Might patients with cerebellar ataxia benefit from the Computer Assisted Rehabilitation ENvironment (CAREN)? A pilot study focusing on gait and balance.

Introduction: Ataxia is a neurological symptom that causes decreased balance, loss of coordination, and gait alterations. Innovative rehabilitation devices like virtual reality (VR) systems can provide task-oriented, repetitive and intensive training with multisensorial feedback, thus promoting neuroplastic processes. Among these VR technologies, the Computer Assisted Rehabilitation ENvironment (CAREN) associates a split belt treadmill on a 6-degrees of freedom platform with a 180° VR screen and a Vicon motion capture system to monitor patients' movements during training sessions. Methods: Eight patients affected by cerebellar ataxia were enrolled and received 20 sessions of CAREN training in addition to standard rehabilitation treatment. Each patient was evaluated at the beginning and at the end of the study with 3D gait analysis and clinical scales to assess balance, gait function and risk of falls. Results: We found improvements in kinematic, kinetic, and electromyographic parameters (as per pre-post- CAREN training), as well as in clinical outcomes, such as balance and risk of falls in ataxic patients. In addition, we found that trunk rotation improved, after CAREN intervention, approximating to the normative values. Discussion: Our results suggested that CAREN might be useful to improve specific biomechanical parameters of gait in ataxic patients.

Effect of Immersive Virtual Reality by a Computer Assisted Rehabilitation Environment (CAREN) in Juvenile Huntington's Disease: A Case Report.

Various studies have proven the utility of immersive virtual reality (VR) as a complementary approach to conventional neurorehabilitation therapy for improving neuromuscular and cognitive outcomes in several neurological diseases. We hereby report findings from a single-case experience of a 21-year-old woman affected by juvenile Huntington's disease (HD) who underwent a targeted rehabilitative approach using an advanced Computer Assisted Rehabilitation Environment (CAREN) with a three sessions/week schedule for six months. At the end of the program, a manifested improvement was noticed in the Falls Efficacy Scale International score, in the Tinetti Scale, in the Berg Balance score and in the lower limb strength (MRC scale). Minor although tangible improvements were also noticed in some physical performance tests (10 m walking test, time up and go test). Findings reported, although preliminary, extend for the first time the usefulness of neurorehabilitation using innovative VR technologies also to juvenile HD, a condition for which common rehabilitation strategies bring only marginal physical benefits in the majority of cases. Future, controlled studies are awaited for generalizing these observations to larger populations and for clarifying whether such benefits may persist also in the long-term.

Cerebellar Atrophy Associated with Primary Sjögren's Syndrome: Diagnosis, Therapy, and Virtual Reality Rehabilitation: A Case Report.

Cerebellar involvement in primary Sjögren's syndrome (pSS) is an uncommon condition, with only a limited number of cases described worldwide. A 43-year-old woman affected by cerebellar atrophy associated with pSS was referred to our center to undergo a cycle of physical rehabilitation therapy. Although motor symptoms started when the patient was 23 years of age, the underlying disease remained undiagnosed for several years. Neurological examination before rehabilitation revealed ataxic gait, dysmetria, nystagmus, and hypermetric saccades; the patients complained about unsteadiness while standing or walking. To improve balance and gait abilities, a 20-session cycle of balance rehabilitation, based on a combination of conventional physical therapy and virtual reality exergames, was prescribed. The outcomes of rehabilitation were evaluated with balance tests and three-dimensional (3D) gait analysis. To our knowledge, this is the first case describing the diagnostic workout for cerebellar atrophy associated with pSS and the subsequent motor rehabilitation. This work highlights the importance of early diagnosis and rehabilitation in patients with central nervous system involvement in pSS.

Structural Connectivity-Based Parcellation of the Dopaminergic Midbrain in Healthy Subjects and Schizophrenic Patients.

Background and objectives: Functional deregulation of dopaminergic midbrain regions is a core feature of schizophrenia pathophysiology. Anatomical research on primates suggests that these regions may be subdivided into distinct, topographically organized functional territories according to their connectivity to the striatum. The aim of the present work was the reconstruction of dopaminergic midbrain subregions in healthy subjects and schizophrenic patients and the evaluation of their structural connectivity profiles. Materials and Methods: A hypothesis-driven connectivity-based parcellation derived from diffusion tractography was applied on 24 healthy subjects and 30 schizophrenic patients to identify distinct territories within the human dopaminergic midbrain in vivo and non-invasively. Results: We identified a tripartite subdivision of dopaminergic midbrain, including limbic, prefrontal and sensorimotor territories. No significant differences in structural features or connectivity were found between subjects and patients. Conclusions: The parcellation scheme proposed herein may help to achieve detailed characterization of structural and functional anomalies of the dopaminergic midbrain in schizophrenic patients.

Anton's Syndrome associated with autotopagnosia.

We describe an unusual case of a 68-year-old male affected by cerebral amyloid angiopathy and cortical blindness associated with Anton's syndrome. In addition, our patient presented with autotopagnosia, a form of agnosia characterized by loss of body spatial representation. Neuropsychological assessment evidenced cognitive impairment. Magnetic Resonance Imaging showed hemorrhagic foci in the left occipital and right occipito-parietal lobe, paratrigonal white matter, and post-ischemic parenchymal gliosis. The pattern-reversal of visual evoked potentials were indicative bilateral visual pathway of integrity of the. After a neurological damage, patients could show a denial of their own deficit; however, the association between anosognosia and autotopagnosia represents a rare neurological condition. The simultaneous onset of unusual neuropsychological syndromes could be related to involvement of a complex brain network.

Improving motor performance in Parkinson's disease: a preliminary study on the promising use of the computer assisted virtual reality environment (CAREN).

BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disorder characterized by various motor symptoms including balance and gait impairment. Several studies have shown that physiotherapy, cueing techniques, treadmill training, and cognitive movement strategies are useful in improving balance and gait in patients with PD. Devices employing virtual reality (VR) have been shown to be promising in neurorehabilitation as they can provide the patients with multisensory stimulation creating a realistic environment and improve the motivation and the adhesion of patients to the rehabilitation program. This preliminary study is aimed at testing the efficacy and feasibility of gait training based on the computer-assisted virtual reality environment (CAREN) in a sample of PD. METHODS: In this preliminary study, 22 outpatients affected by PD who attended the Behavioral and Robotic Neurorehab Laboratory of the IRCCS Neurolesi between August 2017 and October 2018 were enrolled. All PD patients underwent 20 conventional physiotherapy sessions followed by 3-month of rest. Then, the patients were provided with 20 sessions of CAREN training. Gait and balance performances were rated before, after each training protocol, and 3 months later. Gait analysis was also performed before and after CAREN training. RESULTS: All patients completed both of the rehabilitation trainings without any adverse event. All considered scales improved significantly at the end of both rehabilitation treatments. However, patients presented with a greater clinical improvement after the CAREN training, compared with conventional physiotherapy. In particular, patients walked faster and with more stability, with wider, longer steps. CONCLUSIONS: Even though further neurophysiological details are required to identify the patients who may benefit from CAREN training, our findings suggest that this innovative device is an effective and feasible tool to train balance and gait in patients with PD.

The cortico-rubral and cerebello-rubral pathways are topographically organized within the human red nucleus.

The Red Nucleus (RN) is a large nucleus located in the ventral midbrain: it is subdivided into a small caudal magnocellular part (mRN) and a large rostral parvocellular part (pRN). These distinct structural regions are part of functionally different networks and show distinctive connectivity features: the mRN is connected to the interposed nucleus, whilst the pRN is mainly connected to dentate nucleus, cortex and inferior olivary complex. Despite functional neuroimaging studies suggest RN involvement in complex motor and higher order functions, the pRN and mRN cannot be distinguished using conventional MRI. Herein, we employ high-quality structural and diffusion MRI data of 100 individuals from the Human Connectome Project repository and constrained spherical deconvolution tractography to perform connectivity-based segmentation of the human RN. In particular, we tracked connections of RN with the inferior olivary complex, the interposed nucleus, the dentate nucleus and the cerebral cortex. We found that the RN can be subdivided according to its connectivity into two clusters: a large ventrolateral one, mainly connected with the cerebral cortex and the inferior olivary complex, and a smaller dorsomedial one, mainly connected with the interposed nucleus. This structural topography strongly reflects the connectivity patterns of pRN and mRN respectively. Structural connectivity-based segmentation could represent a useful tool for the identification of distinct subregions of the human red nucleus on 3T MRI thus allowing a better evaluation of this subcortical structure in healthy and pathological conditions.

Is hydrokinesitherapy effective on gait and balance in patients with stroke? A clinical and baropodometric investigation.

BACKGROUND: Patients with stroke present an asymmetric posture, severe balance dysfunction with delayed and disrupted equilibrium reactions, exaggerated postural sway and abnormal gait with an increased risk of falling. The aim of this study is to evaluate the efficacy of hydrokinesytherapy on stance, balance and gait in individuals after stroke. METHODS: In this single-blinded randomized controlled trial, patients with stroke were divided into two groups: an experimental one (G1), performing hydrokinesytherapy (3 times/week) in addition to a conventional physical therapy (3 times/week) and a control one (G2), performing only a conventional physical therapy (6 times/week). All of the participants underwent a proper clinical and baropodometric evaluation before and after 8 weeks of treatment. RESULTS: The two groups presented similar clinical and instrumental features at enrolment (mean modified Rankin Scale of 3, and a disease duration of 6.3 ± 1.4 months). After treatment, the patients undergoing hydrokinesytherapy showed a significantly greater improvement than those undergoing traditional training. CONCLUSIONS: Hydrokinesytherapy may be considered a promising treatment in improving gait and balance in individuals following stroke.