Successful Treatment of Post COVID-19 Neurogenic Dysphagia with Botulinum Toxin.

Introduction: Dysphagia in post COVID-19 patients could be caused by several factors, including reduced pharyngolaryngeal coordination due to SARS-CoV-2 tropism to the central and/or peripheral nervous system. To our knowledge, this is the first reported case of COVID-19-related dysphagia successfully treated with botulinum toxin type A injection. Case description: We report the case of a patient with severe oropharyngeal dysphagia due to COVID-19 confirmed by fibre endoscopy. As a result, the patient required an enteral feeding tube. After two months of traditional swallowing therapies, there was only limited improvement. An electrophysiologic evaluation of the cricopharyngeal muscle was performed and showed a normal inhibition of the cricopharyngeal muscle, followed by a hypertonic rebound. Based on this result, we decided to perform a unilateral laryngeal injection of botulinum toxin type A. After the injection, the patient's swallowing function improved significantly, allowing him to return to oral feeding. Discussion: Newly diagnosed oropharyngeal dysphagia was found in 35.3% of hospitalised patients with COVID-19. There are several possible causes of COVID-19-associated dysphagia, including stroke, encephalitis, critical illness neuropathy, Guillain-Barré syndrome and skeletal muscle injury. In our case, since stroke was excluded by brain MRI, cranial nerve injury was a possible explanation for the difficult recovery of swallowing despite daily swallowing therapy. Conclusion: We suggest that electrophysiology is a valid tool for the diagnosis and follow-up of patients with oropharyngeal dysphagia. LEARNING POINTS: SARS-CoV-2 tropism to the central and/or peripheral nervous system can cause dysphagia in post COVID-19 patients.An electrophysiologic approach is useful for the diagnosis and follow-up of patients with oropharyngeal dysphagia.A single botulinum toxin type A injection is a valid treatment option to improve the swallowing function in patients with post COVID-19 dysphagia.

Increasing the Passive Range of Joint Motion in Stroke Patients Using Botulinum Toxin: The Role of Pain Relief.

By blocking the release of neurotransmitters, botulinum toxin A (BoNT-A) is an effective treatment for muscle over-activity and pain in stroke patients. BoNT-A has also been reported to increase passive range of motion (p-ROM), the decrease of which is mainly due to muscle shortening (i.e., muscle contracture). Although the mechanism of action of BoNT-A on p-ROM is far from understood, pain relief may be hypothesized to play a role. To test this hypothesis, a retrospective investigation of p-ROM and pain was conducted in post-stroke patients treated with BoNT-A for upper limb hypertonia. Among 70 stroke patients enrolled in the study, muscle tone (Modified Ashworth Scale), pathological postures, p-ROM, and pain during p-ROM assessment (Numeric Rating Scale, NRS) were investigated in elbow flexors (48 patients) and in finger flexors (64 patients), just before and 3-6 weeks after BoNT-A treatment. Before BoNT-A treatment, pathological postures of elbow flexion were found in all patients but one. A decreased elbow p-ROM was found in 18 patients (38%). Patients with decreased p-ROM had higher pain-NRS scores (5.08 ± 1.96, with a pain score ≥8 in 11% of cases) than patients with normal p-ROM (0.57 ± 1.36) (p < 0.001). Similarly, pathological postures of finger flexion were found in all patients but two. A decreased finger p-ROM was found in 14 patients (22%). Pain was more intense in the 14 patients with decreased p-ROM (8.43 ± 1.74, with a pain score ≥ 8 in 86% of cases) than in the 50 patients with normal p-ROM (0.98 ± 1.89) (p < 0.001). After BoNT-A treatment, muscle tone, pathological postures, and pain decreased in both elbow and finger flexors. In contrast, p-ROM increased only in finger flexors. The study discusses that pain plays a pivotal role in the increase in p-ROM observed after BoNT-A treatment.

On the performance assessment during the practice of an exergame for cerebellar ataxia patients.

Cerebellar ataxias are a large family of movement disorders that generally follow a stroke. The clinical picture is very complicated and normal activities become difficult for ataxic patients. For instance, dynamic ataxia involves both walk and upper-limbs movement, thus affecting the possibility to fulfill daily life tasks. Rehabilitation treatments and strategies for cerebellar ataxia are nowadays controversial, since different opinions on the several approaches are spread among the clinical community. The purpose of the present work is not to shed some light on such disagreements. Indeed, here a solution for delivering rehabilitation activities in the form of videogame is presented. Data related to patient's performance are collected and analyzed in order to provide the clinical staff with objective indicators that properly describe the activity. Such information can also be used to discuss the effectiveness and the incidence of some strategy adopted for fulfilling some task. The experimental phase is conducted on two case-studies with regards to the upper-limb rehabilitation. The adoption of the strategy of weighting the limb when performing the movement is discussed. The indicators computed in both sessions with and without strategy are compared, also referring to the practice of some healthy subjects. The present work introduces the preliminary phase of a wider study and foretells its future development conducted on a larger population.

A Study Protocol for Occupational Rehabilitation in Multiple Sclerosis.

Digital medical solutions can be very helpful in restorative neurology, as they allow the patients to practice their rehabilitation activities remotely. This work discloses ReMoVES, an IoMT system providing telemedicine services, in the context of Multiple Sclerosis rehabilitation, within the frame of the project STORMS. A rehabilitative protocol of exercises can be provided as ReMoVES services and integrated into the Individual Rehabilitation Project as designed by a remote multidimensional medical team. In the present manuscript, the first phase of the study is described, including the definition of the needs to be addressed, the employed technology, the design and the development of the exergames, and the possible practical/professional and academic consequences. The STORMS project has been implemented with the aim to act as a starting point for the development of digital telerehabilitation solutions that support Multiple Sclerosis patients, improving their living conditions. This paper introduces a study protocol and it addresses pre-clinical research needs, where system issues can be studied and better understood how they might be addressed. It also includes tools to favor remote patient monitoring and to support the clinical staff.

I can't count, but I can beat you playing cards: a case report on autoimmune encephalitis.

BACKGROUND: Autoimmune encephalitis (AE) is a rare inflammatory disorder characterized by important psychiatric and neurologic symptoms. The literature documents high rates of neuropsychological dysfunction in N-methyl D-aspartate-receptor (NMDAr) encephalitis but papers don't consider specifically calculation disturbances between the long-term deficits, although deficits in executive control and episodic memory were less likely to resolve. CASE REPORT: Here we present a severe case of NMDAr encephalitis in a young patient without a relevant past medical history. Upon first examination he presented psycho-motor slowdown, speech disorders, severe cognitive deficits in all areas: concentration, attention, memory, language, dual task functions, increased latency in responses, severe dyscalculia. Upon first evaluation, the young patient underwent a battery of neuropsychological tests and he showed a dysexecutive syndrome with performances significantly low for age and education. Our patient hence underwent 1 month of intensive cognitive rehabilitation. After the rehabilitation treatment, he presented an amelioration in all domains except calculations. CONCLUSIONS: In our patient the calculation disorder has proved to be the most relevant problem and the most difficult to treat. Clinicians should consider a careful approach to determine the prognosis of this syndrome because of the wide range of deficits, the need of prolonged treatment and the rate of long-term sequelae.

Improved visuospatial neglect after tDCS and computer-assisted cognitive training in Posterior Cortical Atrophy: a single-case study.

Visuospatial neglect (VN) frequently occurs in Posterior Cortical Atrophy (PCA) and requires specific rehabilitation. In this single-case study, we investigated the efficacy of a computer-assisted cognitive training (CCT) alone or coupled with multiple sessions of anodal transcranial direct-current stimulation (A-tDCS) over the right posterior parietal cortex in improving left VN symptoms in a patient with PCA. The digital ReMoVES platform was used for both VN assessment and training. We found a significant improvement after CCT combined with A-tDCS within the limits of a single-case, our results suggest, for the first time, the usefulness of this combined approach in a neurodegenerative disorder.

Transcranial Direct Current Stimulation in the Treatment of Subacute Post-Stroke Thalamic Aphasia.

BACKGROUND: Although many studies have demonstrated the effectiveness of transcranial direct current stimulation (tDCS) in improving speech recovery in post-stroke aphasia, as far as we know patients affected by thalamic aphasia have never been investigated. PATIENT AND METHOD: A 65-year-old man with severe non-fluent aphasia due to a left thalamic haemorrhagic stroke underwent intensive daily speech therapy combined with tDCS. RESULTS: The patient showed progressive improvement with almost complete recovery of his speech disorder, behavioural disinhibition and apathy. CONCLUSIONS: Our findings suggest that tDCS with concurrent speech therapy can be useful in patients with subcortical stroke lesions. LEARNING POINTS: The thalamus has a central role in the development of the higher functions, such as memory, regulation of behaviour and emotions, and language elaboration.Transcranial direct current stimulation (tDCS) applied to the cerebral cortex is a promising tool for improving language recovery in patients with post-stroke aphasia.Combined treatment with tDCS and speech and language therapy (SLT) was effective in a patient with subacute thalamic aphasia, who showed improvement in all aspects of linguistic and behavioural communication.

Unilateral spatial neglect rehabilitation supported by a digital solution: two case-studies.

Digital solutions for unilateral spatial neglect (USN) assessment and treatment are nowadays of great interest, because of both the possibility of combining them with other rehabilitation practices, and the easy-to-understand data and indicators they collect. The ReMoVES platform, developed in DITEN laboratories, is conceived in the Assistive Technologies framework and provides motor and cognitive exergames and activities to be performed in conjunction with traditional rehabilitation. In this work, two case-studies, related to the USN rehabilitation, are presented. The combination of cognitive therapy, delivered by the ReMoVES platform, and transcranial direct-current stimulation (tDCS) technique was used as rehabilitation treatment for both the patients. Data collected at the beginning or at the end of the rehabilitation process, or also during the treatment sessions, are shown and discussed in this paper. This work is a preliminary part of a wider one, that will be conducted involving many different rehabilitation centers, aimed at proving the validity of such an approach to USN treatments.

Long-term assessment of the cognitive effects of nabiximols in patients with multiple sclerosis: A pilot study.

OBJECTIVE: Moderate to severe spasticity is commonly reported in Multiple Sclerosis (MS) and its management is still a challenge. Cannabinoids were recently suggested as add-on therapy for the treatment of spasticity and chronic pain in MS but there is no conclusive scientific evidence on their safety, especially on cognition and over long periods. The aim of this prospective pilot study was to assess the long-term effects of a tetrahydrocannabinol-cannabidiol (THC/CBD) oromucosal spray (Sativex®) on cognition, mood and anxiety. PATIENTS AND METHODS: An extensive and specific battery of neuropsychological tests (Symbol Digit Modalities Test-SDMT, California Verbal Learning Test-CVLT, Brief Visuospatial Memory Test-BVMT; PASAT-3 and 2; Free and Cued Selective Remind Test-FCSRT, Index of Sensitivity of Cueing-ISC) was applied to longitudinally investigate different domains of cognition in 20 consecutive MS patients receiving Sativex for spasticity. The primary endpoint was to assess any variation in cognitive performance. Secondary outcomes regarding mood and anxiety were investigated by means of Beck Depression Inventory (BDI) and Hamilton Anxiety Rating Scale (HAM-A). Any change in patients' spasticity was evaluated using the 0-10 Numerical Rating Scale (NRS). RESULTS: Twenty per protocol patients were followed up and evaluated at baseline, 6 and 12 months. Domains involving processing speed and auditory verbal memory significantly improved within the first 6 months of therapy (SDMT: p < 0.001; CVLT: p = 0.0001). Mood and anxiety did not show any significant variation. Additionally, the NRS score significantly improved since the beginning (p < 0.0001). CONCLUSIONS: These results are encouraging in supporting possible long-term benefits of Sativex on cognition and a wider role than symptom alleviator. Further studies on larger groups of patients would be necessary in order to test this intriguing possibility.

Long-term effects of transcranial direct-current stimulation in chronic post-stroke aphasia: a pilot study.

Transcranial direct-current stimulation (tDCS) has been suggested to improve language function in patients with post-stroke aphasia. Most studies on aphasic patients, however, were conducted with a very limited follow-up period, if any. In this pilot, single-blind study on chronic post-stroke aphasic patients, we aimed to verify whether or not tDCS is able to extend its beneficial effects for a longer period of time (21 weeks after the end of stimulation). Three aphasic patients underwent anodal tDCS (A-tDCS, 20 min, 1.5 mA) and sham stimulation (S-tDCS) over the left frontal (perilesional) region, coupled with a simultaneous naming training (on-line tDCS). Ten consecutive sessions (5 days per week for 2 weeks) were implemented. In the first five sessions, we used a list of 40 figures, while in the subsequent five sessions we utilized a second set of 40 figures differing in word difficulty. At the end of the stimulation period, we found a significant beneficial effect of A-tDCS (as compared to baseline and S-tDCS) in all our subjects, regardless of word difficulty, although with some inter-individual differences. In the follow-up period, the percentage of correct responses persisted significantly better until the 16th week, when an initial decline in naming performance was observed. Up to the 21st week, the number of correct responses, though no longer significant, was still above the baseline level. These results in a small group of aphasic patients suggest a long-term beneficial effect of on-line A-tDCS.