Gait Analysis and Magnetic Resonance Imaging Characteristics in Patients with Isolated Rapid Eye Movement Sleep Behavior Disorder.

BACKGROUND: Isolated rapid eye movement sleep behavioral disorder (iRBD) can precede neurodegenerative diseases. There is an urgent need for biomarkers to aid early intervention and neuroprotection. OBJECTIVE: The aim is to assess quantitative motor, cognitive, and brain magnetic resonance imaging (MRI) characteristics in iRBD patients. METHODS: Thirty-eight polysomnography-confirmed iRBD patients and 28 age- and sex-matched healthy controls underwent clinical, cognitive, and motor functional evaluations, along with brain MRI. Motor tasks included nine-hole peg test, five-times-sit-to-stand test, timed-up-and-go test, and 4-meter walking test with and without cognitive dual task. Quantitative spatiotemporal gait parameters were obtained using an optoelectronic system. Brain MRI analysis included functional connectivity (FC) of the main resting-state networks, gray matter (GM) volume using voxel-based morphometry, cortical thickness, and deep GM and brainstem volumes using FMRIB's Integrated Registration and Segmentation Tool and FreeSurfer. RESULTS: iRBD patients relative to healthy subjects exhibited a poorer performance during the nine-hole peg test and five-times-sit-to-stand test, and greater asymmetry of arm-swing amplitude and stride length variability during dual-task gait. Dual task significantly worsened the walking performance of iRBD patients more than healthy controls. iRBD patients exhibited nonmotor symptoms, and memory, abstract reasoning, and visuospatial deficits. iRBD patients exhibited decreased FC of pallidum and putamen within the basal ganglia network and occipital and temporal areas within the visuo-associative network, and a reduced volume of the supramarginal gyrus. Brain functional alterations correlated with gait changes. CONCLUSIONS: Subtle motor and nonmotor alterations were identified in iRBD patients, alongside brain structural and functional MRI changes. These findings may represent early signs of neurodegeneration and contribute to the development of predictive models for progression to parkinsonism. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Use of the combination of spirometry, arterial blood gas analysis and overnight oximetry to predict the outcomes of patients affected by motor neuron disease: The Milan-Torin respiratory score (Mi-To-RS).

BACKGROUND AND PURPOSE: The use of multiple tests, including spirometry, arterial blood gas (ABG) analysis and overnight oximetry (OvOx), is highly recommended to monitor the respiratory function of patients with motor neuron disease (MND). In this study, we propose a composite score to simplify the respiratory management of MND patients and better stratify their prognosis. MATERIALS AND METHODS: We screened the clinical charts of 471 non-ventilated MND patients referred to the Neuro-rehabilitation Unit of the San Raffaele Scientific Institute of Milan (January 2001-December 2019), collecting spirometric, ABG and OvOx parameters. To evaluate the prognostic role of each measurement, univariate Cox regression for death/tracheostomy was performed, and the variables associated with survival were selected to design a scoring system. Univariate and multivariate Cox regression analyses were then carried out to evaluate the prognostic role of the score. Finally, results were replicated in an independent cohort from the Turin ALS Center. RESULTS: The study population included 450 patients. Six measurements were found to be significantly associated with survival and were selected to design a scoring system (maximum score = 8 points). Kaplan-Meier analysis showed significant stratification of survival and time to non-invasive mechanical ventilation adaptation according to score values, and multivariate analysis confirmed the independent effect of the respiratory score on survival of each cohort. CONCLUSION: Forced vital capacity, ABG and OvOx parameters provide complementary information for the respiratory management and prognosis of MND patients and the combination of these parameters into a single score might help neurologists predict prognosis and guide decisions on the timing of the implementation of different diagnostic or therapeutic approaches.

Action Observation and Motor Imagery Improve Dual Task in Parkinson's Disease: A Clinical/fMRI Study.

BACKGROUND: Action observation training and motor imagery may improve motor learning in Parkinson's disease (PD). OBJECTIVES: The objectives of this study were to assess mobility and balance (performing motor and dual tasks) and brain functional reorganization following 6 weeks of action observation training and motor imagery associated with dual-task gait/balance exercises in PD patients with postural instability and gait disorders relative to dual-task training alone. METHODS: Twenty-five PD-postural instability and gait disorder patients were randomized into 2 groups: the DUAL-TASK+AOT-MI group performed a 6-week gait/balance training consisting of action observation training-motor imagery combined with practicing the observed-imagined exercises; the DUAL-TASK group performed the same exercises combined with watching landscape videos. Exercises were increasingly difficult to include the dual task. At baseline and at 6 weeks, patients underwent: mobility, gait, and balance evaluations (also repeated 2 months after training), cognitive assessment, and functional MRI, including motor and dual tasks. RESULTS: Dual-task gait/balance training enhanced mobility, during both single- and dual-task conditions, and executive functions in PD-postural instability and gait disorders, with a long-lasting effect at 14 weeks. When exercises were preceded by action observation training-motor imagery, PD-postural instability and gait disorders showed greater improvement of balance and gait velocity both with and without the dual task, particularly during the turning phase. After training, the DUAL-TASK+AOT-MI group showed reduced recruitment of frontal areas and increased activity of cerebellum during functional-MRI motor and dual task, correlating with balance/turning velocity and executive improvements, respectively. The DUAL-TASK group showed reduced activity of supplementary motor area and increased recruitment of temporo-parietal areas during the dual task and decreased cerebellar activity during the motor task correlating with faster turning velocity. Functional MRI results were not corrected for multiple comparisons and should be interpreted carefully. CONCLUSIONS: Adding action observation training-motor imagery to dual-task gait/balance training promotes specific functional reorganization of brain areas involved in motor control and executive-attentive abilities and more long-lasting effects on dual-task mobility and balance in PD-postural instability and gait disorders. © 2021 International Parkinson and Movement Disorder Society.

Lung Ultrasound in COVID-19 A Role Beyond the Acute Phase?

OBJECTIVES: Coronavirus disease 2019 (COVID-19) is a viral illness caused by severe acute respiratory syndrome coronavirus 2. With the increasing number of improved and discharged patients with COVID-19, the definition of an adequate follow-up strategy is needed. The purpose of this study was to assess whether lung ultrasound (LUS) is an effective indicator of subclinical residual lung damage in patients with COVID-19 who meet discharge criteria. METHODS: We prospectively enrolled 70 consecutive patients with COVID-19 who had a prolonged hospitalization with inpatient rehabilitation between April 6 and May 22, 2020. All of the patients underwent an LUS evaluation at discharge. Data of patients with more severe disease during the acute phase (ie, required ventilatory support) were compared to those of patients with milder disease. RESULTS: Among the 70 patients with COVID-19 (22 women and 48 men; mean age ± SD, 68 ± 13 years), the LUS score before discharge was still frankly pathologic and higher in patients who had more severe disease during the acute phase compared to patients with milder disease (median [interquartile range], 8.0 [5.5-13.5] versus 2.0 [1.0-7.0]; P < .001), even when both categories met internationally defined discharge criteria. CONCLUSIONS: Lung ultrasound can identify the persistence of subclinical residual lung damage in patients with severe COVID-19 even if they meet discharge criteria. Considering the low cost, easy application, and lack of radiation exposure, LUS seems the ideal tool to be adopted in outpatient and primary care settings for the follow-up of patients with COVID-19.

Role of Rehabilitation Department for Adult Individuals With COVID-19: The Experience of the San Raffaele Hospital of Milan.

The rapid evolution of the health emergency linked to the spread of severe acute respiratory syndrome coronavirus 2 requires specifications for the rehabilitative management of patients with coronavirus disease 2019 (COVID-19). The symptomatic evolution of patients with COVID-19 is characterized by 2 phases: an acute phase in which respiratory symptoms prevail and a postacute phase in which patients can show symptoms related to prolonged immobilization, to previous and current respiratory dysfunctions, and to cognitive and emotional disorders. Thus, there is the need for specialized rehabilitative care for these patients. This communication reports the experience of the San Raffaele Hospital of Milan and recommends the setup of specialized clinical pathways for the rehabilitation of patients with COVID-19. In this hospital, between February 1 and March 2, 2020, about 50 patients were admitted every day with COVID-19 symptoms. In those days, about 400 acute care beds were created (intensive care/infectious diseases). In the following 30 days, from March 2 to mid-April, despite the presence of 60 daily arrivals to the emergency department, the organization of patient flow between different wards was modified, and several different units were created based on a more accurate integration of patients' needs. According to this new organization, patients were admitted first to acute care COVID-19 units and then to COVID-19 rehabilitation units, post-COVID-19 rehabilitation units, and/or quarantine/observation units. After hospital discharge, telemedicine was used to follow-up with patients at home. Such clinical pathways should each involve dedicated multidisciplinary teams composed of pulmonologists, physiatrists, neurologists, cardiologists, physiotherapists, neuropsychologists, occupational therapists, speech therapists, and nutritionists.

Sensory-motor training with virtual reality as a complementary intervention to manual therapy for persistent non-specific neck pain: a randomized controlled trial.

BACKGROUND: Persistent non-specific neck pain (NP) is a widespread condition described as a complex biopsychosocial disorder, characterized by physical and psychological symptoms. Virtual reality (VR) shows promise in NP treatment, potentially reducing pain, kinesiophobia, and improving range of motion (ROM) and motor control. AIM: The primary aim of the study was to assess the effectiveness of VR sensorimotor training, combined with manual therapy, in reducing the level of disability in persistent non-specific NP individuals. The secondary aim was to determine if this VR-enhanced approach also contributes to improvement in overall function, pain perception and kinesiophobia. DESIGN: Monocentric, single-blind, randomized controlled trial. SETTING: We conducted this trial at San Raffaele Scientific Institute, Department of Rehabilitation and Functional Recovery, Milan, Italy. POPULATION: Forty NP participants were enrolled in the study and randomly allocated into two groups. METHODS: The study involved a 6-week rehabilitation program, comprising 12 sessions of 45 minutes each, twice weekly. Both intervention groups underwent manual therapy as a consistent component of their treatment. The Experimental Group (VRT) was additionally engaged in sensorimotor rehabilitation exercises using Virtual Reality, whereas the Control Group (CT) performed the same exercises without VR. We assessed subjects at baseline (T0) and after six weeks of rehabilitation (T1). The primary outcome was the disability (Neck Disability Index) while the secondary outcomes were: pain perception (Numeric Rating Scale, NP and Disability Scale, Central Sensitization Inventory) function (Cervical Kinematics) and kinesiophobia (Tampa Scale of Kinesiophobia). RESULTS: Both groups demonstrated significant reduction in level of disability, pain perception, and kinesiophobia. Significant advancements in kinematics were observed: VRT group showed enhanced ROM during craniocervical rotation (P=0.039), lateral bending (P=0.001), flexion-extension (P=0.009), and mean velocity across movements (P<0.001), whereas CT group improved in maximal ROM during lateral bending rotation (P=0.001). Between-group analysis, after Bonferroni's correction for multiple comparisons, revealed that VRT group had significantly better outcomes in ROM during rotation (P=0.040), ratio of the primary over the secondary movement while performing rotation (P=0.021), and mean velocity during lateral bending (P=0.031). CONCLUSIONS: Sensorimotor training, combined with manual therapy, could enhance kinematic outcomes for NP patients, supporting the potential of VR in rehabilitation. CLINICAL REHABILITATION IMPACT: This study highlighted that both groups demonstrated significant reduction in level of disability, pain perception, and kinesiophobia after sensorimotor training combined with manual therapy. It is important to underscore that in terms of reducing the level of neck disability, both interventions proved to be equally effective. This parity in efficacy is a critical finding, reaffirming the robustness of our therapeutic approaches for this specific outcome.

The disembodiment effect of negation: negating action-related sentences attenuates their interference on congruent upper limb movements.

Human languages can express opposite propositions by means of the negative operator "not," which turns affirmative sentences into negative ones. Psycholinguistic research has indicated that negative meanings are formed by transiently reducing the access to mental representations of negated conceptual information. Neuroimaging studies have corroborated these findings, showing reduced activation of concept-specific embodied neural systems by negative versus affirmative sentences. This "disembodiment effect" of sentential negation should have two distinct consequences: first, the embodied systems should be computationally more free to support concurrent tasks when processing negative than affirmative sentences; second, the computational interference should only be reduced when there is a strict semantic congruency between the negated concept and the referent targeted by concurrent tasks. We tested these two predictions in two complementary experiments involving the comprehension of action-related sentences and kinematic measurements of its effects on concurrent, congruent actions. Sentences referred to actions involving either proximal or distal arm musculature. In experiment 1, requiring a proximal arm movement, we found interference reduction for negative proximal sentences. In experiment 2, requiring a distal arm movement, we found interference reduction for negative distal sentences. This dissociation provides the first conclusive evidence in support of a disembodiment theory of negation. We conclude that the computational cost resulting from the insertion of an additional lexical item ("not") in negative sentences is compensated by solely storing a concept in affirmative form in semantic memory, since its negative counterpart can be produced by transiently reducing the access to such stored semantic information.

Myofascial trigger points and innervation zone locations in upper trapezius muscles.

BACKGROUND: Myofascial trigger points (MTrPs) are hyperirritable spots located in taut bands of muscle fibres. Electrophysiological studies indicate that abnormal electrical activity is detectable near MTrPs. This phenomenon has been described as endplate noise and it has been purported to be associated MTrP pathophysiology. Thus, it is suggested that MTrPs will be overlap the innervation zone (IZ). The purpose of this work was to describe the location of MTrPs and the IZ in the right upper trapezius. METHODS: We screened 71 individuals and eventually enrolled 24 subjects with neck pain and active MTrPs and 24 neck pain-free subjects with latent MTrPs. Surface electromyography (sEMG) signals were detected using an electrode matrix during isometric contraction of the upper trapezius. A physiotherapist subsequently examined the subject's trapezius to confirm the presence of MTrPs and establish their location. IZ locations were identified by visual analysis of sEMG signals. IZ and MTrPs locations were described using an anatomical coordinate system (ACS), with the skin area covered by the matrix divided into four quadrants. RESULTS: No significant difference was observed between active and latent MTrPs locations (P = 0.6). Forty-five MTrPs were in the third quadrant of the ACS, and 3 were included in second quadrant. IZs were located approximately midway between the seventh cervical vertebrae and the acromial angle in a limited area in the second and third quadrants. The mean distance between MTrP and IZ was 10.4 ± 5.8 mm. CONCLUSIONS: According to the acquired results, we conclude that IZ and MTrPs are located in well-defined areas in upper trapezius muscle. Moreover, MTrPs in upper trapezius are proximally located to the IZ but not overlapped.

Cerebellar alterations in Parkinson's disease with postural instability and gait disorders.

BACKGROUND: Few studies interrogated the involvement of cerebellum in modulating gait in Parkinson's disease (PD) patients with postural instability and gait disorders (PD-PIGD). This study aimed at assessing cerebellar atrophy and activity alterations during functional MRI (fMRI) gait-simulating motor- and dual-tasks in PD-PIGD. METHODS: Twenty-one PD-PIGD and 23 healthy controls underwent clinical assessment, structural MRI, and fMRI including a motor-task (foot anti-phase movements) and a dual-task (foot anti-phase movements while counting backwards by threes). Grey matter cerebellar volumes were assessed using SUIT atlas. FMRI activations were extracted from each cerebellar lobule, and we correlated cerebellar and basal ganglia activity. RESULTS: PD-PIGD patients had reduced volumes of cerebellar motor and non-motor areas relative to controls. During fMRI motor-task, patients showed greater activation of cognitive cerebellar areas (VI and Crus I-II) vs controls. During fMRI dual-task, PD-PIGD patients showed increased activity of cognitive areas (Crus II) and reduced activity of motor areas (I-IV). Cerebellar structural alterations correlated with increased fMRI activity of cerebellar cognitive areas and with lower executive-attentive performance. The increased activity of Crus I during the motor-task correlated with a better motor performance in PD-PIGD. Moreover, the increased activity of cerebellum correlated with a reduced activity of putamen. CONCLUSIONS: In PD-PIGD, the increased activity of non-motor cerebellar areas during gait-simulating tasks may be a consequence of grey matter atrophy or an attempt to compensate the functional failure of cerebellar motor areas and basal ganglia. Cerebellar MRI metrics are useful to characterize brain correlates of motor and dual-task abilities in PD-PIGD patients.

Continuity of care for patients with dementia during COVID-19 pandemic: flexibility and integration between in-person and remote visits.

Introduction: During the pandemic, the Cognitive Disorders Unit of San Raffaele Hospital (Milan, Italy) offered patients the opportunity to undergo neuropsychological evaluations and cognitive training through telemedicine. Method: We conducted an investigation to assess how patients responded to this option and to determine if telemedicine could ensure continuity of care. Results: Between October 2019 and May 2022, a total of 5,768 telemedicine appointments and 8,190 in-person outpatient appointments were conducted, resulting in an increase in the rate of telemedicine activity from 16.81% in January 2020 to 23.21% in May 2022. Peaks in telemedicine activity reached 85.64% in May 2020 and 83.65% in February 2021, both representing a significant portion of the total activity. Interestingly, there was a notable positive correlation between telemedicine activity and the worsening of the Italian pandemic (r = 0.433, p = 0.027). Discussion: During the peaks of contagion, the total number of visits remained stable, highlighting that telemedicine effectively served as a valuable and efficient tool to ensure continuity of care for vulnerable patients. This was evident from the integration of remote visits with in-person appointments.

SARCOPENIA IS A FREQUENT DISEASE IN SARS-COV-2 INFECTION.

Objective: We aimed to investigate the clinical symptoms and specific care requirements of SARS-CoV-2 patients who were admitted to a COVID-19 Rehabilitation Unit while still infectious for SARS-CoV-2 and in the subacute phase of the disease. Methods: Patients admitted to our COVID-19 Rehabilitation Unit from March 2020 to December 2020 were evaluated for sarcopenia, and they also completed the following assessments: functional independence measure, short physical performance battery and Hamilton Rating Scale for Depression. Age and body mass index and symptoms of dysosmia or dysgeusia were also recorded. Results: A total of 126 patients were enrolled (50 women, median age 72 years, 18.7 years), of whom 82% of patients presented with low grip strength. Sarcopenia was diagnosed in 52 patients. Sarcopenic patients were older than non-sarcopenic ones (median age 73.4 years, IQR 13.2 vs 63.9 years, IQR 14.5, respectively, p = 0.014). Sarcopenia was associated with the presence of depression (p = 0.008), was more common in women (p = 0.023) and was associated with greater functional deficits (functional independence measure and short physical performance battery analyses, p < 0.05). Sarcopenic patients also had a lower body mass index than other patients (p < 0.01). Conclusion: More than 40% of our patients suffered from sarcopenia, which was associated with ageing, depression, low body mass index, reduction in functional autonomy and being a woman. Such data provide evidence for the need to assist hospitalized COVID-19 patients by means of a multidisciplinary specialist team.

Quantitative muscle strength assessment in duchenne muscular dystrophy: longitudinal study and correlation with functional measures.

BACKGROUND: The aim of this study was to perform a longitudinal assessment using Quantitative Muscle Testing (QMT) in a cohort of ambulant boys affected by Duchenne muscular dystrophy (DMD) and to correlate the results of QMT with functional measures. This study is to date the most thorough long-term evaluation of QMT in a cohort of DMD patients correlated with other measures, such as the North Star Ambulatory Assessment (NSAA) or three 6-min walk test (6MWT). METHODS: This is a single centre, prospective, non-randomised, study assessing QMT using the Kin Com(®) 125 machine in a study cohort of 28 ambulant DMD boys, aged 5 to 12 years. This cohort was assessed longitudinally over a 12 months period of time with 3 monthly assessments for QMT and with assessment of functional abilities, using the NSAA and the 6MWT at baseline and at 12 months only. QMT was also used in a control group of 13 healthy age-matched boys examined at baseline and at 12 months. RESULTS: There was an increase in QMT over 12 months in boys below the age of 7.5 years while in boys above the age of 7.5 years, QMT showed a significant decrease. All the average one-year changes were significantly different than those experienced by healthy controls. We also found a good correlation between quantitative tests and the other measures that was more obvious in the stronger children. CONCLUSION: Our longitudinal data using QMT in a cohort of DMD patients suggest that this could be used as an additional tool to monitor changes, providing additional information on segmental strength.

Mobile application tool for remote rehabilitation after discharge from coronavirus disease-19 rehabilitation unit.

A smartphone application (Medico-Amico) has been developed by the collaboration of San Raffaele Scientific Institute and Khymeia Group S.R.L. with the aim of providing physical exercises and communicating with patients after their hospitalization in a coronavirus disease (COVID)-rehabilitation unit. Thirty patients used the application for remote rehabilitation for 4 weeks. They were prescribed personalized motor exercises to perform three times a week. Clinicians could interact with each patient by an encrypted video call in order to give encouragement, mental support, modify intensity during training sessions, or to prescribe new exercises. Patients were asked to perform motor exercises and also to monitor their vital signs, such as temperature, blood pressure, and oxygen saturation, inserting scores in a specific section of the application. After 4 weeks of remote rehabilitation patients showed improvements in independence during activity of daily living and strength. Also, satisfaction and mobile application usability scores reached patients' appreciation and enjoyment.

Virtual reality balance training to improve balance and mobility in Parkinson's disease: a systematic review and meta-analysis.

BACKGROUND: In the last few years, virtual reality (VR) has been increasingly used to strengthen the effect of balance training (BT) in Parkinson's disease (PD). OBJECTIVE: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the effects of VR-BT relative to BT alone for improving balance and mobility PD subjects with balance/mobility difficulties. METHODS: Four electronic databases were searched: two reviewers independently selected RCTs, extracted data, and applied the Cochrane risk-of-bias tool for randomized trials (version 2) and the GRADE framework for assessing the certainty of evidence. Primary outcomes were balanced (Berg Balance Scale-BBS), mobility (Timed Up and Go-TUG) and walking speed. Secondary outcomes were falls, walking distance and stability, spatial gait parameters, balance confidence, sensory integration ability, motor signs and quality of life. RESULTS: We included 22 studies (901 patients). Meta-analysis on fourteen trials (430 patients) showed a mean difference (MD) of 2.09 points (95% confidence interval [CI] 0.86-3.33) on BBS favoring VR-BT compared to BT (low certainty evidence). Subgroup analyses showed higher balance improvement in most affected subjects (moderate certainty evidence) and using VR rehabilitation-specific systems vs. VR non-specific systems. Eight trials (236 patients) assessing mobility showed a MD of 1.55 s (95% CI 0.04-3.06) on TUG favoring VR-BT (very low certainty evidence). No differences were observed in walking speed. Estimated effects were not maintained for any outcome at follow-up. CONCLUSIONS: This review suggests that VR-BT is more effective than BT to improve balance in PD subjects immediately after training, particularly in individuals with higher postural instability at baseline.

Validation of a graphic test to quantitatively assess the dominant hand dexterity.

Dexterity dysfunction is a key feature of disability in many neurological and non-neurological diseases. The Nine-Hole Peg Test (NHPT) is the most used test to assess hand dexterity in clinical practice but presents limitations. A new graphic test to enhance objective evaluation of the of the dominant hand dexterity is proposed. The task consists in drawing a continuous line in paths composed by a part with multiple orthogonal changes of direction ('meander'), and a second part derived from the Archimedean spiral ('spiral'). The test was validated in 200 healthy controls and 93 neurological patients. 48 patients performed also the NHPT. Several parameters were analyzed, among which total time, total length, number of touches and number of crossings. Healthy subjects display statistically significant differences with respect to pathological subjects in the case of total time, number of touches, and number of crossings (p<0.001), but not in the case of total length (p = 0.27) needed to complete the second sheet. Moreover, healthy controls display a learning effect, the time needed to complete the second sheet was significantly lower than for the first sheet (p<0.001), and an inverse correlation with age was observed (r = 0.56, p<0.001). The comparison between the NHPT and the new test showed a strong positive correlation (r = 0.71, p<0.001) whereas touches and crossing a weak positive one (r = 0.35, p = 0.01). The new test distinguishes between a slow but precise performance and a fast but imprecise performance, thus providing additional information with respect to NHPT.

Virtual Reality Augmented Feedback Rehabilitation Associated to Action Observation Therapy in Buccofacial Apraxia: Case Report.

BACKGROUND: Buccofacial Apraxia is defined as the inability to perform voluntary movements of the larynx, pharynx, mandible, tongue, lips and cheeks, while automatic or reflexive control of these structures is preserved. Buccofacial Apraxia frequently co-occurs with aphasia and apraxia of speech and it has been reported as almost exclusively resulting from a lesion of the left hemisphere. Recent studies have demonstrated the benefit of treating apraxia using motor training principles such as Augmented Feedback or Action Observation Therapy. In light of this, the study describes the treatment based on immersive Action Observation Therapy and Virtual Reality Augmented Feedback in a case of Buccofacial Apraxia. PARTICIPANT AND METHODS: The participant is a right-handed 58-years-old male. He underwent a neurosurgery intervention of craniotomy and exeresis of infra axial expansive lesion in the frontoparietal convexity compatible with an atypical meningioma. Buccofacial Apraxia was diagnosed by a neurologist and evaluated by the Upper and Lower Face Apraxia Test. Buccofacial Apraxia was quantified also by a specific camera, with an appropriately developed software, able to detect the range of motion of automatic face movements and the range of the same movements on voluntary requests. In order to improve voluntary movements, the participant completed fifteen 1-hour rehabilitation sessions, composed of a 20-minutes immersive Action Observation Therapy followed by a 40-minutes Virtual Reality Augmented Feedback sessions, 5 days a week, for 3 consecutive weeks. RESULTS: After treatment, participant achieved great improvements in quality and range of facial movements, performing most of the facial expressions (eg, kiss, smile, lateral angle of mouth displacement) without unsolicited movement. Furthermore, the Upper and Lower Face Apraxia Test showed an improvement of 118% for the Upper Face movements and of 200% for the Lower Face movements. CONCLUSION: Performing voluntary movement in a Virtual Reality environment with Augmented Feedbacks, in addition to Action Observation Therapy, improved performances of facial gestures and consolidate the activations by the central nervous system based on principles of experience-dependent neural plasticity.

Dual-task clinical and functional MRI correlates in Parkinson's disease with postural instability and gait disorders.

BACKGROUND: Dual-task is a challenge for Parkinson's disease patients with postural instability and gait disorders (PD-PIGD). OBJECTIVE: This study investigated clinical, cognitive and functional brain correlates of dual-task deficits in PD-PIGD patients using quantitative gait analysis, neuropsychological evaluations and functional MRI (fMRI). METHODS: Twenty-three PD-PIGD patients performed a clinical assessment of gait/balance abilities. Single and dual-task Timed-Up-and-Go tests were monitored using an optoelectronic system to study turning velocity. Patients underwent executive-attentive function evaluation and two fMRI tasks: motor-task (foot anti-phase movements), and dual-task (foot anti-phase movements while counting backwards by threes starting from 100). Twenty-three healthy subjects underwent neuropsychological and fMRI assessments. RESULTS: Dual-task in PD-PIGD patients resulted in worse gait performance, particularly during turning. Performing the dual-task relative to the motor-fMRI task, healthy subjects showed widespread increased recruitment of sensorimotor, cognitive and cerebellar areas and reduced activity of inferior frontal and supramarginal gyri, while PD-PIGD patients showed increased recruitment of inferior frontal gyrus and supplementary motor area and reduced activity of primary motor, supramarginal and caudate areas. Dual-task gait alterations in patients correlated with balance and executive deficits and with altered dual-task fMRI brain activity of frontal areas. CONCLUSIONS: This study suggested the correlation between dual-task gait difficulties, postural instability and executive dysfunction in PD-PIGD patients. FMRI results suggest that an optimized recruitment of motor and cognitive networks is associated with a better dual-task performance in PD-PIGD. Future studies should evaluate the effect of specific gait/balance and dual-task trainings to improve gait parameters and optimize brain functional activity during dual-tasks.

COVID-19 cognitive deficits after respiratory assistance in the subacute phase: A COVID-rehabilitation unit experience.

INTRODUCTION: COVID-19 complications can include neurological, psychiatric, psychological, and psychosocial impairments. Little is known on the consequences of SARS-COV-2 on cognitive functions of patients in the sub-acute phase of the disease. We aimed to investigate the impact of COVID-19 on cognitive functions of patients admitted to the COVID-19 Rehabilitation Unit of the San Raffaele Hospital (Milan, Italy). MATERIAL AND METHODS: 87 patients admitted to the COVID-19 Rehabilitation Unit from March 27th to June 20th 2020 were included. Patients underwent Mini Mental State Evaluation (MMSE), Montreal Cognitive Assessment (MoCA), Hamilton Rating Scale for Depression, and Functional Independence Measure (FIM). Data were divided in 4 groups according to the respiratory assistance in the acute phase: Group1 (orotracheal intubation), Group2 (non-invasive ventilation using Biphasic Positive Airway Pressure), Group3 (Venturi Masks), Group4 (no oxygen therapy). Follow-ups were performed at one month after home-discharge. RESULTS: Out of the 87 patients (62 Male, mean age 67.23 ± 12.89 years), 80% had neuropsychological deficits (MoCA and MMSE) and 40% showed mild-to-moderate depression. Group1 had higher scores than Group3 for visuospatial/executive functions (p = 0.016), naming (p = 0.024), short- and long-term memory (p = 0.010, p = 0.005), abstraction (p = 0.024), and orientation (p = 0.034). Group1 was younger than Groups2 and 3. Cognitive impairments correlated with patients' age. Only 18 patients presented with anosmia. Their data did not differ from the other patients. FIM (<100) did not differ between groups. Patients partly recovered at one-month follow-up and 43% showed signs of post-traumatic stress disorder. CONCLUSION: Patients with severe functional impairments had important cognitive and emotional deficits which might have been influenced by the choice of ventilatory therapy, but mostly appeared to be related to aging, independently of FIM scores. These findings should be integrated for correct neuropsychiatric assistance of COVID-19 patients in the subacute phase of the disease, and show the need for long-term psychological support and treatment of post-COVID-19 patients.

Can action observation modulate balance performance in healthy subjects?

BACKGROUND: Action observation activates brain motor networks and, if followed by action imitation, it facilitates motor learning and functional recovery in patients with both neurological and musculoskeletal disorders. To date, few studies suggested that action observation plus imitation can improve balance skills; however, it is still unclear whether the simple repetitive observation of challenging balance tasks is enough to modify postural control. Thus, the primary aim of this study was to investigate whether repetitive action observation of balance exercises without imitation has the potential to improve balance performance; the secondary aim was to estimate the different training effects of action observation, action observation plus imitation and balance training relative to a control condition in healthy subjects. METHODS: Seventy-nine healthy young adults were randomly assigned to 4 groups: action observation, action observation plus imitation, balance training and control. The first three groups were trained for about 30 minutes every day for three weeks, whereas the control group received no training. Center of pressure path length and sway area were evaluated on a force platform at baseline and after training using posturographic tests with eyes open and closed. RESULTS: As expected, both action observation plus imitation and balance training groups compared to the control group showed balance improvements, with a medium to large effect size performing balance tasks with eyes open. Action observation without imitation group showed a balance improvement with eyes open, but without a significant difference relative to the control group. CONCLUSIONS: Both action observation plus imitation and balance training have similar effects in improving postural control in healthy young subjects. Future studies on patients with postural instability are necessary to clarify whether AOT can induce longer lasting effects. Action observation alone showed a trend toward improving postural control in healthy subjects, suggesting the possibility to study its effects in temporarily immobilized diseased subjects.