Moving toward Appropriate Motor Assessment Tools in People Affected by Severe Acquired Brain Injury: A Scoping Review with Clinical Advices.

Severe acquired brain injury (SABI) is among the leading causes of death and disability worldwide. Patients following SABI may develop motor, sensory and cognitive disorders, alone or in combination. This review aims to point out the most used scales to assess motor function in SABI patients, also attempting to give some indications on their applicability in clinical practice. Studies were identified by searching on PubMed, Web of Science, PeDro and Cochrane databases between January and March 2022. We found that motor assessment tools are currently used by researchers/clinicians either in the acute/post-acute phase (for prognosis and rehabilitation purposes) or in the chronic phase (when functional items may also be considered). Moreover, specific scales exist only for patients with disorders of consciousness, whereas regarding motor function, SABI is mainly assessed by adapting the tools commonly used for stroke. Although some doubts remain about the validity of some of these assessment tools in SABI, to investigate motor outcomes is fundamental to establish a correct prognosis and plan a tailored rehabilitation training in these very frail and vulnerable patients.

Stroke Telerehabilitation in Calabria: A Health Technology Assessment.

Introduction: Telerehabilitation (TR) is defined as a model of home service for motor and cognitive rehabilitation, ensuring continuity of care over time. TR can replace the traditional face-to-face approach as an alternative method of delivering conventional rehabilitation and applies to situations where the patient is unable to reach rehabilitation facilities or for low-income countries where outcomes are particularly poor. For this reason, in this study, we sought to demonstrate the feasibility and utility of a well-known TR intervention on post-stroke patients living in one of the poorest indebted regions of Italy, where the delivery of rehabilitation services is inconsistent and not uniform. Materials and Methods: Nineteen patients (13 male/6 female; mean age: 61.1 ± 8.3 years) with a diagnosis of first-ever ischemic (n = 14) or hemorrhagic stroke (n = 5), who had been admitted to the intensive rehabilitation unit (IRU) of the Institute S. Anna (Crotone, Italy), were consecutively enrolled to participate in this study. After the discharge, they continued the motor treatment remotely by means of a home-rehabilitation system. The entire TR intervention was performed (online and offline) using the Virtual Reality Rehabilitation System (VRRS) (Khymeia, Italy). All patients received intensive TR five times a week for 12 consecutive weeks (60 sessions, each session lasting about 1h). Results: We found a significant motor recovery after TR protocol as measured by the Barthel Index (BI); Fugl-Meyer motor score (FM) and Motricity Index (MI) of the hemiplegic upper limbs. Conclusions: This was the first demonstration that a well-defined virtual reality TR tool promotes motor and functional recovery in post-stroke patients living in a low-income Italian region, such as Calabria, characterized by a paucity of specialist rehabilitation services.

Pattern of treatment of behavioural and psychological symptoms of dementia and pain: evidence on pharmacoutilization from a large real-world sample and from a centre for cognitive disturbances and dementia.

PURPOSE: Data concerning the number of diagnoses and of the drugs prescribed to patients affected by dementia are still scarce. Here we test whether or not (1) prescription of symptomatic drugs against Alzheimer's disease (AD) may approximate the number of patients affected by dementia in Italy and (2) adherence to this treatment affects the pattern of prescription of drugs (i.e. antipsychotics and antidepressants) for behavioural and psychological symptoms of dementia (BPSD) and the previously reported limited prescription of analgesics. METHODS: This retrospective observational study concerns 84,235 subjects older than 60 years and registered in the provincial prescription database of the health district of Cosenza accounting for a population of 298,000 inhabitants. The prescribing pattern of antipsychotics, antidepressants, and analgesics has been investigated in patients receiving concurrent prescriptions of acetylcholinesterase inhibitors (AChEI) and/or memantine. Data from a single centre for cognitive disturbances and dementia (CDCD) in the same health district were used to explore at which stage dementia was diagnosed. The study was approved by Calabria Region Ethical Committee no. 31/2017 and registered on October 31, 2017. RESULTS: The data show that 859 patients are treated with AChEI and/or memantine; 420 patients (48.89%) receive at least 80% of the recommended medications. CDCD data indicate a delay in dementia diagnosis, which often was made when the patients were moderately to severely demented (Mini Mental State Examination, MMSE ≤ 20). Adherence did not influence prescription of most of the drugs explored, but use of non-steroidal anti-inflammatory drugs was higher in non-adherent patients. Antipsychotics and antidepressants are frequently used (20.61-20.71% and 42.37-51.43%, respectively), and this, at least in part, might stem from the observed under-treatment of chronic pain (opioids are prescribed in the 4.76% and 12.46% of adherent and non-adherent patients and gabapentin and pregabalin are used in the 4.29% and 4.07% of adherent and non-adherent patients respectively), resulting in more frequent BPSD. 16.43% of patients receive antipsychotics for longer than 6-12 weeks. CONCLUSION: This 2-year period study, including a wide cohort of community demented patients, shows that dementia is diagnosed late and that prevalence of BPSD prescriptions is high and not impacted by adherence to anti-dementia drugs. The rate of prescription of potentially harmful antipsychotics and antidepressants appears to be high though whether the concomitantly observed limited prescription of analgesics might be a contributing factor needs to be further investigated. Our data support the development of strategies to improve the management of BPSD.

Factors Influencing Burden in Spouse-Caregivers of Patients with Chronic-Acquired Brain Injury.

In this cross-sectional study, we assess associated factors of burden in spouse-caregivers of patients with acquired brain injury (ABI) in the chronic phase. 35 spouse-caregivers (71% female, mean age ± SD: 55.7 ± 11.1y) of patients with mild/moderate ABI (29% female, mean age ± SD: 57.5 ± 10.7y), admitted to the intensive rehabilitation unit of the Institute S. Anna (Crotone, Italy) between January 2013 and December 2017, were contacted 2 years postinjury and asked to complete a series of questionnaires. The outcome measure was the Caregiver Burden Inventory (CBI) test, while several demographical and clinical data were considered as predictive factors. Two years after injury, a high level of burden was reported in 34.2% of spouse-caregivers. Stepwise multiple linear regression analyses revealed that caring for a patient with more severe disability (as measured by the Barthel Index scale) and the family life cycle (from the initial phase of engagement to marriage with adult children) explain the vast majority of variance for higher caregiver burden. The functional clinical status and the stages through which a family may pass over time were identified as areas in which the spouse-caregiver of ABI patients experienced high levels of burden in the chronic phase.

The assessment of trunk recovery in stroke patients using 3D kinematic measures.

The kinematic analysis of trunk recovery in patients with stroke has sparsely been investigated. This study is aimed at evaluating the validity of a kinematic system for measuring trunk movements. Forty-five right-handed stroke patients in the post-acute phase were assessed in a within-subject design, before and after intensive conventional neurorehabilitation treatment. An eight-camera system was used to analyze the three-dimensional (3D) kinematics of trunk during typical displacements (anterior/posterior and right/left lateral). Kinematic trunk measurements and clinical evaluations were performed immediately in a blind fashion before and after rehabilitation treatments. Of the 9 kinematic variables, 4 showed a significant relationship with the clinical measure of the trunk: Trunk Control Test (TCT). Among these, only the kinematic evaluation of the lateral pelvic was the best predictor (R2= 0.2; p-level< 0.006; beta= 0.41) of clinical recovery measured with TCT. Here, we present a 3D kinematic system for assessing trunk impairments in stroke patients. We found that different kinematic variables reflect motor recovery as assessed by conventional clinical scale. Further evaluations, including reliability analysis and application on patients with gait impairments, are required.

Diabetic retinopathy and age-related macular degeneration: a survey of pharmacoutilization and cost in Calabria, Italy.

The aged population is constantly growing, thus fostering an increase in age-dependent diseases. Among these, diabetic retinopathy (DR) along with age-related macular degeneration entails progressive vision loss. Since such conditions are associated with the proliferation of novel vessels, their pharmacotherapeutic management consists of the intravitreal injection of anti-vascular endothelial growth factor drugs, able to hinder the driving of vascular proliferation prompted by vascular endothelial growth factor. The humanized anti-vascular endothelial growth factor monoclonal antibody ranibizumab provided evidence for efficacy in several trials, hence earning approval by the US Food and Drug Administration for therapeutic use in all the stages of DR. Due to the lack of epidemiologic and pharmacoeconomic evaluation in the local Calabria Region context, the present retrospective observational study focused on prevalence of DR and age-related macular degeneration, treatment and cost of therapy with ranibizumab in 870 patients arriving to clinical observation at the "Mater Domini" University Hospital in Calabria, Italy from January 2014 to June 2017. Data were extracted from the database of ophthalmology ward and subjected to statistical analysis. The results suggest that the most frequent retinal diseases are age-related macular degeneration and DR and that the use of ranibizumab has been decreasing over the 4-year study period together with the associated cost per patient which was similar for both disorders. Therefore, appropriateness of treatment with drugs other than ranibizumab needs to be assessed in this setting and deep monitoring of pharmacologic treatment for retinal diseases is necessary to prevent or delay visual acuity decrease and complete vision loss. Study procedures were performed in accordance with the "Mater Domini" University Hospital ethical standards of the responsible committee on human experimentation.

Telerehabilitation in individuals with severe acquired brain injury: Rationale, study design, and methodology.

BACKGROUND: Severe acquired brain injury (SABI) rehabilitation should be as intensive and long as to allow the patients get the best independence and quality of life (QoL), but facing with the rehabilitation socioeconomic burden. Telerehabilitation (TR) could supply frail subjects requiring long-term rehabilitation. METHODS: A multicenter, prospective, parallel design, single-blind trial will be conducted at the IRCCS Neurolesi Bonino Pulejo (Messina, Italy) and IRCCS Hospital San Camillo (Venice, Italy) involving patients suffering from SABI and requiring home motor and cognitive rehabilitation. We will investigate the use of TR, based on advanced Information and Communication Technology (ICT) solutions, taking into account that the supervision of rehabilitation at home will be enriched with the counseling and vital parameters monitoring. The enrolled patients will be balanced for pathology, and randomized in 2 groups, performing TR (G1) or standard rehabilitation training (G2), respectively, according to a pc-generated random assignment. TR will be delivered by means of an advanced video-conferencing system, whereas the patient will be provided with low-cost monitoring devices, able to collect data about his/her health status and QoL. In both the groups each treatment (either cognitive or motor, or both as per patient functional status) will last about 1 hour a day, 5 days/week, for 12 weeks. Two structured telephone interviews will be administered to the patients (when possible) and/or their caregivers, and to all the healthcare professionals involved in the patient management, 1 week after the beginning and at the end of the TR. All the patients will undergo a complete neurological and cognitive examination performed by skilled physicians and psychologists, blindly. Clinical evaluations will be administered blindly, before and after the treatments. RESULTS: the data of this study should demonstrate that TR is at least non-inferior in comparison with the same amount of usual territorial rehabilitative physical treatments, taking into account patients' functional recovery, psychological well-being, caregiver burden, and healthcare costs. CONCLUSION: data coming from this study could demonstrate the usefulness of TR in facing the rehabilitation socioeconomic burden of managing patients with SABI, so to allow the patients get the best independence and quality of life (QoL).

Assessment of Event-Related EEG Power After Single-Pulse TMS in Unresponsive Wakefulness Syndrome and Minimally Conscious State Patients.

In patients without a behavioral response, non-invasive techniques and new methods of data analysis can complement existing diagnostic tools by providing a method for detecting covert signs of residual cognitive function and awareness. The aim of this study was to investigate the brain oscillatory activities synchronized by single-pulse transcranial magnetic stimulation (TMS) delivered over the primary motor area in the time-frequency domain in patients with the unresponsive wakefulness syndrome or in a minimally conscious state as compared to healthy controls. A time-frequency analysis based on the wavelet transform was used to characterize rapid modifications of oscillatory EEG rhythms induced by TMS in patients as compared to healthy controls. The pattern of EEG changes in the patients differed from that of healthy controls. In the controls there was an early synchronization of slow waves immediately followed by a desynchronization of alpha and beta frequency bands over the frontal and centro-parietal electrodes, whereas an opposite early synchronization, particularly over motor areas for alpha and beta and over the frontal and parietal electrodes for beta power, was seen in the patients. In addition, no relevant modification in slow rhythms (delta and theta) after TMS was noted in patients. The clinical impact of these findings could be relevant in neurorehabilitation settings for increasing the awareness of these patients and defining new treatment procedures.

Assessment and treatment of the upper limb by means of virtual reality in post-stroke patients.

The disability deriving from stroke impacts heavily on the economic and social aspects of western countries because stroke survivors commonly experience various degrees of autonomy reduction in the activities of daily living. Recent developments in neuroscience, neurophysiology and computational science have led to innovative theories about the brain mechanisms of the motor system. Thereafter, innovative, scientifically based therapeutic strategies have initially arisen in the rehabilitation field. Promising results from the application of a virtual reality based technique for arm rehabilitation are reported.