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Autoimmune hemolytic anemia (AIHA) is a heterogeneous and relatively unknown disease caused by premature immune destruction of red blood cells. While its occurrence is uncommon among children, it is sometimes severe and resistant to treatment. The warm-reactive type contains 70% to 80% of all cases, in which the first-line treatment is considered to be a steroid. Moreover, splenectomy, rituximab (a monoclonal antibody), and immunosuppressive drugs are used in refractory cases, with unclear efficacy and deep suppression of the immune system, which consequently lead to various side effects. This study reports the successful treatment of a life-threatening case using a new method. In this regard, it was stated that using the capacity of Iranian traditional medicine (ITM) as one of the complementary therapies can help in the treatment of this disease. In this case report, we documented the successful treatment of a severe and refractory warm AIHA in a boy, who was resistant to the currently recommended treatments such as corticosteroids, rituximab, and cyclosporine at different time periods. Based on ITM, a novel treatment was performed, which was daily swallowing 4-6 live small freshwater fishes (from Cyprinidae family) for an eight-week period and later being tapered. As a result, this treatment had a rapid response time with no side effects. At the time of performing this study, the patient was in his 5th-year disease-free period. For future research, we recommend the researchers to study the use of this novel treatment in case of resistance to the current established therapies of warm AIHA disease.

(1) Background: Increasing the amount of therapy time has been shown to improve motor function in stroke survivors. However, it is often not possible to increase the amount of therapy time provided in the current one-on-one therapy models. Rehabilitation-based virtual reality exergame systems, such as Jintronix, can be offered to stroke survivors as an adjunct to traditional therapy. The goal of this study was to examine the safety and feasibility of providing additional therapy using an exergame system and assess its preliminary clinical efficacy. (2) Methods: Stroke survivors receiving outpatient rehabilitation services participated in this pilot randomized control trial in which the intervention group received 4 weeks of exergaming sessions in addition to traditional therapy sessions. (3) Results: Nine subjects in the intervention and nine subjects in the control group completed the study. The intervention group had at least two extra sessions per week, with an average duration of 44 min per session and no serious adverse events (falls, dizziness, or pain). The efficacy measures showed statistically meaningful improvements in the activities of daily living measures (i.e., MAL-QOM (motor activity log-quality of movement) and both mobility and physical domains of the SIS (stroke impact scale) with mean difference of 1.0%, 5.5%, and 6.7% between the intervention and control group, respectively) at post-intervention. (4) Conclusion: Using virtual reality exergaming technology as an adjunct to traditional therapy is feasible and safe in post-stroke rehabilitation and may be beneficial to upper extremity functional recovery.

Approximately 80% of individuals with chronic stroke present with long lasting upper extremity (UE) impairments. We propose the perSonalized UPper Extremity Rehabilitation (SUPER) intervention, which combines robotics, virtual reality activities, and neuromuscular electrical stimulation (NMES). The objectives of our study were to determine the feasibility of the SUPER intervention in individuals with moderate/severe stroke. Stroke participants received a 4-week intervention (3x per week), based on their functional level. Their level of corticospinal tract recovery was assessed using the Predict Recovery Potential algorithm, involving measurements of motor evoked potentials and manual muscle testing. Those with low potential for hand recovery (shoulder group) received an intervention focusing on elbow and shoulder movements. Those with a good potential for hand recovery (hand group) also received EMG-triggered NMES. Outcomes included the Fugl-Meyer UE assessment, the Motor Activity Log and the Stroke Impact Scale. Approximately 40% of participants in either the hand or shoulder group showed changes in the Fugl-Meyer UE assessment superior to its minimum clinically important difference. This indicates that our personalized approach may be effective in improving UE function in specific individuals with moderate and severe impairments due to stroke.

The aim of the current study was to examine the role of environment, whether virtual or physical, on robot-assisted reaching movements in chronic stroke and healthy individuals, within a single session. Twenty-three subjects participated in the current study divided into three groups: nine chronic stroke individuals able to perform a reaching task with no need for the robot assistance, nine chronic stroke individuals who needed robot assistance to complete the reaching task, and five healthy individuals. The task was to reach six target buttons in two identical physical and virtual environments. The outcomes consisted of specific kinematic measures (amount of movement completion without robot assistance, mean speed, peak speed, straightness, and shakiness) and a custom questionnaire to assess how the stroke subjects perceived and experienced the reaching task in both environments. The results showed no differences between the two environments in terms of the outcome measures in any of the groups. Our findings suggest that the choice of environment, whether physical or virtual, is not a key factor in designing a simple robot-assisted reaching task for stroke survivors. Further studies are required for more complex environments and tasks as well as robot-assisted training protocols.

Background. Clinical trials have demonstrated some benefits of electromyogram-triggered/controlled neuromuscular electrical stimulation (EMG-NMES) on motor recovery of upper limb (UL) function in patients with stroke. However, EMG-NMES use in clinical practice is limited due to a lack of evidence supporting its effectiveness. Objective. To perform a systematic review and meta-analysis to determine the effects of EMG-NMES on stroke UL recovery based on each of the International Classification of Functioning, Disability, and Health (ICF) domains. Methods. Database searches identified clinical trials comparing the effect of EMG-NMES versus no treatment or another treatment on stroke upper extremity motor recovery. A meta-analysis was done for outcomes at each ICF domain (Body Structure and Function, Activity and Participation) at posttest (short-term) and follow-up periods. Subgroup analyses were conducted based on stroke chronicity (acute/subacute, chronic phases). Sensitivity analysis was done by removing studies rated as poor or fair quality (PEDro score

Robot-assisted training (RT) is a novel technique with promising results for stroke rehabilitation. However, benefits of RT on individuals with long-term chronic stroke have not been well studied. For this case study, we developed an arm-based RT protocol for reaching practice in physical and virtual environments and tracked the outcomes in an individual with a long-term chronic stroke (20+ years) over 10 half-hour sessions. We analyzed the performance of the reaching movement with kinematic measures and the arm motor function using the Fugl-Meyer Assessment-Upper Extremity scale (FMA-UE). The results showed significant improvements in the subject's reaching performance accompanied by a small increase in FMA-UE score from 18 to 21. The improvements were also transferred into real life activities, as reported by the subject. This case study shows that even in long-term chronic stroke, improvements in motor function are still possible with RT, while the underlying mechanisms of motor learning capacity or neuroplastic changes need to be further investigated.

Equifinality, during arm reaching movements, relates to the capacity of the neuromuscular system to attain the same final position in the presence or absence of transient perturbations. There have been several controversies regarding equifinality in the literature. A brief elastic perturbation, applied during a fast arm movement or just before its initiation, typically does not affect final arm position. On the other hand, several experiments have shown that velocity-dependent perturbations, such as Coriolis force or negative damping, while transient in nature, have a significant effect on final arm position when compared to unperturbed movements. In this study, an unloading paradigm was used to study the role of reflexes with respect to equifinality. The effects on final arm position of suddenly decreasing a static load maintained by fourteen subjects were analyzed. Subjects maintained an initial load produced by a double-joint manipulandum moving in the horizontal plane. The load was suddenly decreased, either in one or in two successive steps with different time intervals, resulting in a rapid reflex-mediated change in arm position. Unloading led to short-latency changes in the activity of shoulder and elbow muscles and significant variations in tonic activity. It was found that the final hand position was shorter for double- versus single-step unloading if the time between two successive changes in load was greater than 100 ms. With a shorter time interval, the final hand positions were the same. This difference in final hand positions was inversely proportional to the hand velocity at the time of the second change in load. Further, agonist/antagonist co-activation increased in double-step unloading. Thus, the change in both the load and the movement velocity may influence the magnitude of the unloading reflex. This may be indicative of a dependence of stretch reflexes on velocity. Perturbation may cause a reflex-mediated increase in joint stiffness, which could explain why equifinality is not preserved after some perturbations, such as velocity-dependant external forces.

Introduction Virtual reality (VR) can promote functional rehabilitation of arm movements through environments allowing the practice of a variety of tasks while providing feedback [1] . We evaluated an affordable VR system for arm rehabilitation, developed by Jintronix Inc and based on the Microsoft Kinect, that provides three unilateral and two bilateral activities, each with ten difficulty levels. Objectives Our objectives were to (1) determine which activities and levels of difficulty are appropriate for rehabilitation of arm movements in stroke patients with different degrees of motor impairment; and (2) determine the ease of use and subjective experience of patients using the VR arm rehabilitation system. Methods Clinicians each supervised two to four stroke patients who participated in three 20-minute sessions with the Jintronix system. We determined the highest level of difficulty attained by patients in each activity with a performance score of at least 50%. Arm impairment was assessed using the upper extremity section of the Chedoke-McMaster Scale (CM) [2] . Patients and clinicians completed a questionnaire on the usability of the Jintronix system, based on the technology acceptance model (FD Davis [3] ). Results Fifteen clinicians supervised a total of 40 stroke patients. Over 80% of the clinicians and patients provided positive feedback in terms of ease of use and VR experience. For each activity of the Jintronix system, results indicated a positive correlation between the CM score and the maximal difficulty level reached by stroke patients. Discussion Our data demonstrate the feasibility of using an affordable VR arm rehabilitation system in a clinical setting and provide clinical guidelines for the selection of impairment-specific difficulty levels.

A research protocol will be presented to validate a new low cost virtual reality system as a rehabilitation tool for enhancing motor recovery of the upper limb in stroke survivors. To this aim, we will assess the usability of a Kinect-based rehabilitation gaming system by evaluating responses from 24 stroke patients and 8 clinicians. We will create an initial flowchart, linking the level of motor impairment of stroke patients with their performance on the activities of the rehabilitation gaming system.

We systematically reviewed and analyzed the literature to find randomized controlled trials (RCTs) that employed robotic devices in upper-limb rehabilitation of people with stroke. Out of 574 studies, 12 matching the selection criteria were found. The Fugl-Meyer, Functional Independence Measure, Motor Power Scale, and Motor Status Scale outcome measures from the selected RCTs were pooled together, and the corresponding effect sizes were estimated. We found that when the duration/intensity of conventional therapy (CT) is matched with that of the robot-assisted therapy (RT), no difference exists between the intensive CT and RT groups in terms of motor recovery, activities of daily living, strength, and motor control. However, depending on the stage of recovery, extra sessions of RT in addition to regular CT are more beneficial than regular CT alone in motor recovery of the hemiparetic shoulder and elbow of patients with stroke; gains are similar to those that have been observed in intensive CT.