Cognitive impairment is associated with gait variability and fall risk in amyotrophic lateral sclerosis.

BACKGROUND: In amyotrophic lateral sclerosis (ALS), gait abnormalities contribute to poor mobility and represent a relevant risk for falls. To date, gait studies in ALS patients have focused on the motor dimension of the disease, underestimating the cognitive aspects. METHODS: Using a wearable gait analysis device, we compared gait patterns in ambulatory ALS patients with mild cognitive impairment (ALS MCI+; n = 18), and without MCI (ALS MCI-; n = 24), and healthy subjects (HS; n = 16) under two conditions: (1) normal gait (single task) and (2) walking while counting backward (dual task). Finally, we examined if the occurrence and number of falls in the 3 months following the baseline test were related to cognition. RESULTS: In the single task condition, ALS patients, regardless of cognition, displayed higher gait variability than HS, especially for stance and swing time (p < 0.001). The dual task condition revealed additional differences in gait variability parameters between ALS MCI+ and ALS MCI- for cadence (p = 0.005), stance time (p = 0.04), swing time (p = 0.04) and stability index (p = 0.02). Moreover, ALS MCI+ showed a higher occurrence (p = 0.001) and number of falls (p < 0.001) at the follow-up. Regression analyses demonstrated that MCI condition predicted the occurrence of future falls (ß = 3.649; p = 0.01) and, together with executive dysfunction, was associated with the number of falls (cognitive impairment: ß = 0.63; p < 0.001; executive dysfunction: ß = 0.39; p = 0.03), regardless of motor impairment at clinical examination. CONCLUSION: In ALS, MCI is associated with exaggerated gait variability and predicts the occurrence and number of short-term falls.

Alteration of interoceptive sensitivity: expanding the spectrum of behavioural disorders in amyotrophic lateral sclerosis.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder with progressive loss of upper and lower motor neurons. Non-motor-symptoms, such as cognitive, emotional, autonomic, and somatosensory alterations, have been also described. Interoception represents the link between the body and brain, since it refers to the ability to consciously perceive the physical condition of the inner body, including one's heartbeat (i.e., interoceptive sensitivity, IS). OBJECTIVES: To evaluate IS in ALS patients by means of a well-established task: the heartbeat perception task. Moreover, we evaluated possible correlations between IS and neuropsychological, affective, and disease-related characteristics. METHODS: Fifty-five ALS patients (mean-age = 60.3 ± 12.5 years; mean disease-duration = 20.9 ± 18.8 months) and 41 caregivers (CG) underwent the heartbeat perception task and an extensive evaluation of motor, cognitive, body awareness, affective, and emotion domains. RESULTS: ALS patients showed lower IS than CG (0.68 ± 0.24 vs 0.82 ± 0.16; p = 0.003). Significant correlations were found between IS and self-reported measures of alexithymia (subscale of Toronto Alexithymia scale-20 "difficulties in describing feelings"; rho = - .391, p = .003) and interoceptive awareness (subscale of Multidimensional assessment of interoceptive awareness "not worrying about pain"; rho = .405, p = .002). No significant differences were found on questionnaires for depression and anxiety between patients with ALS and their caregivers (p > .05). CONCLUSIONS: ALS patients show reduced interoceptive sensitivity that is associated with poorer ability to describe feelings and with lower focalization on pain, regardless of cognitive and motor impairment. Alteration of interoception may represent a specific behavioural sign within the spectrum of emotion processing deficits described in ALS patients.

Peripheral Neuropathy in Patients Recovering from Severe COVID-19: A Case Series.

Background and Objectives: Neurological manifestations have been reported in a significant proportion of coronavirus disease 2019 (COVID-19) patients. We aimed to evaluate the prevalence and severity of peripheral nervous system (PNS) involvement in a large group of convalescent COVID-19 patients undergoing in-hospital multidisciplinary rehabilitation. Materials and Methods: Convalescent COVID-19 patients admitted to a Pulmonary Rehabilitation Unit were consecutively screened for inclusion within 48 h of discharge from an acute care setting. All included patients underwent electrophysiological examinations. Results: Among 102 enrolled patients (mean age 62.0 years, 82.4% males), PNS electrophysiological alterations were detected in 42.2%. Mononeuropathies exclusively involving the peroneal nerve were observed in 8.8% (n = 9), while multiple mononeuropathies were similarly reported in nine patients (8.8%). A symmetric sensorimotor polyneuropathy was documented in 24.5% of participants (n = 25). A significant difference was found for exercise capacity and pulmonary function in post hoc comparisons between the three study groups. Conclusions: The risk of neuropathy in the convalescent phase of COVID-19 is relevant. This should be considered when planning multidisciplinary rehabilitation strategies.

The Italian validation of the Communicative Effectiveness Index Questionnaire: a multicentric study.

INTRODUCTION: Common assessment tools for aphasia evaluate single language impairments but not their functional impact on patient's communication skills in daily life. The lack of tools focused on ecological aspects might affect the choice of rehabilitative trainings. The Communicative Effectiveness Index (CETI) represents an attempt to assess the communicative abilities in "ecologic" context. This study aimed to explore psychometrics properties of the Italian translation and adaptation of CETI (I-CETI). METHODS: Sixty-eight patients with aphasia due to left hemispheric stroke admitted to post-acute rehabilitation units and their relatives were included in the study. Data were collected in three different sessions. At study entry, patients were assessed for language, depression, and functional abilities, while their caregivers and speech therapists independently completed the I-CETI to assess inter-rater agreement (baseline). One week later, caregivers and speech therapists completed again I-CETI, to assess test-retest reliability (T1). Last, at discharge, patients completed again the evaluation protocol, and caregivers and speech therapists completed I-CETI (T2). RESULTS: I-CETI showed high internal validity, excellent reliability, and good correlation between scores obtained by speech therapists and caregivers. Moreover, scores of I-CETI had quite good correlations with a traditional tool to assess language, and with measures of functional independence both at study entry and at discharge. DISCUSSION: I-CETI showed good psychometric proprieties. These results allowed considering I-CETI as a reliable tool to assess effects of speech treatments on the communicative abilities in patients with aphasia. Furthermore, I-CETI might help clinicians to develop treatments more tailored on the "ecologic" difficulties of patients.

'Less is more': validation with Rasch analysis of five short-forms for the Brain Injury Rehabilitation Trust Personality Questionnaires (BIRT-PQs).

BACKGROUND: Previous analyses demonstrated a lack of unidimensionality, item redundancy, and substantial administrative burden for the Brain Injury Rehabilitation Trust Personality Questionnaires (BIRT-PQs). OBJECTIVE: To use Rasch Analysis to calibrate five short-forms of the BIRT-PQs, satisfying the Rasch model requirements. METHODS: BIRT-PQs data from 154 patients with severe Acquired Brain Injury (s-ABI) and their caregivers (total sample = 308) underwent Rasch analysis to examine their internal construct validity and reliability according to the Rasch model. RESULTS: The base Rasch analyses did not show sufficient internal construct validity according to the Rasch model for all five BIRT-PQs. After rescoring 18 items, and deleting 75 of 150 items, adequate internal construct validity was achieved for all five BIRT-PQs short forms (model chi-square p-values ranging from 0.0053 to 0.6675), with reliability values compatible with individual measurements. CONCLUSIONS: After extensive modifications, including a 48% reduction of the item load, we obtained five short forms of the BIRT-PQs satisfying the strict measurement requirements of the Rasch model. The ordinal-to-interval measurement conversion tables allow measuring on the same metric the perception of the neurobehavioral disability for both patients with s-ABI and their caregivers.

The unidimensionality of the five Brain Injury Rehabilitation Trust Personality Questionnaires (BIRT-PQs) may be improved: preliminary evidence from classical psychometrics.

Objective: To assess the internal construct validity (ICV) of the five Brain Injury Rehabilitation Trust Personality Questionnaires (BIRT-PQ) with Classical Test Theory methods.Methods: Multicenter cross-sectional study involving 11 Italian rehabilitation centers. BIRT-PQs were administered to patients with severe Acquired Brain Injury and their respective caregivers. ICV was assessed by the mean of an internal consistency analysis (ICA) and a Confirmatory Factor Analysis (CFA).Results: Data from 154 patients and their respective caregivers were pooled, giving a total sample of 308 subjects. Despite good overall values (alphas ranging from 0.811 to 0.937), the ICA revealed that several items within each scale did not contribute as expected to the total score. This result was confirmed by the CFA, which showed the misfit of the data to a unidimensional model (RMSEA ranging from 0.077 to 0.097). However, after accounting for local dependency found within the data, fitness to a unidimensional model improved significantly (RMSEA ranging from 0.050 to 0.062).Conclusion: Despite some limitations, our analyses demonstrated the lack of ICV for the BIRT-PQ total scores. It is envisaged that a more comprehensive ICV analysis will be performed with Rasch analysis, aiming to improve both the measurement properties and the administrative burden of each BIRT-PQ.

Selegiline in Patients With Disorder of Consciousness: An Open Pilot Study.

This open study investigated the clinical effects of 10-week selegiline administration in six patients in vegetative state and in four patients in a minimally conscious state, at least 6 months after onset. Clinical outcome was assessed by Coma Recovery Scale-Revised once a week during selegiline administration and 1 month later. Three patients stopped treatment because of possible side effects. After treatment and at 1 month of follow-up, four patients showed improvements in clinical diagnosis, and three patients showed an increase in arousal level only. Selegiline might represent a relatively safe option to enhance arousal and promote recovery in brain-injured patients with disorders of consciousness.

Visual pursuit of one's own face in disorders of consciousness: a quantitative analysis.

BACKGROUND: Eye behaviour is important to distinguish minimally conscious state (MCS) from vegetative state (VS). OBJECTIVE: To search for conditions most suitable to characterize patients in MCS and in VS on quantitative assessment of visual tracking. DESIGN: This is a cross-sectional study. PARTICIPANTS: In total, 20 patients in VS, 13 in MCS plus and 11 in MCS minus participated in this study. SETTING: Neurorehabilitation Unit. METHODS: Evaluation of eye behaviour was performed by infrared system; stimuli were represented by a red circle, a picture of a patient's own face and a picture of an unfamiliar face, slowly moving on a personal computer (PC) monitor. Visual tracking on the horizontal and vertical axes was compared. MAIN OUTCOME MEASURES: The main outcome measures were proportion of on-target fixations and mean fixation duration. RESULTS: The proportion of on-target fixations differed as a function of the stimulus in patients in MCS plus but not in other groups. Own face and unfamiliar face elicited a similar proportion of on-target fixations. Tracking along the horizontal axis was more accurate than that along the vertical axis in patients in both MCS plus and MCS minus. Fixation duration did not differ among the three groups. CONCLUSIONS: Horizontal visual tracking of salient stimuli seems particularly suitable for eliciting on-target fixations. Quantitative assessment of visual tracking can complement clinical evaluation for reducing diagnostic uncertainty between patients in MCS or VS.

A multicentre study of intentional behavioural responses measured using the Coma Recovery Scale-Revised in patients with minimally conscious state.

OBJECTIVE: To investigate which conscious behaviour is most frequently detected using the Coma Recovery Scale-Revised in patients with minimally conscious state. DESIGN: Multicentre, cross-sectional study. SETTING: One intensive care unit, 8 post-acute rehabilitation centres and 2 long-term facilities. SUBJECTS: Fifty-two patients with established diagnosis of minimally conscious state of different aetiology. MAIN MEASURES: All patients were assessed by the Coma Recovery Scale-Revised. RESULTS: In most patients (34/52) non-reflexive responses were identified by two or more subscales of the Coma Recovery Scale-Revised, whereas in 14 patients only the visual subscale could identify cortically-mediated behaviours, and in the remaining 4 patients only the motor subscale did so.The clinical signs of intentional behaviour were most often detected by the visual subscale (43/52 patients) and by the motor subscale (31/52), and least frequently by the oromotor/verbal subscale (3/52) of the Coma Recovery Scale-Revised. This clinical pattern was observed independently from time post-onset and aetiology. CONCLUSIONS: Non-reflexive visual behaviour, identified by the visual subscale of Coma Recovery Scale-Revised, is the most frequently detected intentional sign consistent with the diagnosis of minimally conscious state, independently from aetiology and time post-onset.

Clinical and neuropsychological long-term outcomes after late recovery of responsiveness: a case series.

OBJECTIVE: To report clinical conditions and neuropsychological functioning of patients with late recovery of responsiveness at least 5 years after injury. DESIGN: Patient series. SETTING: Patients discharged from an inpatient rehabilitation unit. PARTICIPANTS: Patients (N=13) who recovered from a vegetative state 1 year after severe traumatic brain injury or 6 months after nontraumatic brain injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Coma Recovery Scale-Revised, Disability Rating Scale, and FIM. For patients who recovered full consciousness, neuropsychological tests specifically adapted for patients with very severe disabilities were used. RESULTS: After regaining responsiveness, 2 patients died because of severe clinical complications. Among the remaining 11 patients, 5 were still in a minimally conscious state at their last assessment, but 4 of them had recovered some complex behavioral responses to the environment (eg, they could follow simple commands, albeit inconsistently). Six patients had emerged from a minimally conscious state at the last evaluation. Severe functional disability was present in both patients who were conscious and patients who were minimally conscious. No patient was autonomous in common daily life activities or in transfers. All patients who were conscious showed variable cognitive impairments, and some of them also developed behavioral and psychological symptoms. However, such disturbances did not impede the patients' interaction with relatives and caregivers. CONCLUSIONS: This study provides systematic data about the course of the disease in a cohort of patients that was previously considered as exceptional. Patients with late recovery show a variable degree of functional recovery, although they experience marked residual motor and cognitive disabilities. The present findings contribute to enhance the understanding of the course of the disease in patients with late recovery and might help clinicians optimize the levels of care and provide the patients' families with correct information.

A study of the psychological distress in family caregivers of patients with prolonged disorders of consciousness during in-hospital rehabilitation.

OBJECTIVES: To study psychological distress in a sample of caregivers of patients affected by prolonged disorders of consciousness during hospital stay in the Neurorehabilitation Unit. MATERIALS AND METHODS: Twenty-four caregivers of 22 patients affected by prolonged disorders of consciousness admitted to postacute rehabilitation center, completed self-reported questionnaires for assessment of depressive symptoms, state and trait anxiety, psychophysiological disturbances, prolonged grief disorder, psychological coping strategies, quality of perceived needs, perceived social support, and caregiver burden; at admission, and after four and eight months. RESULTS: At admission depressive symptoms were found in 20/24 caregivers, high levels of anxiety in 16, and relevant psychophysiological disturbances in 10 participants; eight caregivers (32%) met criteria for prolonged grief disorder. The scores on questionnaires did not differ as a function of relatives' diagnosis (vegetative state vs. minimally conscious state). The longitudinal study (n = 18) showed a progressive and statistically significant increase of "emotional burden" during the hospital stay, whereas the remaining variables did not change significantly. CONCLUSIONS: Data confirmed the presence of severe psychological problems in caregivers of patients with prolonged disorders of consciousness. The levels of psychological distress tend to be constant over time, while the emotional burden increases.

Quality of Life in Children with Neurofibromatosis Type 1: Agreement between Parents and Patients, and the Role of Disease Severity and Visibility.

BACKGROUND: Neurofibromatosis type 1 (NF1) is a genetic disorder that affects multiple systems in the body, often leading to physical disfigurements and a wide range of clinical symptoms. This study aims to investigate the relationship between NF1 severity and visibility and the quality of life (QoL) in children. METHODS: The Pediatric Quality of Life Inventory (PedsQL) and a modified version of the Ablon scale were used to assess QoL and NF1 severity and visibility, respectively. Self-reported and parent-reported QoL scores were compared, and the associations between NF1 severity/visibility and QoL were explored. RESULTS: Thirty-eight pediatric NF1 patients and their parents were enrolled. QoL scores did not differ significantly between patient self-reports and parent reports. However, correlational analyses revealed that higher NF1 severity was associated with lower physical QoL in patients, and greater NF1 visibility was linked to lower physical and social QoL. For parents, higher NF1 severity correlated with lower school functioning, whereas NF1 visibility did not show a significant correlation with QoL. CONCLUSION: The severity and visibility of NF1 have distinct impacts on various aspects of QoL in children, highlighting the need for tailored interventions that address both physical and psychological challenges. These findings underscore the importance of comprehensive care approaches in managing NF1 in pediatric populations.

Visual vertical neglect in acquired brain injury: a systematic review.

Vertical neglect represents a visuospatial deficit occurring as a possible consequence of acquired brain injury (ABI). Differently from unilateral spatial neglect on horizontal space, vertical neglect is poorly studied in the literature and rarely assessed in clinical practice. In the available studies, the terms "radial," "vertical," and "altitudinal" neglect are often used interchangeably, although they do not describe the same spatial dimension. "Altitudinal" and "vertical" refer to the sagittal plane, whereas "radial" refers to the transverse plane. The term "vertical" is sometimes used interchangeably with respect to both axes. The aim of this systematic review was to identify the main characteristics of vertical neglect after ABI, the diagnostic tools used, and the treatment options. We also proposed a clarification of the manifestations and characteristics of vertical and radial neglect. The 23 articles reviewed, showed that the vertical neglect occurred more frequently on the lower space than on the upper space, that its presence was associated with horizontal neglect, and that it could also occur with compromise of the radial space, with the near radial being more common. The most frequent etiology associated with vertical neglect is vascular, particularly ischaemic. The lesions side are very heterogeneous and include both cortical and subcortical areas and all lobes, although the temporal lobe is most affected. With regard to the assessment tools, paper and pencil tasks are the most commonly used diagnostic tools to identify vertical neglect, although in recent years the use of computer-based tasks increased. Taken together, our results suggest that vertical neglect may be underestimated in patients with right hemisphere lesions and should always be assessed, especially in cases where the patient shows signs of horizontal neglect. The clinical assessment of vertical neglect is very important since it can lead to important functional limitations in everyday life, such as poor wheelchair handling, stumbling over unnoticed obstacles located below (or above), walking down stairs, taking off shoes.

Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation.

BACKGROUND: Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs. AIM: The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC. DESIGN: Cross-sectional study. SETTING: Post-acute Unit of Neurorehabilitation. POPULATION: DOC due to severe brain injury. METHODS: Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence). RESULTS: Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious). CONCLUSIONS: Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach. CLINICAL REHABILITATION IMPACT: In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.

Implementing Translational Research to Understand the Future of COVID-19 and Its Long-Term Consequences: A Degrowth Perspective or the Transformation of a Global Emergency?

It has now been three years since the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) first gave rise to a global health crisis [...].

Gait asymmetry in stroke patients with unilateral spatial neglect.

The recovery of independent gait represents one of the main functional goals of the rehabilitative interventions after stroke but it can be hindered by the presence of unilateral spatial neglect (USN). The aim of the paper is to study if the presence of USN in stroke patients affects lower limb gait parameters between the two body sides, differently from what could be expected by the motor impairment alone, and to explore whether USN is associated to specific gait asymmetry. Thirty-five stroke patients (right or left lesion and ischemic or hemorrhagic etiology) who regained independent gait were assessed for global cognitive functioning and USN. All patients underwent a gait analysis session by using a wearable inertial system, kinematic parameters were computed. Enrolled patients presented altered motion parameters. Stroke patients with USN showed specific asymmetries in the following parameters: stance phase, swing phase, and knee range of motion. No differences in the clinical scores were found as the presence of USN. The presence of USN was associated with a specific form of altered gait symmetry. These findings may help clinicians to develop more tailored rehabilitative training to enhance gait efficacy of patients with motor defects complicated by the presence of selected cognitive impairments. Overview of the experiment setup. The workflow shows: diagnosis of unilateral spatial neglect by the neuropsychologist, sensors placement, gait analysis protocol and evaluation of the gait asymmetry together with the statistically significant features.

The definition of "R1" lymph node dissection status in patients undergoing curative-aim gastrectomy for gastric carcinoma: A proof of concept study.

INTRODUCTION: The aim of this study was to define and investigate the prognostic impact of "R1-Lymph-node dissection" during gastrectomy. METHODS: This was a retrospective study conducted with 499 patients undergoing curative-aim gastrectomy. We defined R1-Lymph dissection as an involvement of lymph node stations anatomically connected with lymph node stations outside the declared level of dissection (D1 to D2+). The primary outcomes were disease-free and disease-specific survival (DFS and DSS). RESULTS: At multivariable analysis, the type of gastrectomy, pT and pN were associated with DFS, and the type of gastrectomy, R1-Margin status, R1-Lymph status, pT, pN and adjuvant therapy were associated with DSS. Moreover, pT and R1-Lymph status were the only factors associated with overall loco-regional recurrence. CONCLUSIONS: In this study, we introduced the concept of R1-Lymph-node dissection, which was significantly associated with DSS and appeared to be a stronger prognostic factor for loco-regional recurrence than the R1 status on the resection margin.