The Effectiveness of Paired Associative Stimulation on Motor Recovery after Stroke: A Scoping Review.

Paired associative stimulation (PAS) is a non-invasive brain stimulation technique combining transcranial magnetic stimulation and peripheral nerve stimulation. PAS allows connections between cortical areas and peripheral nerves (C/P PAS) or between cortical regions (C/C PAS) to be strengthened or weakened by spike-timing-dependent neural plasticity mechanisms. Since PAS modulates both neurophysiological features and motor performance, there is growing interest in its application in neurorehabilitation. We aimed to synthesize evidence on the motor rehabilitation role of PAS in stroke patients. We performed a literature search following the PRISMA Extension for Scoping Reviews Framework. Eight studies were included: one investigated C/C PAS between the cerebellum and the affected primary motor area (M1), seven applied C/P PAS over the lesional, contralesional, or both M1. Seven studies evaluated the outcome on upper limb and one on lower limb motor recovery. Although several studies omit crucial methodological details, PAS highlighted effects mainly on corticospinal excitability, and, more rarely, an improvement in motor performance. However, most studies failed to prove a correlation between neurophysiological changes and motor improvement. Although current studies seem to suggest a role of PAS in post-stroke rehabilitation, their heterogeneity and limited number do not yet allow definitive conclusions to be drawn.

Head-Mounted Displays for Upper Limb Stroke Rehabilitation: A Scoping Review.

Upper extremity (UE) paresis is one of the most frequent and disabling clinical consequences after stroke. Head-Mounted Displays (HMDs) are wearable virtual reality devices that seem effective in promoting the recovery of functional abilities by increasing adherence levels in this population. This scoping review is aimed at collecting available evidence on the use of HMD-based immersive virtual reality systems for UE rehabilitation treatment in stroke survivors. Four electronic bibliographic databases were consulted from inception until 18 January 2023. A total of 19 clinical trials in which HMDs were used as a clinical tool for increasing UE functioning, as a single intervention or in adjunct to other rehab treatments, were included; no restrictions were applied for UE paresis severity or stroke onset. The large majority of the clinical trials involved chronic stroke patients (15 out of 19), with a wide range of UE impairments. Overall, HMD use seemed to be well-tolerated and promising for increasing UE motor function in adult chronic stroke survivors, with benefits in subjects' arm use and independence. The possibility of executing highly realistic and task-oriented movements appears to be promising in enhancing gesture relevance, thus promoting new motor strategies in a "virtual ecological way". Across studies, we found a high heterogeneity in protocol design and a lack of reporting that prevents us drawing conclusions regarding potential subgroups of patients that could benefit more from HMD-based interventions or suggested treatment modalities.

A Multimodal Analysis to Explore Upper Limb Motor Recovery at 4 Weeks After Stroke: Insights From EEG and Kinematics Measures.

Background. Stroke is a leading cause of death and disability worldwide and there is a very short period of increased synaptic plasticity, fundamental in motor recovery. Thus, it is crucial to acquire data to guide the rehabilitation treatment. Promising results have been achieved with kinematics and neurophysiological data, but currently, few studies integrate these different modalities. Objectives. We explored the correlations between standardized clinical scales, kinematic data, and EEG measures 4 weeks after stroke. Methods. 26 patients were considered. Among them, 20 patients also performed the EEG study, beyond the kinematic analysis, at 4 weeks. Results. We found correlations between the Fugl-Meyer Assessment-Upper Extremity, movement duration, smoothness measures, and velocity peaks. Moreover, EEG measures showed a tendency for the healthy hemisphere to vicariate the affected one in patients characterized by better clinical conditions. Conclusions. These results suggest the relevance of kinematic (in particular movement duration and smoothness) and EEG biomarkers to evaluate post-stroke recovery. We emphasize the importance of integrating clinical data with kinematic and EEG analyses from the early stroke stages, in order to guide rehabilitation strategies to best leverage the short period of increased synaptic plasticity.

Quantitative Comparison of Hand Kinematics Measured with a Markerless Commercial Head-Mounted Display and a Marker-Based Motion Capture System in Stroke Survivors.

Upper-limb paresis is common after stroke. An important tool to assess motor recovery is to use marker-based motion capture systems to measure the kinematic characteristics of patients' movements in ecological scenarios. These systems are, however, very expensive and not readily available for many rehabilitation units. Here, we explored whether the markerless hand motion capabilities of the cost-effective Oculus Quest head-mounted display could be used to provide clinically meaningful measures. A total of 14 stroke patients executed ecologically relevant upper-limb tasks in an immersive virtual environment. During task execution, we recorded their hand movements simultaneously by means of the Oculus Quest's and a marker-based motion capture system. Our results showed that the markerless estimates of the hand position and peak velocity provided by the Oculus Quest were in very close agreement with those provided by a marker-based commercial system with their regression line having a slope close to 1 (maximum distance: mean slope = 0.94 ± 0.1; peak velocity: mean slope = 1.06 ± 0.12). Furthermore, the Oculus Quest had virtually the same sensitivity as that of a commercial system in distinguishing healthy from pathological kinematic measures. The Oculus Quest was as accurate as a commercial marker-based system in measuring clinically meaningful upper-limb kinematic parameters in stroke patients.

Predictors of Clinically Meaningful Results of Bracing in a Large Cohort of Adolescents with Idiopathic Scoliosis Reaching the End of Conservative Treatment.

BACKGROUND: We need good outcome predictors to maximize the treatment efficiency of adolescents with idiopathic scoliosis (AIS). The in-brace correction has shown an important predictive effect on brace failure, while the influence of other variables is still debated. We aimed to identify new outcome predictors from a big prospective database of AIS. METHODS: Design: Retrospective analysis of prospectively collected data. INCLUSION CRITERIA: AIS between 21 and 45°, Risser 0-2, brace prescription during the observation, treatment conclusion. All of the participants followed a personalized conservative approach according to the SOSORT Guidelines. OUTCOMES: End of growth below 30°-40°-50°. The regression model included age, BMI, Cobb angle, ATR, TRACE score, real brace wear (RBW), and in-brace correction (IBC). RESULTS: A total of 1050 patients, 84% females, ages 12.1 ± 1.1, 28.2 ± 7.9° Cobb. IBC increased by 30%, 24%, and 23% the odds of ending treatment below 30°, 40°, and 50°, respectively. The OR did not change after the covariate adjustment. Cobb angle and ATR at the start also showed a predictive effect. CONCLUSIONS: The systematic evaluation of IBC in clinics is useful for individuating the patient response to brace treatment more accurately, even in relation to the Cobb angle and ATR degrees at the start. Further studies are needed to increase the knowledge on predictors of AIS treatment results.

Personal and Clinical Determinants of Brace-Wearing Time in Adolescents with Idiopathic Scoliosis.

Adolescent idiopathic scoliosis (AIS) is a three-dimensional spine and trunk deformity. Bracing is an effective treatment for medium-degree curves. Thermal sensors help monitor patients' adherence (compliance), a critical issue in bracing treatment. Some studies investigated adherence determinants but rarely through sensors or in highly adherent cohorts. We aimed to verify the influence of personal and clinical variables routinely registered by physicians on adherence to brace treatment in a large cohort of consecutive AIS patients from a highly adherent cohort. We performed a cross-sectional study of patients consecutively recruited in the last three years at a tertiary referral institute and treated with braces for one year. To ensure high adherence, for years, we have provided specific support to brace treatment through a series of cognitive-behavioural interventions for patients and parents. We used iButton thermal sensor systematic data collection to precisely analyse the real brace-wearing time. We included 514 adolescents, age 13.8 ± 1.6, with the worst scoliosis curve of 34.5 ± 10.3° Cobb. We found a 95% (95CI 60-101%) adherence to the brace prescription of 21.9 ± 1.7 h per day. Determinants included gender (91% vs. 84%; females vs. males) and age < 14 years (92% vs. 88%). Brace hours prescription, BMI, and all clinical variables (worst curve Cobb degrees, angle of trunk rotation, and TRACE index for aesthetics) did not influence adherence.

A novel immersive virtual reality environment for the motor rehabilitation of stroke patients: A feasibility study.

We designed and implemented an immersive virtual reality (VR) environment for upper limb rehabilitation, which possesses several notable features. First, by exploiting modern computer graphics its can present a variety of scenarios that make the rehabilitation routines challenging yet enjoyable for patients, thus enhancing their adherence to the therapy. Second, immersion in a virtual 3D space allows the patients to execute tasks that are closely related to everyday gestures, thus enhancing the transfer of the acquired motor skills to real-life routines. Third, in addition to the VR environment, we also developed a client app running on a PC that allows to monitor in real-time and remotely the patients' routines thus paving the way for telerehabilitation scenarios. Here, we report the results of a feasibility study in a cohort of 16 stroke patients. All our patients showed a high degree of comfort in our immersive VR system and they reported very high scores of ownership and agency in embodiment and satisfaction questionnaires. Furthermore, and notably, we found that behavioral performances in our VR tasks correlated with the patients' clinical scores (Fugl-Meyer scale) and they could thus be used to assess improvements during the rehabilitation program. While further studies are needed, our results clearly support the feasibility and effectiveness of VR-based motor rehabilitation processes.

Construct Validity and Responsiveness of the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) in a Cohort of Italian Hospitalized COVID-19 Patients.

Post-COVID Syndrome (PCS) is characterized by physical, psychological and cognitive symptoms with a negative impact on daily activities. This study tested the responsiveness and construct validity of the original version of the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) in a cohort of Italian hospitalized COVID-19 patients. This longitudinal study involved 79 hospitalized COVID-19 patients with rehabilitation needs, assessed after 12 and 26 weeks post-infection. Functional and patient-reported outcome measures were correlated with 10 items of the C19-YRS to test the construct validity, whereas distribution-based methods were used for the responsiveness over time. After 12 weeks since infection, 88.5% of patients reported fatigue, 83.3% breathlessness, 69.4% anxiety, 55.6% depression, and 44.9% pain. Moreover, 84.6% experienced reduced mobility, 75.7% had difficulties with usual activities, and 47.4% with personal care. Single items for each symptom had significant correlation (rho 0.25-0.60) with well-established scales for these symptoms. At 26 weeks, except for anxiety, all the PCS symptoms were still present but significantly reduced. The C19-YRS had moderate responsiveness for the most represented deficit reported. The C19-YRS was a valuable patient-reported outcome for screening, assessing severity, and monitoring the persistence of symptoms after 12 and 26 weeks from SARS-CoV2 infection in a cohort of Italian hospitalized patients.

Video game therapy on mobility and dual tasking in multiple sclerosis: study protocol for a randomised controlled trial.

INTRODUCTION: Multiple sclerosis (MS) is one of the major causes of disability in young adults and affects mobility, compromising daily living activities and participation in social life. Cognitive domain is also frequently impaired in people with MS (PwMS), particularly the capacity to perform dual-task activities. Impaired cognitive processing abilities need to be treated, and motor and cognitive aspects need to be considered together. Recently, video game therapy (VGT) has been used in rehabilitation to improve motor outcomes and cognitive processing speed. The aim of this study is to test the efficacy of commercially available VGT on mobility and dual tasking in PwMS compared with standardised balance platform training (BPT). METHODS AND ANALYSIS: This will be a parallel-assignment, double-blinded, randomised control trial. Forty-eight (24 per arm) PwMS with Expanded Disability Status Scale 4-5.5 will be randomly assigned to receive 1 hour training session over 4 weeks (three sessions/week) of either: (1) VGT on commercial video game console to train balance and mobility-related activities or (2) BPT to perform balance, postural stability and weight-shifting exercises with and without visual feedback. The same assessor will evaluate outcome measures at points: before and after the 12 training sessions and at 3 months of follow-up. The primary outcome will be functional mobility, assessed by the Timed Up and Go test. We will also evaluate gait, risk of fall, fatigue and health-related quality of life as well as cognitive and psychological aspects (depression, anxiety and attentional performance) and stability through posturographic evaluation. Dual-tasking assessment will be performed combining posturographic and neuropsychological tests. Data analysis will be performed to compare the efficacy of the two treatments. ETHICS AND DISSEMINATION: Ethical approval have been granted from the local Ethics Committee. Study results will be communicated through high-quality journals and national and international conferences. TRIAL REGISTRATION NUMBER: NCT03353974.