Looking toward predicting functional recovery in disorders of consciousness: can sensorimotor integration help us?

PRIMARY OBJECTIVE: Only a few objective prognostic markers are available for patients with disorders of consciousness (DoC). We assessed whether the magnitude of short-latency afferent inhibition (SAI) might be a useful predictor of responsiveness recovery and functional outcome in patients with DoC. RESEARCH DESIGN: We enrolled 40 patients with prolonged Minimally Conscious State (MCS) and Unresponsive Wakefulness Syndrome (UWS) in a longitudinal, observational study. METHODS AND PROCEDURES: Clinical features (including Coma Recovery Scale-Revised, CRS-R, and Glasgow Outcome Scale, GOS) and SAI were collected at the study entry and after 18 months from study inclusion, to assess a correlation between SAI and the clinical outcome. MAIN OUTCOMES AND RESULTS: At the follow-up, 19 patients remained in their baseline condition, whereas 7 UWS evolved into MCS or emerged-from-MCS (EMCS), eight MCS evolved into EMCS, and two MCS- evolved into MCS+. Two UWS and one MCS+ died for cardiopulmonary complications. The patients who showed the highest GOS, the highest CRS-R and the lowest SAI strength at study entry, improved at the follow-up. CONCLUSIONS: Our findings suggest that an objective and simple neurophysiologic measure as SAI strength could provide useful information to predict the outcome and the behavioral responsiveness of patients with DoC.

Walking to your right music: a randomized controlled trial on the novel use of treadmill plus music in Parkinson's disease.

BACKGROUND: Rhythmic Auditory Stimulation (RAS) can compensate for the loss of automatic and rhythmic movements in patients with idiopathic Parkinson's disease (PD). However, the neurophysiological mechanisms underlying the effects of RAS are still poorly understood. We aimed at identifying which mechanisms sustain gait improvement in a cohort of patients with PD who practiced RAS gait training. METHODS: We enrolled 50 patients with PD who were randomly assigned to two different modalities of treadmill gait training using GaitTrainer3 with and without RAS (non_RAS) during an 8-week training program. We measured clinical, kinematic, and electrophysiological effects of both the gait trainings. RESULTS: We found a greater improvement in Functional Gait Assessment (p < 0.001), Tinetti Falls Efficacy Scale (p < 0.001), Unified Parkinson Disease Rating Scale (p = 0.001), and overall gait quality index (p < 0.001) following RAS than non_RAS training. In addition, the RAS gait training induced a stronger EEG power increase within the sensorimotor rhythms related to specific periods of the gait cycle, and a greater improvement of fronto-centroparietal/temporal electrode connectivity than the non_RAS gait training. CONCLUSIONS: The findings of our study suggest that the usefulness of cueing strategies during gait training consists of a reshape of sensorimotor rhythms and fronto-centroparietal/temporal connectivity. Restoring the internal timing mechanisms that generate and control motor rhythmicity, thus improving gait performance, likely depends on a contribution of the cerebellum. Finally, identifying these mechanisms is crucial to create patient-tailored, RAS-based rehabilitative approaches in PD. TRIAL REGISTRATION: NCT03434496 . Registered 15 February 2018, retrospectively registered.

Effects of virtual reality-based training with BTs-Nirvana on functional recovery in stroke patients: preliminary considerations.

AIM OF THE STUDY: Cognitive impairment occurs frequently in post-stroke patients. This study aimed to determine the effects of a virtual reality training (VRT) with BTs-Nirvana (BTsN) on the recovery of cognitive functions in stroke patients, using the Interactive-Semi-Immersive Program (I-SIP). MATERIALS AND METHODS: We enrolled 12 subjects (randomly divided into two groups: experimental group (EG); and control group (CG)), who attended the Laboratory of Robotic and Cognitive Rehabilitation of IRCCS Neurolesi of Messina from January to June 2016. The EG underwent a VRT with BTsN, whereas CG received a standard cognitive treatment. Both the groups underwent the same conventional physiotherapy program. Each treatment session lasted 45 minutes and was repeated three times a week for 8 weeks. All the patients were evaluated by a specific clinical-psychometric battery before (T0), immediately (T1), and one month (T2) after the end of the training. RESULTS: At T1, the EG presented a greater improvement in the trunk control test (p = 0.03), the Montreal Cognitive Assessment (p = 0.01), the selective attention assessment scores (p = 0.01), the verbal memory (p = 0.03), and the visuospatial and constructive abilities (p = 0.01), as compared to CG. Moreover, such amelioration persisted at T2 only in the EG. CONCLUSIONS: According to these preliminary data, VRT with I-SIP can be considered a useful complementary treatment to potentiate functional recovery, with regard to attention, visual-spatial deficits, and motor function in patients affected by stroke.

Tele-health-care in the elderly living in nursing home: the first Sicilian multimodal approach.

BACKGROUND: The continued aging of the population is affecting the health of the industrialized countries, with an increasing burden for the healthcare system. Thus, during the last decade, we assisted to relevant progress in the medical treatment and rehabilitation techniques and devices, including the development of telemedicine for geriatric care. AIM: To demonstrate the effectiveness of a novel tele-health-care model allowing a better management of elderly living in nursing homes. METHODS: Fifty-nine elderly patients (19 males and 40 females; mean age 79.1 (±9.2), were randomly divided into two groups: the experimental group that performed a proper telemonitoring with a multimodal approach (including monitoring of the vital signs and neurological/psychological counseling), and the control group, which underwent standard in-home nursing care. Neurobehavioral symptoms and quality of life were assessed in both the groups at baseline, and after the telecare protocol's end. RESULTS: The experimental group had a statistically significant reduction in Geriatric Depression Scale (p < 0.01) and Brief Psychiatric Rating Scale (p < 0.05) scores, and an improvement in their quality of life. Moreover, mean blood pressure and heart rate were lower in the experimental than in the control group (p < 0.05), and admission to health care services was higher in the control than in the experimental group (p < 0.05). CONCLUSIONS: Telemedicine can be considered as an important tool in improving health and quality of life in the elderly living in nursing homes, and potentially reducing healthcare service access, hospitalization, and costs.

Paving the way for a better management of pain in patients with spinal cord injury: An exploratory study on the use of Functional Electric Stimulation(FES)-cycling.

CONTEXT/OBJECTIVE: Chronic pain is common in patients with spinal cord injury (SCI), for whom it negatively affects quality of life, and its treatment requires an integrated approach. To this end, lower limb functional electrical stimulation (FES) cycling holds promise. OBJECTIVE: To investigate pain reduction in a sample of patients with SCI by means of lower limb rehabilitation using FES cycling. DESIGN, SETTING AND PARTICIPANTS: Sixteen patients with incomplete and complete SCIs, attending the Neurorobotic Unit of our research institute and reporting pain at or below the level of their SCI were recruited to this exploratory study. INTERVENTIONS: Patients undertook two daily sessions of FES cycling, six times weekly, for 6 weeks. OUTCOME MEASURES: Pain outcomes were measured using the 0-10 numerical rating scale (NRS), the Multidimensional Pain Inventory for SCI (MPI-SCI), and the 36-Item Short Form Survey (SF-36). Finally, we assessed the features of dorsal laser-evoked potentials (LEPs) to objectively evaluate Aδ fiber pathways. RESULTS: All participants tolerated the intervention well, and completed the training without side effects. Statistically significant changes were found in pain-NRS, MPI-SCI, and SF-36 scores, and LEP amplitudes. Following treatment, we found that three patients experienced high pain relief (an NRS decrease of at least 80%), six individuals achieved moderate pain relief (an NRS decrease of about 30-70%), and five participants had mild pain relief (an NRS decrease of less than 30%). CONCLUSION: Our preliminary results suggest that FES cycling training is capable of reducing the pain reported by patients with SCI, regardless of American Spinal Injury Association scoring, pain level, or the neurological level of injury. The neurophysiological mechanisms underlying such effects are likely to be both spinal and supraspinal.

Improving post-stroke cognitive and behavioral abnormalities by using virtual reality: A case report on a novel use of nirvana.

Cognitive impairment, as well as mood and anxiety disorders, occur frequently in patients following stroke. Aim of this study was to evaluate the effects of a combined rehabilitative treatment using conventional relaxation and respiratory techniques, in a specific rehabilitative virtual environment (by using Bts-Nirvana). A 58-year-old woman, affected by hemorrhagic stroke, underwent two different rehabilitation trainings, including either standard relaxation techniques alone in a common clinical setting or the same psychological approach in a semi-immersive virtual environment with an augmented sensorial (audio-video) and motor feedback (sensory motor-interaction). We evaluated the patient's cognitive and psychological profile before and after the two different trainings, by using a specific psychometric battery, aimed to assess cognitive status, attention processes and to estimate the presence of mood alterations, anxiety and coping strategies. Only at the end of the combined approach, we observed a significant improvement in attention and memory functions, with a nearly complete relief of anxiety symptoms and an improvement in coping strategies. Relaxation and respiratory techniques in a semi-immersive virtual reality environment, using Bts-Nirvana, may be a promising tool in improving attention process, coping strategies, and anxiety in individuals with neurological disorders, including stroke.

Robotic gait training in multiple sclerosis rehabilitation: Can virtual reality make the difference? Findings from a randomized controlled trial.

Gait, coordination, and balance may be severely compromised in patients with multiple sclerosis (MS), with considerable consequences on the patient's daily living activities, psychological status and quality of life. For this reason, MS patients may benefit from robotic-rehabilitation and virtual reality training sessions. Aim of the present study was to assess the efficacy of robot-assisted gait training (RAGT) equipped with virtual reality (VR) system in MS patients with walking disabilities (EDSS 4.0 to 5.5) as compared to RAGT without VR. We enrolled 40 patients (randomized into two groups) undergoing forty RAGT±VR sessions over eight weeks. All the patients were assessed at baseline and at the end of the treatment by using specific scales. Effect sizes were very small and non-significant between the groups for Berg Balance Scale (-0.019, CI95% -2.403 to 2.365) and TUG (-0.064, 95%CI -0.408 to 0.536) favoring RAGT+VR. Effects were moderate-to-large and significant for positive attitude (-0.505, 95%CI -3.615 to 2.604) and problem-solving (-0.905, 95%CI -2.113 to 0.302) sub-items of Coping Orientation to Problem Experienced, thus largely favoring RAGT+VR. Our findings show that RAGT combined with VR is an effective therapeutic option in MS patients with walking disability as compared to RAGT without VR. We may hypothesize that VR may strengthen RAGT thanks to the entrainment of different brain areas involved in motor panning and learning.

Spasticity Management: The Current State of Transcranial Neuromodulation.

This narrative review aims to provide an objective view of the noninvasive neuromodulation (NINM) protocols available for treating spasticity, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS). On the basis of the relevant randomized controlled trials, we infer that NINM is more effective in reducing spasticity when combined with the conventional therapies than used as a stand-alone treatment. However, the magnitude of NINM after-effects depends significantly on the applied hemisphere and the underlying pathology. Being in line with these arguments, low-frequency rTMS and cathodal-tDCS over the unaffected hemisphere are more effective in reducing spasticity than high-frequency rTMS and anodal-tDCS over the affected hemisphere in chronic poststroke. However, most of the studies are heterogeneous in the stimulation setup, patient selection, follow-up duration, and the availability of the sham operation. Therefore, the available data on the usefulness of NINM in reducing spasticity need to be confirmed by larger and multicentric randomized controlled trials to gather evidence on the efficiency of NINM regimens in reducing spasticity in various neurologic conditions. LEVEL OF EVIDENCE: V.