Enrique Noé

Self-awareness after acquired brain injury--predictors and rehabilitation.

ObjectiveTo investigate the factors contributing to deficit in self-awareness following acquired brain injury and to study change in self-awareness during a group support program.MethodsSixty-two patients (mean age: 35.4±15.3 years) attending our Service (295±525 days after injury) were included in the study (41 of them had sustained a head injury). Thirty-six patients were admitted to a multidisciplinary rehabilitation program including a group support program designed to improve self-awareness deficits. All patients were assessed with the Patient Competency Rating Scale as a measure of self-awareness and with a broad range of neuropsychological tests, checklists of psychopathological symptoms, and several functional scales.ResultsThirty patients showed high levels of self-awareness while 32 showed impaired self-awareness. Patients with appropriate perception of their deficits showed less psychopathological symptoms, better neuropsychological function and higher functional independence than those with impaired SA (Student’s t test, p<0.05). Both groups improved, but with different patterns, after rehabilitation (MANOVA, p<0.05). Multiple regression analysis revealed that cognitive status was predictive of level of self-awareness.ConclusionThe level of self-awareness after acquired brain injury is a useful prognostic index of the neuropsychological, psychopathological and functional status of the patient. We recommend the evaluation of this symptom after acquired brain injury due to its clinical relevance.

Effectiveness, usability, and cost-benefit of a virtual reality-based telerehabilitation program for balance recovery after stroke: a randomized controlled trial

OBJECTIVES First, to evaluate the clinical effectiveness of a virtual reality (VR)-based telerehabilitation program in the balance recovery of individuals with hemiparesis after stroke in comparison with an in-clinic program; second, to compare the subjective experiences; and third, to contrast the costs of both programs. DESIGN Single-blind, randomized, controlled trial. SETTING Neurorehabilitation unit. PARTICIPANTS Chronic outpatients with stroke (N=30) with residual hemiparesis. INTERVENTIONS Twenty 45-minute training sessions with the telerehabilitation system, conducted 3 times a week, in the clinic or in the home. MAIN OUTCOME MEASURES First, Berg Balance Scale for balance assessment. The Performance-Oriented Mobility Assessment balance and gait subscales, and the Brunel Balance Assessment were secondary outcome measures. Clinical assessments were conducted at baseline, 8 weeks (posttreatment), and 12 weeks (follow-up). Second, the System Usability Scale and the Intrinsic Motivation Inventory for subjective experiences. Third, cost (in dollars). RESULTS Significant improvement in both groups (in-clinic group [control] and a home-based telerehabilitation group) from the initial to the final assessment in the Berg Balance Scale (ηp(2)=.68; P=.001), in the balance (ηp(2)=.24; P=.006) and gait (ηp(2)=.57, P=.001) subscales of the Tinetti Performance-Oriented Mobility Assessment, and in the Brunel Balance Assessment (control: χ(2)=15.0; P=.002; experimental: χ(2)=21.9; P=.001). No significant differences were found between the groups in any balance scale or in the feedback questionnaires. With regard to subjective experiences, both groups considered the VR system similarly usable and motivating. The in-clinic intervention resulted in more expenses than did the telerehabilitation intervention (

Improvement in balance using a virtual reality-based stepping exercise: a randomized controlled trial involving individuals with chronic stroke:

654.72 per person). CONCLUSIONS First, VR-based telerehabilitation interventions can promote the reacquisition of locomotor skills associated with balance in the same way as do in-clinic interventions, both complemented with a conventional therapy program; second, the usability of and motivation to use the 2 interventions can be similar; and third, telerehabilitation interventions can involve savings that vary depending on each scenario.

A voxel-based analysis of FDG-PET in traumatic brain injury: regional metabolism and relationship between the thalamus and cortical areas.

Objective: To study the clinical effectiveness and the usability of a virtual reality-based intervention compared with conventional physical therapy in the balance recovery of individuals with chronic stroke. Design: Randomized controlled trial. Setting: Outpatient neurorehabilitation unit. Participants: A total of 20 individuals with chronic stroke. Interventions: The intervention consisted of 20 one-hour sessions, five sessions per week. The experimental group combined 30 minutes with the virtual reality-based intervention with 30 minutes of conventional training. The control group underwent one hour conventional therapy. Main measures: Balance performance was assessed at the beginning and at the end of the trial using the Berg Balance Scale, the balance and gait subscales of the Tinetti Performance-Oriented Mobility Assessment, the Brunel Balance Assessment, and the 10-m Walking Test. Subjective data of the virtual reality-based intervention were collected from the experimental group, with a feedback questionnaire at the end of the trial. Results: The results revealed a significant group-by-time interaction in the scores of the Berg Balance Scale (p < 0.05) and in the 10-m Walking Test (p < 0.05). Post-hoc analyses showed greater improvement in the experimental group: 3.8 ±2.6 vs. 1.8 ±1.4 in the Berg Balance Scale, –1.9 ±1.6 seconds vs. 0.0 ±2.3 seconds in the 10-m Walking Test, and also in the number of participants who increased level in the Brunel Balance Assessment (χ2 = 2.5, p < 0.01). Conclusions: Virtual reality interventions can be an effective resource to enhance the improvement of balance in individuals with chronic stroke.

Voxel-based statistical analysis of thalamic glucose metabolism in traumatic brain injury: relationship with consciousness and cognition

The objective was to study the correlations and the differences in glucose metabolism between the thalamus and cortical structures in a sample of severe traumatic brain injury (TBI) patients with different neurological outcomes. We studied 49 patients who had suffered a severe TBI and 10 healthy control subjects using 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET). The patients were divided into three groups: a vegetative or minimally-conscious state (MCS&VS) group (n=17), which included patients who were in a vegetative or a minimally conscious state; an In-post-traumatic amnesia (In-PTA) group (n=12), which included patients in PTA; and an Out-PTA group (n=20), which included patients who had recovered from PTA. SPM5 software was used to determine the metabolic differences between the groups. FDG-PET images were normalized and four regions of interest were generated around the thalamus, precuneus, and the frontal and temporal lobes. The groups were parameterized using Students t-test. Principal component analysis was used to obtain an intensity-estimated-value per subject to correlate the function between the structures. Differences in glucose metabolism in all structures were related to the neurological outcome, and the most severe patients showed the most severe hypometabolism. We also found a significant correlation between the cortico-thalamo-cortical metabolism in all groups. Voxel-based analysis suggests a functional correlation between these four areas, and decreased metabolism was associated with less favorable outcomes. Higher levels of activation of the cortico-cortical connections appear to be related to better neurological condition. Differences in the thalamo-cortical correlations between patients and controls may be related to traumatic dysfunction due to focal or diffuse lesions.

Behavioral Recovery in Disorders of Consciousness: A Prospective Study With the Spanish Version of the Coma Recovery Scale–Revised

Objective: To study the relationship between thalamic glucose metabolism and neurological outcome after severe traumatic brain injury (TBI). Methods: Forty-nine patients with severe and closed TBI and 10 healthy control subjects with 18F-FDG PET were studied. Patients were divided into three groups: MCS&VS group (n = 17), patients in a vegetative or a minimally conscious state; In-PTA group (n = 12), patients in a state of post-traumatic amnesia (PTA); and Out-PTA group (n = 20), patients who had emerged from PTA. SPM5 software implemented in MATLAB 7 was used to determine the quantitative differences between patients and controls. FDG-PET images were spatially normalized and an automated thalamic ROI mask was generated. Group differences were analysed with two sample voxel-wise t-tests. Results: Thalamic hypometabolism was the most prominent in patients with low consciousness (MCS&VS group) and the thalamic hypometabolism in the In-PTA group was more prominent than that in the Out-PTA group. Healthy control subjects showed the greatest thalamic metabolism. These differences in metabolism were more pronounced in the internal regions of the thalamus. Conclusions: The results confirm the vulnerability of the thalamus to suffer the effect of the dynamic forces generated during a TBI. Patients with thalamic hypometabolism could represent a sub-set of subjects that are highly vulnerable to neurological disability after TBI.

Eficacia del sistema Armeo®Spring en la fase crónica del ictus. Estudio en hemiparesias leves-moderadas

OBJECTIVE To describe the clinical characteristics and short-term pattern of evolution of a sample of patients within 1 year after acquiring a brain injury that led to a vegetative state (VS) or a minimally conscious state (MCS). DESIGN Cohort study. SETTING Inpatient brain injury rehabilitation program. PARTICIPANTS Patients with acquired brain injury (N=32; 47% traumatic, 37.5% hemorrhagic, 15.5% anoxic) who were in a VS or an MCS according to Coma Recovery Scale-Revised (CRS-R) scores. INTERVENTION Integrative multisensory program comprising daily physical rehabilitation procedures and multimodal sensory stimulation. MAIN OUTCOME MEASURE All patients were assessed with a Spanish version of the CRS-R at admission and then monthly for at least 6 months or until emergence from MCS. RESULTS At the time of admission, 12 patients were diagnosed as being in a VS and 20 as being in an MCS. Eight patients were able to emerge from their MCS during follow-up. Seven of these 8 patients were diagnosed as being in an MCS at inclusion, and only 1 was diagnosed as being in a VS. Emergence from an MCS was mostly associated with improvement in both the communication and motor function scales (n=4). Lesser chronicity (P=.01) and the presence of more than visual behavioral responses at admission (P=.05) were both significant predictors of emergence from an MCS. CONCLUSIONS The CRS-R seems appropriate for establishing an immediate prognosis in this population. A quick referral of these patients for specialized assessment and rehabilitation facilities is recommended.

Effect of a mixed reality-based intervention on arm, hand, and finger function on chronic stroke

OBJECTIVE To evaluate the efficacy of a gravity-supported, computer-enhanced device (Armeo® Spring) for upper limb rehabilitation in chronic stroke patients. MATERIAL AND METHODS We included 23 chronic hemiparetic patients (chronicity: 328 ± 90.8 days; distribution: 17 men and 6 women) aged 54.6 ± 9.5 years, who had sustained ischaemic stroke (n=12) or haemorrhagic stroke (n=11). All patients completed 36 one-hour sessions using the Armeo® Spring system. Arm movement was assessed at the beginning and end of the treatment programme and once more 4 months later. Main outcome measurements covered structure, activity, and function, as per the International Classification of Functioning, Disability and Health: Modified Ashworth Scale, Motricity Index (MI), Fugl-Meyer Assessment Scale (FM), Motor Assessment Scale (MAS), Manual Function Test (MFT), and Wolf Motor Function Test (WMFT). RESULTS Repeated measures ANOVA showed significant improvement (time effect) for all function scales (P<.01 for FM and MI) and activity scales (P<.01 for MAS, MFT and WMFT-ability, and P<.05 WMFT-time) without significant changes in muscle tone. The post-hoc analysis (Bonferroni) showed different evolutionary patterns for function and activity measurements, and clear benefits related to Armeo® Spring training, especially on activity scales. CONCLUSIONS Armeo® Spring is an effective tool for rehabilitating the affected arm in patients with hemiparesis secondary to ictus, even in the chronic stage.

Validation of a low-cost virtual reality system for training street-crossing. A comparative study in healthy, neglected and non-neglected stroke individuals

BackgroundVirtual and mixed reality systems have been suggested to promote motor recovery after stroke. Basing on the existing evidence on motor learning, we have developed a portable and low-cost mixed reality tabletop system that transforms a conventional table in a virtual environment for upper limb rehabilitation. The system allows intensive and customized training of a wide range of arm, hand, and finger movements and enables interaction with tangible objects, while providing audiovisual feedback of the participants’ performance in gamified tasks. This study evaluates the clinical effectiveness and the acceptance of an experimental intervention with the system in chronic stroke survivors.MethodsThirty individuals with stroke were included in a reversal (A-B-A) study. Phase A consisted of 30 sessions of conventional physical therapy. Phase B consisted of 30 training sessions with the experimental system. Both interventions involved flexion and extension of the elbow, wrist, and fingers, and grasping of different objects. Sessions were 45-min long and were administered three to five days a week. The body structures (Modified Ashworth Scale), functions (Motricity Index, Fugl-Meyer Assessment Scale), activities (Manual Function Test, Wolf Motor Function Test, Box and Blocks Test, Nine Hole Peg Test), and participation (Motor Activity Log) were assessed before and after each phase. Acceptance of the system was also assessed after phase B (System Usability Scale, Intrinsic Motivation Inventory).ResultsSignificant improvement was detected after the intervention with the system in the activity, both in arm function measured by the Wolf Motor Function Test (p < 0.01) and finger dexterity measured by the Box and Blocks Test (p < 0.01) and the Nine Hole Peg Test (p < 0.01); and participation (p < 0.01), which was maintained to the end of the study. The experimental system was reported as highly usable, enjoyable, and motivating.ConclusionsOur results support the clinical effectiveness of mixed reality interventions that satisfy the motor learning principles for upper limb rehabilitation in chronic stroke survivors. This characteristic, together with the low cost of the system, its portability, and its acceptance could promote the integration of these systems in the clinical practice as an alternative to more expensive systems, such as robotic instruments.

Utilidad clínica de la versión en castellano del Mississippi Aphasia Screening Test (MASTsp): validación en pacientes con ictus

Unilateral spatial neglect is a common consequence of stroke that directly affects the performance of activities of daily living. This impairment is traditionally assessed with paper-and-pencil tests that can lack correspondence to real life and are easily compensated. Virtual reality can immerse patients in more ecological scenarios, thus providing therapists with new tools to assess and train the effects of this impairment in simulated real tasks. This paper presents the clinical validation and convergent validity of a low-cost virtual reality system for training street-crossing in stroke patients with and without neglect. The performance of neglect patients was significantly worse than the performance of non-neglect and healthy participants. In addition, several correlations between the scores in the system and in the traditional scales were detected.