International Journal of Neurorehabilitation

Characterization of open-field behavior and locomotor activity is widely used to assess the influence of a drug on animal behavior. In this study, we developed an index to characterize the behavior of drug-administered mice (C57BL/6). A three-exponential-model exhibited the best fit to the log-log plots of moving duration vs. frequency data of the different probability density functions. Therefore, as a heuristic argument, we divided each walking event into three categories according to the duration of movement. Then, we examined the number of walking events, and travel distances in each walking categories. Significant differences were observed more often when walking events were divided into the three categories. Therefore, this process would be useful to detect the effect of drugs on locomotor activity in mice.

The relation between psychiatry and epilepsy remains one of the topics that have been continuously attracting attention in medical literature since the time of Hippocrates. Forced normalization was later conceptualized when biological treatment for psychiatric disorders was developed. Recently, several reports were published regarding possible adverse psychiatric effects of antiepileptic medications. The picture is further complicated by the fact that psychotropic medications, which may be used for treatment of psychiatric disorders in epilepsy, can have negative effects on seizure control. This paper aimed to review psychiatric presentations in individuals with epilepsy and the adverse psychiatric effects of antiepileptic medications. The paper also briefly discusses available treatment options with regards of better psychotropic treatment options. Recent developments in this field led to the observation that psychiatric symptoms, in relation to seizure, can be categorized into the following types pre-ictal, post-ictal, inter-ictal and ictal symptoms. Depression and anxiety are commonly associated with epilepsy and can occur as pre-ictal, ictal, post-ictal or inter-ictal symptoms. Depression can be severe and suicidal behavior has been reported as one of the common psychiatric associations with epilepsy and has also been linked to use of some antiepileptic drugs. Psychosis can occur as an acute or chronic form. Transient pleomorphic postictal psychosis particularly observed in those with hippocampal sclerosis. There is an increased risk of developing schizophrenia and schizophrenia-like psychosis in patients with epilepsy. Psychiatric symptoms can also emerge during use of some of the antiepileptic drugs. Adverse psychiatric events include depression, psychosis, suicidal risk, and cognitive impairment. Some of the psychotropic medications are known to be epileptogenic. Therefore, selection of psychotropic medications should be based on their possible effects on seizures and those known to be epileptogenic should be avoided.

The aim of this study was to investigate the possible effects of flooring and affected hemi body on the ground reaction forces and on the required coefficient of friction (RCOF) in stroke barefoot gait. Twenty-four volunteers participated in this study, being 12 stroke patients and 12 age-matched healthy subjects as control group. The participant was oriented to walk barefoot, on its own preferred speed, over two force plates on the following flooring: 1) homogeneous vinyl (HOV); 2) carpet; 3) heterogeneous vinyl (HTV); 4) mixed (the first half part of the pathway were covered by HOV and the second by HTV). All the four surfaces presented safe coefficient of friction (ranging from 0.44-0.55) and they are widely used in residences and public facilities. The flooring effect was found on RCOF during the toe off for the affected and unaffected side. Moreover, differences among hemi bodies for RCOF in heel contact and toe off phases were also observed. The control group presented higher RCOF than the stroke unaffected and affected side, and the unaffected showed higher friction than the affected side. In conclusion, the gait of stroke patient was altered due to the four flooring tested in the toe off phase.

Stroke is a leading cause of disability in the United States. Available treatments for stroke have only a modest effect on motor rehabilitation and about 50-60% of stroke patients remain with some degree of motor impairment after standard treatment. Non-invasive brain stimulation (NIBS) techniques have been proposed as adjuvant treatments to physical therapy for motor recovery after stroke. High frequency rTMS and anodal tDCS can be delivered over the affected motor cortex in order to increase cortical excitability and induce brain plasticity with the intention to enhance motor learning and achieve functional goals in stroke patients. Similarly, low frequency rTMS and cathodal tDCS can be delivered to the unaffected motor cortex to reduce interhemispheric inhibition and hinder maladaptive plasticity. The use of several drugs such as amphetamines, selective serotonin reuptake inhibitors (SSRIs), levodopa and cholinergic agents have been also proposed to enhance the motor function. Given that both NIBS and pharmacotherapy might provide some treatment effect independently for motor rehabilitation in stroke and with the rationale that they could work in a synergistic fashion, we believe that a combined therapy- NIBS plus pharmacotherapy- can lead to better outcomes than one or the other alone. In this paper we review the literature that support the potential use of a combined approach in stroke recovery and present the studies that have already investigated this idea.

Background and Purpose: The purpose of this study was to investigate the impact of passive static and cyclical stretching of the fingers on hand function in subacute stroke survivors.
Participants: Thirteen stroke survivors, 2-5 months post-incident, with moderate to severe hand impairment took part in the study.
Method: Each participant completed three separate sessions, separated by at least one week, consisting of 30 minutes of: static stretch of the digits, cyclical stretch, or rest. Stretching was performed by a powered glove orthosis (X-Glove). Outcome measures, comprised of three timed hand-specific tasks from the Graded Wolf Motor Function Test (GWMFT-Time), grip termination time (GTT), grip strength, and lateral pinch strength, were assessed at the beginning and end of each session. Change in outcome score during each session was used for analysis.
Results: Data suggested a trend for improvement following stretching. Reduction in mean completion time for the GWMFT-Time after the cyclic stretching was 5 times greater than for the rest condition (P=0.010). After the static stretching, GTT was 31% faster than the mean pre-test times (P=0.055). Improvements in grip and pinch strength were also evident following the stretching interventions, although these changes did not reach statistical significance.
Discussion and Conclusion: While more study is needed, cyclically stretching the finger muscles in the stroke hand appears to be a promising treatment for stroke survivors in the subacute phase of recovery. It may prove especially effective as an adjuvant therapy facilitating subsequent performance of active movement therapy. Future studies exploring the neural correlates of improvement are warranted.

Epilepsy is a chronic dynamic medical problem requiring long-term treatment. In addition to seizures, patients with epilepsy often face a wide range of limitations in school, social situations, and employment, primarily because of cognitive impairments, especially of memory and attention. Cognitive rehabilitation therapy to restore patients’ ability to deal with routine activities of daily lives has been used for years. Moreover, other studies have reported that these programs are effective in the epilepsy in memory and attention domains, and thus can be incorporated into comprehensive care programs. We reviewed studies on the two basic pragmatic approaches-retraining and compensation methods-especially the latter.

Objective: The subiculum, one major output structure in the hippocampus, is considered to participate in seizure generation and modulation in temporal lobe epilepsy (TLE) since stimulation of the subiculum was found to suppress seizures in a seizure model. The current study aimed to investigate whether acute scheduled or responsive stimulation of the subiculum can suppress spontaneous seizures and affect local excitability of the subiculum in a chronic TLE model.
Methods: Wistar rats were administrated intraperitoneally with kainic acid (KA) repeatedly to induce status epilepticus (SE). 4 months later the rats were implanted with stimulation electrodes in the subiculum. After one-week baseline recording, they received either responsive or scheduled high frequency stimulation (HFS, 125 Hz) for two days and then were swapped to the other type of stimulation for two days with one-week interval. All the rats also received pulse stimuli (100 μs, interval of 5-7 s) at different intensities (20, 50, 100 mA) before and after stimulation while evoked responses were elicited. Results: Acute HFS of the subiculum-both scheduled and responsive stimulation-suppressed spontaneous focal seizures in rats. The excitability of the subiculum, measured by evoked responses, did not show obvious changes before and after HFS.
Conclusion: The preliminary outcomes revealed the anticonvulsant effects of subicular stimulation on spontaneous seizures, suggesting that the subiculum is a promising target candidate for deep brain stimulation to control seizures in TLE. The absence of changes in subicular excitability indicates that HFS affects the hippocampal network rather than the excitability of the subiculum per se.

We report the case of a patient with drug resistant epilepsy scheduled for amygdalohippocampectomy (AHS). During this type of surgery, Density Spectral Array (DSA) belonging to the Bilateral Bispectral Index (BIS) VISTATM Monitoring System (BVMS) was used. DSA, but no BIS trend, was helpful to detect differences in the power spectrum between both cerebral hemispheres during propofol- remifentanyl-dexmedetomidine anesthesia. This case provides novel evidence to support the clinical utility of DSA in monitoring depth of anaesthesia and sedation.

Repetitive transcranial magnetic stimulation (rTMS) as a new non-invasive painless procedure has been tested for augmentation of motor performance and reduction of spasticity in post-stroke patients. Stroke patients (N = 34) were recruited for rTMS treatment and brain activity analysis (EEG) was performed before and after rTMS. The effect of rTMS was evaluated using National Institute of Health Stroke Scale (NIHSS), Barthel – Index and Ashworth Scale. The content of L-tryptophan (L-TRP), L-kynurenine (L-KYN), kynurenic acid (KYNA) and anthranilic acid (ANA) was determined in the serum of stroke patients before the 1st, after the 5th and after 10th rTMS application using high performance liquid chromatography. In a separate experiment, L-TRP metabolites were determined in the serum of an independent group of stroke patients (N=47) and control subjects (N=6). The content of L-TRP and L-TRP metabolites in the serum of stroke patients was significantly increased, L-TRY was 121% of CO; L-KYN 161% of CO, p<0.015; ANA 280 % of CO, p<0.001; KYNA 243% of CO, p<0.001, compared to control subjects. Similar changes were found in stroke patients recruited for rTMS. After the 10th rTMS treatment L-KYN and ANA levels increased moderately but significantly in the serum and it was L-KYN 107%, p<0.01; ANA 110%, p=0.055, versus the value before 1st rTMS, respectively. The ratios L-KYN/TRP and ANA/KYNA increased moderately but significantly after the 10th rTMS. Creatin kinase and prolactin levels were in normal range during rTMS. Stroke patients treated with rTMS have shown a significant enhancement of motor performance and moderate reduction of spasticity. The alteration of ANA/KYNA ratio after rTMS might be of significance with respect to the clinical improvement of patients. The present study gives favour for rTMS as a means for neurorehabilitation of patients after stroke. Notable, the management of therapies following rTMS are of importance for an improvement of hand and fingers activities, as observed within this study.

Purpose: To determine the effects of a physical activity-based rehabilitation focused on quality of life in individuals with FA who completed a five-year program. Methods: The study design was longitudinal and observational with pre- and post-test assessments, and two years follow-up. We studied 16 patients with FA. Participants received pharmacological treatment and took part in a physical activity rehabilitation program (intervention group) or received pharmacological treatment alone (controls). They were all assessed using the International Cooperative Ataxia Rating Scale (ICARS), SF-36 Health Survey and Functional Independence Measure (FIM). Changes over time and differences between groups were assessed with repeated measure analysis of variance (ANOVA) and Student´s t-tests. Results: In the intervention group, a change in the distribution of the mean ICARS score from 93.10 ± 4.63 to 94.90 ± 4.50 suggested a slight worsening in ataxia (not significant). In contrast, the means on the SF-36 (43.89 ± 5.55 to 51.70 ± 4.19) and FIM (50.20 ± 16.02 to 59.20 ± 15.01) both increased significantly over time. That is, after the treatment, patients in the intervention group showed a significant improvement in communication, daily living skills and socialization, and the improvement in their quality of life was maintained at the two-year follow-up. Conclusions: Long-term rehabilitation improved physical capacity and health-related quality of life. This study provides evidence for maintaining long-term physical activity programs in institutionalized patients with FA.

Background: The transpedicular approach, fitting of an expandable cage, and posterior fusion, is a procedure that enables the neurosurgeons to treat severe burst fractures through a familiar access for them. This treatment has been described for selected patients in order to avoid the morbidity associated with the anterior approaches (vascular injury, aspiration, pleural effusions effusion, pneumothorax, decreased pulmonary function, etc).
Methods: We review the Literature about upper thoracic fractures treated with this procedure, analyze the indications and surgical technique, and present the case of a severe T4 burst fracture operated upon by transpedicular corpectomy, self-expanding cage and posterior transpedicular fusion.
Results: Literature review showed a relative rarity of reports of non-pathological fractures treated by this procedure in the upper thoracic region (about 7 upper spine fractures reported with a similar treatment to ours). A lesser incidence of complications, in comparison to anterior routes, is reported. According to the review and our experience, the procedure can provide both an effective decompression as a solid stabilization, along with less postoperative complications than the anterior routes.
Conclusions: Upper thoracic spine fractures have only rarely been treated with transpedicular posterior approach. Neurosurgeons are familiar with this route. Therefore, more similar cases need to be communicated, in order to assess the reliability and safety of the procedure in selected patients, eventually increasing the indications of the procedure and progressively involving upper levels of thoracic spine.

Epilepsy is the fourth most common neurological disorder in the US, affecting nearly 2.5 million Americans. The economic impact of epilepsy represents estimated direct and indirect costs of 12.5 billion dollars per year. Patients with this disorder experience increased morbidity and mortality with long term fatality rates of 24%. Multiple diagnostic tools are used to identify and classify the seizure type/syndrome, etiology and localization of seizures, including electroencephalogram (EEG), magnetic resonance imaging (MRI), positron emission tomography (PET), and single photon emission computed tomography (SPECT), magneto encephalogram (MEG), and neuropsychiatric testing. Despite 29 different antiepileptic medications that are available in the US, one third of patients remain refractory to pharmacological treatment. In these intractable epilepsy patients, non-pharmacological treatments can be considered. Commonly used non-pharmacological treatment options for epilepsy include epilepsy surgery, neurostimulation therapy, and diet therapy.

Background: Hashimoto’s encephalopathy is a relapsing encephalopathy occurring in association with Hashimoto’s thyroiditis, with high titers of anti-thyroid antibodies. Clinically the patients may presents with acute or subacute encephalopathy, seizure, myoclonus, and tremulousness, stroke like episode, amnesia or dementia. Here we are reporting a case of hashimoto’s encephalopathy who presented with features of acute psychosis. Case Report: A 56 years old Asian female presented with acute onset of altered behavioural abnormality and declining brain function. Serology revealed high anti thyroperoxidase antibodies. EEG and MRI were consistent with hashimoto’s encephalopathy. Conclusion: Hashimoto’s encephalopathy is a rare complication of hashimoto’s thyroiditis and is a diagnosis of exclusion and should be suspected in a case of encephalopathy, high anti thyroid antibodies and response to glucocorticoid.

In contact sports, head-to-head collisions can lead to concussions, which pose serious health risks to players. This research aims to understand the force transfer from the helmet to the brain that causes concussions in collisions using a rheological model. Experimental data was gathered from players in the National Football League and testing of one type of helmet and padding. The rheological model was verified with published data and good correlation was achieved. Further sensitivity analysis of concussion risk was performed with respect to force, body weight, mass, and impact duration fit to normal and Weibull distributions using Monte Carlo simulations of impacts. A 50% threshold for moderate concussion was found based on these physiological variables. Average weight and velocity values for an NFL player in a collision gave a 50% concussion risk to a helmet to helmet impact that has a deceleration over 6.365 ms or less. Analysis of children ranging from 10 to 15 years of age was also conducted with the assumption of identical equipment to NFL players due a dearth of other research into the properties of equipment used by children. As the equipment is assumed to decrease in quality over time, this established an upper bound to the tolerance values for children. For a 50th percentile weight 10 year old male or female child, this gives thresholds of 2.483 or 2.573 ms respectively.

Objective: Impaired autonomic function has been associated with an increased risk of mortality in patients with epilepsy. Autonomic dysfunction involving both sympathetic and parasympathetic systems has also been demonstrated in Epileptic disease using cardiovascular reflex tests based on heart rate to various stimuli. The aim of this study is to propose novel approach using Volterra kernel for system identification of nonlinear relationship between input stimulus (lowering and raising leg) and the output (HRV signals) using entrainment method based on lowering and raising leg of patients to assess in qualitative and quantitative methods the autonomic function of healthy subjects and patients with epilepsy disease and provide medical indices for assessment and neurorehabilitation of autonomic system in Epilepsy
Methods: Forty eight patients with Epilepsy and forty eight of healthy subjects age matched controls participated in this study from July to September 2010 at Johns Hopkins Hospital, Baltimore, Maryland, and the Medical Center, Cookeville, Tennessee, United States of America. All subjects signed consent to participate in the research prior to their inclusion in the study and the consent of ethical committee was obtained and approved the study protocol. The study design was to carry out experimental procedure of lowering and raising a leg at different frequency rate whiles the subject in supine. By applying an algorithm and considering the process of lowering and raising a leg as stimulus input and the Heart Rate Variability signal (HRV) as output for system identification, a mathematical model is expressed as integral equations, whose input-output behavior is nearly identical to that of the system in both healthy subjects and epilepsy disease patients. The model for each group contains the linear part (first order kernel) and nonlinear part (second order kernel).
Results: A difference equation model was employed to represent the system for both control subjects and patients with Epilepsy disease .The results show significant difference in first and second kernel for both groups. Both the first kernel and second kernel of epileptic patients show low variation with respect to healthy subjects. Introducing Normalized Mean Square Errors (NMSE) of first order and second order kernel prediction of both groups may be considered as medical index for to assess the autonomic nervous system in health and disease.
Conclusion: Using first order kernel and second order kernel, it is possible noninvasively to differentiate and assess autonomic function qualitatively and quantitatively in both groups. Future studies are needed to investigate model quantitative indices using this methodology to assess the autonomic nervous system in health and disease.