ExoBand, A Passive Wearable Device as a Walking Aid in Neuromuscular Patients: First Quantitative Assessment.

Objective: Exoband (by Moveo, Padova, Italy) functions as a walking brace, comprising a belt and two leg loops connected by a mechanism that stores energy during the initial phase of the gait cycle and releases it in the subsequent phase. This enhances hip flexor thrust, leading to functional improvement in walking for individuals with conditions characterized by proximal weakness. It has been approved as a passive wearable device for individuals with impaired walking abilities. Objective of this study was to establish a protocol to assess the use of Exoband in patients with various neuromuscular disorders. Methods: This exploratory retrospective study includes consecutive patients diagnosed with neuromuscular disorders (CIDP, motor polyneuropathy, MND), exhibiting a proximal involvement and gait abnormalities. The evaluation protocol incorporated specific walking-related outcome measures, the 10-meter walk test (10mWT), Time-up-and-go test (TUG), and 2-minute walking test (2MWT). The assessments were conducted both with and without the Exoband under standard conditions. Results: Eight patients (6 males, aged 60-78 years) were tested. An increase in velocity was observed in the 10mWT (median 13.4 sec, IQR 12.0-15.7 vs. 12.2 sec, IQR 11.3-14.2 seconds, p <  0.05) and the TUG (14.0 sec, IQR 13-16.2 vs 13.35 sec, IQR 11-13.8; p <  0.05, by non-parametric Wilcoxon test), and a trend of increase in 2MWT (median 88.2 vs 92.6 m, n.s.). Six out of 8 patients reported subjective benefits from the very first use, including improved walking stability, speed, confidence, and reduced fatigue. Conclusions: Our protocol provides a quantitative assessment of Exoband usefulness for patients affected by neuropathies with gait abnormalities. Further investigations are warranted to assess the long-term effects of its regular Exoband use, its efficacy in specific neuromuscular diseases, and its potential role as a rehabilitation device.

Electrophysiological Screening to Assess Foot Drop Syndrome in Severe Acquired Brain Injury in Rehabilitative Settings.

BACKGROUND: Foot drop syndrome (FDS), characterized by severe weakness and atrophy of the dorsiflexion muscles of the feet, is commonly found in patients with severe acquired brain injury (ABI). If the syndrome is unilateral, the cause is often a peroneal neuropathy (PN), due to compression of the nervous trunk on the neck of the fibula at the knee level; less frequently, the cause is a previous or concomitant lumbar radiculopathy. Bilateral syndromes are caused by polyneuropathies and myopathies. Central causes, due to brain or spinal injury, mimic this syndrome but are usually accompanied by other symptoms, such as spasticity. Critical illness polyneuropathy (CIP) and myopathy (CIM), isolated or in combination (critical illness polyneuromyopathy, CIPNM), have been shown to constitute an important cause of FDS in patients with ABI. Assessing the causes of FDS in the intensive rehabilitation unit (IRU) has several limitations, which include the complexity of the electrophysiological tests, limited availability of neurophysiology consultants, and the severe disturbance in consciousness and lack of cooperation from patients. OBJECTIVES: We sought to propose a simplified electrophysiological screening that identifies FDS causes, particularly PN and CIPNM, to help clinicians to recognize the significant clinical predictors of poor outcomes in severe ABI at admission to IRU. METHODS: This prospective, single-center study included 20 severe ABI patients with FDS (11 females/9 males, mean age 55.10 + 16.26; CRS-R= 11.90 + 6.32; LCF: 3.30 + 1.30; DRS: 21.45 + 3.33), with prolonged rehabilitation treatment (≥2 months). We applied direct tibialis anterior muscle stimulation (DMS) associated with peroneal nerve motor conduction evaluation, across the fibular head (NCS), to identify CIP and/or CIM and to exclude demyelinating or compressive unilateral PN. RESULTS: At admission to IRU, simplified electrophysiological screening reported four unilateral PN, four CIP and six CIM with a CIPNM overall prevalence estimate of about 50%. After 2 months, the CIPNM group showed significantly poorer outcomes compared to other ABI patients without CIPNM, as demonstrated by the lower probability of achieving endotracheal-tube weaning (20% versus 90%) and lower CRS-R and DRS scores. Due to the subacute rehabilitation setting of our study, it was not possible to evaluate the motor results of recovery of the standing position, functional walking and balance, impaired by the presence of unilateral PN. CONCLUSIONS: The implementation of the proposed simplified electrophysiological screening may enable the early identification of unilateral PN or CIPNM in severe ABI patients, thereby contributing to better functional prognosis in rehabilitative settings.

Rehabilitation approaches in West Nile Virus survivors: a systematic review.

INTRODUCTION: Periodic increases in West Nile virus (WNV) infections have been documented. Proper rehabilitative management is essential for these patients, who may experience limitations in daily activities even after the resolution of the acute infection. Since there are currently no globally accepted guidelines, our aim is to conduct a best-evidence synthesis on rehabilitative management for patients with neuroinvasive WNV. EVIDENCE ACQUISITION: We screened the literature with two independent researchers conducting searches on PubMed, Embase, SCOPUS, and Google Scholar databases for WNV-related studies in the field of rehabilitation. Suitable studies were identified and selected through a rigorous process. The review includes original research articles published up to August 15, 2023. EVIDENCE SYNTHESIS: Despite the potential for bias in the studies, the literature suggests that a comprehensive and interdisciplinary rehabilitation program, which includes physical therapy with neuromotor and respiratory interventions, occupational therapy, neurocognitive interventions, and speech therapy for dysphagia and communication issues, can lead to functional improvement in WNV patients. This program should be tailored to address each patient's specific challenges, and the duration of the rehabilitation program may vary depending on the individual patient's needs. CONCLUSIONS: Even if additional research with larger cohorts and higher evidence levels is needed for a comprehensive understanding of WNV patient rehabilitation, an early and comprehensive rehabilitation approach addressing respiratory, neuromuscular, and cognitive aspects appears effective for WNV patient recovery.

Transient Worsening of Dysphagia and Dysarthria after Treatment with Botulinum Toxin in Patients with Acquired Brain Injury.

Although botulinum toxin is widely considered an effective and safe treatment for a variety of neurological conditions (such as disabling spasticity), local or systemic adverse effects have often been reported. This study describes three cases of patients with severe acquired brain injury who were receiving speech therapy for recovering dysphagia and dysarthria but showed worsening of these symptoms after receiving BoNT treatment for motor spasticity. To increase clinicians' knowledge of these adverse effects, we present our cases and explore their significance to avoid major complications such as aspiration pneumonia.

Stimulation with acoustic white noise enhances motor excitability and sensorimotor integration.

Auditory white noise (WN) is widely used in neuroscience to mask unwanted environmental noise and cues, e.g. TMS clicks. However, to date there is no research on the influence of WN on corticospinal excitability and potentially associated sensorimotor integration itself. Here we tested the hypothesis, if WN induces M1 excitability changes and improves sensorimotor performance. M1 excitability (spTMS, SICI, ICF, I/O curve) and sensorimotor reaction-time performance were quantified before, during and after WN stimulation in a set of experiments performed in a cohort of 61 healthy subjects. WN enhanced M1 corticospinal excitability, not just during exposure, but also during silence periods intermingled with WN, and up to several minutes after the end of exposure. Two independent behavioural experiments highlighted that WN improved multimodal sensorimotor performance. The enduring excitability modulation combined with the effects on behaviour suggest that WN might induce neural plasticity. WN is thus a relevant modulator of corticospinal function; its neurobiological effects should not be neglected and could in fact be exploited in research applications.

Auditory driven gamma synchrony is associated with cortical thickness in widespread cortical areas.

OBJECTIVE: Gamma synchrony is a fundamental functional property of the cerebral cortex, impaired in multiple neuropsychiatric conditions (i.e. schizophrenia, Alzheimer's disease, stroke etc.). Auditory stimulation in the gamma range allows to drive gamma synchrony of the entire cortical mantle and to estimate the efficiency of the mechanisms sustaining it. As gamma synchrony depends strongly on the interplay between parvalbumin-positive interneurons and pyramidal neurons, we hypothesize an association between cortical thickness and gamma synchrony. To test this hypothesis, we employed a combined magnetoencephalography (MEG) - Magnetic Resonance Imaging (MRI) study. METHODS: Cortical thickness was estimated from anatomical MRI scans. MEG measurements related to exposure of 40 Hz amplitude modulated tones were projected onto the cortical surface. Two measures of cortical synchrony were considered: (a) inter-trial phase consistency at 40 Hz, providing a vertex-wise estimation of gamma synchronization, and (b) phase-locking values between primary auditory cortices and whole cortical mantle, providing a measure of long-range cortical synchrony. A correlation between cortical thickness and synchronization measures was then calculated for 72 MRI-MEG scans. RESULTS: Both inter-trial phase consistency and phase locking values showed a significant positive correlation with cortical thickness. For inter-trial phase consistency, clusters of strong associations were found in the temporal and frontal lobes, especially in the bilateral auditory and pre-motor cortices. Higher phase-locking values corresponded to higher cortical thickness in the frontal, temporal, occipital and parietal lobes. DISCUSSION AND CONCLUSIONS: In healthy subjects, a thicker cortex corresponds to higher gamma synchrony and connectivity in the primary auditory cortex and beyond, likely reflecting underlying cell density involved in gamma circuitries. This result hints towards an involvement of gamma synchrony together with underlying brain structure in brain areas for higher order cognitive functions. This study contributes to the understanding of inherent cortical functional and structural brain properties, which might in turn constitute the basis for the definition of useful biomarkers in patients showing aberrant gamma synchronization.

Resting state network connectivity is attenuated by fMRI acoustic noise.

INTRODUCTION: During the past decades there has been an increasing interest in tracking brain network fluctuations in health and disease by means of resting state functional magnetic resonance imaging (rs-fMRI). Rs-fMRI however does not provide the ideal environmental setting, as participants are continuously exposed to noise generated by MRI coils during acquisition of Echo Planar Imaging (EPI). We investigated the effect of EPI noise on resting state activity and connectivity using magnetoencephalography (MEG), by reproducing the acoustic characteristics of rs-fMRI environment during the recordings. As compared to fMRI, MEG has little sensitivity to brain activity generated in deep brain structures, but has the advantage to capture both the dynamic of cortical magnetic oscillations with high temporal resolution and the slow magnetic fluctuations highly correlated with BOLD signal. METHODS: Thirty healthy subjects were enrolled in a counterbalanced design study including three conditions: a) silent resting state (Silence), b) resting state upon EPI noise (fMRI), and c) resting state upon white noise (White). White noise was employed to test the specificity of fMRI noise effect. The amplitude envelope correlation (AEC) in alpha band measured the connectivity of seven Resting State Networks (RSN) of interest (default mode network, dorsal attention network, language, left and right auditory and left and right sensory-motor). Vigilance dynamic was estimated from power spectral activity. RESULTS: fMRI and White acoustic noise consistently reduced connectivity of cortical networks. The effects were widespread, but noise and network specificities were also present. For fMRI noise, decreased connectivity was found in the right auditory and sensory-motor networks. Progressive increase of slow theta-delta activity related to drowsiness was found in all conditions, but was significantly higher for fMRI . Theta-delta significantly and positively correlated with variations of cortical connectivity. DISCUSSION: rs-fMRI connectivity is biased by unavoidable environmental factors during scanning, which warrant more careful control and improved experimental designs. MEG is free from acoustic noise and allows a sensitive estimation of resting state connectivity in cortical areas. Although underutilized, MEG could overcome issues related to noise during fMRI, in particular when investigation of motor and auditory networks is needed.

Reply on the comments about Piccione F, Maccarone MC, Cortese AM, Rocca G, Sansubrino U, Piran G, Masiero S. Rehabilitative management of pelvic fractures: a literature-based update. Eur J Transl Myol. 2021 Sep 17;31(3):9933. doi: 10.4081/ejtm.2021.9933.

We thank the authors of the Letter of Zehua Li, et al. (2021)1 and the Editor for the opportunity to discuss our work more thoroughly. The comments on the article written by Piccione et al. (2021)2 are certainly interesting and highlight limitations of the previously published article. However, we need to make some clarifications.

Rehabilitative management of pelvic fractures: a literature-based update.

A comprehensive rehabilitation program is required after Pelvic Fracture (PF). In a PF rehabilitation setting an effective treatment and a proper management of complications is supplied by an appropriate and reliable clinical assessment. In this literature-based update, we search on MEDLINE, EMBASE, and the Cochrane Database of Systematic reviews to find articles, scientific society guidelines and practioners experiences defining the rehabilitative management of clinically PF outcomes. Based on literature evidences and expert opinions, a set of key topics was collated to generate advices and recommendations to put into daily practice. Even if there are no high-quality evidence for rehabilitative interventions after PF in terms of duration and modality of therapy, rehabilitation setting, care pathways, and long-term functional outcomes, it is strongly recommended an early multidisciplinary intervention to improve recovery from PF.

Skeletal muscle weakness in older adults home-restricted due to COVID-19 pandemic: a role for full-body in-bed gym and functional electrical stimulation.

Persons suffering with systemic neuromuscular disorders or chronic organ failures, spend less time for daily physical activity, aggravating their mobility impairments. From 2020, patients at risk are also older adults, who, though negative for the SARS-Cov-2 infection, suffer with a fatigue syndrome due to home restriction/quarantine. Besides eventual psycological managements, it could be useful to offer to these patients a rehabilitation workouts easy to learn and to independently repeat at home (Full-Body In-Bed Gym). Inspired by the proven capability to recover skeletal muscle contractility and strength by home-based volitional exercises and functional electrical stimulation (FES), we suggest for this fatigue syndrome a 10-20 min long daily routine of easy and safe physical exercises that may recover from muscle weakness the main 400 skeletal muscles used for every-day activities. Leg muscles could be trained also by an adjunctive neuro-muscular electrical stimulation (NMES) in frail old persons. Many of the exercises could be performed in bed (Full-Body in-Bed Gym), thus hospitalized patients can learn this light training before leaving the hospital. Full-Body in-Bed Gym is, indeed, an extension of well-established cardiovascular-ventilation rehabilitation training performed by patients after heavy surgery. Blood pressure readings, monitored before and after daily routine of Full-Body in-Bed Gym, demonstrate a transient decrease in peripheral resistance due to increased blood flow to major body muscles. Continued regularly, Full-Body in-Bed Gym may help maintaining independence of frail people, including those suffering with the fatigue syndrome related to the restrictions/quarantine imposed to the general population during the COVID-19 pandemic.

Neurofunctional Components of Simple Calculation: A Magnetoencephalography Study.

Our ability to calculate implies more than the sole retrieval of the correct solution. Essential processes for simple calculation are related to the spreading of activation through arithmetic memory networks. There is behavioral and electrophysiological evidence for these mechanisms. Their brain location is, however, still uncertain. Here, we measured magnetoencephalographic brain activity during the verification of simple multiplication problems. Following the operands, the solutions to verify could be preactivated correct solutions, preactivated table-related incorrect solutions, or unrelated incorrect solutions. Brain source estimation, based on these event-related fields, revealed 3 main brain networks involved in simple calculation: 1) bilateral inferior frontal areas mainly activated in response to correct, matching solutions; 2) a left-lateralized frontoparietal network activated in response to incorrect table-related solutions; and (3) a strikingly similar frontoparietal network in the opposite hemisphere activated in response to unrelated solutions. Directional functional connectivity analyses revealed a bidirectional causal loop between left parietal and frontal areas for table-related solutions, with frontal areas explaining the resolution of arithmetic competition behaviorally. Hence, this study isolated at least 3 neurofunctional networks orchestrated between hemispheres during calculation.

Correction: Combined botulinum toxin type A and electrical stimulation in individuals with C5-C6 and C6-C7 tetraplegia: a pilot study.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Combined botulinum toxin type A and electrical stimulation in individuals with C5-C6 and C6-C7 tetraplegia: a pilot study.

STUDY DESIGN: Single-blind pilot study. OBJECTIVES: (1) To evaluate combined BoNT-A injection of spastic antagonistic muscles and ES of wrist extensors in order to improve hand function in incomplete cervical SCI patients. (2) To identify prognostic indicators of hand improvements, as a function of motor levels of injury. SETTING: Ten incomplete asymmetric SCI tetraplegics admitted to San Camillo Hospital (Venezia, Italy), who were not able to perform automatic grasping, were enrolled in the study. A better motor level (BML) C6-C7 and worse motor level (WML) C5-C6 were assigned to take into account asymmetric motor strength. METHODS: Administration of 100-200 UI BoNT-A per limb into flexor carpi radialis (FCR), extensor digitorum communis (EDC), brachial biceps (BB), and pectoralis major (PM) was performed. This was in conjunction with 6 weeks of 30-min ES sessions repeated three times a day for 6 days a week in wrist extensor muscles, and 6 weeks of 30-min hand rehabilitation for 6 days a week. Assessments included wrist Range of Motion (w-RoM), Modified Ashworth Score (MAS), Functional Independence Measure motor scores (FIM motor), and Nine Hole Peg Test (NHPT). RESULTS: Treatments produced a significant reduction in motor spasticity (MAS) and better dexterity (NHPT) in the C6-C7 BML with respect to the WML cases (p level = 0.007; p = 0.01, respectively). FIM motor scores improved more in BML (median: 20; range 20/22) than in WML (median: 10; range 8/17). CONCLUSIONS: Hand function improvement, determined by combined BONT-A and ES, was better in C6-C7 than in C5-C6 SCI patients.

Pearl and pitfalls in brain functional analysis by event-related potentials: a narrative review by the Italian Psychophysiology and Cognitive Neuroscience Society on methodological limits and clinical reliability-part II.

This review focuses on new and/or less standardized event-related potentials methods, in order to improve their knowledge for future clinical applications. The olfactory event-related potentials (OERPs) assess the olfactory functions in time domain, with potential utility in anosmia and degenerative diseases. The transcranial magnetic stimulation-electroencephalography (TMS-EEG) could support the investigation of the intracerebral connections with very high temporal discrimination. Its application in the diagnosis of disorders of consciousness has achieved recent confirmation. Magnetoencephalography (MEG) and event-related fields (ERF) could improve spatial accuracy of scalp signals, with potential large application in pre-surgical study of epileptic patients. Although these techniques have methodological limits, such as high inter- and intraindividual variability and high costs, their diffusion among researchers and clinicians is hopeful, pending their standardization.

Pearls and pitfalls in brain functional analysis by event-related potentials: a narrative review by the Italian Psychophysiology and Cognitive Neuroscience Society on methodological limits and clinical reliability-part I.

Event-related potentials (ERPs) are obtained from the electroencephalogram (EEG) or the magnetoencephalogram (MEG, event-related fields (ERF)), extracting the activity that is time-locked to an event. Despite the potential utility of ERP/ERF in cognitive domain, the clinical standardization of their use is presently undefined for most of procedures. The aim of the present review is to establish limits and reliability of ERP medical application, summarize main methodological issues, and present evidence of clinical application and future improvement. The present section of the review focuses on well-standardized ERP methods, including P300, Contingent Negative Variation (CNV), Mismatch Negativity (MMN), and N400, with a chapter dedicated to laser-evoked potentials (LEPs). One section is dedicated to proactive preparatory brain activity as the Bereitschaftspotential and the prefrontal negativity (BP and pN). The P300 and the MMN potentials have a limited but recognized role in the diagnosis of cognitive impairment and consciousness disorders. LEPs have a well-documented usefulness in the diagnosis of neuropathic pain, with low application in clinical assessment of psychophysiological basis of pain. The other ERP components mentioned here, though largely applied in normal and pathological cases and well standardized, are still confined to the research field. CNV, BP, and pN deserve to be largely tested in movement disorders, just to explain possible functional changes in motor preparation circuits subtending different clinical pictures and responses to treatments.

EEG to Identify Attempted Movement in Unresponsive Wakefulness Syndrome.

Assessment of consciousness following severe brain-injury is challenging. Our hypothesis is that electroencephalography (EEG) can provide information on awareness, in terms of oscillatory activity and network task-related modifications, in people with disorders of consciousness. Similar results were obtained with neuroimaging techniques; we aim at demonstrating the use of EEG, which is low cost and routinely implemented, to the same goal. Nineteen-channel EEG was recorded in 7 persons with unresponsive wakefulness syndrome (UWS) and in 10 healthy subjects during the execution of active (attempted movement) and passive motor tasks as well as 2 mental imagery tasks. Event-related synchronization/desynchronization (ERS/ERD), coherence and network parameters were calculated in delta (1-4 Hz), theta (4-8 Hz), alpha1 (8-10 Hz), alpha2 (10-12 Hz), and beta (13-30 Hz) ranges. In UWS subjects, passive movement induced a weak alpha2 ERD over contralateral sensorimotor area. During motor imagery, ERD was detected over the frontal and motor contralateral brain areas; during spatial imagery, ERS in lower alpha band over the right temporo-parietal regions was missing. In UWS, functional connectivity provided evidence of network disruption and isolation of the motor areas, which cannot dialog with adjacent network nodes, likely suggesting a diffuse structural alteration. Our findings suggest that people with a clinical diagnosis of UWS were able to modulate their brain activity when prompted to perform movement tasks and thus suggest EEG as a potential tool to support diagnosis of disorders of consciousness.

Brain Connectivity Modulation After Exoskeleton-Assisted Gait in Chronic Hemiplegic Stroke Survivors: A Pilot Study.

OBJECTIVE: The aim of this study was to investigate electroencephalographic (EEG) connectivity short-term changes, quantified by node strength and betweenness centrality, induced by a single trial of exoskeleton-assisted gait in chronic stroke survivors. DESIGN: Study design was randomized crossover. Electroencephalographic data (64-channel system) were recorded before gait (baseline) and after unassisted overground walking and overground exoskeleton-assisted walking. Coherence was estimated for alpha1, alpha2, and beta frequency ranges. Graph analysis assessed network model properties: node strength and betweenness centrality. RESULTS: Nine participants were included in the final analysis. In the group (four participants) with a left-hemisphere stroke lesion (dominant hemisphere), over the vertex, node strength increased in alpha1, alpha2, and beta bands, and betweenness centrality decreased in alpha2 both after unassisted overground walking and exoskeleton-assisted walking. In the group (five participants) with a right-hemisphere lesion (nondominant hemisphere), node strength increased in alpha1 and alpha2 over the contralesional sensorimotor area and ipsilesional prefrontal area after overground exoskeleton-assisted walking, compared with baseline and unassisted overground walking. CONCLUSION: A single session of exoskeleton training provides short-term neuroplastic modulation in chronic stroke. In participants with a nondominant hemisphere lesion, exoskeleton training induces activations similar to those observed in able-bodied participants, suggesting a role of lesion lateralization in networks' reorganization.