Investigating the Brain Mechanisms of Externally Cued Sit-to-Stand Movement in Parkinson's Disease.

BACKGROUND: One of the more challenging daily-life actions for Parkinson's disease patients is starting to stand from a sitting position. Parkinson's disease patients are known to have difficulty with self-initiated movements and benefit from external cues. However, the brain processes underlying external cueing as an aid remain unknown. The advent of mobile electroencephalography (EEG) now enables the investigation of these processes in dynamic sit-to-stand movements. OBJECTIVE: To identify cortical correlates of the mechanisms underlying auditory cued sit-to-stand movement in Parkinson's disease. METHODS: Twenty-two Parkinson's disease patients and 24 healthy age-matched participants performed self-initiated and externally cued sit-to-stand movements while cortical activity was recorded through 32-channel mobile EEG. RESULTS: Overall impaired integration of sensory and motor information can be seen in the Parkinson's disease patients exhibiting less modulation in the θ band during movement compared to healthy age-matched controls. How Parkinson's disease patients use external cueing of sit-to-stand movements can be seen in larger high ß power over sensorimotor brain areas compared to healthy controls, signaling sensory integration supporting the maintenance of motor output. This appears to require changes in cognitive processing to update the motor plan, reflected in frontal θ power increases in Parkinson's disease patients when cued. CONCLUSION: These findings provide the first neural evidence for why and how cueing improves motor function in sit-to-stand movement in Parkinson's disease. The Parkinson's disease patients' neural correlates indicate that cueing induces greater activation of motor cortical areas supporting the maintenance of a more stable motor output, but involves the use of cognitive resources to update the motor plan. © 2024 International Parkinson and Movement Disorder Society.

Design of an SMA-Based Actuator for Replicating Normal Gait Patterns in Pediatric Patients with Cerebral Palsy.

Cerebral Palsy refers to a group of incurable motor disorders affecting 0.22% of the global population. Symptoms are managed by physiotherapists, often using rehabilitation robotics. Exoskeletons, offering advantages over conventional therapies, are evolving to be more wearable and biomimetic, requiring new flexible actuators that mimic human tissue. The main objective behind this article is the design of a flexible exosuit based on shape-memory-alloy-based artificial muscles for pediatric patients that replicate the walking cycle pattern in the ankle joint. Thus, four shape-memory-alloy-based actuators were sewn to an exosuit at the desired actuation points and controlled by a two-level controller. The loop is closed through six inertial sensors that estimate the real angular position of both ankles. Different frequencies of actuation have been tested, along with the response of the actuators to different walking cycle patterns. These tests have been performed over long periods of time, comparing the reference created by a reference generator based on pediatric walking patterns and the response measured by the inertial sensors. The results provide important measurements concerning errors, working frequencies and cooling times, proving that this technology could be used in this and similar applications and highlighting its limitations.

Cognitive driven gait freezing phase detection and classification for neuro-rehabilitated patients using machine learning algorithms.

BACKGROUND: The significance of diagnosing illnesses associated with brain cognitive and gait freezing phase patterns has led to a recent surge in interest in the study of gait for mental disorders. A more precise and effective way to characterize and classify many common gait problems, such as foot and brain pulse disorders, can improve prognosis evaluation and treatment options for Parkinson patients. Nonetheless, the primary clinical technique for assessing gait abnormalities at the moment is visual inspection, which depends on the subjectivity of the observer and can be inaccurate. RESEARCH QUESTION: This study investigates whether it is possible to differentiate between gait brain disorder and the typical walking pattern using machine learning driven supervised learning techniques and data obtained from inertial measurement unit sensors for brain, hip and leg rehabilitation. METHOD: The proposed method makes use of the Daphnet freezing of Gait Data Set, consisted of 237 instances with 9 attributes. The method utilizes machine learning and feature reduction approaches in leg and hip gait recognition. RESULTS: From the obtained results, it is concluded that among all classifiers RF achieved highest accuracy as 98.9 % and Perceptron achieved lowest i.e. 70.4 % accuracy. While utilizing LDA as feature reduction approach, KNN, RF and NB also achieved promising accuracy and F1-score in comparison with SVM and LR classifiers. SIGNIFICANCE: In order to distinguish between the different gait disorders associated with brain tissues freezing/non-freezing and normal walking gait patterns, it is shown that the integration of different machine learning algorithms offers a viable and prospective solution. This research implies the need for an impartial approach to support clinical judgment.

Comprehensive and integrated management of basilar impression, platybasia and cranio-vertebral junction abnormality- a case report.

AIM: To report a case of anomalous development of base of skull (platybasia, Basilar invagination and C1-C2 vertebral fusion); and emphasize nonsurgical management in inoperable cases that can improve quality of life of the patient. MATERIALS AND METHODS: The case is reported as a descriptive study of a 17-year-old female who presented to a rural teaching tertiary care hospital in Wardha, Maharashtra, India; with chief complaints of weakness in all four limbs since 10 years of age. RESULT AND CONCLUSION: Platybasia is a developmental defect of the occipital bone and upper cervical spine resulting from anomalous development. The mechanism of such anomalies is not known; however, the most accepted theory includes abnormal basi-occiput development. The pressure effects may present signs similar to progressive spastic paralysis, cerebellar symptoms, or cranial nerve palsy, in addition to musculoskeletal symptoms. It is, therefore, crucial for physicians and radiologists to be familiar with clinical manifestations and radiological findings. In the following case of a patient with base of skull anomalies, surgical intervention in view of progressive worsening of motor symptoms was advised, however, the guardians declined the same due to high risk involved. Due to financial constraints, genetic studies were unaffordable, and a lack of awareness regarding the disease hampered the guardians from making a decision on the definite management of the disease. Besides radical neurosurgery, intensive physiotherapy can prove vital in significantly improving the quality of life for the patient.

Recovery of Volitional Motor Control and Overground Walking in Participants With Chronic Clinically Motor Complete Spinal Cord Injury: Restoration of Rehabilitative Function With Epidural Spinal Stimulation (RESTORES) Trial-A Preliminary Study.

Spinal cord injury (SCI) is damage to any part of the spinal cord resulting in paralysis, bowel and/or bladder incontinence, and loss of sensation and other bodily functions. Current treatments for chronic SCI are focused on managing symptoms and preventing further damage to the spinal cord with limited neuro-restorative interventions. Recent research and independent clinical trials of spinal cord stimulation (SCS) or intensive neuro-rehabilitation including neuro-robotics in participants with SCI have suggested potential malleability of the neuronal networks for neurological recovery. We hypothesize that epidural electrical stimulation (EES) delivered via SCS in conjunction with mental imagery practice and robotic neuro-rehabilitation can synergistically improve volitional motor function below the level of injury in participants with chronic clinically motor-complete SCI. In our pilot clinical RESTORES trial (RESToration Of Rehabilitative function with Epidural spinal Stimulation), we investigate the feasibility of this combined multi-modal approach in restoring volitional motor control and achieving independent overground locomotion in participants with chronic motor complete thoracic SCI. Secondary aims are to assess the safety of this combination therapy including the off-label SCS usage as well as improving functional outcome measures. To our knowledge, this is the first clinical trial that investigates the combined impact of this multi-modal EES and rehabilitation strategy in participants with chronic motor complete SCI. Two participants with chronic motor-complete thoracic SCI were recruited for this pilot trial. Both participants have successfully regained volitional motor control below their level of SCI injury and achieved independent overground walking within a month of post-operative stimulation and rehabilitation. There were no adverse events noted in our trial and there was an improvement in post-operative truncal stability score. Results from this pilot study demonstrates the feasibility of combining EES, mental imagery practice and robotic rehabilitation in improving volitional motor control below level of SCI injury and restoring independent overground walking for participants with chronic motor-complete SCI. Our team believes that this provides very exciting promise in a field currently devoid of disease-modifying therapies.

Toward social-health integration in Sicily: description of the first hub and spoke model to improve the diagnostic therapeutic care paths for neurorehabilitation.

Introduction: The study describes a hub and spoke network for neuro-rehabilitation recently activated in Sicily, and evaluates the before-after changes yielded, in terms of integrated care. Methods: A set of indicators based on data contained in the administrative database of inpatients of the Regional Health System are presented and discussed. Statistical analysis was conducted both globally and separately for the 9 Sicilian provinces (Agrigento, Caltanissetta, Catania, Enna, Messina, Palermo, Siracusa, Ragusa, and Trapani). Results: Results showed an increase in admissions of people residing in the province where the Spokes have been opened: Trapani (+32.4%), Messina (+7.8%) and Palermo (+4.4%); besides a significant increase of patients from healthcare facilities proportion (p = 0.001) and from acute wards (p = 0.029). In addition, we found a decrease of discharge to protected healthcare facilities (p = 0.001) and to acute wards (p < 0.001), as well as an increase of discharges to home (p = 0.018). Discussion: In conclusion, it would seem that the activation of this network has facilitated the management of these patients, avoiding unnecessary migrations to other provinces and/or regions, and improving the regional care service for neuro-rehabilitation. Future research will be direct to investigate this aspect, focusing on before-after variations in hospitalization rates and origin- destination patient flows.

Individualized closed-loop TMS synchronized with exoskeleton for modulation of cortical-excitability in patients with stroke: a proof-of-concept study.

Background: Repetitive TMS is used in stroke rehabilitation with predefined passive low and high-frequency stimulation. Brain State-Dependent Stimulation (BSDS)/Activity-Dependent Stimulation (ADS) using bio-signal has been observed to strengthen synaptic connections. Without the personalization of brain-stimulation protocols, we risk a one-size-fits-all approach. Methods: We attempted to close the ADS loop via intrinsic-proprioceptive (via exoskeleton-movement) and extrinsic-visual-feedback to the brain. We developed a patient-specific brain stimulation platform with a two-way feedback system, to synchronize single-pulse TMS with exoskeleton along with adaptive performance visual feedback, in real-time, for a focused neurorehabilitation strategy to voluntarily engage the patient in the brain stimulation process. Results: The novel TMS Synchronized Exoskeleton Feedback (TSEF) platform, controlled by the patient's residual Electromyogram, simultaneously triggered exoskeleton movement and single-pulse TMS, once in 10 s, implying 0.1 Hz frequency. The TSEF platform was tested for a demonstration on three patients (n = 3) with different spasticity on the Modified Ashworth Scale (MAS = 1, 1+, 2) for one session each. Three patients completed their session in their own timing; patients with (more) spasticity tend to take (more) inter-trial intervals. A proof-of-concept study on two groups-TSEF-group and a physiotherapy control-group was performed for 45 min/day for 20-sessions. Dose-matched Physiotherapy was given to control-group. Post 20 sessions, an increase in ipsilesional cortical-excitability was observed; Motor Evoked Potential increased by ~48.5 µV at a decreased Resting Motor Threshold by ~15.6%, with improvement in clinical scales relevant to the Fugl-Mayer Wrist/Hand joint (involved in training) by 2.6 units, an effect not found in control-group. This strategy could voluntarily engage the patient. Conclusion: A brain stimulation platform with a real-time two-way feedback system was developed to voluntarily engage the patients during the brain stimulation process and a proof-of-concept study on three patients indicates clinical gains with increased cortical excitability, an effect not observed in the control-group; and the encouraging results nudge for further investigations on a larger cohort.

A Survey of Traumatic Brain Injuries from Road Traffic Collisions in a Lower Middle-Income Country.

The burden of traumatic brain injury (TBI) from road traffic collisions (RTCs) is great in low-and middle-income countries (LMICs) due to shortfalls in preventative measures, and the lack of relevant, accurate data collection. To address this gap, we sought to study the epidemiology of TBI from RTCs in two LMIC neurosurgical centres in order to identify factors amenable to preventative strategies. A prospective survey of all adult and paediatric cases of TBI from RTCs admitted to Northwest General Hospital (NWGH) and Hayatabad Medical Complex (HMC) over a four-week period was carried out. Data on patient demographics, risk factors, injury details, pre-hospitalisation details, admission details and post-acute care was collected and analysed. A total of 68 patients were included in the study. 18 (26%) of the patients were male and in the 30 to 39 age group. Fifty-two percent were two-wheeler riders and/or passengers. 51 (75%) of the RTCs occurred between 12 noon and 12 midnight and in rural areas (66.2%). The most commonly documented risk factor that led to the RTC was speeding (35.3%). Pre-hospital care was either absent or undocumented. Up to two-thirds of patients were not direct transfers, and most were transported in private vehicles (48.5%) arriving later than an hour after injury (94.1%). Less than half with documented disabilities were referred for rehabilitation (38.5%). There are still gaps in the prevention of TBI from RTCs and in relevant data collection. Data collection systems must be strengthened, and further exploratory research carried out in order to improve the prevention of TBI from RTCs.

Post-Stroke Rehabilitation of Distal Upper Limb with New Perspective Technologies: Virtual Reality and Repetitive Transcranial Magnetic Stimulation-A Mini Review.

Upper extremity motor impairment is the most common sequelae in patients with stroke. Moreover, its continual nature limits the optimal functioning of patients in the activities of daily living. Because of the intrinsic limitations in the conventional form of rehabilitation, the rehabilitation applications have been expanded to technology-driven solutions, such as Virtual Reality and Repetitive Transcranial Magnetic Stimulation (rTMS). The motor relearning processes are influenced by variables, such as task specificity, motivation, and feedback provision, and a VR environment in the form of interactive games could provide novel and motivating customized training solutions for better post-stroke upper limb motor improvement. rTMS being a precise non-invasive brain stimulation method with good control of stimulation parameters, has the potential to facilitate neuroplasticity and hence a good recovery. Although several studies have discussed these forms of approaches and their underlying mechanisms, only a few of them have specifically summarized the synergistic applications of these paradigms. To bridge the gaps, this mini review presents recent research and focuses precisely on the applications of VR and rTMS in distal upper limb rehabilitation. It is anticipated that this article will provide a better representation of the role of VR and rTMS in distal joint upper limb rehabilitation in patients with stroke.

National quality standards for neuro rehabilitation in a community setting: Do they achieve their purpose?

RATIONALE: There is known variation in neuro-rehabilitation service provision, however, the extent of service variation and impact on people who experience an acquired brain injury (ABI) is not articulated in the literature. The aim of this study was to assess and determine the extent to which neuro-rehabilitation services in one part of the United Kingdom (UK) are meeting national quality standards. METHOD: A mixed method design, across five community neuro-rehabilitation providers and six districts in South London, comprised of ABI population incidence data, web-based surveys to determine compliance with the National Institute for Health and Care Excellence (NICE) Head Injury Quality Standard, and focus groups to understand the patient perspective of community neuro-rehabilitation service provision. RESULTS: The population incidence of ABI amongst districts demonstrated differences between the datasets analyzed, resulting in an inability to determine whether service variation was based on population need. The web-based surveys revealed that five community neuro-rehabilitation providers have variations between the models of care provided, including clinical referral criteria, duration, intensity of therapy interventions, and overall cost per patient, which was correlated with workforce capacity and patient waiting times. Focus group discussion highlighted current key challenges of service restraints, disconnect between services and limited professional support, as well as improvement opportunities pertaining to access, flexible, local and timely health and social care services. CONCLUSION: This study indicates that despite the publication of the NICE Head Injury Quality Standard, there is variation in the local provision of community neuro-rehabilitation across six districts in South London. Each district partly meets the recommendations, highlighting variability in the model of care delivered, that impacts consumers/carers accessing quality neuro-rehabilitation services. A disconnect remains between evidence-based quality standards and implementation. No standardized ABI data set is available in the UK, which impacts planning for future clinical service delivery.

Improvement After Surgery in a Patient With Prolonged Tetraplegia Due to Cervical Spinal Cord Injury Without Bone Injury.

Treatment strategies for patients with cervical spinal cord injury (CSCI) without major bone injury in the acute phase are under debate. For CSCI without major bone injury, conservative treatment is often the first choice owing to the absence of fractures and spinal column instability. However, treatment of CSCI without major bone injury by either surgery or conservative measures remains controversial. We described a case of a 48-year-old man with cervical American Spinal Cord Injury Association Impairment Scale (AIS) grade C tetraplegia as a result of a fall. Computed tomography scan and magnetic resonance imaging revealed no fractures and widespread T2-hyperintense signal changes in the cord centered on C3-4. The paralyzed condition of his lower extremities remained unchanged with conservative treatment for eight months after the injury. Therefore, he underwent decompression surgery eight months after the injury. At two weeks postoperatively, he could transfer and walk using a walker. After discharge, he underwent regular home-visit rehabilitation and gradually improved his physical functions, including gait ability one year postoperatively. We encountered a case in which surgery and intensive rehabilitation eight months after the injury improved motor function. The combination of surgery in the chronic phase and postoperative rehabilitation can therefore improve the outcomes. The message in this paper is by no means a recommendation for "late surgery." However, we suggested that surgical treatment might be an option if the functional improvement is poor, as even quite late surgery can provide functional improvement.

Technology Acceptance Model for Exoskeletons for Rehabilitation of the Upper Limbs from Therapists' Perspectives.

Over the last few years, exoskeletons have been demonstrated to be useful tools for supporting the execution of neuromotor rehabilitation sessions. However, they are still not very present in hospitals. Therapists tend to be wary of this type of technology, thus reducing its acceptability and, therefore, its everyday use in clinical practice. The work presented in this paper investigates a novel point of view that is different from that of patients, which is normally what is considered for similar analyses. Through the realization of a technology acceptance model, we investigate the factors that influence the acceptability level of exoskeletons for rehabilitation of the upper limbs from therapists' perspectives. We analyzed the data collected from a pool of 55 physiotherapists and physiatrists through the distribution of a questionnaire. Pearson's correlation and multiple linear regression were used for the analysis. The relations between the variables of interest were also investigated depending on participants' age and experience with technology. The model built from these data demonstrated that the perceived usefulness of a robotic system, in terms of time and effort savings, was the first factor influencing therapists' willingness to use it. Physiotherapists' perception of the importance of interacting with an exoskeleton when carrying out an enhanced therapy session increased if survey participants already had experience with this type of rehabilitation technology, while their distrust and the consideration of others' opinions decreased. The conclusions drawn from our analyses show that we need to invest in making this technology better known to the public-in terms of education and training-if we aim to make exoskeletons genuinely accepted and usable by therapists. In addition, integrating exoskeletons with multi-sensor feedback systems would help provide comprehensive information about the patients' condition and progress. This can help overcome the gap that a robot creates between a therapist and the patient's human body, reducing the fear that specialists have of this technology, and this can demonstrate exoskeletons' utility, thus increasing their perceived level of usefulness.

Co-creating system-wide improvement for people with traumatic brain injury across one integrated care system in the United Kingdom to initiate a transformation journey through co-production.

BACKGROUND AND OBJECTIVE: There is a need for better integration of services across communities and sectors for people living with traumatic brain injury (TBI) to meet their complex needs. Building on insights gained from earlier pilot work, here we report the outcomes of a participatory workshop that sought to better understand the challenges, barriers and opportunities that currently exist within the care pathway for survivors of TBI. METHODS: A diverse range of stakeholders from the acute and rehabilitation care pathway and the health and social care system were invited to participate in a 3-h workshop. The participants worked in four mixed subgroups using practice development methodology, which promotes person-centred, inclusive and participatory action. RESULTS: Thematic analysis identified shared purposes and values that were used to produce a detailed implementation and impact framework for application at both the level of the care interface and the overarching integrated care system. A variety of enablers were identified that related to collective values and behaviours, case management, team leadership and integrated team working, workforce capability, evidence-based practice and resourcing. The clinical, economic, cultural and social outcomes associated with these enablers were also identified, and included patient safety, independence and well-being, reduced waiting times, re-admission rates, staff retention and professional development. CONCLUSION: The co-produced recommendations made within the implementation and impact framework described here provide a means by which the culture and delivery of health and social care services can be better tailored to meet the needs of people living with TBI. We believe that the recommendations will help shape the formation of new services as well as the development of existing ones. PATIENT OR PUBLIC CONTRIBUTION: Patient and public involvement have been established over a 10-year history of relationship building through a joint forum and events involving three charities representing people with TBI, carers, family members, clinicians, service users, researchers and commissioners, culminating in a politically supported event that identified concerns about the needs of people following TBI. These relationships formed the foundation for the interactive workshop, the focus of this publication.

Technology-assisted assessment of spasticity: a systematic review.

BACKGROUND: Spasticity is defined as "a motor disorder characterised by a velocity dependent increase in tonic stretch reflexes (muscle tone) with exaggerated tendon jerks". It is a highly prevalent condition following stroke and other neurological conditions. Clinical assessment of spasticity relies predominantly on manual, non-instrumented, clinical scales. Technology based solutions have been developed in the last decades to offer more specific, sensitive and accurate alternatives but no consensus exists on these different approaches. METHOD: A systematic review of literature of technology-based methods aiming at the assessment of spasticity was performed. The approaches taken in the studies were classified based on the method used as well as their outcome measures. The psychometric properties and usability of the methods and outcome measures reported were evaluated. RESULTS: 124 studies were included in the analysis. 78 different outcome measures were identified, among which seven were used in more than 10 different studies each. The different methods rely on a wide range of different equipment (from robotic systems to simple goniometers) affecting their cost and usability. Studies equivalently applied to the lower and upper limbs (48% and 52%, respectively). A majority of studies applied to a stroke population (N = 79). More than half the papers did not report thoroughly the psychometric properties of the measures. Analysis identified that only 54 studies used measures specific to spasticity. Repeatability and discriminant validity were found to be of good quality in respectively 25 and 42 studies but were most often not evaluated (N = 95 and N = 78). Clinical validity was commonly assessed only against clinical scales (N = 33). Sensitivity of the measure was assessed in only three studies. CONCLUSION: The development of a large diversity of assessment approaches appears to be done at the expense of their careful evaluation. Still, among the well validated approaches, the ones based on manual stretching and measuring a muscle activity reaction and the ones leveraging controlled stretches while isolating the stretch-reflex torque component appear as the two promising practical alternatives to clinical scales. These methods should be further evaluated, including on their sensitivity, to fully inform on their potential.

Focal electrical stimulation of human retinal ganglion cells for vision restoration.

Objective. Vision restoration with retinal implants is limited by indiscriminate simultaneous activation of many cells and cell types, which is incompatible with reproducing the neural code of the retina. Recent work has shown that primate retinal ganglion cells (RGCs), which transmit visual information to the brain, can be directly electrically activated with single-cell, single-spike, cell-type precision - however, this possibility has never been tested in the human retina. In this study we aim to characterize, for the first time, direct in situ extracellular electrical stimulation of individual human RGCs.Approach. Extracellular electrical stimulation of individual human RGCs was conducted in three human retinas ex vivo using a custom large-scale, multi-electrode array capable of simultaneous recording and stimulation. Measured activation properties were compared directly to extensive results from macaque.Main results. Precise activation was in many cases possible without activating overlying axon bundles, at low stimulation current levels similar to those used in macaque. The major RGC types could be identified and targeted based on their distinctive electrical signatures. The measured electrical activation properties of RGCs, combined with a dynamic stimulation algorithm, was sufficient to produce an evoked visual signal that was nearly optimal given the constraints of the interface.Significance. These results suggest the possibility of high-fidelity vision restoration in humans using bi-directional epiretinal implants.

Advantages of a Structured Conditioning Program to Optimize the Aerobic Capacity and Functional Independence of a Patient With Acute Inflammatory Demyelinating Polyneuropathy.

Acute demyelinating inflammatory polyneuropathy is a variant of Guillain-Barre syndrome (GBS) - an asymmetrical condition that primarily affects the segment of the peripheral nervous system. Weakness or tingling sensations that be commenced in the inferior limbs and progress to the brachium and face are early signs of this condition. Physiotherapy plays a very crucial role in acute demyelinating inflammatory polyneuropathy in combination with medical management. Criteria through which the clinicians conclude the same are marked affection in the proximal musculature, lower motor neuron type of manifestation, and commencement of symptoms in an ascending sequence. In this study, we presented a case of a 62-year-old male who manifested with the complaint of bilateral superior and inferior limb weakness and was admitted to our hospital. He was diagnosed with acute demyelinating inflammatory polyneuropathy after investigations, such as a lumbar puncture, which revealed a raised level of proteins in cerebrospinal fluid (CSF). With these complaints, he was referred to the physiotherapy wing, and physiotherapy rehabilitation was commenced. Thus, we concluded from this study that in the case of acute demyelinating inflammatory polyneuropathy, physiotherapy rehabilitation was proven to be fruitful in the speedy recovery of the patient and preventing secondary complications along with improving strength and activities of daily living (ADLs) and enhancing the overall quality of life.

Design and Validation of Virtual Reality Task for Neuro-Rehabilitation of Distal Upper Extremities.

Stroke, affecting approximately 15 million people worldwide, has long been a global cause of death and disability. Virtual Reality (VR) has shown its potential as an assistive tool for post-stroke rehabilitation. The objective of this pilot study was to define the task-specific performance metrics of VR tasks to assess the performance level of healthy subjects and patients quantitatively and to obtain their feedback for improving the developed framework. A pilot prospective study was designed. We tested the designed VR tasks on forty healthy right-handed subjects to evaluate its potential. Qualitative trajectory plots and three quantitative performance metrics-time taken to complete the task, percentage relative error, and trajectory smoothness-were computed from the recorded data of forty healthy subjects. Two patients with stroke were also enrolled to compare their performance with healthy subjects. Each participant received one VR session of 90 min. No adverse effects were noticed throughout the study. Performance metrics obtained from healthy subjects were used as a reference for patients. Relatively higher values of task completion time and trajectory smoothness and lower values of relative % error was observed for the affected hands w.r.t the unaffected hands of both the patients. For the unaffected hands of both the patients, the performance levels were found objectively closer to that of healthy subjects. A library of VR tasks for wrist and fingers were designed, and task-specific performance metrics were defined in this study. The evaluation of the VR exercises using these performance metrics will help the clinicians to assess the patient's progress quantitatively and to design the rehabilitation framework for a future clinical study.

Vitamin C Deficiency as a Risk Factor for Bell's Palsy: A New Association.

A 28-year-old female developed gum hypertrophy after five months of Bell's palsy (BP). The vitamin C level was severely low. After vitamin C supplementation for one month, gingival hypertrophy was completely resolved. Facial deviation also improved following rehabilitation. Vitamin C is commonly considered as an antioxidant, anti-inflammatory, and immunomodulator, and it hastens recovery of neuritis caused by herpes (cause of BP). BP too has an immune-inflammatory background. To the best of our knowledge, for the first time, vitamin C deficiency has been reported as a cause or triggering/risk factor for Bell's palsy and at the same time immune-inflammation triggered in BP also may lead to vitamin C deficiency as existing vitamin C in the body starts scavenging free radicals to prevent oxidative damage. Vitamin C levels must be checked in all cases of BP, and intake of vitamin C-rich food should be encouraged in people who are at risk of developing BP.