Moving into the wide clinical spectrum of consciousness disorders: Pearls, perils and pitfalls

The last few years have been characterized by a growing interest of the medical and scientific world for the field of consciousness and its related disorders. Medically speaking, conscious- ness can be defined as the state of awareness of self and environment and the alertness to external stimulation, besides responsiveness to inner need. Transient loss of consciousness can be due to alterations in cerebral blood flow leading to fainting or syncope, migraine, metabolic dysfunctions, unexpected intracranial pressure increases, epileptic seizures, and sleep disorders. Chronic disorders of consciousness are a tragic success of high-technology treatment, in an attempt to maintain or reestablish brain function, which is to be considered as the main goal of therapeutics. Management of vegetative or a minimally conscious state individuals involves charily getting the right diagnosis with an evidence-based prognosis, also taking into account the medical, ethical, and legal key factors of the ideal treatment. This paper is aimed at exploring the wide spectrum of consciousness disorders and their clinical differential diagnosis, with particular regards to those with a negative impact on patient and their caregiver quality of life, including epilepsy, sleep disorders, and vegetative/minimally conscious state

Improving Outcomes in People with Spinal Cord Injury: Encouraging Results from a Multidisciplinary Advanced Rehabilitation Pathway

Spinal cord injury (SCI) consists of damage to any segment of the spinal cord extending to potential harm to nerves in the cauda equina. Rehabilitative efforts for SCI can involve conventional physiotherapy, innovative technologies, as well as cognitive treatment and psychological support. The aim of this study is to evaluate the feasibility of a dedicated, multidisciplinary, and integrated intervention path for SCI, encompassing both conventional and technological interventions, while observing their impact on cognitive, motor, and behavioral outcomes and the overall quality of life for individuals with SCI. Forty-two patients with SCI were included in the analysis utilizing electronic recovery system data. The treatment regimen included multidisciplinary rehabilitation approaches, such as traditional physiotherapy sessions, speech therapy, psychological support, robotic devices, advanced cognitive rehabilitation, and other interventions. Pre–post comparisons showed a significant improvement in lower limb function (Fugl Meyer Assessment-FMA p p p < 0.001). In addition, we assessed patient satisfaction using the Short Form of the Patient Satisfaction Questionnaire (PSQ), offering insights into the subjective evaluation of the intervention. In conclusion, this retrospective study provides positive results in terms of improvements in motor function, cognitive functions, and quality of life, highlighting the importance of exploring multidisciplinary approaches

Innovation technology in neurorehabilitation: introducing a hub and spoke model to avoid patient "migration" in Sicily

Purpose: In the Italian National Health Service, hospital planning has been influenced by two aspects: patients' freedom to choose their healthcare provider and the equal distribution of centers spread throughout country. Unfortunately, while every Italian region should be able to meet the health needs of its own inhabitants, consistent migration among regions exists, especially from the southern areas of the country, including Sicily. As it has been demonstrated that a hub-and-spoke model (HSM) can provide medical care to even the most rural areas, the aim of this study is to propose a new Sicilian model to avoid patients' migration. Design, methodology, approach: The IRCCS Centro Neurolesi "Bonino-Pulejo" of Messina, together with the Ministry of Health and the Sicilian government, has incorporated an HSM into a Sicilian healthcare program that provides neurological rehabilitation by means of innovative technologies such as robotics. Findings: The authors expected, thanks to this novel HSM, that patients may benefit from advanced robotic neurorehabilitation even in rural areas, and therefore be properly treated in their own cities, avoiding unnecessary and expensive migrations to other regions and/or countries. Indeed, since the introduction of this model, there has been a reduction in patient migration, especially in the province of Messina, with a reduction of costs for admission outside the region of about 260.000 euros. Originality/value: The use of innovative technology in the context of the promising HSM will help clinicians increase the intensity of therapies and improve working cost/efficacy, with better functional outcomes in patients

Applications of transcranial magnetic stimulation in migraine: evidence from a scoping review

Transcranial magnetic stimulation (TMS), a non-invasive brain stimulation method, is trying to emerge as a migraine management strategy for both attack treatment and prevention. This scoping review presents 16 among single-pulse (to manage episodic and chronic migraine) and repetitive TMS randomized clinical trials (to manage chronic migraine). The works we reviewed suggest that TMS may be adopted as add-on therapy in those patients who are refractory to pharmacological therapy only with special arrangements for individualized treatment strategies or research. There are still limited clinical research programs and metaanalysis to promote routinely TMS employment, as TMS has been shown either to have no significant effects for any outcome or to be effective for migraine. These diverging conclusions depend on several biasing factors, including the lack of reliable, large, sham-controlled clinical trials, the dyshomogeneity in study designs (including the area of stimulation, the frequency of stimulation, the number of pulses, pulse intensity, and the number of sessions), patient selection criteria (migraine w/o aura, episodic and chronic migraine; TMS contraindication), and the lack of outcomes homogeneity and long-term real-world efficacy data. Therefore, in the future, it will be important to conduct larger randomized trials to confirm TMS usefulness in migraine management (acute attack and prophylactic treatment), identify those patients who may benefit from TMS, maybe independently of pharmacological treatments (i.e., using TMS as an alternative and not only as an add-on treatment). Otherwise, TMS will play a role in treating migraine only with special arrangements for individualized management strategies or research

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

Shaping neuroplasticity by using powered exoskeletons in patients with stroke: a randomized clinical trial

Abstract Background The use of neurorobotic devices may improve gait recovery by entraining specific brain plasticity mechanisms, which may be a key issue for successful rehabilitation using such approach. We assessed whether the wearable exoskeleton, Ekso™, could get higher gait performance than conventional overground gait training (OGT) in patients with hemiparesis due to stroke in a chronic phase, and foster the recovery of specific brain plasticity mechanisms. Methods We enrolled forty patients in a prospective, pre-post, randomized clinical study. Twenty patients underwent Ekso™ gait training (EGT) (45-min/session, five times/week), in addition to overground gait therapy, whilst 20 patients practiced an OGT of the same duration. All individuals were evaluated about gait performance (10 m walking test), gait cycle, muscle activation pattern (by recording surface electromyography from lower limb muscles), frontoparietal effective connectivity (FPEC) by using EEG, cortico-spinal excitability (CSE), and sensory-motor integration (SMI) from both primary motor areas by using Transcranial Magnetic Stimulation paradigm before and after the gait training. Results A significant effect size was found in the EGT-induced improvement in the 10 m walking test (d = 0.9, p < 0.001), CSE in the affected side (d = 0.7, p = 0.001), SMI in the affected side (d = 0.5, p = 0.03), overall gait quality (d = 0.8, p = 0.001), hip and knee muscle activation (d = 0.8, p = 0.001), and FPEC (d = 0.8, p = 0.001). The strengthening of FPEC (r = 0.601, p < 0.001), the increase of SMI in the affected side (r = 0.554, p < 0.001), and the decrease of SMI in the unaffected side (r = − 0.540, p < 0.001) were the most important factors correlated with the clinical improvement. Conclusions Ekso™ gait training seems promising in gait rehabilitation for post-stroke patients, besides OGT. Our study proposes a putative neurophysiological basis supporting Ekso™ after-effects. This knowledge may be useful to plan highly patient-tailored gait rehabilitation protocols. Trial registration ClinicalTrials.gov, NCT03162263

Emotional Impact of COVID-19 Pandemic on Nursing Students Receiving Distance Learning: An Explorative Study

Social restrictions have a significant impact on higher education, especially on nursing students. The main goal of our study was to assess the emotional state of nursing students who received e-learning during the second wave of the COVID-19 pandemic. The secondary objective was instead to measure the usability and acceptability of distance learning systems. A cross-sectional survey design was used to assess the psychological effects of the COVID-19 pandemic on 1st-, 2nd-, and 3rd-year undergraduate nursing students attending the University of Messina, Italy, using an anonymous online questionnaire. The data of 522 nursing students were examined. All participants completed the online questionnaire, declaring the good usability of e-learning education (SUS mean 68.53 ds: 16.76). Moreover, we found that high levels of satisfaction in the use of the means of distance learning (based on the SUS score) were positively correlated with low levels of stress, anxiety, depression, and mental distress. In conclusion, the present study provided relevant information on usability and mental distress related to e-learning and use in a sample of nursing students. It was found that students generally found this method to be good for use. Although e-learning can be a valuable and usable teaching tool, the study suggests that students prefer a blended or presence modality, based on their perception of learning. So teaching nursing students in the future could integrate the two ways to enhance learning. Further studies are needed to evaluate this aspect

What about the Consequences of the Use of Distance Learning during the COVID-19 Pandemic? A Survey on the Psychological Effects in Both Children and Parents

Background: The COVID-19 pandemic implicated many social restrictions, including the use of distance learning (DL). Indeed, parents were obligated to support their children in online lessons and schoolwork. The aim of this study was to investigate the psycho-emotional impact of the COVID-19 pandemic on parents and children submitted to DL. Methods: One hundred and ninety-two participants (96 parents and 96 children) were enrolled in this study. Parents and children completed an online questionnaire, structured in four sections. Results: The results showed that parents had higher levels of stress and anxiety. In particular, the stress for DL was positively correlated with depression and anxiety. Parents&rsquo; jobs were negatively correlated with their levels of anxiety and stress. On the other hand, children reported higher levels of depressive symptoms and event-related anxiety, which increased as children got older. The stress and the anxiety in parents were positively correlated with the mood depression and anxiety of their children. Conclusions: The COVID-19 pandemic had a negative impact on the psychological well-being of children and parents who used DL. Although DL could be an alternative teaching method during pandemics, face-to-face teaching is fundamental and irreplaceable as it encourages dialogue, involvement, and human contact

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