Musical and electrical stimulation as intervention in disorder of consciousness (DOC) patients: A randomised cross-over trial.

BACKGROUND: Disorders of consciousness (DOC), i.e., unresponsive wakefulness syndrome (UWS) or vegetative state (VS) and minimally conscious state (MCS), are conditions that can arise from severe brain injury, inducing widespread functional changes. Given the damaging implications resulting from these conditions, there is an increasing need for rehabilitation treatments aimed at enhancing the level of consciousness, the quality of life, and creating new recovery perspectives for the patients. Music may represent an additional rehabilitative tool in contexts where cognition and language are severely compromised, such as among DOC patients. A further type of rehabilitation strategies for DOC patients consists of Non-Invasive Brain Stimulation techniques (NIBS), including transcranial electrical stimulation (tES), affecting neural excitability and promoting brain plasticity. OBJECTIVE: We here propose a novel rehabilitation protocol for DOC patients that combines music-based intervention and NIBS in neurological patients. The main objectives are (i) to assess the residual neuroplastic processes in DOC patients exposed to music, (ii) to determine the putative neural modulation and the clinical outcome in DOC patients of non-pharmacological strategies, i.e., tES(control condition), and music stimulation, and (iii) to evaluate the putative positive impact of this intervention on caregiver's burden and psychological distress. METHODS: This is a randomised cross-over trial in which a total of 30 participants will be randomly allocated to one of three different combinations of conditions: (i) Music only, (ii) tES only (control condition), (iii) Music + tES. The music intervention will consist of listening to an individually tailored playlist including familiar and self-relevant music together with fixed songs; concerning NIBS, tES will be applied for 20 minutes every day, 5 times a week, for two weeks. After these stimulations two weeks of placebo treatments will follow, with sham stimulation combined with noise for other two weeks. The primary outcomes will be clinical, i.e., based on the differences in the scores obtained on the neuropsychological tests, such as Coma Recovery Scale-Revised, and neurophysiological measures as EEG, collected pre-intervention, post-intervention and post-placebo. DISCUSSION: This study proposes a novel rehabilitation protocol for patients with DOC including a combined intervention of music and NIBS. Considering the need for rigorous longitudinal randomised controlled trials for people with severe brain injury disease, the results of this study will be highly informative for highlighting and implementing the putative beneficial role of music and NIBS in rehabilitation treatments. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05706831, registered on January 30, 2023.

Pragmatic Communication Deficit and Functional Outcome in Patients with Right- and Left-Brain Damage: A Pilot Study.

Pragmatic communication abilities refer to the capacity to use language in a social context. Despite evidence to the contrary, the left cerebral hemisphere of the majority of right handers has been considered exclusively specialized for control of language phonology, syntax and semantics, whereas the right hemisphere has been specialized for the control of language pragmatics. Many studies have shown the non-exclusivity of the left hemisphere for language skills. Communication deficits observed in these studies for patients with right hemisphere damage confirmed the necessity for integrity of the right hemisphere across a number of language components. The aim of this study is to investigate the specific role of the right and left hemispheres across several aspects of communication deficits, with particular attention given to the influence of these deficits on functional outcome. The second aim is to characterize possible correlations between pragmatic and other cognitive deficits. We evaluated 22 patients, 15 with left- and 7 with right-brain ischemic or hemorrhagic damage, using cognitive, pragmatic and language tests. We deployed the Right Hemisphere Language Battery-Santa Lucia and Montreal d'Evaluation de la Communication to assess pragmatic abilities. The results showed no statistically significant differences between patients with left- and right-brain damage, highlighting the importance of integration between the two hemispheres in the communication process. Multiple significant correlations were found between pragmatic abilities and cognitive tests assessing global cognitive functioning, pantomime expression and comprehension. Pragmatic deficits were also shown to correlate with functional cognitive outcome. It is important to assess pragmatic abilities in patients with cognitive deficits after both left and right stroke for tailoring neuropsychological intervention to mitigate pragmatic disabilities in functional outcomes.

Free Thyroxine (fT4) as a Potential Biomarker of Neurological and Functional Outcome in Acquired Brain Injury: A Prospective Multicenter Cohort Study.

The potential involvement of thyroid hormones (THs) in the neurological and functional recovery of patients with brain damage has been hypothesized. We aimed at investigating the role of THs and their variations during the rehabilitation process as predictive biomarkers of neurological and functional outcome in patients with acquired brain injury (ABI). This prospective, multicenter cohort study included 220 patients with ABI consecutively admitted for a 6-month neurorehabilitation program. Data on the etiology of the brain injury, occurrence of seizures, neurosurgical procedures, and death during hospitalization were collected. Both at the baseline (T0) and at the end of the rehabilitation process (T1), the following variables were evaluated: thyroid function (TSH, fT4, and fT3) and outcome measure including the Glasgow Coma Scale (GCS), Glasgow Outcome Scale-Extended (GOS-E), and Functional Independence Measure (FIM) scale. During neurorehabilitation, a significant decrease in fT4 levels was documented in the population as a whole and in patients with severe ABI (p < 0.0001), whereas no significant variations were found in TSH and fT3 levels. No significant associations were found between THs and seizure occurrence, while the neurological and functional outcomes were associated with the variation in fT4 levels during rehabilitation. In particular, a higher magnitude of decrease in fT4 levels emerged as an independent predictor of more severe neurological damage (OR = 3.48, CI 95% 1.04-11.69, p = 0.04) and a lower functional recovery (ß = -0.22, p = 0.01). In conclusion, serum fT4 variation during neurorehabilitation could represent a potential biomarker of neurological and functional outcome in patients with ABI. Further studies are needed to investigate the mechanisms underlying this association.

Is There a New Road to Spinal Cord Injury Rehabilitation? A Case Report about the Effects of Driving a Go-Kart on Muscle Spasticity.

BACKGROUND: Traumatic spinal cord injury (SCI) is a neurological disorder that causes a traumatic anatomical discontinuity of the spinal cord. SCI can lead to paraplegia, spastic, or motor impairments. Go-karting for people with SCI is an adapted sport that is becoming increasingly popular. The purpose of this case report is to shed light on the effects of driving a go-kart on a patient with SCI-related spasticity and to deepen understanding of the possible related role of whole-body vibration (WBV) and neuroendocrine reaction. METHODS: The patient was a 50-year-old male with a spastic paraplegia due to traumatic SCI. He regularly practiced go-kart racing, reporting a transient reduction in spasticity. He was evaluated before (T0), immediately after (T1), 2 weeks after (T2), and 4 weeks after (T3) a go-kart driving session. On both sides, long adductor, femoral bicep, and medial and lateral gastrocnemius spasticity was assessed using the Modified Ashworth Scale (MAS), and tone and stiffness were assessed using MyotonPro. RESULTS: It was observed that a go-kart driving session could reduce muscle spasticity, tone, and stiffness. CONCLUSIONS: Go-kart driving can be a valid tool to obtain results similar to those of WBV and hormone production in the reduction of spasticity.

Applying graph theory to improve the quality of scientific evidence from textual information: Neural injuries after gynaecologic pelvic surgery for genital prolapse and urinary incontinence.

AIMS: To provide the overall rate for all types of neurologic iatrogenic injuries during urogynaecologic surgery from textual data. METHODS: Systematic research focused on complications of gynaecologic surgery and neurologic injuries in abstracts. Keywords concerning complications (cluster A), unspecific; neurologic issues (cluster B); surgery (generic words) (cluster C); specific gynaecologic operations (cluster D); and specific gynaecologic operations for pelvic organ prolapse and urinary incontinence (cluster E) were extracted. Associations among clusters of keywords were assessed by using multiple runs of text-mining software Semantic Brand Score (SBS, https://semanticbrandscore.com/#primary). Association scores were converted into probabilities. The rate of neurologic complications in urogynaecologic surgery was calculated ("a priori" probability) by applying Bayes' theorem. Textual estimates of neurological injuries in urogynaecologic surgery are 0.035554 (95% confidence intervals 0.019607-0.0515001; no quantitative data were found). To test if the probability calculated on textual information was the same as quantitative data reports ("a posteriori" probability), the rate of neurologic complication of all gynaecologic surgery was calculated using a meta-analytics approach and was compared with the textual analysis value. RESULTS: The rate of neurologic complications in gynaecologic surgery after meta-analytic data synthesis has been 0.016489 (95% confidence intervals 0.012163-0.022320), which is equal to the textual estimate (0.016889, 95% confidence intervals 0.019607-0.051501). Therefore, 0.035554 is a reliable likelihood to observe a neurologic complication in urogynaecologic surgery. CONCLUSION: Iatrogenic nerve injuries in urogynaecologic surgery are higher than whole gynaecologic surgery. Text-mining software SBS and probability conversion can provide reliable answers from overall scholars' opinions on unsolved clinical questions when better evidence is lacking.

A survey of clinical practice concerning long-term follow-up of neurogenic lower urinary tract dysfunction due to spinal cord injury in Italy.

CONTEXT/OBJECTIVE: This study aimed to assess the clinical practice for long-term follow-up (FU) of neurogenic lower urinary tract dysfunction (NLUTD) due to spinal cord injury (SCI) in Italy and compare this practice with the clinical practice in other countries and with the international guidelines. DESIGN: Data concerning the long-term urological FU of individuals with SCI were collected using a questionnaire and analyzed by means of descriptive and inferential statistics. SETTING: Twenty-one Italian centers following SCI patients. PARTICIPANTS: One physician at each center (either a permanent staff member or chief). OUTCOME MEASURES: Questions addressed the treatment of urinary tract infections (UTI), frequency of visits, urinary tract imaging examinations and urodynamic tests (UD), distinguishing between suprasacral and sacral SCI. RESULTS: Nineteen out of 21 centers completed the survey. In most centers, patients were recommended to undergo a visit and an ultrasound examination of urinary tract (UT) at least once a year. While the median interval between FU visits was identical (12 months) for individuals with suprasacral and sacral SCI, the two interval distributions were significantly different (suprasacral SCI: min-max 4-18, IQR = 6; sacral SCI: min-max 6-24; IQR = 8.5; P = 0.02), showing people with suprasacral SCI are followed up more often. Approximately 80% of the surveyed centers performed scheduled UD, with a yearly median frequency of 12 months (range 6-36) for patients with suprasacral SCI, as compared to a median frequency of 18 months for sacral SCI (range 0-36, P = 0.04). VideoUD and antibiotic prophylaxis for recurrent UTIs are carried out only by urologists in 63% and 47.4% of the centers, respectively. Overall, Italian centers share common strategies that compare to standards, including yearly visits, yearly UT examinations and stricter follow-up of people with suprasacral SCI, but may not have standard protocols for antibiotic prophylaxis of UTI, and in few cases control visits and UD are carried out too often. CONCLUSIONS: Even though most Italian centers follow up patients with NLUTD secondary to SCI according to international guidelines, heterogeneity in frequency of FU examinations still exists. A tailored approach to the SCI patient that minimizes unnecessary examinations and groups different tests in a single access could improve patients' compliance with FU and reduce costs for the Health system.

Changes in gut microbiota in the acute phase after spinal cord injury correlate with severity of the lesion.

After spinal cord injury (SCI), patients face many physical and psychological issues including intestinal dysfunction and comorbidities, strongly affecting quality of life. The gut microbiota has recently been suggested to influence the course of the disease in these patients. However, to date only two studies have profiled the gut microbiota in SCI patients, months after a traumatic injury. Here we characterized the gut microbiota in a large Italian SCI population, within a short time from a not only traumatic injury. Feces were collected within the first week at the rehabilitation center (no later than 60 days after SCI), and profiled by 16S rRNA gene-based next-generation sequencing. Microbial profiles were compared to those publicly available of healthy age- and gender-matched Italians, and correlated to patient metadata, including type of SCI, spinal unit location, nutrition and concomitant antibiotic therapies. The gut microbiota of SCI patients shows distinct dysbiotic signatures, i.e. increase in potentially pathogenic, pro-inflammatory and mucus-degrading bacteria, and depletion of short-chain fatty acid producers. While robust to most host variables, such dysbiosis varies by lesion level and completeness, with the most neurologically impaired patients showing an even more unbalanced microbial profile. The SCI-related gut microbiome dysbiosis is very likely secondary to injury and closely related to the degree of completeness and severity of the lesion, regardless of etiology and time interval. This microbial layout could variously contribute to increased gut permeability and inflammation, potentially predisposing patients to the onset of severe comorbidities.

Machine learning to predict mortality after rehabilitation among patients with severe stroke.

Stroke is among the leading causes of death and disability worldwide. Approximately 20-25% of stroke survivors present severe disability, which is associated with increased mortality risk. Prognostication is inherent in the process of clinical decision-making. Machine learning (ML) methods have gained increasing popularity in the setting of biomedical research. The aim of this study was twofold: assessing the performance of ML tree-based algorithms for predicting three-year mortality model in 1207 stroke patients with severe disability who completed rehabilitation and comparing the performance of ML algorithms to that of a standard logistic regression. The logistic regression model achieved an area under the Receiver Operating Characteristics curve (AUC) of 0.745 and was well calibrated. At the optimal risk threshold, the model had an accuracy of 75.7%, a positive predictive value (PPV) of 33.9%, and a negative predictive value (NPV) of 91.0%. The ML algorithm outperformed the logistic regression model through the implementation of synthetic minority oversampling technique and the Random Forests, achieving an AUC of 0.928 and an accuracy of 86.3%. The PPV was 84.6% and the NPV 87.5%. This study introduced a step forward in the creation of standardisable tools for predicting health outcomes in individuals affected by stroke.