY FOR ELECTROMYOGRAPHY BASED DIAGNOSIS OF NEUROMUSCULAR DISEASES FOR A...ijbbjournal
Assistive Rehabilitation aims at developing procedures and therapies which reinstate lost body functions
for individuals with disabilities. Researchers have monitored electrophysiological activity of muscles using
biofeedback obtained from Electromyogram signals collected at appropriate innervation points. In this
paper, we present a comprehensive technique for detection of neuromuscular disease in a subject and a
strategy for continuous therapeutic assessment using the Rehabilitation Assessment Matrix. The decision
making tool has been trained using a wide spectrum of synthetic physiological data incorporating varying
degrees of myopathy and neuropathy from beginning stages to acute. The statistical, spectral and cepstral
features extracted from EMG have been used to train a Cascade Correlation Neural Network Classifier
for disease assessment. The diagnostic yield of the classifier is 91.2% accuracy, 85.3% specificity and
91.35% sensitivity. The strategy has also been extended to include isotonic contractions in addition to
static isometric contractions. This comprehensive strategy is proposed to aid physicians plan and schedule
treatment procedures to maximize the therapeutic value of the rehabilitation process.
Reduced Short- and Long-Latency Afferent Inhibition Following Acute Muscle Pa...Antonio Martinez
Corticomotor output is reduced in re-
sponse to acute muscle pain, yet the mechanisms
that underpin this effect remain unclear. Here the au-
thors investigate the effect of acute muscle pain on
short-latency afferent inhibition, long-latency afferent
inhibition, and long-interval intra-cortical inhibition to
determine whether these mechanisms could plausibly
contribute to reduced motor output in pain.
Learn more in how the brain functions and how important physical therapy is for recovery.
The basis of neuro rehabilitation.
Brain has an incredible adaptation capacity and here you'll know just how to...explore it
Transcranial Magnetic Stimulation ( TMS) for Chronic PainDr. Rafael Higashi
Aula sobre avanço no tratamento da dor crônica com o uso de Estimulação Magnética Transcraniana (EMT) ministrada por Dr. Rafael Higashi, médico neurologista, no departamento de tratamento da dor do Centro Médico da Universidade de Nova York, NYU, EUA.
www.estimulacaoneurologica.com.br
Abnormal changes in cortical activity in women with migraine bet.docxdaniahendric
Abnormal changes in cortical activity in women with migraine between episodes
subject
Migraine group: 21 female migraine patients (mean age: 34.6 + 6.7 years), all with right hand, ranged from 1 year to 22 years.
Healthy control group: 10 females (mean age: 30.2 + 4.3 years), all of whom were right-handed, and their education degree matched that of the migraine group
task
Flip board
Is generated by
Direct(version 9; Microsoft Inc., Redmond, WA, USA)Brain X, The white board is made up of black and white children and yellow dots at the center , The brightness of the white checkerboard is
80cd/m², The flip frequency is
1HZ,( There is a 600ms interval between the two stimuli and the duration of the stimulus is 400ms ), The image was projected by a projector about 32cm from the subject's nasal roots , Participants' perspectives and board into 30 °.
The standard set
Criteria for inclusion of migraine patients:
(1) According to the international classification of headache diseases edition 2 (ICHD).II) criteria for the diagnosis of unthreatened migraine and confirmed by neurologists
(2) Exclusion of other neurological diseases;
(3) The patient had no history of visual system and eye diseases
(4) Patients with the disease were not treated with migraine preventive drugs within 1 week before the test.
(5) No migraine occurred 72 hours before, on the day of and 24 hours after MEG examination
Inclusion criteria of healthy control group:
(1) No history of visual system-related diseases;
(2) No history of neuropsychiatric disorders
;
(3) His first-degree relatives had no history of migraine
。
Exclusion criteria for both groups:
Patients with metal implants (severely interfering with the brain magnetogram signal);
A history of other major neurological or psychiatric disorders ;
A history of extensive developmental disorders
;
A history of clinically significant systemic diseases
Cannot stay still during MEG recording and MR/scan
Don't move;
;
Subjects with claustrophobia or during pregnancy
DATA analysis ----No 1Morphology
(waveform):VEFII Is the most stable of visual evoked potential composition, therefore, the main observation indexes for this experiment, the incubation period the VEFII approximately 2.5 -100 hz frequency (latency) is relatively more clearly and wave (Amplitude) interference factors, and can reflect the strength of the temporary only, reason is not included in the result analysis.
Result:
Result --waveform
The composition of VEF II was longer in the migraine group than in the healthy control group (HC)
122±3.02ms VS 118±3.78ms(p<0.05)
trigger
Sensor level analysis
(Time–frequency analysis)
1.By Morlet continuous wavelet(CWT)polarity contour maps can be showed to Study the spatial characteristics of visual evoked potential
2. Measuring the energy characteristics of the visually induced magnetic field VEF: select the most representative channel and calculate the absolute wave energy of the VEF measured by its root- ...
In this presentation the author, David Lopez Chiropractor DC and Kinesiologyst (PT) from Chile expose about the different principles under the scope of the osteopathic manipulation of the spine. Dr. Lopez is director of the progran in Chiropractic for healh professional of the "Universidad Central de Chile" and director of the Diplomats in Manual Therapy of the "Universidad Santo Tomas de Chile. The interest is to review the fundamentals to understand the approach of the Osteopathy to the practice of the manual therapy and healthcare. This vision was exposed in Poland in the framework of an international symposium of Physiotherapy.
Magnets - Not Drugs: TMS IMMH San Antonio 2014Louis Cady, MD
In this talk, Dr. Cady covers a remarkable new treatment for depression: transcranial magnetic stimulation. The historical roots of this treatment are traced, followed by a review of the literature in terms of the proven efficacy of this treatment. A comparison with ECT shows that TMS has a very favorable profile, with remarkably fewer side effects and incredibly better tolerated side effects compared to ECT. Given that this was a "CME" talk, off-label uses of TMS were reviewed, including stepping stones for future avenues to explore
Neuroplasticity, also known as brain plasticity, is an umbrella term that describes lasting change to the brain throughout an animal's life course. The term gained prominence in the latter half of the 20th century, when new research showed many aspects of the brain remain changeable (or "plastic") even into adulthood.
EFFECT OF MIRROR THERAPY ON UPPER EXTREMITY MOTOR FUNCTION IN STROKE PATIENTSismailabinji
EFFECT OF MIRROR THERAPY ON UPPER EXTREMITY MOTOR FUNCTION IN STROKE PATIENTS
Stroke is one of the main causes of disability around the globe. plegia (complete paralysis) or paresis (partial weakness ) are common following a stroke. According to the Journal of Physical Therapy Science, about 85 percent of stroke survivors will suffer from hemiplegia, and at least 69 percent will experience a loss of motor function in the upper limb.
Although these changes may not be permanent, some people regain partial or full limb function, the road to recovery can be long. But did you know that it is possible to trick the brain into believing what it sees? Mirror therapy is being used more and more in stroke rehabilitation to dupe the brain and restore limb function.
STROKE: is defined as the rapidly developed clinical signs of global or focal disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than of vascular origin. (WHO, 2017)
MOTOR FUNCTION motor function is the ability to learn or to demonstrate the skillful and efficient assumption, maintenance, modification, and control of voluntary postures and movement patterns.
In mirror therapy, a mirror is placed beside the unaffected limb, blocking the view of the affected limb. This creates the illusion that both limbs are functioning properly.
Mirror theory is based on evidence that action observation activates the same motor areas of the brain as action execution. Observed actions lead to the generation of intended actions, engaging motor planning and execution.
Mirror neurons are type of brain cell that respond equally when we perform an action and when we witness someone else perform the same action. They were first discovered in the early 1990s, when a team of Italian researchers found individual neurons in the brains of macaque monkeys that fired both when the monkeys grabbed an object and also when the monkeys watched another primate grab the same object.
Patient characteristics
Motor abilities
Vision
Trunk control
Non affected limb
Cognitive abilities (Wade DT et al., 2011)
Informing the patient
Possible Negative effect
Environment and required materials
Surrounding
Jewellery and other marks
Mirror
The NEUROMOVE is a neurological re-learning tool, a therapy device, which has been proven to help stroke and other patients recover lost movement. Once a stroke has occurred, the brain loses neurons which cause limb weakness or paralysis. The NeuroMove can train healthy neurons to assume functions lost by damaged brain cells; a concept known as Neuroplasticity. This rehabilitation tool can be used even when there is no muscle movement available. It is sophisticated enough to use in the clinic, yet simple enough for patients to use at home. Thirty minutes a day in four to five months can provide dramatic results.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. Studies to date have used treatment regimes that involve relatively brief periods of use: 30–60 min, three to five times
per week (Fields 1987; Kraft et al. 1992; Chae et al. 1998; Francisco et al. 1998; Sonde et al. 1998; Powell et al. 1999;
Cauraugh et al. 2000) and are typically used in the clinical setting. We wanted to determine whether a longer duration
of use applied in a home use setting would produce more benefit. Thus, we investigated a combination of
electromyographically (EMG)-triggered NMES and cyclic NMES in an intensive self-operated home environment. In
addition to investigating the functional improvement associated with NMES, we were also interested in investigating
whether functional improvement was reflected in cortical activation.
Treatment with NMES to the median nerve performed during functional magnetic resonance imaging (fMRI) in
healthy subjects has been shown to activate the primary sensory and primary motor regions of the brain in the
hemisphere contralateral to the stimulation (Spiegel et al. 1999; Kampe et al. 2000). Khaslavskaia (2002), using
transcranial magnetic stimulation (TMS), found increased amplitude of motor evoked potentials (MEP) in the tibialis
anterior following NMES to the peroneal nerve. This increase was maintained for up to 110 min. Recently, Smith and
colleagues (2003) demonstrated a dose-response relationship between NMES to the lower extremity and brainactivation in sensory and motor regions contralateral to the stimulation. While these studies have lent evidence
supporting the existence of a central effect during NMES in healthy subjects, studies have not been performed on a
population suffering from stroke.
The purposes of this study were to investigate whether moderately impaired subjects with chronic stroke would
improve on functional tests of ability in the hand after intensive home treatment with NMES and whether evidence of
a long-term cortical effect could be seen 48 h after treatment ceased.
Materials and methods
Subjects
Sixteen subjects with stroke were randomly assigned either to a treatment group (N=8) or to a group receiving sham
treatment (N=8). Ages were 33–78 years (mean ± standard deviation = 60.1±14.5 years). To control for spontaneous
recovery, subjects were at least 6 months post-stroke. The mean time since stroke was 35.5±25.1 months. Subjects
were recruited by visits to stroke-support groups, by advertisements in local newspapers, and through contacts with
physical and occupational therapists in the region. The neuroanatomical location of the stroke and the subjects
demographic data are recorded in Table 1.
Table 1 Characteristics of subjects
Subject
Group
Sex
Age
(years)
Hemiplegic
side
Poststroke
(months)
Stroke location
MiniMental
Prestroke
handedness
Modified Ashworth Tone
Scale
1
Sham
F
75
Left
7
R posterior putamen, PLIC
26
Right
2
Sham
M
68
Right
16
L PLIC
30
Right
E=1, W=1
3
Sham
M
41
Left
68
R MCA distribution
29
Right
E=1+, W=2+, Fi=1
4
Sham
M
78
Right
69
L posterior putamen, PLIC
29
Right
W=1+, T=1, Fi=1+
56
R posterior putamen, PLIC,
external and extreme capsule
29
Left
E=1,W=1+,Fi=1+
5
Sham
6
Sham
M
60
Right
10
L upper pons
29
Right
0
7
Sham
M
46
Right
74
L putamen
29
Right
E=1+, W=1+
8
Sham
M
59
Left
8
R posterior putamen, PLIC
28
Right
0
9
Treatment
M
68
Right
22
L thalamus, PLIC
27
Right
Fi=1+
10
Treatment
M
58
Right
11
L PLIC
30
Right
S=2, E=1+, W=3, Fi=2
Treatment
F
65
Left
23
R pre/post central gyrus,
interparietal sulcus
30
Right
S=1,E=2,W=1+,Fi=2
12
Treatment
M
67
Right
11
L inferior parietal, PLIC,
putamen
28
Left
0
13
Treatment
M
75
Left
12
R cerebral peduncle
27
Right
E=1,W=2, Fi=2
14
Treatment
M
40
Left
51
R MCA distribution, cortical
only
28
Right
S=2,E=2,W=3,T=3,Fi=3
15
Treatment
F
61
Right
58
L putamen, PLIC
28
Right
0
16
Treatment
F
33
Left
39
R internal capsule
30
Right
E=1, W=1+, Fi=1+
11
F
75
Left
E=1,W=1,Fi=2
M male, F female, PLIC posterior limb internal capsule, MCA middle cerebral artery, S shoulder, E elbow, W wrist, Fi fingers, T thumb
2
3. NMES has previously been shown to be most effective in results for the mild to moderately impaired patient (Chae
and Yu 2000), so we required that subjects have at least 10 deg of active flexion/extension movement at the
metacarpophalangeal (MP) joint of the index finger. Since independent operation of the stimulator was also a
requirement, mental capacity was tested using the Mini-Mental State Examination (Folstein et al. 1975) and we
required subjects to have a score of 25 out of a possible 30. The University of Minnesota Internal Review Board and
the General Clinical Research Center approved this study. All subjects gave informed consent.
Instrumentation and procedure
All subjects were tested a minimum of two times. Those in the treatment-receiving group were tested pre-test and posttest. Those in the group receiving sham treatment were tested pre-test, post-test, and again at post-crossover (after the
true treatment had been given).
Functional testing
The following tests were conducted: Box and Block, Motor Activity Log, Jebsen Taylor Hand Function Test, isometric
strength of the index finger extension, finger-movement tracking, and fMRI. A trained investigator with 7 years
experience as a physical therapist and who was blinded to the designation of the subject s group performed all testing.
Box and block test
Changes in functional grasp and release of objects were tested using the Box and Block Test (BB) (Mathiowetz et al.
1985). The BB Test has been used previously to examine for functional gains in manual performance following
treatment in subjects with stroke (Cauraugh et al. 2000; Carey et al. 2002). Subjects performed three timed (60-s)
trials. The dependent variable was the average number of 2.54-cm3 blocks transported from one side of a partitioned
box to the other. Good reliability and validity of the BB Test has been reported (Desrosiers et al. 1994; Carey et al.
2002).
Motor Activity Log
The Motor Activity Log (MAL) (Taub et al. 1993) was used because it is an indicator of real world function as
judged by the subject. The MAL is a structured interview during which patients indicate how often and how well they
use their paretic arm in 30 activities of daily living such as using a fork or spoon for eating, picking up the telephone,
and using a key to unlock a door. The MAL has been shown to be a reliable instrument (Miltner et al. 1999). For each
task the subject rates the ability of the hemiplegic hand on a 0–5 scale for two different categories: amount of use
(AS), and how well (HW) the hand performs. A score of zero indicates that the affected hand is not used for that task
and a score of 5 indicates that the affected hand performs that task as often as before the stroke or as well as before the
stroke. A summary score is used, which is the average of all activities for each category.
Jebsen Taylor Hand Function Test
The Jebsen Taylor Hand Function Test (JTHFT) (Jebsen et al. 1969) is composed of seven timed testing activities,
including: 1) writing a sentence, 2) turning over cards, 3) picking up small objects (e.g., pennies, paper clips) and
placing them in a container, 4) stacking checkers, 5) simulating eating, 6) moving large empty cans, and 7) moving
large weighted cans. Since some of the subjects were using their (pre-stroke) non-dominant hand, we excluded the
handwriting portion of the test for all subjects. This test has been shown to have good validity and reliability (Jebsen et
al. 1969).
Strength
Strength of finger extensors was measured using a load cell (Model SM-50, Interface, Scottsdale, AZ, USA). With the
subject s wrist in neutral and the metacarpophalangeal (MP) joint in 70 deg of flexion, the proximal phalanx of the
index finger was connected to the load cell. The subject performed three 5-s maximal voluntary isometric contractions,
separated by 1-min rests. The dependent variable was the average peak force of these three trials, recorded in Newtons
(N). The load cell was calibrated before each testing session and was found to have a maximum of 2.5% error in
reading compression-forces over the range of 2–200 N.
3
4. Finger-movement control
Precision in control of finger movements was measured with a finger-movement tracking task that the subject
performed during the fMRI (Carey et al. 1994, 2002). An electrogoniometer attached to the MP joint of the hemiplegic
index finger was connected to a computer displaying a sine wave (0.4 Hz) that served as a target for the subject to
track using the computer screen cursor. The subject s uninvolved hand was lightly holding a rubber bulb that he or she
could squeeze to gain our attention during the scanning. This served not only as device for communication, but also as
a method to deter any mirror movement of the uninvolved hand. Once positioned inside the magnet, the subject
tracked for approximately half a minute to adjust to the task. This allowed an investigator to monitor for any mirror
movements (Cramer 1999). No subjects displayed mirror movement while under observation.
The complete tracking test lasted 6 min and consisted of the following phases, each of 1 min in duration, making up
the model used for activation analysis: control 1, task 1, control 2, task 2, control 3 and task 3. For each control
phase, the subject merely watched the screen but exerted no effort. For each task phase, the subject looked at the
screen and attempted to track the sine wave as accurately as possible using careful finger-extension and finger-flexion
movements. The amplitude of the sine wave was standardized to each subject s active range of motion at the MP joint
of the index finger, as recorded during set-up. With maximal flexion set as 0% of the subject s active range and
maximal extension set as 100%, the extension (upper) peaks of the sine wave were set at 125% of the range and the
flexion (lower) peaks were set at 15% of the range. The range used originally at pre-test was the range used at posttest. The upper peaks were set above the subject s full range to allow for any increases in extension range that might
occur from treatment.
fMRI
Images of the brain were collected on a customized, 4.0 Tesla whole-body research MRI system (Oxford, UK). A head
volume coil (Vaughan et al. 2001) was used to allow for the collection of images over the entire volume of the brain.
Padding was used around the head to minimize movement.
T 1 -weighted inversion recovery magnetic resonance (MR) images were obtained in the transverse, coronal, and
sagittal planes for anatomical localization (multi-slice turboFLASH sequence, echo time (T E ) = 5 ms, repetition time
(T R ) = 9 ms, inversion time (T I ) = 1.2 s, in-plane resolution = 1.56×1.56 mm, slice thickness=5 mm, 2 averages
(NEX)). These images were used at the time of the experiment to determine the appropriate volume for the subsequent
functional images, and again in post processing to identify landmarks such as the anterior and posterior commissures
for standardizing into Talairach space.
Blood oxygen level-dependent (BOLD) T 2 *-weighted functional MR images were obtained in the transverse plane
using a blipped echo-planar imaging (EPI) sequence with a T E of 25 ms. The total imaged volume extended from the
superior pole of the cortex to a depth of 135 mm in 24 slices. Functional images had an axial in-plane resolution of
3.125×3.125 mm and a 5-mm slice thickness. Each set of 24 images was acquired in 3.0 s during the 6-min
experiment.
Treatment
Group receiving electrical stimulation
The goal was to investigate intensive home use of electrical stimulation, thus the amount of treatment selected was 60
total hours of use. All subjects were instructed in the operation of the electrical stimulator at the first visit (pre-test).
Since the exclusionary criteria required that the subject have good cognitive ability, all subjects were able to apply this
machine safely. We maintained contact with the subjects by telephone at least weekly to answer any questions and
encourage compliance. Subjects were instructed to use the machine 6 h per day, for 10 days over the course of
3 weeks. Subjects maintained records of use to show compliance. Records were analyzed visually to look for any
differing patterns of use. All subjects completed the required total time use and the patterns of use were very similar,
typically 3–6 h per day every day or every other day.
The device used for treatment was the Automove Model AM 706 Stimulator (Danmeter, Boulder, CO, USA). In this
device the electrodes function as both EMG pickup and stimulation delivery. The EMG activity detected from
underlying muscles must reach a set threshold that then triggers electrical stimulation to the muscles, producing
4
5. stronger contractions than those achieved voluntarily. This then gives sensory bombardment centrally through
cutaneous and proprioceptive afferents. The stimulation threshold is pre-programmed by the manufacturer to start at a
high level and then is automatically lowered in a step-wise fashion until the subject s EMG effort does succeed in
reaching threshold. Once triggered, the stimulator delivered pulses (pulse width 200 µs, asymmetrical rectangular
biphasic, constant current) at 50 Hz and intensity was set to produce finger- and wrist-extension movements. The
duration of the resultant evoked contraction following the initial trigger lasted 5 s plus a 1-s ramp-up and a 1-s rampdown. A 15-s rest period occurred between contractions to minimize fatigue. Half of the treatment time was spent with
active effort on the subject s part required to trigger a stimulated response (trigger mode), while the other half of the
time was spent with the machine automatically stimulating the muscle to contract cyclically without any volitional
trigger from the patient (cyclic mode). This was done because pilot work suggested that due to the conscious effort
required, it was too difficult to schedule the full treatment of trigger mode into each day. No instructions were given to
encourage increased hand use or to modify behavior in any other way.
Group receiving sham treatment
Subjects randomly assigned to the group receiving sham treatment received the same instructions as the EMG
treatment group. Subjects receiving sham treatment used a very similar device (Automove Model 700S, Danmeter,
Boulder, CO, USA) that shows a light when the device is in the on phases, and they were told to advance the
current dial to an indicated level; however, the machine did not deliver any current. They were told that there are
different levels of stimulation being studied and that they may not feel the level assigned to them. As with the true
treatment, for half the hours of treatment, the subjects were asked to lift the hand actively when the light came on and
the stimulation started. At the conclusion of the period of sham treatment, all subjects were retested (post-test) and
then crossed over to receive the true stimulation, in exactly the same manner as the group receiving true treatment.
Subjects in this group also were monitored by phone and maintained records of compliance both during the sham
treatment and after the crossover. Seven of eight subjects were then retested following completion of the real treatment
(post-crossover). One subject was unable to complete post-treatment testing due to an unrelated hospitalization.
Analysis of data
Tracking
The computer quantified the tracking performance in each of the three task periods of the 6-min tracking test inside the
magnet by calculating an accuracy index (AI) (Carey 1990). The maximum possible score is 100%. Negative scores
are possible. Previous work showed good reliability in the average accuracy index with ICC values ranging from 0.92
to 0.97 for subjects with stroke (Carey 1990). The validity of the finger-movement tracking test in discriminating
between the performance of healthy subjects and subjects with stroke has been demonstrated (Carey et al. 1998).
fMRI
Analysis of the MR images was done on a Sun Ultra 60 (Sun Microsystems, Palo Alto, CA, USA) workstation using
the interactive image analysis software Stimulate (Strupp 1996). The raw data for each individual were logtransformed and detrended. The logarithmic transformation was dictated by the lack of normality in the distribution of
activation intensities (Lewis et al. 2002). The detrending was necessary due to the presence of time trends; control and
task periods were detrended following the log transformation. To eliminate large vessel contributions, a mask was
applied to the functional data (Kim et al. 1994). Two types of fMRI analysis were performed: voxel count and
intensity.
Voxel count
Our predefined area of investigation for this analysis included bilateral frontal and parietal lobes. Activation was
determined using a cross-correlation ( boxcar ) method correlating the hemodynamic response in comparison with the
alternating control and task phases in our activation model. The activation model is defined by the sequence of magnetic
resonance scans that correspond to each task or control phase and takes into account the lag in blood flow change
that occurs with activation (Ugurbil et al. 1999). A voxel was considered active if it met or exceeded a predetermined
threshold of correlation (r=0.40) and formed part of a cluster (>3) of contiguous voxels that also met or exceeded this
threshold. In this method of analysis, the question was whether NMES treatment produced a change in the number of
active voxels in a given brain area during the finger-tracking task. The anatomical location of each cluster of active voxels
5
6. was recorded to each hemisphere (either contralateral or ipsilateral to tracking hand) as determined by Talairach
coordinates (Talairach and Tournoux 1988). These locations were as follows: gyrus postcentralis, gyrus precentralis, gyrus
frontalis superior, gyrus frontalis medius, gyrus frontalis inferior, precuneus, gyrus cinguli, lobulus paracentralis, lobulus
parietalis inferior and gyrus frontalis medialis. The investigator analyzing the data was blinded as to the group of each
subject. Under these conditions, we estimate the resultant value of significance for active voxels to be at p<0.001 (Xiong et
al. 1995).
Intensity
The intersession variability of the MR signal in voxel count has been found to be consistently higher than the
variability of signal intensity, suggesting that the latter is a more reliable indicator of cortical activation (Waldvogel et
al. 2000). In measurements of intensity, the question was whether subjects who have received NMES show a different
intensity of activation during the task period. That is, NMES may not increase the number of voxels that are active but,
instead, may increase the BOLD signal intensity for the average of all voxels in a given region of interest. For this
measure, analysis was restricted to the gyrus precentralis (GPrC) and gyrus postcentralis (GPoC). The increase in
signal suggests that there is increased neural activity (thus increasing BOLD signal) but does not specify whether this
is excitatory or inhibitory.
We chose GPoC and GPrC as the most likely areas to demonstrate change in intensity given the results from imaging
studies conducted during NMES (Hamdy et al. 1998; Spiegel et al. 1999; Kampe et al. 2000; Stefen et al. 2000; Abo et
al. 2001; Backes et al. 2002; Fraser et al. 2002; Kaelin-Lang et al. 2002; McKay et al. 2002; Smith et al. 2003).
For each region separately, we calculated an Intensity Index (II):
(1)
where IntensityTASK is the average signal intensity during the task periods and IntensityREST is the average
signal intensity during the rest periods. There is intrinsic variability in signal intensity between and within subjects
(Cohen and DuBois 1999), making direct comparisons on raw intensity values difficult. Normalizing the task data to
the rest data allows for intersubject and intrasubject comparisons (Georgopoulos et al. 2001). The information was
obtained by drawing regions of interest around GPoC and GPrC at each level of the MRI scan containing the specified
region. The precentral gyrus was defined as the area bounded anteriorly by the precentral sulcus, posteriorly by the
central sulcus, medially by the sagittal fissure, and laterally by the sylvian fissure. The postcentral gyrus was the area
bounded anteriorly by the central sulcus, posteriorly by the postcentral sulcus, medially by the sagittal fissure, and
laterally by the sylvian fissure. Sulci were identified according to Ono and colleagues (1990). This analysis has an
advantage of not having any arbitrary threshold applied. Intensity Index values are in arbitrary units.
Statistical analysis
Two group t-tests were done to determine equality between groups at baseline on all variables. All data from
functional tests were analyzed with preplanned, one-tailed, paired t-tests if the data were normally distributed or
Wilcoxon Signed-Rank tests if not. The brain activation data (both voxel count and intensity index) were analyzed
using two-tailed paired t-tests. Statistical significance was set at p<0.05.
Results
All subjects (N=16) were included in the tests of hand function, but of those subjects the MRI data from four were
discarded due to excessive head movement (one subject from the treatment group and one from the sham group). Of
the five remaining subjects in the sham group, one subject was unable to complete post-crossover testing due to an
unrelated hospitalization. So the brain activation analysis is based on seven subjects in the group receiving EMG
treatment, five in the group receiving sham treatment, and four at post-crossover. The analysis to determine
equivalence between groups at baseline showed no significant differences between groups for either behavioral or
cortical data.
6
7. Changes in functional performance
There was significant improvement in performance for the group receiving treatment on the following functional tests:
Box and Block, isometric finger-extension strength, MAL (AS and HW) scores, and in the JTHFT for small objects,
stacking, and heavy cans. There was a trend toward improvement in the JTHFT for page turning (p=0.053). The group
receiving sham treatment improved in isometric finger-extension strength, but no other test. Following crossover for
the group receiving sham treatment, subjects improved from post-test on Box and Block, isometric finger-extension
strength, MAL (AS and HW) scores, JTHFT for page-turning, and feeding. There was a trend toward improvement in
JTHFT for small objects (p=0.060). There was no improvement in the tracking task performed during the fMRI for
either group. Table 2 summarizes all data of functional tests.
Table 2 Functional test scores (mean ± standard error) for groups receiving NMES and sham treatment
NMES treatment
Test
Pre-test
Post-test
Significance
Sham treatment
Pre-test
Post-test
Significance
Sham-crossover comparison
Pre-crossovera Post-crossover
Box/block (blocks)
23.7±4.0
27.0±4.8
t(7)=2.06,p=0.039 23±6.1
24.3+6.1
NS
Strength (Newton s)
9.2±1.7
12.9±7.9
z(7)=2.52,p=0.006 7.05±2.5
8.9±2.3
t(7)=2.91,p=0.01 8.42±2.59
MAL: AS
1.5±0.27
1.9+0.82
t(7)=7.6,p<0.001
1.3±0.71
NS
1.3±0.29
1.8±0.39
t(6)=2.63,p=0.008
MAL: HW
1.6±0.97
2.1±0.84
t(7)=3.82,p=0.003 1.3±0.62
1.4±0.73
NS
1.3±0.29
1.7±0.43
t(6)=2.63,p=0.020
NS
19.5±4.3
NS
21.1±4.58
15.±2.8
t(6)=2.82,p=0.015
z(7)=2.31,p=0.043 49.3±16.5 41.4±12.6 NS
45.6±13.8
33.7±9.5
NS
JTHFT: page turn (seconds) 31.1±12.7 17.1±5.7
Small objects (seconds)
41.9+13
25±5.3
Feeding (seconds)
6.9+2.62
6.7±2.52
Stacking (seconds)
43.7±15.9 25.3±7.6
Light cans (seconds)
35.7±25.2 34.9±25.8 NS
Heavy cans (seconds)
45.1±35
Tracking accuracy (%)
–23±17
1.4±0.7
28±9.2
27.9±6.9
21.7±6.3
Significance
26±6
t(6)=3.42,p=0.007
11.1±2.5
t(6)=3.4,p=0.007
NS
32.8±8.5
NS
29.6±7.66
20.6±4.2
t(6)=2.20,p=0.023
z(7)=2.31,p=0.01
42.5±15.6 56.7±26.6 NS
63.6±29.7
32.1±10.4
NS
14.4±5.7
10.8±2.1
NS
11.8±2.43
12±4.7
NS
42.4±35
t(6)=4.21,p=0.002 37.8±27
30.8±21
NS
37.3±21
12.2±2
NS
–30.±21
NS
–17.1±16 –6.2±16
NS
–8.3±18
–13.7±19
NS
MAL Motor Activity Log, AS amount of use score, HWhow well score, JTHFT Jebsen Taylor Hand Function Test, NS not significant
a
Pre-crossover scores are different from group receiving sham treatment post-test scores because one subject was unable to complete true treatment
Cortical activation data
Voxel count
There were no changes in voxel count from pre-test to post-test in any of the designated anatomical areas in either
hemisphere for either group. Figures 1 and 2 summarize the data on voxel counts for the ipsilateral and contralateral
hemispheres, respectively.
Fig. 1 Voxel count analysis data for ipsilateral (nonlesioned hemisphere) anatomical areas while tracking with hemiplegic right
hand before (pre) and after (post) NMES or sham. GPoC gyrus postcentralis, GPrC gyrus precentralis, GFs gyrus frontalis superior,
GFm gyrus frontalis medius, PCu precuneus, GC gyrus cinguli, LPi lobulus paracentralis, GFd gyrus frontalis medialis
7
8. Fig. 2 Voxel count data on contralateral (lesioned hemisphere) anatomical areas while tracking with hemiplegic hand before (pre)
and after (post) NMES or sham. GPoC gyrus postcentralis, GPrC gyrus precentralis, GFs gyrus frontalis superior, GFm gyrus
frontalis medius, PCu precuneus, GC gyrus cinguli, LPi lobulus paracentralis, GFd gyrus frontalis medialis
Intensity
In the group receiving treatment, there was a significant (p=0.046) increase in the Intensity Index from pre-test to posttest in the GPoC area in the hemisphere ipsilateral to the hemiplegic (treated) hand. There was no change in the
ipsilateral GPrC or in the contralateral GPoC or GPrC in the group receiving treatment. The Intensity Index did not
change in any area in the sham group. The scores for mean Intensity Index are reported in Table 3. Figure 3 is a graph
showing individual pre-test and post-test Intensity Index scores for the ipsilateral GPoC.
Table 3 Intensity Index values for groups receiving NMES and sham treatment (mean ± SE)
NMES treatment
Pre-test
Post-test
Significance
Sham treatment
Pre-test
Post-test Significance
Ipsi GPoC
0.16±0.07 0.24±0.09 t(6)=2.52,p=0.045 0.33±0.06 0.16±0.09 NS
Ipsi GPrC
0.25±0.05 0.34±0.12 NS
0.26+0.09 0.18±0.09 NS
Contra GPoC 0.13±0.05 0.23±0.09 NS
0.25±0.15 0.35±0.16 NS
Contra GPrC 0.16±0.05 0.16±0.08 NS
0.37±0.15 0.37±0.12 NS
Ipsi ipsilateral hemisphere, Contra contralateral hemisphere,GPrC gyrus precentralis, GPoC gyrus postcentralis
Fig. 3 Intensity Index values for gyrus postcentralis (GPoC) for each subject at pre-test and post-test
In the subjects receiving sham treatment, after crossover there were fMRI data from only four remaining people. There
was a mean Intensity Index increase in the ipsilateral GPoC, with a pre-test mean of 0.227 and a post-test mean of
0.377. Due to the low N, this was not a significant difference.
8
9. Discussion
The important findings of this study were that NMES, when performed in an intensive manner, produced significant
improvements in functional activities in the group receiving NMES treatment. The group receiving sham treatment
only showed gains in strength without functional improvements from pre-test to post-test; however, after crossing over
to receive treatment, they showed significant functional gains that mimicked the group receiving NMES treatment. We
did not find a change in the number of active voxels in any neuroanatomical area in the group receiving NMES
treatment, but the treatment group had a significant increase in the intensity index for the GPoC ipsilateral to the
paretic hand, whereas the group receiving sham treatment did not.
Functional tests
We chose functional tests that would focus on finger movements, particularly finger extension, since controlled release
of an object is the function we expected to improve the most with the NMES treatment. The BB test and JTHFT
focused on this function. We chose the MAL because we were also interested in the subjects own assessment of
whether improvements would transfer into hand use in daily activity. We examined isometric finger-extension strength
of the index finger as a separate variable.
The BB test and the small objects and stacking components of the JTHFT specifically tested the ability to pick up and
release small objects. The group receiving NMES treatment improved performance on all these tests. In addition, this
group improved on the component of the JTHFT, which tests grasping and releasing of a heavy can object. This, in
combination with the finding that the group receiving sham treatment did not improve on these functions, suggests that
the improvement was due to a real treatment effect and not to expectation effects associated with any treatment. The
finding that the group receiving sham treatment did improve on the BB test and the page-turning and simulated
feeding components of the JTHFT after crossing over to receive the real treatment adds strength to this interpretation.
We attribute the absence of significant improvement, although trends were observed, on small objects and stacking
components of the JTHFT to the reduced power associated with the loss of one subject following the sham period.
Both the treatment and the sham groups showed significant increases in strength. We believe that the improvement in
strength in the group receiving sham treatment stems from repeatedly extending their fingers voluntarily in synchrony
with the stimulation phases of the sham treatment. We elected to have all subjects perform this voluntary
movement so that the only difference between the two groups would be the stimulation itself. Although this repeated
movement may have been sufficient to improve strength in the sham subjects, it did not translate into improved
functional hand movements. Thus, functional hand movements may depend more on orchestrating synergistic control
of multiple muscular forces than on sheer strength alone, and the possibility exists that NMES helps to activate
neurons that can improve such control.
The MAL showed significant improvement in the AS and HW scores in both the group receiving treatment and in the
group receiving sham treatment after they had crossed over and received the true treatment. The mean changes
reported were quite small, however, and it is not clear that the statistically significant changes we observed translate to
being clinically significant. The MAL asks a wide variety of questions that could be limited by restricted motion in the
shoulder or elbow, which our intervention did not strive to improve, such as getting out of the car , combing your
hair , or shaving . Thus, a large improvement in a few activities such as carrying an object in your hand and
removing an item of clothing from a drawer could produce only a modest gain in composite score, but a profound
gain in function of particular tasks. Consequently, the MAL may not be the best indicator of improved performance for
interventions narrowly focused to such a specific function as finger and wrist extension. It is possible that the
increased use of the hand was the source of other effects unique to the treatment group. We feel this is unlikely,
however, given that the amount of increased use was quite small (1.5–1.9) and of questionable clinical relevance.
The tracking task failed to show improvement in any group. This task was chosen because it challenges subjects to
execute carefully controlled finger movements, which more closely resemble functional activities than the often used
finger opposition task. Finger-movement tracking requires visual spatial control of flexion and extension
movements (Carey et al. 1998). It has previously been shown that tracking performance can be improved in subjects
with stroke (Carey et al. 2002) with training in finger tracking, which is intended to challenge and develop such
control. In the current study, however, the intervention did not involve visual spatial problem solving or training of
precision finger movements. These results, along with earlier results (Carey et al. 2002), invite further research to
examine whether NMES combined with tracking training may produce greater gains in functional hand movements
than either treatment alone. More research is also required to determine whether a different functional task would have
revealed similar cortical results.
9
10. Cortical changes
Others have shown in healthy subjects that NMES given during fMRI (Spiegel et al. 1999; Backes et al. 2000; Kampe
et al. 2000; Smith et al. 2003) or TMS (Ridding et al. 2000, 2001) increases activation (as measured by voxel count)
contralaterally in the sensorimotor cortex. Intensity of activation has not been reported. Testing has not been done on
human subjects with stroke, but in rats that have recovered from induced stroke, receiving NMES to the recovered
hindlimb during fMRI activates the ipsilateral, non-infarcted hemisphere (Abo et al. 2001).
Importantly, in a related study, patients with acute stroke were studied during pharyngeal stimulation, and it was found
that there was a marked increase in the pharyngeal topographic motor representation in the undamaged (ipsilateral)
hemisphere as measured by TMS (Fraser et al. 2002). Our results, combined with these findings, provide mounting
evidence that there is a cortical component to NMES. However, our finding may simply be demonstrating the
consequence of the individual stroke damage interacting with NMES whereby the ipsilateral pathway is the primary
mechanism available.
In studies investigating recovery processes after stroke there is an emerging hypothesis that the activation in the stroke
hemisphere is predictive of better recovery (for review see Calautti and Baron 2003). Indeed, the uncrossed cortical spinal
tract has only marginal physiological function as demonstrated by transcranial magnetic stimulation studies in normal
subjects but is activated during complex motor tasks (Carr et al. 1994). This could indicate a role for ipsilateral control in
the early recovery stage following stroke (Calautti and Baron 2003) or when an individual with stroke is receiving
treatment, as in the current study.
Since there was an increase in the Intensity Index in the ipsilateral GPoC, why was there not also an increase in voxel
count? Voxel count and intensity do not mirror each other in what they are measuring. In our voxel count analysis,
significance is based upon activation following the time course of the signal relative to the model, whereas the
intensity index is based on the amplitude of the signal during the task relative to rest (Carey et al. 2003). The
possibility exists that the time course of the changing signal could fail to reach the correlation threshold for
activation, but have a large difference in signal amplitude creating a significant change in the Intensity Index.
The other question that remains to be answered is why there was evidence of functional improvements, but no change
in motor cortex activation (either Intensity Index or voxel count). There are a number of possible reasons. The answer
could lie in the type of intervention. The key to achieving voxel count reorganization may be active engagement. In
NMES treatment, even with active effort triggering the stimulation, there is repetition, but it does not require any
cortical problem solving. It has been shown that active repetitive movements are a key factor in recovery from stroke
(Taub et al. 1993; Nudo and Milliken 1996; Nudo et al. 1996b; Feys et al. 1998), but beyond simple repetition, an
element of problem solving is also required. This finding was illustrated in the study by Plautz and colleagues (2000)
in which monkeys who were trained in a repetitive easy task did not produce functional reorganization of cortical
maps, whereas monkeys trained in a difficult task that required improvements in a motor skill did produce taskrelated changes in movement representations in the motor cortex (Nudo et al. 1996a). Also using intracortical
microstimulation (ICMS) in monkeys recovering from an induced lesion, the use of a restraint jacket to the healthy
limb alone resulted in no change in mapped hand representations in the brain beyond that seen with spontaneous
recovery, but with the added component of repetitive problem solving, the area of hand representation expanded (Friel
et al. 2000).
Relatedly, Kleim and colleagues (1997) showed evidence of significantly greater neuroplastic change in rats that were
trained in an acrobatic walkway condition requiring problem solving compared with rats that experienced the simple
walkway condition. In our case, the repetitive practice of opening and closing one s hand (as in the group receiving
sham treatment) did increase strength, but did not improve any other measure of functional ability, nor was there any
evidence of cortical changes. When the repetitive task of hand opening and closing was paired with electrical
stimulation, there was now sufficient intervention to produce improvement in functional tests and produce a change in
cortical intensity in the sensory cortex, but not in the motor cortex. Additionally, the result that strength increases
alone do not produce cortical reorganization has also been shown in rats in a study that found that skilled forelimb
movement, not increased forelimb strength, was associated with a reorganization of forelimb movement
representations within the motor cortex (Remple et al. 2001).
With these results we can speculate that simple repetition of movement does not produce changes in cortical
activation, but if it is paired with somatosensory stimulation provided by NMES, there is evidence of cortical effects.
The fact that the change was in the sensory cortex instead of the motor cortex may also reflect an increased
10
11. sensitization of those neurons associated with finger movement, which might indicate an LTP-like process (Butefisch
et al. 2000).
Another potential reason for the lack of an increased active voxel count may be related to the time interval between the
last treatment session and the post-test. McKay and colleagues (2002) suggested that a longer period of stimulation
may produce a longer duration of cortical effect. Certainly, our treatment protocol of stimulation over 3 weeks was of
long duration, but our post-test was also long after (48 h) the last treatment. This duration was selected because we
were most interested in long-term effects, not immediate affects during or after the stimulation.
Somewhat related to simple NMES treatment is a treatment involving low-frequency (0.05 Hz) stimulation to the
median nerve paired with TMS to the motor cortex. In one study the investigators treated healthy subjects for 30 min
and found an increase in the motor cortex excitability that reverted to pre-stimulation levels within a few hours (Stefen
et al. 2000). Another study that followed a similar protocol but repeated it over 3 consecutive days showed that the
increased excitability persisted for 2 days (McKay et al. 2002). Further investigation is required to determine whether
voxel count changes can be observed immediately after NMES treatment in subjects with stroke.
The third potential reason for lack of increased voxel count may be due to the fact that there was not a behavioral
improvement in the tracking test, the task performed during fMRI. Further investigation is needed to determine
whether a grasping task would have shown a reorganizational change.
Mechanisms
There are three major processes that have been proposed to be of importance in recovery from stroke: 1) peri-infarct
reorganization (Nudo et al. 1996b); 2) neural plasticity, with an increase in dendritic branching in the contralateral
hemisphere (Jones and Schallert 1994); and 3) increased activation in the ipsilateral (non-infarcted) hemisphere
(Aizawa et al. 1991; Cao et al. 1998). Our finding of an ipsilateral cortical effect from an intervention has been
observed often in subjects with stroke (Weiller et al. 1993; Nelles et al. 1999, 2001), but has been shown to be
associated with poorer stroke recovery (Calautti and Baron 2003). It is hypothesized that after cerebral damage,
normally suppressed ipsilateral motor tracts may become unmasked by a lack of inhibitory control from the affected
hemisphere (Caramia et al. 1996; Ziemann et al. 1999) or activated due to excess recruitment (Calautti et al. 2001) and
that this may be a pattern that benefits acute or subacute stroke recovery.
Indeed, somatosensory input is required for accurate motor performance and for learning new skills (Panizza et al.
1992) and a reduction of sensory input by local anesthesia impairs motor control in healthy subjects (Aschersleben et
al. 2001). Also, in patients with stroke, somatosensory deficits are associated with a slower recovery of motor function
(Reding and Potes 1998). Therefore, increased sensory input via ipsilateral pathways may be an important recovery
mechanism in motor learning in subjects with stroke.
The majority of work with NMES and the great majority of all rehabilitation procedures has been done on subjects
with at least some motor function. More research is needed with single and additive rehabilitation procedures on
subjects with severe paralysis to explore effectiveness as well as cortical changes. Current work invites more research
to determine whether the augmented proprioceptive feedback from NMES with its possible facilitatory effect on the
sensory cortex, as shown here, combined with effects of challenging motor skill training such as tracking training
(Carey et al. 2002, 2003) might be more effective than either treatment given alone.
In conclusion, the novel findings of this study were that NMES could be effectively self-administered by stroke
patients in a home-use environment in an intensive manner. Repetitive movements, without NMES, did cause an
increase in strength, but this increase did not translate into improved hand function nor give evidence of cortical
change. Repetitive movements with NMES were effective in producing improvements in hand function and were
associated with an increase in the cortical intensity index in the ipsilateral primary sensory cortex. No changes were
seen in the motor cortex in either hemisphere, perhaps signifying the need for active engagement in rehabilitation to
facilitate motor cortex changes.
Acknowledgements We gratefully acknowledge the support for this work from the National Institute on Disability and
Rehabilitation Research (US Department of Education #H133G010077) and the National Institutes of Health (National Centers for
Research Resources P41RR08079 and M01RR00400).
11
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