Virtual Art Therapy: Application of Michelangelo Effect to Neurorehabilitation of Patients with Stroke.

In neurorehabilitation, some studies reported the effective use of art therapy for reducing psychological disorders and for enhancing physical functions and cognitive abilities. Neuroaesthetical studies showed that seeing an art masterpiece can spontaneously elicit a widespread brain arousal, also involving motor networks. To combine contemplative and performative benefits of art therapy protocols, we have developed an immersive virtual reality system, giving subjects the illusion that they are able to paint a copy of famous artistic paintings. We previously observed that during this virtual task, subjects perceived less fatigue and performed more accurate movements than when they were asked to color the virtual canvas. We named this upshot the Michelangelo effect. The aim of this study was to test the rehabilitative efficacy of our system. Ten patients with stroke in the subacute phase were enrolled and trained for one month with virtual art therapy (VAT) and physiotherapy. Their data were compared with those of ten patients matched for pathology, age and clinical parameters, trained only with conventional therapy for the same amount of time. The VAT group showed a significantly higher improvements in the Barthel Index score, a measure of independency in activities of daily living (66 ± 33% vs. 31 ± 28%, p = 0.021), and in pinching strength (66 ± 39% vs. 18 ± 33%, p = 0.008), with respect to the group treated with conventional rehabilitation.

Neural modifications in lower limb amputation: an fMRI study on action and non-action oriented body representations.

The loss of sensorimotor and visual information that follows limb amputation is known to affect both the action-oriented (body schema, BS) and non-action oriented (NA) body representations. However, the neural underpinnings of these effects have not yet been fully understood. We investigated the neural correlates of body representations in a group of 9 healthy right-handed individuals with left lower limb amputation (LLA) and 11 healthy age-matched controls (HC) by using event-related functional magnetic resonance imaging. Participants were scanned while performing mental rotation of body parts (i.e. hand, foot and eye) and objects (i.e. a rear-view mirror). Although the performance of LLA were similar to that of HC, they showed a different activation profile in relation to both BS and to NA within a wide range of brain areas. The bilateral intraparietal sulcus was less activated in LLA than HC, whereas the bilateral anterior insula as well as the fusiform body area, the precentral gyrus, the supplementary motor area in the left hemisphere and the inferior occipital gyrus in the right hemisphere were more activated during the mental rotation of left stimuli in the LLA. Also, the left EBA showed higher activation during the mental rotation of the foot than that of the eye in the LLA but not in the HC. Our results are consistent with the hypothesis that left LLA yields to a modification in the body representation network even when it does not lead to clear behavioral deficits.

Action and Non-Action Oriented Body Representations: Insight from Behavioural and Grey Matter Modifications in Individuals with Lower Limb Amputation.

OBJECTIVE: Following current model of body representations, we aimed to systematically investigate the association between brain modifications, in terms of grey matter loss, and body representation deficits, in terms of alterations of the body schema (BS) and of non-action oriented body representations (NA), in individuals with lower limb amputation (LLA). METHOD: BS and NA (both semantic and visuospatial NA) were evaluated in 11 healthy controls and in 14 LLA, considering the impact of clinical variables such as prosthesis use. The association between BS and NA deficits and grey matter loss was also explored in LLA by using Voxel Based Morphometry analysis. RESULTS: LLA's performance was fine in terms of semantic NA, while it showed behavioural impairments both in BS and visuospatial NA as compared to healthy controls. Interestingly the visuospatial NA performance was related to the amount of prosthesis use. NA deficits in terms of visuospatial body map processing were associated with grey matter reduction in left (lobule VIII) and right (crus II) cerebellum, while BS deficits were associated with grey matter reduction in right anterior cingulate cortex and the bilateral cuneus. No significant association was detected for semantic NA. CONCLUSION: The study of BS and NA representations after limb loss has informed our understanding of the different dynamics (i.e., adjustments to body change) of such representations, supporting current cognitive models of body representation. The clinical relevance of present findings is also discussed.

Cerebellar grey matter modifications in lower limb amputees not using prosthesis.

Plastic brain changes following peripheral deafferentation, in particular those following limb amputations, are well-documented, with significant reduction of grey matter (GM) in the sensory-motor cerebral areas representing the amputated limb. However, few studies have investigated the role played by the use of a prosthesis in these structural brain modifications. Here we hypothesized that using a functional prosthesis that allows individuals to perform actions may reduce grey matter reduction. We investigated the brain structural reorganization following lower limb amputation by using a Voxel Based Morphometry (VBM) analysis of structural magnetic resonance imaging (MRI) in 8 right-handed individuals with lower limb amputation (LLA) fitted with prostheses (LLAwp), compared to 6 LLA who had never used a prosthesis (LLAnp). 14 age-matched healthy controls were also enrolled (HC). We did not find any significant effect when comparing LLAwp and HC. However we found a decreased GM volume in the bilateral cerebellum in LLAnp compared with HC. These results suggest that prosthesis use prevents GM decrease in the cerebellum after lower limb amputation.

Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial.

OBJECTIVE: To evaluate the reduction in phantom pain and sensation with combined training of progressive muscle relaxation, mental imagery, and phantom exercises. DESIGN: Randomized controlled prospective trial with 2 parallel groups. SETTING: Amputee unit of a rehabilitation hospital. PARTICIPANTS: Subjects with unilateral lower limb amputation (N=51) with phantom limb pain (PLP) and/or phantom limb sensation (PLS). INTERVENTIONS: The experimental group performed combined training of progressive muscle relaxation, mental imagery, and phantom exercises 2 times/wk for 4 weeks, whereas the control group had the same amount of physical therapy dedicated to the residual limb. No pharmacological intervention was initiated during the trial period. MAIN OUTCOME MEASURES: The Prosthesis Evaluation Questionnaire and the Brief Pain Inventory were used to evaluate changes over time in different aspects (intensity, rate, duration, and bother) of PLS and PLP. Blind evaluations were performed before and after treatment and after 1-month follow-up. RESULTS: The experimental group showed a significant decrease over time in all the Prosthesis Evaluation Questionnaire domains (in terms of both PLS and PLP; P<.04 for both) and the Brief Pain Inventory (P<.03). No statistically significant changes were observed in the control group. Between-group analyses showed a significant reduction in intensity (average and worst pain) and bother of PLP and rate and bother of PLS at follow-up evaluation, 1 month after the end of the treatment. CONCLUSIONS: Combined training of progressive muscle relaxation, mental imagery, and modified phantom exercises should be taken into account as a valuable technique to reduce phantom limb pain and sensation.