Back in control of intentional action: Improvement of ideomotor apraxia by mirror box treatment.

OBJECTIVES: A novel method of rehabilitation for ideomotor apraxia (IMA), using a modified version of the mirror box (MB), is proposed. The rationale is based on the theory that disrupted body representation occurs in IMA and that MB training may improve body representation. In the present MB training, patients observed and reproduced movements made by the experimenter in a mirror. The visual perspective gave the illusory sensation of seeing one's own affected hand in the mirror. METHODS: Thirteen patients were included in the study; apraxia was measured four times: i) at baseline; ii) after a week of unspecific poststroke rehabilitation (rest); iii) after a week of imitation training for apraxia, used as a control; and iv) after a week of MB training. Imitation and mirror box training were presented in counterbalanced order between participants. The effect of the mirror box on a measure of body representation was also assessed. RESULTS: The results show that MB training improved apraxia when compared to the outcomes in both the imitation and rest conditions. The improvement correlates with the impact of the mirror box on the body representation (i.e., the degree of embodiment). CONCLUSIONS: MB training shows promising effects in promoting recovery from apraxia. The hypothesis is that the mirror box triggers a quickly generated sense of embodiment of the reflected moving arm into the observer's body representation. This embodiment of the visuomotor features of the observed movements would positively affect motor programming, promoting motor improvement. Crucially, this effect seems to extend to actions performed outside the mirror box setup, enhancing patients' performance on an apraxia test.

Epidemiological and clinical characteristics of 492 patients in a vegetative state in 29 Italian rehabilitation units. What about outcome?

Recent studies on recovery of consciousness of subjects in a vegetative state (VS) admitted to rehabilitation units have focused mainly on the identification of prognostic factors, whereas few studies have focused on outcome. The aim of this study was to compare demographic and clinical data and report functional outcome of patients in a VS due to severe acquired brain injury (ABI) of different aetiologies. The study was a retrospective multicentre cohort study and involved 492 patients in a VS due to traumatic (TBI) or non-traumatic (NTBI) severe ABI admitted to 29 Italian rehabilitation units. Demographic and clinical data recorded included age, gender, aetiology, Glasgow Coma Scale score; onset-to-admission interval; length of stay in the rehabilitation unit; the department from which they were referred; and the presence of percutaneous endoscopic gastrostomy or tracheostomy. Recovery of consciousness and disability were evaluated using a discharge Disability Rating Scale. At discharge, 53.11% patients had emerged from VS, with TBI subjects significantly more likely to recover consciousness than NTBI ones. Subjects with NTBI had a significantly worse prognosis than those with TBI, and within the NTBI group, subjects with a cerebrovascular aetiology had a better outcome than those with an anoxic aetiology. Among the patients who emerged from VS, 71.30% of TBI and 83.06% of NTBI subjects presented extremely severe disability. Only 37.93% of subjects affected by TBI and 17.44% of those affected by NTBI who presented extremely severe disability returned home after their rehabilitation stay. Even though almost a half of the patients emerged from VS, a large number of these subjects showed severe disability, often making it impossible for them to return home. This situation has a major impact on the healthcare system.

Analysis of Italian regulations on pathways of care for patients in a vegetative or minimally conscious state.

Different rehabilitation models for persons diagnosed with disorders of consciousness have been proposed in Europe during the last decade. In Italy, the Ministry of Health has defined a national healthcare model, although, to date, there is a lack of information on how this has been implemented at regional level. The INCARICO project collected information on different regional regulations, analysing ethical aspects and mapping care facilities (numbers of beds and medical units) in eleven regional territories. The researchers found a total of 106 laws; differences emerged both between regions and versus the national model, showing that patients with the same diagnosis may follow different pathways of care. An ongoing cultural shift from a treatment-oriented medical approach towards a care-oriented integrated biopsychosocial approach was found in all the welfare and healthcare systems analysed. Future studies are needed to explore the relationship between healthcare systems and the quality of services provided.

Error-based training and emergent awareness in anosognosia for hemiplegia.

Residual forms of awareness have recently been demonstrated in subjects affected by anosognosia for hemiplegia, but their potential effects in recovery of awareness remain to date unexplored. Emergent awareness refers to a specific facet of motor unawareness in which anosognosic subjects recognise their motor deficits only when they have been requested to perform an action and they realise their errors. Four participants in the chronic phase after a stroke with anosognosia for hemiplegia were recruited. They took part in an "error-full" or "analysis of error-based" rehabilitative training programme. They were asked to attempt to execute specific actions, analyse their own strategies and errors and discuss the reasons for their failures. Pre- and post-training and follow-up assessments showed that motor unawareness improved in all four patients. These results indicate that unsuccessful action attempts with concomitant error analysis may facilitate the recovery of emergent awareness and, sometimes, of more general aspects of awareness.

The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients.

BACKGROUND: The lack of knowledge about epidemiological and clinical data of patients with Acquired Brain Injury (ABI) admitted to Rehabilitation facilities in Italy led to the creation, in June 2008, of a data collection on-line registry. AIM: To collect epidemiological and clinical data and to evaluate functional outcome of patients with severe traumatic and non-traumatic ABI admitted to Rehabilitation facilities in Italy between June 2008 and December 2011 and to compare data of patients with ABI of different aetiologies. DESIGN: Observational retrospective study. SETTING: The study involved 29 Italian Rehabilitation facilities. POPULATION: The study enrolled 1469 patients with severe traumatic (TBI) and non-traumatic ABI (NTBI). METHODS: Data collected included demographic (number of patients with TBI and NTBI, gender, age) and clinical characteristics (provenience, number of days elapsed between onset and rehabilitation admission, rehabilitation length of stay, discharge destination, death and vegetative state diagnosis, presence of percutaneous endoscopic gastrostomy, tracheostomy, pressure sores and paraosteoarthropathies). Functional outcome was evaluated using the Disability Rating Scale. RESULTS: Of the whole population studied, 44.31% and 55.69% patients had suffered a TBI and a NTBI, respectively. In the NTBI group 40.09% had a cerebrovascular injury, 12.04% an anoxic brain damage, 3.6% had a brain injury of other causes. The mean age was 43.67 and 56.68 for subjects with TBI and NTBI, respectively. Patients with TBI showed a lower onset-admission interval (OAI), compared with NTBI group; no difference in rehabilitation length of stay (LOS) was recorded between groups. Patients with TBI presented a lower DRS score at admission and discharge and returned home more frequently than NTBI group. CONCLUSIONS: The creation of a National registry allows the collection of data about patients with ABI in order to study the clinical course, the functional outcome and to establish a basis for comparison with other data sources. Clinical Rehabilitation Impact. Data collection could be useful in the evaluation and planning of rehabilitation pathways, and to assess the allocation of healthcare and rehabilitative resources.

Rehabilitation of acquired brain injuries: a multicentric prospective survey.

BACKGROUND: The rehabilitation of the persons with Severe Acquired Brain Injury (ABI) is an important concern to be approached with a comprehensive program aimed to improve the recovery of patients.The efficacy of an early and intensive rehabilitation program has been shown in large number of studies. Few studies focused on the prevalence of TBI and the data are often extrapolated in indirect ways. AIM: An analysis of the demographic characteristics of the population included in the GISCAR (Gruppo Italiano per lo Studio delle Gravi Cerebrolesioni Acquisite e Riabilitazione- Italian Group for the Study of the severe ABI) database, type and conditions associated to the index event; the treatment administered during hospitalization; and the prognosis according to outcome measures. DESIGN: The study was an observational prospective survey looking at management of ABI (both traumatic and non-traumatic). SETTING: In hospital rehabilitation. POPULATION: Patients consecutively admitted in each of the 52 GISCAR centres. METHODS: Every centre included a consecutive cohort and recorded demographic data and index event characteristics. RESULTS: In the study population were included 2626 subjects suffering of a severe ABI. The difference of length of stay (LOS) was significantly different with 67.5 days for traumatic patients compared to the 80 days of non traumatic ones. In the study population the probability of discharge at home is significantly greater for the traumatic condition (odds ratio 0,4587; CI 0.3671-0.5731). The overall benefit of the rehabilitative treatment was encountered in a net gain in all disability scores taken into account: LCF classes; DRS as well as GOS scores. At discharge the main destination for severe ABI patients was home (67.2%). CONCLUSIONS: A large number of patients admitted in Italian rehabilitative facilities for a severe ABI suffered from a TBI, more often these subjects were young male victims of road accident. The majority of subjects during the rehabilitative hospitalization demonstrated a significant recovery. CLINICAL REHABILITATION IMPACT: Considering the evidence of an early treatment benefit the delay ofthe rehabilitation program start is far from being satisfactory. The high frequency of the home discharge indicate a good compliance of national family network.

Massive somatic deafferentation and motor deefferentation of the lower part of the body impair its visual recognition: a psychophysical study of patients with spinal cord injury.

Embodied cognition theories postulate that perceiving and understanding the body states of other individuals are underpinned by the neural structures activated during first-hand experience of the same states. This suggests that one's own sensorimotor system may be used to identify the actions and sensations of others. Virtual and real brain lesion studies show that visual processing of body action and body form relies upon neural activity in the ventral premotor and the extrastriate body areas, respectively. We explored whether visual body perception may also be altered in the absence of damage to the above cortical regions by testing healthy controls and spinal cord injury (SCI) patients whose brain was unable to receive somatic information from and send motor commands to the lower limbs. Participants performed tasks investigating the ability to visually discriminate changes in the form or action of body parts affected by somatosensory and motor disconnection. SCI patients showed a specific, cross-modal deficit in the visual recognition of the disconnected lower body parts. This deficit affected both body action and body form perception, hinting at a pervasive influence of ongoing body signals on the brain network dedicated to visual body processing. Testing SCI patients who did or did not practise sports allowed us to test the influence of motor practice on visual body recognition. We found better upper body action recognition in sport-practising SCI patients, indicating that motor practice is useful for maintaining visual representation of actions after deafferentation and deefferentation. This may be a potential resource to be exploited for rehabilitation.

Exploring variables associated with rehabilitation length of stay in brain injuries patients.

BACKGROUND: The impact of outcome measure as early variables on rehabilitation length of stay (LOS) in traumatic brain injury (TBI) patients remains poorly investigated. AIM: To investigate: 1) the association between LOS and motor and functional outcomes; 2) the predictive factors of LOS in TBI patients admitted to a rehabilitation center. DESIGN: Retrospective study. SETTING: Inpatient TBI Rehabilitation Centre. POPULATIONS: 241 TBI patients (190 males and 51 females, mean age 43.61±19.4 years, initial Glasgow Coma Scale of 6.96±3.39). METHODS: We recorded demographic characteristics (age, sex, setting and LOS in the acute phase, rehabilitation LOS) and outcome measures (Glasgow Outcome Scale, Disability Rating Scale, Levels of Cognitive Functioning, Functional Independence Measure). RESULTS: Average rehabilitation LOS was 58.82±58 days; 191 (79%) subjects were discharged from the rehabilitation center within 90 days. Rehabilitation LOS was significantly correlated with acute-care LOS (P=0.001) and Glasgow Coma Scale, but not with patients' age (P=0.250) or sex (P= 0.348). Rehabilitation LOS was significantly correlated with functional and cognitive admission outcome scores but not with gains during rehabilitation. Rehabilitation LOS was significantly less in the group of patients that returned back home respect to others. Regression analysis also illustrated that longer acute-care LOS was independently associated with significantly increased rehabilitation LOS (P<0.001). CONCLUSION: Our retrospective study suggests that rehabilitation LOS in TBI patients is correlated with timing of and score at admission to the rehabilitation setting rather than with gains in functional outcome. CLINICAL REHABILITATION IMPACT: This result may help to optimize inpatient service utilization, especially in term of LOS.

Visual body recognition in a prosopagnosic patient.

Conspicuous deficits in face recognition characterize prosopagnosia. Information on whether agnosic deficits may extend to non-facial body parts is lacking. Here we report the neuropsychological description of FM, a patient affected by a complete deficit in face recognition in the presence of mild clinical signs of visual object agnosia. His deficit involves both overt and covert recognition of faces (i.e. recognition of familiar faces, but also categorization of faces for gender or age) as well as the visual mental imagery of faces. By means of a series of matching-to-sample tasks we investigated: (i) a possible association between prosopagnosia and disorders in visual body perception; (ii) the effect of the emotional content of stimuli on the visual discrimination of faces, bodies and objects; (iii) the existence of a dissociation between identity recognition and the emotional discrimination of faces and bodies. Our results document, for the first time, the co-occurrence of body agnosia, i.e. the visual inability to discriminate body forms and body actions, and prosopagnosia. Moreover, the results show better performance in the discrimination of emotional face and body expressions with respect to body identity and neutral actions. Since FM's lesions involve bilateral fusiform areas, it is unlikely that the amygdala-temporal projections explain the relative sparing of emotion discrimination performance. Indeed, the emotional content of the stimuli did not improve the discrimination of their identity. The results hint at the existence of two segregated brain networks involved in identity and emotional discrimination that are at least partially shared by face and body processing.

Use of early indicators in rehabilitation process to predict functional outcomes in subjects with acquired brain injury.

BACKGROUND: The use of Evaluation Scales in ABI is necessary for measure of outcome, but not always they are used as predictor factors for rehabilitation processes and organization. AIM: The aim of this study was to evaluate the effectiveness and efficiency of an inpatient rehabilitation program for patients with traumatic brain injury through the use of selected indicators and to identify predictive factors for functional outcome. DESIGN: This was a retrospective database analysis. SETTING: Patients admitted to an Intensive Rehabilitation Unit as inpatient (Sacro Cuore-Don Calabria Hospital, Negrar-Verona). POPULATION: The population included patients with traumatic brain injury. METHODS: The study enrolled 175 patients admitted to an Intensive Rehabilitation Unit between 2004 and 2007. Data collected included demographic characteristics, first 24-hours worst GCS, length of acute and rehabilitative stay at admission and discharge FIM, DRS, LCF and GOS. RESULTS: There was a statistically significant recovery over the course of admission for all assessment tools (P<0.000). When patients were subdivided on the basis of admission DRS categories a linear correlation among variables could be observed, with most disabled patients showing the longest acute and rehabilitation stays and the lowest functional gains. Within each DRS category age appeared to affect improvement (P<0.005) while final outcome was influenced not only by age but also by initial functional status (P<0.000) and time from injury to admission (P<0.004). CONCLUSIONS AND CLINICAL REHABILITATION IMPACT: Systematic data collection in intensive rehabilitation is of great importance to monitor recovery and plan appropriate programs on the basis of admission functional status.

Reintegration after severe brain injury: a retrospective study.

PRIMARY OBJECTIVE: The evaluation of school and work reintegration of patients following severe brain injury and of the relationship between the most common (early and late) prognostic indicators and reintegration itself. RESEARCH DESIGN: A retrospective study on a population of 353 patients consecutively admitted to an intensive rehabilitation unit (S. Cuore Hospital, Negrar, Italy) from 1991-1999. METHODS AND PROCEDURES: Evaluation of school and work outcome in this population up to December 2001 (follow-up from 2-10 years post-trauma). Data collection was made using the EBIS (European Brain Injury Society) protocol. RESULTS: In December 2001, 53% of those previously working had returned to competitive work; 76.5% of students were continuing with their studies or had progressed into work. There was a significant difference between employed and non-employed groups in terms of GCS, post-traumatic amnesia (PTA), in-patient rehabilitation length of stay (LOS) and GOS at 6 and at 12 months post-injury. CONCLUSIONS: The data confirm the predictive value of the indices used regarding work reintegration in TBI patients. Nevertheless, prolonged and intensive rehabilitation programmes can lead to high re-employment rates in patients whose initial prognosis seemed very poor.

A computerized version of EBIS evaluation chart and its opportunities in the rehabilitation program of TBI patients.

The need of rehabilitation programs for severely traumatic brain injured (TBI) patients is great and is growing, but these programs are long, costly and it would be very useful if we could demonstrate and quantify the benefits of our approaches. We think that scarcity of literature in this field is a consequence of the well known and real difficulty in this kind of investigations (too many variability factors, groups of population not homogeneous, ethical problems for double blind studies and so on). It is our opinion that EBIS Protocol could be a very useful instrument for the evaluation of rehabilitation programs benefits, provided that the protocol is used regularly for a long time after the acute phase and in many different TBI centres: in this way it would be possible to compare and to elaborate data concerning a large number of patients. This instrument could also become an opportunity for a continuous and more coordinated collaboration between rehabilitation centres of different countries. We think that this target is realistic only if we dispose of a commonly accepted computerized version of EBIS Protocol with a data exchange via Internet. Since 1996 we have been using a computerized version of the EBIS protocol for data archivation and follow up of TBI patients treated in our centre. The data bank concerns actually n. 341 TBI patients. Objective of the present research is the presentation of a computerized version of EBIS protocol. This program is freely available and it could contribute to a more common use of this evaluation tool. We thank particularly Prof. Truelle and Prof. Brooks who gave us the permission for the use of EBIS document.

Influence of perceptual and semantic conflicts between the two halves of chimeric stimuli on the expression of visuo-spatial neglect.

We investigated how perceptual and semantic relationships between the left and right half of chimeric stimuli influence overt and covert visual processing by asking eight right brain damaged (RBD) patients with hemispatial neglect to identify complete, half-, and chimeric drawings. Chimeric stimuli belonged in one of four categories defined according to the perceptual and semantic relatedness between the two compounding hemi-figures. Thus, the hemi-figures could be related both perceptually and semantically, only perceptually, only semantically, or neither perceptually nor semantically. Although patients often appeared to base their report on the right part of the chimerics, the number of errors was minimal when conflicts between the two hemi-figures were maximal. Moreover, perceptual conflicts, which mainly affect the perception of the shape, appeared to influence the performance more than semantic conflicts. Since the analysis of shape incongruency is probably accomplished at early levels of information processing, the result suggests that preattentive analysis is largely spared in the experimental patients and that, in our task, bottom-up factors more than top-down factors modulate the expression of left neglect.

Overt and covert processing of left-side information in unilateral neglect investigated with chimeric drawings.

Overt and covert processing of contralesional information was investigated in 6 right-brain-damaged (RBD) patients with or without left hemispatial neglect by using three bedside tests that require the analysis of whole, half, and chimeric drawings. In the first task, patients named these stimuli. In the second task, patients designated as "same" or "different" drawings in a pair where one drawing was always whole and the other could be whole, half, or chimeric. In the third task, patients pointed to the more veridical, complete drawing that was presented with one half drawing, and two chimeric drawings. Although patients with no neglect performed without error in all conditions, patients with severe neglect based their performance on the analysis of the right side of the stimuli. In patients with mild neglect, not only did performance rely upon the right side of stimuli but it was also modulated by left-side information acquired either overtly or unconsciously.

Voluntary regularization method of the respiratory act applied to chronic obstructive pulmonary disease.

Respiration is a vital, complex function, fundamentally automatic that can be modulated by will. The aim of the original method submitted is the progressive rehabilitation of the patient to strain, by a gradual reduction of respiratory frequency at the progressive increase in expiration phases and the execution of a growing effort in strict relation to the execution of the method itself. The patient learns to beat out the rhythm of his respiration based upon the strokes of the metronome, calibrated at 60 strokes a minute. The most evident documentation of the efficacy of our method of voluntary regularization of the respiratory act is in the evaluation of the effort capacity of each patient, before and after the method. The data are referred to the distance covered by cyclette, in standard conditions. The examined clinical parametres comprehend: cardiac frequency, respiratory frequency, maximal pause and arterial pressure. The laboratory parametres examined include the value of the arterial astrup: pH, pCO2, HCO3-, total CO2, pO2, excess basis. The scarcity of clinical survey examined during our research does not permit the formulation of any conclusive considerations, which would lead to a critical revision of the whole field of the physiology of respiration. For this reason, it is more prudent to establish the modifications of various parametres collected, until a more certain and wider confirmation is available.