Do patients with neurological disorders benefit from immersive virtual reality? A scoping review on the emerging use of the computer-assisted rehabilitation environment.

INTRODUCTION: Virtual reality (VR) is an advanced technology that creates simulated environments and conditions. By offering the possibility of combining motor, cognitive, and well-being in conjunction with the potential to manipulate multi-sensorial features in a safe environment, VR has emerged as a promising powerful rehabilitation tool. Among advanced VR systems, various authors have highlighted promising effects in the rehabilitation of the computer-assisted rehabilitation environment (CAREN - Motekforce Link; Amsterdam, The Netherlands). In our scoping review, we aimed to map the existing evidence on the use of CAREN in the rehabilitation of neurological patients. EVIDENCE ACQUISITION: This scoping review was conducted following the PRISMA guidelines. A search was carried out for all peer-reviewed articles published until June 30, 2023, using the following databases: PubMed, Embase, Cochrane Database, PeDro and Web of Science. The following terms have been used: ("Cognitive Rehabilitation" OR "Motor Rehabilitation" OR "CAREN" or "Computer-Assisted Rehabilitation Environment") AND ("Virtual Reality" OR "Rehab"). EVIDENCE SYNTHESIS: From the assessed studies, only seven met the inclusion criteria: 1) one study concerned cognitive rehabilitation in patients suffering from Parkinson's Disease (PD); 2) one was on the usability of CAREN in PD patients; 3) two studies related to the influence of emotional components to CAREN rehabilitation; 4) three studies were related to motor rehabilitation using CAREN, and involved individuals with PD, Multiple Sclerosis, TBI, respectively. Generally, the few assessed studies demonstrate that CAREN is a safe and potentially effective tool to treat different symptoms (including gait and vestibular disturbances, executive function, depressive mood, and anxiety) in patients with different neurological disorders. CONCLUSIONS: The reviewed literature indicated the potential use of CAREN in improving motor and cognitive skills with conflicting results on emotional aspects. However, since the data comes from few and small sample size studies, further research is needed to confirm the effectiveness of the tool in neurorehabilitation.

Efficacy of non-immersive virtual reality-based telerehabilitation on postural stability in Parkinson's disease: a multicenter randomized controlled trial.

BACKGROUND: The implementation of regular prolonged, and effective rehabilitation in people with Parkinson's disease is essential for ensuring a good quality of life. However, the continuity of rehabilitation care may find barriers related to economic, geographic, and social issues. In these scenarios, telerehabilitation could be a possible solution to guarantee the continuity of care. AIM: To investigate the efficacy of non-immersive virtual reality-based telerehabilitation on postural stability in people with Parkinson's disease, compared to at-home self-administered structured conventional motor activities. DESIGN: Multicenter randomized controlled trial. SETTING: Five rehabilitation hospitals of the Italian Neuroscience and Rehabilitation Network. POPULATION: Individuals diagnosed with Parkinson's disease. METHODS: Ninety-seven participants were randomized into two groups: 49 in the telerehabilitation group (non-immersive virtual reality-based telerehabilitation) and 48 in the control group (at-home self-administered structured conventional motor activities). Both treatments lasted 30 sessions (3-5 days/week for, 6-10 weeks). Static and dynamic balance, gait, and functional motor outcomes were registered before and after the treatments. RESULTS: All participants improved the outcomes at the end of the treatments. The primary outcome (mini-Balance Evaluation Systems Test) registered a greater significant improvement in the telerehabilitation group than in the control group. The gait and endurance significantly improved in the telerehabilitation group only, with significant within-group and between-group differences. CONCLUSIONS: Our results showed that non-immersive virtual reality-based telerehabilitation is feasible, improves static and dynamic balance, and is a reasonably valuable alternative for reducing postural instability in people with Parkinson's disease. CLINICAL REHABILITATION IMPACT: Non-immersive virtual reality-based telerehabilitation is an effective and well-tolerated modality of rehabilitation which may help to improve access and scale up rehabilitation services as suggested by the World Health Organization's Rehabilitation 2030 agenda.

What does evidence tell us about the use of gait robotic devices in patients with multiple sclerosis? A comprehensive systematic review on functional outcomes and clinical recommendations.

INTRODUCTION: There is growing evidence on the efficacy of gait robotic rehabilitation in patients with multiple sclerosis (MS), but most of the studies have focused on gait parameters. Moreover, clear indications on the clinical use of robotics still lack. As part of the CICERONE Italian Consensus on Robotic Rehabilitation, the aim of this systematic review was to investigate the existing evidence concerning the role of lower limb robotic rehabilitation in improving functional recovery in patients with MS. EVIDENCE ACQUISITION: We searched for and systematically reviewed evidence-based studies on gait robotic rehabilitation in MS, between January 1st, 2010 and December 31st, 2020, in the following databases: Cochrane Library, PEDro, PubMed and Google Scholar. The study quality was assessed by the 16-item assessment of multiple systematic reviews 2 (AMSTAR 2) and the 10-item PEDro scale for the other research studies. EVIDENCE SYNTHESIS: After an accurate screening, only 17 papers were included in the review, and most of them (13 RCT) had a level II evidence. Most of the studies used the Lokomat as a grounded robotic device, two investigated the efficacy of end-effectors and two powered exoskeletons. Generally speaking, robotic treatment has beneficial effects on gait speed, endurance and balance with comparable outcomes to those of conventional treatments. However, in more severe patients (EDSS >6), robotics leads to better functional outcomes. Notably, after gait training with robotics (especially when coupled to virtual reality) MS patients also reach better non-motor outcomes, including spasticity, fatigue, pain, psychological well-being and quality of life. Unfortunately, no clinical indications emerge on the treatment protocols. CONCLUSIONS: The present comprehensive systematic review highlights the potential beneficial role on functional outcomes of the lower limb robotic devices in people with MS. Future studies are warranted to evaluate the role of robotics not only for walking and balance outcomes, but also for other gait-training-related benefits, to identify appropriate outcome measures related to a specific subgroup of MS subjects' disease severity.

Robotic-assisted gait rehabilitation following stroke: a systematic review of current guidelines and practical clinical recommendations.

INTRODUCTION: Stroke is the third leading cause of adult disability worldwide, and lower extremity motor impairment is one of the major determinants of long-term disability. Although robotic therapy is becoming more and more utilized in research protocols for lower limb stroke rehabilitation, the gap between research evidence and its use in clinical practice is still significant. The aim of this study was to determine the scope, quality, and consistency of guidelines for robotic lower limb rehabilitation after stroke, in order to provide clinical recommendations. EVIDENCE ACQUISITION: We systematically reviewed stroke rehabilitation guideline recommendations between January 1, 2010 and October 31, 2020. We explored electronic databases (N.=4), guideline repositories and professional rehabilitation networks (N.=12). Two independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and brief syntheses were used to evaluate and compare the different recommendations, considering only the most recent version. EVIDENCE SYNTHESIS: From the 1219 papers screened, ten eligible guidelines were identified from seven different regions/countries. Four of the included guidelines focused on stroke management, the other six on stroke rehabilitation. Robotic rehabilitation is generally recommended to improve lower limb motor function, including gait and strength. Unfortunately, there is still no consensus about the timing, frequency, training session duration and the exact characteristics of subjects who could benefit from robotics. CONCLUSIONS: Our systematic review shows that the introduction of robotic rehabilitation in standard treatment protocols seems to be the future of stroke rehabilitation. However, robot assisted gait training (RAGT) for stroke needs to be improved with new solutions and in clinical practice guidelines, especially in terms of applicability.

How patients with mild dementia living in a nursing home benefit from dementia cafés: a case-control study focusing on psychological and behavioural symptoms and caregiver burden.

BACKGROUND: Dementia is a syndrome, mainly due to neurodegeneration, affecting cognition, behaviour, feelings and relationships. Pharmacological treatment is still challenging and thus different ways to improve/slow down the disease are necessary. METHODS: Twenty-five subjects with mild dementia, living in a nursing home, and their relatives were invited to attend a dementia cafe, a community group which provides support for families affected by dementia. Each patient was evaluated by a neuropsychologist, through the administration of a specific neuropsychological battery, before and at the end of the study. Their outcomes were compared to a matched group of patients with dementia receiving psycho-counselling. RESULTS: After the dementia cafe meetings, patients showed higher significant changes in mood (P < 0.01), behavioural symptoms (P < 0.001), quality of life (P < 0.001), and caregiver burden (P < 0.001). The control group significantly improved only in quality of life with a reduction of caregiver burden. CONCLUSIONS: Our findings confirm that patients with dementia may benefit from the dementia cafe, especially concerning behavioural symptoms. Moreover, caregivers find these cafés to be welcoming, relaxed places to socialise and access support and information. Future dementia cafés should create programs and comfortable environments answering to the different needs of the patients.

Can muscle vibration be the future in the treatment of cerebral palsy-related drooling? A feasibility study.

Background: Drooling is an involuntary loss of saliva from the mouth, and it is a common problem for children with cerebral palsy (CP). The treatment may be pharmacological, surgical, or speech-related. Repeated Muscle Vibration (rMV) is a proprioceptive impulse that activates fibers Ia reaching the somatosensory and motor cortex. Aim: The aim of the study is to evaluate the effectiveness of rMV in the treatment of drooling in CP. Design, setting and population: This was a rater blinded prospective feasibility study, performed at the "Gli Angeli di Padre Pio" Foundation, Rehabilitation Centers (Foggia, Italy), involving twenty-two CP patients affected by drooling (aged 5-15, mean 9,28 ± 3,62). Children were evaluated at baseline (T0), 10 days (T1), 1 month (T2) and 3 months (T3) after the treatment. Methods: The degree and impact of drooling was assessed by using the Drooling Impact Scale (DIS), the Drooling Frequency and Severity Scale (DFSS), Visual Analogue Scale (VAS) and Drooling Quotient (DQ). An rMV stimulus under the chin symphysis was applied with a 30 min protocol for 3 consecutive days. Results: The statistical analysis shows that DIS, DFSS, VAS, DQ improved with significant differences in the multiple comparisons between T1 vs T2, T1 vs T3 and T1 vs T4 (p≤0.001). Conclusion This study demonstrates that rMV might be a safe and effective tool in reducing drooling in patients with CP. The vibrations can improve the swallowing mechanisms and favor the acquisition of the maturity of the oral motor control in children with CP.

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.

Moving towards novel multidisciplinary approaches for improving elderly quality of life: The emerging role of telemedicine in Sicily.

INTRODUCTION: Elderly care is a worldwide social and economic challenge for the public health system, and it requires the development of new management strategies. Telemedicine provides an innovative approach towards elderly care, especially for those with chronic diseases. In this study, we aimed to evaluate the potential role of a multidisciplinary telemedicine approach for improving elderly quality of life. METHODS: Twenty-two participants received weekly vital parameter monitoring and nutritional counselling, biweekly psychological counselling and a monthly consultation with a neurologist. The neuropsychological assessment included the Mini Mental State Examination, the Activities of Daily Living, the Instrumental Activities of Daily Living, the Geriatric Depression Scale and the Short-Form Health Survey, and was administered at enrolment (T0) and at the end of the study (T3). The nutritional evaluation included haematochemical examinations of glycaemia, total cholesterol, and triglycerides at baseline (T0) and every four months (T1, T2, T3). RESULTS: Significant differences in Activities of Daily Living, Geriatric Depression Scale and all domains of the Short-Form Health Survey were observed between baseline and the end of the study. The haematochemical parameters showed obvious changes over time, especially in cholesterol values, and the patients with hypercholesterolaemia and hypertriglyceridaemia showed a reduction in body mass index. Moreover, we found that the haematochemical values were moderately correlated with the Activities of Daily Living, Geriatric Depression Scale and Short-Form Health Survey scores. CONCLUSION: Telemedicine can be a suitable tool for caring for elderly people more efficiently by promoting the remission of depressive symptoms and improving social functioning, cognitive levels and nutritional habits to prevent vascular diseases and exacerbations of pre-existing chronic illness.

A promising tool for flail arm in amyotrophic lateral sclerosis rehabilitation: a case report.

BACKGROUND: Amyotrophic lateral sclerosis flail arm (ALS-FA) is a motor neuron disease form confined to the upper limbs (cervical spinal cord region), often with asymmetric onset. To date, there is no defined neurorehabilitation strategy for ALS patients, although aerobic exercises may be of some help. CASE REPORT: A 69-year-old woman affected by ALS-FA was admitted to our research institute because of upper limb muscle weakness. She was then submitted to two different conventional physiotherapy programs, the first stand-alone and the second combined to a robotic treatment. The patient gained an important motor improvement only after a 2-month treatment of physiotherapy plus Armeo-Power (AP), a robotic rehabilitation exoskeleton for upper limbs training, providing intelligent arm support in a 3D workspace. CLINICAL REHABILITATION IMPACT: Even though this is a single case, our combined neurorehabilitation approach (i.e. conventional physiotherapy plus robotics) could be considered a promising tool in improving upper limb function in patients affected by motoneurons disease, including ALS. Further studies involving a larger cohort of ALS-FA patients and long-term follow-up are needed, in order to evaluate the efficacy of robotics in prolonging patient's independence in active daily living.

Timing for cranioplasty to improve neurological outcome: A systematic review.

INTRODUCTION: Cranioplasty is a surgical technique applied for the reconstruction of the skullcap removed during decompressive craniectomy (DC). Cranioplasty improves rehabilitation from a motor and cognitive perspective. However, it may increase the possibility of postoperative complications, such as seizures and infections. Timing of cranioplasty is therefore crucial even though literature is controversial. In this study, we compared motor and cognitive effects of early cranioplasty after DC and assess the optimal timing to perform it. METHODS: A literature research was conducted in PubMed, Web of Science, and Cochrane Library databases. We selected studies including at least one of the following test: Mini-Mental State Examination, Rey Auditory Verbal Learning Test immediate and 30-min delayed recall, Digit Span Test, Glasgow Coma Scale, Glasgow Outcome Scale, Coma Recovery Scale-Revised, Level of Cognitive Functioning Scale, Functional Independence Measure, and Barthel Index. RESULTS: Six articles and two systematic reviews were included in the present study. Analysis of changes in pre- and postcranioplasty scores showed that an early procedure (within 90 days from decompressive craniectomy) is more effective in improving motor functions (standardized mean difference [SMD] = 0.51 [0.05; 0.97], p-value = 0.03), whereas an early procedure did not significantly improve neither MMSE score (SMD = 0.06 [-0.49; 0.61], p-value = 0.83) nor memory functions (SMD = -0.63 [-0.97; -0.28], p-value < 0.001). No statistical significance emerged when we compared studies according to the timing from DC. CONCLUSIONS: It is believed that cranioplasty performed from 3 to 6 months after DC may significantly improve both motor and cognitive recovery.

Personal computer-based cognitive training in Parkinson's disease: a case study.

Parkinson's disease (PD) is a neurodegenerative disorder that is best managed by a combination of medication and regular physiotherapy. PD's main symptoms involve the motor system, but cognitive disorders can be very severe as well. The aim of this study was to evaluate the effects of the computerized rehabilitative tool Esercizi di Riabilitazione Cognitiva (ERICA) in the cognitive recovery of a patient with PD. The patient was a 65-year-old man affected by PD with motor complications and severe cognitive and behavioural alterations. He underwent two different types of intensive rehabilitation training: standard cognitive rehabilitation alone and in combination with specific personal computer (PC)-based cognitive training. We evaluated his neuropsychological profile before and after the two types of training by using a specific psychometric battery. Only at the end of the PC training did we observe improvement in cognitive function as well as mood stabilization. When used in addition to standard cognitive rehabilitation, PC-based cognitive training may be a valuable tool in improving cognitive skills, with regard to attention, memory process, and executive functions. PC-based cognitive training may be able to help optimize managing the symptoms of PD.

Shedding new light on disorders of consciousness diagnosis: The dynamic functional connectivity.

It has been proposed that awareness may depend on the highly-dynamic functional connectivity of large-scale cortico-thalamo-cortical networks. We investigated how brain connectivity changes over time in the resting state in a group of patients with chronic disorders of consciousness (DoC). To this end, we assessed dynamic functional connectivity (DFC) in the resting state by analyzing the time-dependent EEG phase synchronization in five frequency bands (δ, θ, α, ß, and γ). Patients in Minimally Conscious State (MCS) showed changes in DFC matrices and topography over time (mainly in the γ range), which were significantly different from those observed in patients with Unresponsive Wakefulness Syndrome (UWS). The degree of DFC significantly correlated with the level of behavioral responsiveness measured using the Coma Recovery Scale-Revised. The analysis of DFC seems promising to differentiate patients with DoC. Moreover, sharpening the current knowledge of DFC by using EEG-based approaches may shed light on the processes of consciousness and their pathophysiology, and may help to design neuromodulation protocols aimed at targeting maladaptive and dysfunctional FC.

Training for mobility with exoskeleton robot in spinal cord injury patients: a pilot study.

BACKGROUND: Wearable robots are people-oriented robots designed to be worn all day, thus helping in the daily activities. They can assist in walking, running, jumping higher or even lifting objects too heavy in normal conditions. AIM: The aim of this report was to investigate the changes in gait pattern through 3D gait analysis of subjects with spinal cord injury (SCI) undergoing an adaptive training with a wearable exoskeletal device (ESD). The change in the quality of life was also investigate together with the possibility to wear these devices all day, to improve the mobility. DESIGN: Prospective quasi-experimental study, pre- and post-design. SETTING: Outpatient SCI patients. POPULATION: On a voluntary basis, eight SCI patients who had never used any ESD device were recruited. METHODS: Subjects underwent a three-dimensional gait analysis (3D GA) while wearing the ESD at baseline (inclusion) (T0) and after 20 sessions of training over an expected average of 5/6 weeks (T1). The secondary outcome measures were: Participant Satisfaction Questionnaire, 6-Minute Walking Test (6MWT), Borg Scale (the test was administered in indoor and outdoor conditions) and Timed Up-and-Go test (TUG). Spatiotemporal and kinematic parameters were assessed and their change from the beginning to the end of the training was the secondary outcome. RESULTS: No dropouts were recorded during the training and all subjects were able to terminate the protocol (compliant subjects: N.=8). After the training, all person showed some significant improvements for TUG, 6MWT and 10 MWT (Z=-2.521; P=0.008) and for the spatiotemporal and kinematics parameters. CONCLUSIONS: This paper confirms that the adaptive training with ESD is safe and feasible in a heterogeneous sample of persons with SCI, especially in ameliorating the interaction between the patients and the device with an improvement of spatiotemporal and kinematics parameters. CLINICAL REHABILITATION IMPACT: Since the training has been proven safe and the hypothesis that the subjects with spinal cord injury improving their performance over time and being able to adapt at the use of device in full autonomy at home during all the activities of the daily living has strengthened.

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.

Unmet Needs for Family Caregivers of Elderly People With Dementia Living in Italy: What Do We Know So Far and What Should We Do Next?

Care of the elderly with dementia represents one of the major challenges for the modern society worldwide. The burden of dementia care often falls on the family members, entailing heavy psychosocial and economic consequences. The aim of this study was to evaluate the caregiver's perspective concerning the support for disease management on behalf of the physicians and the local Sicilian administrations (Italy), and the burden of care and effects on their lifestyle, to propose new prevention strategies and service for managing dementia and caregiver's burden. Fifty-nine caregivers of Italian elderly people with dementia (mean age, 73; age range: 63-83) were interviewed, and 55 of them completed an ad hoc self-report questionnaire composed of 54 multiple-choice questions. Our findings suggest that caregivers need more information on the disease's management, as well as on how to deal with the stress due to the disease burden. Moreover, a negative perception about the services offered from the local administration emerged. Assistive technology (AT) could be useful in promoting interaction between general practitioners and specialized centers for diagnosis, pharmacological and psychosocial treatments, and in saving costs. Moreover, case manager could follow patients and support family members within the care pathway, besides collecting and sharing information among the different health professionals involved. Further studies should be aimed at investigating whether AT and/or the use of specific educational strategies could be the right approach for meeting the needs of families living with dementia.