Peri-Personal Space Tracing by Hand-Blink Reflex Modulation in Patients with Chronic Disorders of Consciousness.

The assessment of awareness in patients with chronic Disorders of Consciousness (DoC), including Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS), is challenging. The level of awareness impairment may depend on the degree of deterioration of the large-scale cortical-thalamo-cortical networks induced by brain injury. Electrophysiological approaches may shed light on awareness presence in patients with DoC by estimating cortical functions related to the cortical-thalamo-cortical networks including, for example, the cortico-subcortical processes generating motor responses to the perturbation of the peri-personal space (PPS). We measured the amplitude, latency, and duration of the hand-blink reflex (HBR) responses by recording electromyography (EMG) signals from both the orbicularis oculi muscles while electrically stimulating the median nerve at the wrist. Such a BR is thought to be mediated by a neural circuit at the brainstem level. Despite its defensive-response nature, HBR can be modulated by the distance between the stimulated hand and the face. This suggests a functional top-down control of HBR as reflected by HBR features changes (latency, amplitude, and magnitude). We therefore estimated HBR responses in a sample of patients with DoC (8 MCS and 12 UWS, compared to 15 healthy controls -HC) while performing a motor task targeting the PPS. This consisted of passive movements in which the hand of the subject was positioned at different distances from the participant's face. We aimed at demonstrating a residual top-down modulation of HBR properties, which could be useful to differentiate patients with DoC and, potentially, demonstrate awareness preservation. We found a decrease in latency, and an increase in duration and magnitude of HBR responses, which were all inversely related to the hand-to-face distance in HC and patients with MCS, but not in individuals with UWS. Our data suggest that only patients with MCS have preserved, residual, top-down modulation of the processes related to the PPS from higher-order cortical areas to sensory-motor integration network. Although the sample size was relatively small, being thus our data preliminary, HBR assessment seems a rapid, easy, and first-level tool to differentiate patients with MCS from those with UWS. We may also hypothesize that such a HBR modulation suggests awareness preservation.

Virtual reality in multiple sclerosis rehabilitation: A review on cognitive and motor outcomes.

Multiple sclerosis (MS) is a demyelinating neurodegenerative disease with lesions involving the central nervous system. Clinical symptoms consist of disturbances in motor activity (e.g., weakness, spasticity, and tremor), sensory functioning (e.g., pain), visual functions (e.g., diplopia and optic neuritis), besides different cognitive (attention deficit and executive dysfunction) and behavioral abnormalities. This review aims to evaluate the role of VR tools in cognitive and motor rehabilitation of MS patients. Studies performed between 2010 and 2017 and fulfilling the selected criteria were searched on PubMed, Scopus, Cochrane and Web of Sciences databases, by combining the terms "VR rehabilitation" and "MS". Our findings showed that, following the use of VR training, MS patients presented a significant improvement in motor (especially gait and balance) and cognitive function (with regard to executive and visual-spatial abilities, attention and memory skills). This review supports the idea that rehabilitation through new VR tools could positively affect MS patients' outcomes, by boosting motivation and participation with a better response to treatment.

Cognitive rehabilitation in patients with traumatic brain injury: A narrative review on the emerging use of virtual reality.

Traumatic brain injury (TBI) is a clinical condition characterized by brain damage due to an external, rapid and violent force. TBI causes attention, memory, affectivity, behaviour, planning, and executive dysfunctions, with a significant impact on the quality of life of the patient and of his/her family. Cognitive and motor rehabilitation programs are essential for clinical recovery of TBI patients, improving functional outcomes and the quality of life. Various researches have underlined the possible effectiveness of innovative techniques, with regard to virtual reality (VR), during the different phases of rehabilitation after TBI. This review aims to evaluate the role of VR tools in cognitive assessment and rehabilitation in individuals affected by TBI. Studies performed between 2010 and 2017 and fulfilling the selected criteria were found on PubMed, Scopus, Cochrane and Web of Sciences databases. The search combined the terms VR, assessment, rehabilitation and TBI. Our review has shown that VR has the potential to provide an effective assessment and rehabilitation tool for the treatment of cognitive and behavioral impairment on TBI patients.

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.

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.