Embodied cognition in neurodegenerative disorders: What do we know so far? A narrative review focusing on the mirror neuron system and clinical applications.

Embodied cognition is a theoretical perspective that considers every form of human knowledge and cognition "embodied", as they pass through bodily experience. The aim of this narrative review is to investigate the importance of mirror neurons system in EC, as well as the EC role in neurodegenerative diseases. This narrative review shows deep connections between body and mind: body states influence mental functions such as perception and reasoning, while mental states cause changes in the body, especially in neurodegenerative disorders. Indeed, abnormalities in EC were found in dementia, Parkinson's Disease and Amyotrophic Lateral sclerosis, also in the absence of other cognitive deficits, negatively affecting patients' outcomes. Exploiting EC mechanisms for rehabilitation purposes, also using innovation technologies, could be a promising therapeutic way to increase motor and cognitive outcomes in patients affected by different neurological disorders.

Does embodied cognition allow a better management of neurological diseases? A review on the link between cognitive language processing and motor function.

Embodied cognition (EC) refers to the interplay occurring in thinking among individual's sensorimotor capacities (i.e., the ability of the body to respond to its senses with movement), the body itself, and the environment. The aim of the present narrative review is to provide an overall understanding of whether and how motor training could lead to language recovery, consistently with EC theories (action-perception cycle, mirror neuron systems -MNS-, and embodied semantics). We therefore reviewed the works dealing with EC in terms of the link between language processing, mirror neuron system (MNS), and motor function, evaluating the potential clinical implications for better managing neurological deficits. Connections between body and mind were found, as body states influence cognitive functions, such as perception and reasoning, as well as language processing, especially in neurological disorders. In fact, abnormalities in "embodied language" were found in movement disorders and neurodegenerative diseases, negatively affecting patients' rehabilitation outcomes. Understanding the link between language processing and motor outcomes is fundamental in the rehabilitation field, given that EC can be targeted to improve patients' functional recovery and quality of life.

Improving Healthcare Professional Psychological Well-being in Neurorehabilitation: An Exploratory Study Focusing on Work Stress.

BACKGROUND: Work stress (WS) is a set of harmful physical and emotional reactions that occur when the demands coming from work are not adequate to the skills, resources, or needs of the worker. This causes physical, mental, psychological, or social suffering and dysfunction, which can lead to burnout syndrome. OBJECTIVE: The aim of this study is to evaluate WS in the healthcare professions, evaluating the effectiveness of a professional stress prevention program to promote a reduction in WS. METHODS: Thirty-three healthcare professionals of the Multiple Sclerosis (MS) rehab ward of the IRCCS Neurolesi (Messina, Italy) were enrolled in this study. The professional stress prevention program was based on group support activities, as well as individual support. RESULTS: At baseline, we found a high burnout risk in physiotherapists, physicians, and other healthcare professionals. At the end of the meetings, we found a normalization in WS, with a higher sense of personal realization in all of the health-professions, and a greater use of functional coping strategies. CONCLUSION: The occupational stress-reducing intervention in healthcare teams can promote a reduction of stress and anxiety, encouraging more functional coping strategies to face work difficulties.

Do people with multiple sclerosis benefit from PC-based neurorehabilitation? A pilot study.

Multiple Sclerosis (MS) is an inflammatory degenerative disease of the central nervous system. Cognitive impairment is a frequent feature of MS at both the earlier and later stages of the disease, and it tends to worsen over time. Cognitive rehabilitation (CR) is becoming a standard component of neurorehabilitation in patients with MS. The aim of this study is to evaluate the effect of computerized CR, by using the Italian software ERICA, on cognitive and daily life performance in MS patients with mild to moderate cognitive impairment. We studied 40 individuals affected by MS, randomized into either traditional CR group (TCRG: n = 20), which performed a conventional cognitive training, or the computer-assisted CR group (CCRG: n = 20), which performed PC-based CR. The cognitive dysfunctions were investigated through a complete neuropsychological battery, administered before (T0) and after (T1) each different training. Both the trainings were well-tolerated and led to improvement in cognitive function. Notably, the CCRG had a significant effect in improving memory, attention, and processing speed, as compared to TCRG. ERICA training could be a valuable tool for the CR in patients affected by MS. Further studied are needed to confirm these promising results and evaluate the long-term effects.

Can emerging technologies be effective in improving alexithymia due to brain lesion?: Lessons from a case report.

INTRODUCTION: About 66% of stroke survivors present with cognitive or physical consequences, which are often complicated by emotional instability. Alexithymia is defined as "a difficulty in identifying and describing feelings", although there is no consensus on the exact diagnosis and treatment. PATIENT CONCERNS: A 36-year-old right-handed man, affected by ischemic stroke (which occurred about 3 months before admission) involving the right hemisphere (ie, the fronto-parieto-temporal region) with left hemiparesis and behavioral abnormalities, came to our observation for intensive rehabilitation. He was treated unsuccessfully with a traditional and behavioral training. DIAGNOSIS: Alexithymia due to ischemic stroke. INTERVENTIONS: Then, a specific combined protocol using computerized emotional and virtual emotional training was applied in a semi-immersive virtual reality environment using the BTS-Nirvana device. OUTCOMES: At the end of this novel rehabilitation approach, the patient showed a significant improvement in emotional skills, cognitive performances, and coping strategies. CONCLUSIONS: Virtual reality, in addition to standard therapy, may be a valuable tool in improving emotional abnormalities due to brain lesions, such as alexithymia.

Patients' perspective and usability of innovation technology in a new rehabilitation pathway: An exploratory study in patients with multiple sclerosis.

INTRODUCTION: Multiple sclerosis (MS) is an inflammatory neurodegenerative disease of the central nervous system, which causes sensori-motor and cognitive disabilities, as well as neuropsychiatric abnormalities. Technological innovations could offer a valuable way to improve neurorehabilitation outcomes. Aim of the study is to assess the feasibility and usability of new rehabilitation technologies as perceived by patients suffering from MS. MATERIALS AND METHODS: MS inpatients attending the Robotic and Behavioral Neurorehabilitation Service of the IRCCS Centro Neurolesi Bonino Pulejo (Messina, Italy) from February 2017 to April 2019, were enrolled in this exploratory study. The patients were submitted to a personalized rehabilitation treatment using robotics (such as Lokomat, Geosystem, Ekso, Armeo) and virtual reality (i.e. BTS-Nirvana, CAREN, VRRS), following a dedicated innovative pathway. RESULTS: All patients completed the study. Significant pre-post-treatment differences were found in the perception of patients' quality of life, regarding both physical and mental items (p<0,001), as well as in the achievement of the therapeutic goal. Finally, we observed that patients declared a high usability of the robotic devices, and that rehabilitation with the new devices was well tolerated. CONCLUSIONS: our results support the idea that neurorehabilitation using innovation technologies can be useful for the commitment and motivation during the rehabilitation process, with possible positive effects on the functional and psychological outcomes of patients with MS.

Neuroanatomy and function of human sexual behavior: A neglected or unknown issue?

INTRODUCTION: Sexual desire, arousal, and orgasm are mediated by complex, yet still not fully understood, interactions of the somatic and autonomic nervous systems operating at the central and peripheral levels. Disruption of endocrine, neural, or vascular response, caused by aging, medical illness, neurological diseases, surgery, or drugs, can lead to sexual dysfunctions, thus significantly affecting patients' quality of life. PURPOSE: This narrative review aims at characterizing the involvement of the central nervous system in human sexual behavior. METHODS: A literature search was conducted using PubMed in its entirety up to June 2018, analyzing the studies dealing with the neurobiological and neurophysiological basis of human sexuality. RESULTS: Sexual behavior is regulated by both subcortical structures, such as the hypothalamus, brainstem, and spinal cord, and several cortical brain areas acting as an orchestra to finely adjust this primitive, complex, and versatile behavior. At the central level, dopaminergic and serotonergic systems appear to play a significant role in various factors of sexual response, although adrenergic, cholinergic, and other neuropeptide transmitter systems may contribute as well. CONCLUSIONS: Providing healthcare professionals with information concerning sexual behavior may overcome useless and sometimes dangerous barriers and improve patient management, since sexual well-being is considered one of the most important aspects of one's quality of life.

Improving Cognitive Function after Traumatic Brain Injury: A Clinical Trial on the Potential Use of the Semi-Immersive Virtual Reality.

Traumatic brain injury (TBI) is the most common cause of long-term disability and death among young adults, and it represents an enormous socioeconomic and healthcare burden. Our purpose is to evaluate the effects of a virtual reality training with BTs-Nirvana (BTs-N) on the recovery of cognitive functions in TBI subjects, using the interactive semi-immersive program. One hundred patients with TBI were enrolled in this study and randomized into either the Traditional Cognitive Rehabilitation Group (TCRG: n = 50) or the Virtual Reality Training Group (VRTG: n = 50). The VRTG underwent a VRT with BTs-N, whereas the TCRG received a standard cognitive treatment. Each treatment session lasted 60 minutes and was repeated three times a week for 8 weeks. All of the patients were evaluated by a specific psychometric battery before (T0) and immediately (T1) after the end of the training. VRTG and TCRG had a significant improvement in cognitive functioning and in mood, but only VRTG presented with a significant increase in cognitive flexibility and shifting skills and in selective attention. In conclusion, our results suggest that VR may be a useful and effective approach for the rehabilitation of patients with TBI, leading to better cognitive and behavioral outcomes.

Computer assisted cognitive rehabilitation improves visuospatial and executive functions in Parkinson's disease: Preliminary results.

BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disease due to dopamine deficiency in the basal ganglia, leading to motor symptoms such as bradykinesia, tremor, stiffness, and postural instability. This disease may also be associated with a broad spectrum of non-motor symptoms. More than 24% of patients with PD have one or more cognitive symptoms. OBJECTIVE: To evaluate the effects of computer-assisted cognitive rehabilitation (CACR) in Parkinson's disease (PD). METHODS: Sixty patients with PD were enrolled in this study and were randomly divided into control group (CG) and experimental group (EG). Each participant was evaluated at the beginning (T0) and at the end of training (T1). The CG underwent standard cognitive training (SCT) while EG performed CACR using the ERICA platform, aimed at improving several cognitive domains. In both the group, each training consisted of 3 sessions a week, each of these lasting sixty minutes, for eight weeks. RESULTS: Although both the groups had significant improvement after CR, we observed more significant changes in the EG, especially concerning attention, orientation and visual-spatial domains. CONCLUSIONS: Our data demonstrate that CACR is more effective than SCT in improving visual-spatial and executive deficits, in patients affected by PD.

Using telerehabilitation to improve cognitive function in post-stroke survivors: is this the time for the continuity of care?

Post-stroke cognitive disorders can affect different domains, depending on typology of stroke and lesion localization, onset time, age and diagnostic tools used. In recent years, telerehabilitation using virtual reality has been used to reduce the healthcare costs encouraging continuity of care. The aim of our study is to evaluate the efficacy of a virtual reality rehabilitation system in improving cognitive function in stroke survivors. Forty patients affected by stroke were enrolled in this study and randomized into either the control or the experimental groups in order of recruitment. The study lasted 6 months, and included two phases: (1) during the first phase the experimental group underwent cognitive rehabilitation training using the Virtual Reality Rehabilitation System-Evo, whereas the control group was submitted to standard cognitive training; (2) in the second phase (after discharge), the experimental group was treated by means of virtual reality rehabilitation system Home Tablet (three sessions a week, each session lasting about 50 minutes), and the control group continued the traditional training, with the same amount of treatment. The patients underwent a neuropsychological evaluation before and at the end of the treatment. Linear mixed-effects analysis results showed that the scores of Montreal overall cognitive assessment, attentive matrices, Trail Making Test B, Phonemic Fluency, Semantic Fluency, Rey Auditory Verbal Learning Test I, Hamilton Rating Scale-Anxiety and Hamilton Rating Scale-Depression were affected by the type of the rehabilitative treatment. Our data show the effectiveness of telerehabilitation for the treatment of cognitive disorders following stroke.

Virtual Reality and Cognitive Rehabilitation in People With Stroke: An Overview.

OBJECTIVE: This review evaluates the use of virtual reality (VR) tools in cognitive rehabilitation of stroke-affected individuals. METHODS: Studies performed between 2010 and 2017 that fulfilled inclusion criteria were selected from PubMed, Scopus, Cochrane, and Web of Sciences databases. The search combined the terms "VR," "rehabilitation," and "stroke." RESULTS: Stroke patients experienced significant improvement in many cognitive domains (such as executive and visual-spatial abilities and speech, attention, and memory skills) after the use of VR training. CONCLUSIONS: Rehabilitation using new VR tools could positively affect stroke patient cognitive outcomes by boosting motivation and participation.

Changes in sexual functioning following traumatic brain injury: An overview on a neglected issue.

Traumatic brain injury (TBI) is any damage to the skull and/or the brain and its frameworks due to an external force. Following TBI, patients may report cognitive, physiological and psychosocial changes with a devastating impact on important aspects of the patient's life, such as sexual functioning. Although sexual dysfunction (SD) occurs at a significantly greater frequency in individuals with TBI, it is not commonly assessed in the clinical setting and little information is available on this crucial aspect of patients' quality of life. As the number of people with TBI is on the rise, there is a need for better management of TBI problems, including SD, by providing information to patients and their caregivers to achieve sexual health, with a consequent increase in their quality of life. Discussing and treating sexual problems in TBI patients enters the framework of a holistic approach. The purpose of this narrative review is provide clinicians with information concerning changes in sexual functioning and relationships in individuals with TBI, for a better management of patient's functional outcomes and quality of life.

The role of robotic gait training coupled with virtual reality in boosting the rehabilitative outcomes in patients with multiple sclerosis.

Motor impairment is the most common symptom in multiple sclerosis (MS). Thus, a variety of new rehabilitative strategies, including robotic gait training, have been implemented, showing their effectiveness. The aim of our study was to investigate whether an intensive robotic gait training, preceding a traditional rehabilitative treatment, could be useful in improving and potentiating motor performance in MS patients. Forty-five patients, who fulfilled the inclusion criteria, were enrolled in this study and randomized into either the control group (CG) or the experimental group (EG). A complete clinical evaluation, including the Expanded Disability Severity Scale, the Functional Independence Measure, the Hamilton Rating Scale for Depression, the time up and go test (TUG), and the Tinetti balance scale, was performed at baseline (T0), after 6 week (T1), at the end of rehabilitative training (T2), and 1 month later (T3). A significant improvement was observed in the EG for all the outcome measures, whereas the CG showed an improvement only in TUG. In contrast, from T1 to T2, only CG significantly improved in all outcomes, whereas the EG had an improvement only regarding TUG. From T2 to T3, no significant differences in Functional Independence Measure scores emerged for both the groups, but a significant worsening in Tinetti balance scale and TUG was observed for the CG and in TUG for the EG. Our study provides evidence that robotic rehabilitationn coupled with two-dimensional virtual reality may be a valuable tool in promoting functional recovery in patients with MS.

Does body shadow improve the efficacy of virtual reality-based training with BTS NIRVANA?: A pilot study.

BACKGROUND: Aim of the present study was to evaluate whether the presence of body shadows during virtual reality (VR) training with BTS NIRVANA (BTs-N) may lead to a better functional recovery. METHODS: We enrolled 20 poststroke rehabilitation inpatients, who underwent a neurocognitive-rehabilitative training consisting of 24 sessions (3 times a week for 8 weeks) of BTs-N. All the patients were randomized into 2 groups: semi-immersive virtual training with (S-IVTS group) or without (S-IVT group) body shadows. Each participant was evaluated before (T0) and immediately (T1) after the end of the training (Trial Registration Number: NCT03095560). RESULTS: The S-IVTS group showed a greater improvement in visuo-constructive skills and sustained attention, as compared with the S-IVT group. The other measures showed nonsignificant within-group and between-group differences. CONCLUSION: Our results showed that body shadow may represent a high-priority class of stimuli that act by "pushing" attention toward the body itself. Further studies are needed to clarify the role of body shadow in promoting the internal representation construction and thus self-recognition.

What Do We Know About the Influence of the Cerebellum on Walking Ability? Promising Findings from Transcranial Alternating Current Stimulation.

Several cerebellar functions related to upper limb motor control have been studied using non-invasive brain stimulation paradigms. We have recently shown that transcranial alternating current stimulation (tACS) may be a promising approach in shaping the plasticity of cerebellum-brain pathways in a safe and effective manner. This study aimed to assess whether cerebellar tACS at different frequencies may tune M1-leg excitability and modify gait control in healthy human subjects. To this end, we tested the effects of different cerebellar tACS frequencies over the right cerebellar hemisphere (at 10, 50, and 300 Hz, besides a sham-tACS) on M1-leg excitability, cerebellum-brain inhibition (CBI), and gait parameters in a sample of 25 healthy volunteers. Fifty and 300 Hz tACS differently modified M1-leg excitability and CBI from both lower limbs, without significant gait perturbations. We hypothesize that tACS aftereffect may depend on a selective entrainment of distinct cerebellar networks related to lower limb motor functions. Therefore, cerebellar tACS might represent a useful tool to modulate walking training in people with cerebellum-related gait impairment, given that tACS may potentially reset abnormal cerebellar circuitries.

Effects of cerebellar transcranial alternating current stimulation on motor cortex excitability and motor function.

The cerebellum regulates several motor functions through two main mechanisms, the cerebellum-brain inhibition (CBI) and the motor surround inhibition (MSI). Although the exact cerebellar structures and functions involved in such processes are partially known, Purkinje cells (PC) and their surrounding interneuronal networks may play a pivotal role concerning CBI and MSI. Cerebellar transcranial alternating current stimulation (tACS) has been proven to shape specific cerebellar components in a feasible, safe, effective, and non-invasive manner. The aim of our study was to characterize the cerebellar structures and functions subtending CBI and MSI using a tACS approach. Fifteen healthy individuals underwent a cerebellar tACS protocol at 10, 50, and 300 Hz, or a sham-tACS over the right cerebellar hemisphere. We measured the tACS aftereffects on motor-evoked potential (MEP) amplitude, CBI induced by tACS (tiCBI) at different frequencies, MSI, and hand motor task performance. None of the participants had any side effect related to tACS. After 50-Hz tACS, we observed a clear tiCBI-50Hz weakening (about +30%, p < 0.001) paralleled by a MEP amplitude increase (about +30%, p = 0.001) and a reduction of the time required to complete some motor task (about -20%, p = 0.01), lasting up to 30 min. The 300-Hz tACS induced a selective, specific tiCBI-300Hz and tiCBI-50Hz modulation in surrounding muscles (about -15%, p = 0.01) and MSI potentiation (about +40%, p < 0.001). The 10-Hz tACS and the sham-tACS were ineffective (p > 0.6). Our preliminary data suggest that PC may represent the last mediator of tiCBI and that the surrounding interneuronal network may have an important role in updating MSI, tiCBI, and M1 excitability during tonic muscle contraction, by acting onto the PC. The knowledge of these neurophysiological issues offers new cues to design innovative, non-invasive neuromodulation protocols to shape cerebellar-cerebral functions.