Virtual Reality and Physiotherapy in Post-Stroke Functional Re-Education of the Lower Extremity: A Controlled Clinical Trial on a New Approach.

Numerous Virtual Reality (VR) systems address post-stroke functional recovery of the lower extremity (LE), most of them with low early applicability due to the gait autonomy they require. The aim of the present study was to evaluate the feasibility of a specific VR treatment and its clinical effect on LE functionality, gait, balance, and trunk control post-stroke. A controlled, prospective, clinical trial was carried out with 20 stroke patients, who were divided into two groups: the first group (VR + CP; n = 10) received combined therapy of 1 h VR and 1 h of conventional physiotherapy (CP) and the second group (CP; n = 10) received 2 h of CP (5 days/week, for 3 weeks). The following pre-post-intervention measuring scales were used: Functional Ambulatory Scale (FAC), Functional Independence Measure (FIM), Fugl-Meyer Assessment (FM), Berg Balance Scale (BBS), and Trunk Control Test (TCT). Only VR + CP showed a significant improvement in FAC. In FIM, CP presented a tendency to significance, whereas VR + CP showed significance. Both groups improved significantly in FM (especially in amplitude/pain in VR + CP and in sensitivity in CP) and in BBS. In TCT, there was a non-significant improvement in both groups. The results indicate that the intervention with VR is a feasible treatment in the post-stroke functional re-education of the LE, with the potential to be an optimal complement of CP.

A Frontal Neuropsychological Profile in Fitness to Drive.

Traffic accidents are a global concern due to the elevated mortality rates of both drivers and pedestrians. The World Health Organization declared 2011-2020 as the Decade of Action for Road Safety, endorsing initiatives to reduce traffic-related deaths. Yet, despite these incentives, fatal accidents still occur. Different studies have linked deficits in executive functions to risky driving attitudes and crashes. The present study focuses on demographic, cognitive and personality factors, related to the prefrontal cortex, that are characteristic of drivers prone to risky behavior behind the wheel. The penalty Points System was used to classify drivers as "safe", with no point loss over a two-year period, or "risky", with full point loss during the same interval. A neuropsychological assessment of prefrontal cognitive functions was carried out on each group to identify variables associated with safe and risky behavior. Neuropsychological indexes were obtained from a continuous performance task without cue (Simple Attention), a continuous performance task with cue (Conditioned Attention), the Tower of Hanoi test and the Neurologically-related Changes in Personality Inventory (NECHAPI). A Discriminant Analysis (DA) found that education level, reaction times in Simple and Conditioned Attention, learning errors in the Tower of Hanoi and vulnerability in the personality test, best predicted whether drivers were likely to be in the safe or risky group. Finally, a cross-validation analysis performed on the same sample correctly classified 87.5% of the drivers. These data suggest that prefrontal dysfunction contributes to risky behavior behind the wheel. The inclusion of cognitive programs to identify and train drivers with this propensity could reduce risky driving, and consequently, save lives on the road.

The impact of driver sleepiness on fixation-related brain potentials.

The effects of driver sleepiness are often quantified as deteriorated driving performance, increased blink durations and high levels of subjective sleepiness. Driver sleepiness has also been associated with increasing levels of electroencephalogram (EEG) power, especially in the alpha range. The present exploratory study investigated a new measure of driver sleepiness, the EEG fixation-related lambda response. Thirty young male drivers (23.6 ± 1.7 years old) participated in a driving simulator experiment in which they drove on rural and suburban roads in simulated daylight versus darkness during both the daytime (full sleep) and night-time (sleep deprived). The results show lower lambda responses during night driving and with longer time on task, indicating that sleep deprivation and time on task cause a general decrement in cortical responsiveness to incoming visual stimuli. Levels of subjective sleepiness and line crossings were higher under the same conditions. Furthermore, results of a linear mixed-effects model showed that low lambda responses are associated with high subjective sleepiness and more line crossings. We suggest that the fixation-related lambda response can be used to investigate driving impairment induced by sleep deprivation while driving and that, after further refinement, it may be useful as an objective measure of driver sleepiness.

Driving automation state-of-mind: Using training to instigate rapid mental model development.

The automotive industry is chugging along towards full autonomy, with a yet unknown time of arrival. The next call, however, is partial driving automation. At this interim station lurks many dangers, there-among them issues surrounding the partial performance of the driving task. Despite their potential for increased safety, these systems come with many inherent limitations and caveats, and their safe use depend on drivers correctly understanding their new role. Training is proposed as a potentially effective method of introducing drivers to the central aspects in this human-automation interaction. A proof-of-concept training program designed to introduce drivers to a partial automation system was developed. The effects of training were then evaluated through a between-group mixed-methods simulator experiment. Results indicate that trained drivers both self-report and exhibit an improved understanding of the automation system. They also report a significantly higher inclination to retake control in critical situation, than do their untrained counterparts.

Reinforced Feedback in Virtual Environment for Plantar Flexor Poststroke Spasticity Reduction and Gait Function Improvement.

BACKGROUND: Ankle spasticity is a frequent phenomenon that limits functionality in poststroke patients. OBJECTIVES: Our aim was to determine if there was decreased spasticity in the ankle plantar flex (PF) muscles in the plegic lower extremity (LE) and improvement of gait function in stroke patients after traditional rehabilitation (TR) in combination with virtual reality with reinforced feedback, which is termed "reinforced feedback virtual environment" (RFVE). METHODS: The evaluation, before and after treatment, of 10 hemiparetic patients was performed using the Modified Ashworth Scale (MAS), Functional Ambulatory Category (FAC), and Functional Independence Measure (FIM). The intervention consisted of 1 hour/day of TR plus 1 hour/day of RFVE (5 days/week for 3 weeks; 15 sessions in total). RESULTS: The MAS and FAC reached statistical significance (P < 0.05). The changes in the FIM did not reach statistical significance (P=0.066). The analysis between the ischemic and haemorrhagic patients showed significant differences in favour of the haemorrhagic group in the FIM scale. A significant correlation between the FAC and the months after the stroke was established (P=-0.711). Indeed, patients who most increased their score on the FAC at the end of treatment were those who started the treatment earliest after stroke. CONCLUSIONS: The combined treatment of TR and RFVE showed encouraging results regarding the reduction of spasticity and improvement of gait function. An early commencement of the treatment seems to be ideal, and future research should increase the sample size and assessment tools.

Performance of an Additional Task During Level 2 Automated Driving: An On-Road Study Comparing Drivers With and Without Experience With Partial Automation.

OBJECTIVE: To investigate the influence of prior experience with Level 2 automation on additional task performance during manual and Level 2 partially automated driving. BACKGROUND: Level 2 automation is now on the market, but its effects on driver behavior remain unclear. Based on previous studies, we could expect an increase in drivers' engagement in secondary tasks during Level 2 automated driving, but it is yet unknown how drivers will integrate all the ongoing demands in such situations. METHOD: Twenty-one drivers (12 without, 9 with Level 2 automation experience) drove on a highway manually and with Level 2 automation (exemplified by Volvo Pilot Assist generation 2; PA2) while performing an additional task. In half of the conditions, the task could be interrupted (self-paced), and in the other half, it could not (system-paced). Drivers' visual attention, additional task performance, and other compensatory strategies were analyzed. RESULTS: Driving with PA2 led to decreased scores in the additional task and more visual attention to the dashboard. In the self-paced condition, all drivers looked more to the task and perceived a lower mental demand. The drivers experienced with PA2 used the system and the task more than the novice group and performed more overtakings. CONCLUSIONS: The additional task interfered more with Level 2 automation than with manual driving. The drivers, particularly the automation novice drivers, used some compensatory strategies. APPLICATIONS: Automation designers need to consider these potential effects in the development of future automated systems.

Reduced Attention Allocation during Short Periods of Partially Automated Driving: An Event-Related Potentials Study.

Research on partially automated driving has revealed relevant problems with driving performance, particularly when drivers' intervention is required (e.g., take-over when automation fails). Mental fatigue has commonly been proposed to explain these effects after prolonged automated drives. However, performance problems have also been reported after just a few minutes of automated driving, indicating that other factors may also be involved. We hypothesize that, besides mental fatigue, an underload effect of partial automation may also affect driver attention. In this study, such potential effect was investigated during short periods of partially automated and manual driving and at different speeds. Subjective measures of mental demand and vigilance and performance to a secondary task (an auditory oddball task) were used to assess driver attention. Additionally, modulations of some specific attention-related event-related potentials (ERPs, N1 and P3 components) were investigated. The mental fatigue effects associated with the time on task were also evaluated by using the same measurements. Twenty participants drove in a fixed-base simulator while performing an auditory oddball task that elicited the ERPs. Six conditions were presented (5-6 min each) combining three speed levels (low, comfortable and high) and two automation levels (manual and partially automated). The results showed that, when driving partially automated, scores in subjective mental demand and P3 amplitudes were lower than in the manual conditions. Similarly, P3 amplitude and self-reported vigilance levels decreased with the time on task. Based on previous studies, these findings might reflect a reduction in drivers' attention resource allocation, presumably due to the underload effects of partial automation and to the mental fatigue associated with the time on task. Particularly, such underload effects on attention could explain the performance decrements after short periods of automated driving reported in other studies. However, further studies are needed to investigate this relationship in partial automation and in other automation levels.

Safe driving and executive functions in healthy middle-aged drivers.

The introduction of the point system driver's license in several European countries could offer a valid framework for evaluating driving skills. This is the first study to use this framework to assess the functional integrity of executive functions in middle-aged drivers with full points, partial points or no points on their driver's license (N = 270). The purpose of this study is to find differences in executive functions that could be determinants in safe driving. Cognitive tests were used to assess attention processes, processing speed, planning, cognitive flexibility, and inhibitory control. Analyses for covariance (ANCOVAS) were used for group comparisons while adjusting for education level. The Bonferroni method was used for correcting for multiple comparisons. Overall, drivers with the full points on their license showed better scores than the other two groups. In particular, significant differences were found in reaction times on Simple and Conditioned Attention tasks (both p-values < 0.001) and in number of type-III errors on the Tower of Hanoi task (p = 0.026). Differences in reaction time on attention tasks could serve as neuropsychological markers for safe driving. Further analysis should be conducted in order to determine the behavioral impact of impaired executive functioning on driving ability.

Predictores de la recuperación funcional cognitiva en pacientes con traumatismo craneoencefálico / Predictors of the recovery of cognitive functions in patients with traumatic brain injury

Introducción. Tras un traumatismo craneoencefálico (TCE), el funcionamiento cognitivo de los pacientes puede resultar gravemente alterado. Diversos estudios han tratado de identificar las variables que mejor predicen su recuperación. Objetivos. Evaluar la recuperación funcional cognitiva de pacientes con TCE tras un programa de neurorrehabilitación e identificar las variables predictoras de dicha recuperación. Pacientes y métodos. Estudio pre-post retrospectivo de 58 pacientes adultos con TCE que realizaron un programa de rehabilitación intensivo. Todos fueron evaluados mediante la subescala de funcionalidad cognitiva de la medida de la independencia funcional + medida de la evaluación de la funcionalidad (FIM+FAM), al inicio y al final de la rehabilitación. Ambas puntuaciones fueron comparadas mediante la prueba no paramétrica de Wilcoxon. Se calculó el porcentaje de ganancia funcional cognitiva y se correlacionó con todas las variables recogidas. A partir de toda la información clínica, demográfica y cognitiva recogida, realizamos un análisis de regresión lineal múltiple para identificar los mejores predictores de dicha ganancia. Resultados. La funcionalidad cognitiva aumentó significativamente del 33,6% al 85% (p < 0,01). Los pacientes con mayor porcentaje de ganancia funcional cognitiva fueron aquellos con menor edad y período post-TCE, y mayores puntuaciones en la subescala cognitiva de la FIM+FAM y en las pruebas de atención condicional y curva de aprendizaje de Luria. Los mejores predictores de la recuperación funcional fueron el período post-TCE y la funcionalidad cognitiva al inicio (R2 ajustado = 55,8%). Conclusiones. El comienzo temprano de la rehabilitación y la mayor funcionalidad cognitiva al inicio resultaron ser los mejores predictores de la recuperación funcional cognitiva. Otras variables, como la edad o puntuaciones en pruebas cognitivas, también deben considerarse en futuros estudios (AU)

Introducción. After a traumatic brain injury (TBI), cognitive functionality may be severely altered. Some studies have aimed at identifying the best predictive variables for cognitive recovery, however, results still remain unclear. Aims: To assess the recovery of cognitive functionality in TBI patients after a rehabilitation programme, and to identify the variables that best predict the cognitive recovery. Patients and Methods: We conducted a retrospective pre-post study with 58 adult TBI patients that underwent an intensive rehabilitation programme. All of them were assessed using the cognitive functions sub-scale from the FIM+FAM scale, at admission and discharge. Both scores were compared using non-parametric test Wilcoxon. Cognitive functionality gain percentage was calculated and correlated with all the collected data. A multiple linear regression analysis was carried out to identify the best predictors of cognitive functionality gain percentage by introducing all clinical, demographic and cognitive information. Results. The group's cognitive functionality increased significantly from 33,6% to 85% (p < 0,01). Patients with higher cognitive functionality gain percentage were those with younger age, shorter time post-TBI, and higher scores on cognitive functions sub-scale, conditional attention and Luria's memory word tests. The best predictors for cognitive functionality gain percentage were time post-TBI and cognitive functions at admission (adjusted R2 = 55,8%). Conclusions:. Patients who started rehabilitation sooner and had a higher cognitive functionality at admission, showed the greatest increase in cognitive functionality gain percentage. Other variables like age, or scores on cognitive tests must also be considered in future studies (AU)

Molecular concentration of deoxyHb in human prefrontal cortex predicts the emergence and suppression of consciousness.

This is the first study to use fNIRS to explore anaesthetic depth and awakening during surgery with general anaesthesia. A 16 channel continuous wave (CW) functional near-infrared system (fNIRS) was used to monitor PFC activity. These outcomes were compared to BIS measures. The results indicate that deoxyHb concentration in the PFC varies during the suppression and emergence of consciousness. During suppression, deoxyHb levels increase, signalling the deactivation of the PFC, while during emergence, deoxyHb concentration drops, initiating PFC activation and the recovery of consciousness. Furthermore, BIS and deoxyHb concentrations in the PFC display a high negative correlation throughout the different anaesthetic phases. These findings suggest that deoxyHb could be a reliable marker for monitoring anaesthetic depth, and that the PFC intervenes in the suppression and emergence of consciousness.

The sooner patients begin neurorehabilitation, the better their functional outcome.

PRIMARY OBJECTIVE: To determine whether early neurorehabilitation improves a patient's functional recovery. RESEARCH DESIGN: A retrospective study was carried out on patients with severe traumatic brain injury (TBI) who underwent a minimum of 4 months of integral and multidisciplinary neurorehabilitation. METHODS AND PROCEDURES: Fifty-eight patients with severe TBI were assessed at admission and at discharge using the FIM + FAM scale. Two groups were formed based on time elapsed from brain injury to onset of rehabilitation. The early treatment group (ET) included patients who began rehabilitation within the first 9 months post-trauma; the late treatment group (LT) began after the 9-month cut-off date. Intra- and between-group analysis of FIM + FAM scores were carried out at admission and discharge. Multiple linear regression was used to determine the best predictors for functional rehabilitation. MAIN OUTCOMES AND RESULTS: After neurorehabilitation, all subjects showed significant improvement in cognitive, motor, communication and psychosocial functioning. Moreover, the ET group showed better global functional outcome at discharge than patients who began later treatment. The best predictors for functional neurorehabilitation were months since injury, age, GCS score and months of treatment. CONCLUSIONS: It is concluded that the sooner patients begin neurorehabilitation, the better their functional outcome.