Can patients with severe traumatic brain injury be trained with cognitive telerehabilitation? An inpatient feasibility and usability study

Virtual reality as a method of cognitive training of processing speed, working memory, and sustained attention in persons with acquired brain injury: a protocol for a randomized controlled trial

BACKGROUND

Acquired brain injury (ABI) often leads to persisting somatic, cognitive, and social impairments. Cognitive impairments of processing speed, sustained attention, and working memory are frequently reported and may negatively affect activities of daily living and quality of life. Rehabilitation efforts aiming to retrain these cognitive functions have often consisted of computerized training programs. However, few studies have demonstrated effects that transfer beyond the trained tasks. There is a growing optimism regarding the potential usefulness of virtual reality (VR) in cognitive rehabilitation. The research literature is sparse, and existing studies are characterized by considerable methodological weaknesses. There is also a lack of knowledge about the acceptance and tolerability of VR as an intervention method for people with ABI. The present study aims to investigate whether playing a commercially available VR game is effective in training cognitive functions after ABI and to explore if the possible effects transfer into everyday functioning.

METHODS

One hundred participants (18-65 years), with a verified ABI, impairments of processing speed/attention, and/or working memory, and a minimum of 12 months post injury will be recruited. Participants with severe aphasia, apraxia, visual neglect, epilepsy, and severe mental illness will be excluded. Participants will be randomized into two parallel groups: (1) an intervention group playing a commercial VR game taxing processing speed, working memory, and sustained attention; (2) an active control group receiving psychoeducation regarding compensatory strategies, and general cognitive training tasks such as crossword puzzles or sudoku. The intervention period is 5 weeks. The VR group will be asked to train at home for 30 min 5 days per week. Each participant will be assessed at baseline with neuropsychological tests and questionnaires, after the end of the intervention (5 weeks), and 16 weeks after baseline. After the end of the intervention period, focus group interviews will be conducted with 10 of the participants in the intervention group, in order to investigate acceptance and tolerability of VR as a training method.

DISCUSSION

This study will contribute to improve understanding of how VR is tolerated and experienced by the ABI population. If proven effective, the study can contribute to new rehabilitation methods that persons with ABI can utilize in a home setting, after the post-acute rehabilitation has ended.

Family caregivers improve the diagnostic accuracy of disorders of consciousness: from remote to near-bed auditory stimulation

BACKGROUND

Family caregivers (FC) contribute to reducing the misdiagnosis rate in patients with disorders of consciousness (DOC). Unfortunately, the recent pandemic of COVID-19 imposed drastic restrictions that limited the access of FC to the sensory/cognitive stimulation protocols. Telemedicine approaches have been implemented to avoid discontinuity in care pathways and to ensure caregivers involvement in rehabilitation programs.

AIM

The aim was to investigate whether the presence of FC remotely connected might help clinicians in eliciting higher cortically mediated behavioral responses in patients with DOC.

DESIGN

Cross-sectional study.

SETTING

Post-acute Unit of Neurorehabilitation.

POPULATION

DOC due to severe brain injury.

METHODS

Consecutive patients with DOC were assessed by means of the Coma Recovery Scale-Revised (CRS-R) by two expert examiners. Each patient underwent to five assessments in two weeks in three different conditions: 1) by the examiner only (standard); 2) with the verbal stimulation given by the FC remotely connected by PC tablet (caregiver in remote); and 3) with the verbal stimulation given by the FC physically present (caregiver in presence).

RESULTS

Thirty patients with DOC (VS/UWS=10; MCS=20; mean age: 51, range: 21-79; vascular: 16; anoxic: 6; TBI=8) and their FC were enrolled. Higher total scores of CRS-R were recorded both in "caregiver in remote" and in "caregiver in presence" than in standard condition (standard vs. remote, Z=2.942, P=0.003; standard vs. presence, Z=3.736, P<0.001). Furthermore, the administration of the CRS-R with a FC, elicited higher levels of behavioral responses in MCS patients, than CRS-R performed in standard condition. In particular, 2 patients out of 30 (6.66%) showed higher scores and better diagnosis when the CRS-R was administered with FC in remote. Similarly, 5 out of 30 patients (16.66%) showed better diagnoses when the CRS-R was administered with FC in presence. Five patients changed diagnosis between standard and presence conditions (3 MCS- were diagnosed as MCS+; 2 MCS+ were diagnosed as conscious).

CONCLUSIONS

Our findings add new evidence regarding the beneficial role of family members in the diagnosis of DOC, even mediated by telemedicine approach.

CLINICAL REHABILITATION IMPACT

In future guidelines, FC should have an active and supporting role in the diagnostic and rehabilitative process of DOC.

Cognitive telerehabilitation: an expert consensus paper on current evidence and future perspective

The progressive improvement of the living conditions and medical care of the population in industrialized countries has led to improvement in healthcare interventions, including rehabilitation. From this perspective, Telerehabilitation (TR) plays an important role. TR consists of the application of telemedicine to rehabilitation to offer remote rehabilitation services to the population unable to reach healthcare. TR integrates therapy-recovery-assistance, with continuity of treatments, aimed at neurological and psychological recovery, involving the patient in a family environment, with an active role also of the caregivers. This leads to reduced healthcare costs and improves the continuity of specialist care, as well as showing efficacy for the treatment of cognitive disorders, and leading to advantages for patients and their families, such as avoiding travel, reducing associated costs, improving the frequency, continuity, and comfort of performing the rehabilitation in its own spaces, times and arrangements. The aim of this consensus paper is to investigate the current evidence on the use and effectiveness of TR in the cognitive field, trying to also suggest some recommendations and future perspectives. To the best of our knowledge, this is the first consensus paper among multiple expert researchers that comprehensively examines TR in different neurological diseases. Our results supported the efficacy and feasibility of TR with good adherence and no adverse events among patients. Our consensus summarizes the current evidence for the application of cognitive TR in neurological populations, highlighting the potential of this tool, but also the limitations that need to be explored further.

Assessment of Postural Control in Children with Movement Disorders by Means of a New Technological Tool: A Pilot Study

Considering the variability and heterogeneity of motor impairment in children with Movement Disorders (MDs), the assessment of postural control becomes essential. For its assessment, only a few tools objectively quantify and recognize the difference among children with MDs. In this study, we use the Virtual Reality Rehabilitation System (VRRS) for assessing the postural control in children with MD. Furthermore, 16 children (mean age 10.68 ± 3.62 years, range 4.29-18.22 years) were tested with VRRS by using a stabilometric balance platform. Postural parameters, related to the movements of the Centre of Pressure (COP), were collected and analyzed. Three different MD groups were identified according to the prevalent MD: dystonia, chorea and chorea-dystonia. Statistical analyses tested the differences among MD groups in the VRRS-derived COP variables. The mean distance, root mean square, excursion, velocity and frequency values of the dystonia group showed significant differences (p < 0.05) between the chorea group and the chorea-dystonia group. Technology provides quantitative data to support clinical assessment: in this case, the VRRS detected differences among the MD patterns, identifying specific group features. This tool could be useful also for monitoring the longitudinal trajectories and detecting post-treatment changes.

Effectiveness of telerehabilitation plus virtual reality (Tele-RV) in cognitive e social functioning: A randomized clinical study on Parkinson's disease

INTRODUCTION

Telemedicine could represent an emerging and innovative approach to support cognitive and behavioral rehabilitation reducing the overload of healthcare facilities, favoring home care therapy. The present study aimed to assess the potential efficacy of Tele-VR apps in enhancing cognitive performance and improving social skills in patients with Parkinson's disease (PD).

METHODS

Thirty-four patients with PD were included in the study. Patients were assigned to one of the following treatment groups: Experimental Group 1 (EG1) underwent a Tele-VR program using two cognitive rehabilitation applications (app) on smartphones (Neuronation-Brain Training and Train your Brain); Experimental Group 2 (EG2) received a Tele-VR program through one cognitive rehabilitation app (Neuronation-Brain Training) and one socio-cognitive rehabilitation App (The Sims) on smartphones; Active Control Group (aCG) performed a conventional training using pencil and paper exercises (Not-VR).

RESULTS

At the end of the study, the aCG and EG1 presented an improvement in the executive, attentional and visuospatial cognitive domains. Mood and subjective memory also improved in the EG1. Moreover, in the EG2 group, a significant improvement was found in all cognitive domains, including social cognition skills (theory of mind). The inter-group comparison showed that both EG1 and EG2 had significantly greater improvements than aCG in MoCA score. Finally, both EG1 and EG2 showed a higher improvement in the FAB score, as compared to the aCG.

CONCLUSION

Rehabilitation with smartphone apps could be more useful than conventional rehabilitation in improving cognitive and social cognition skills in patients with PD. Combining cognitive and social cognition training could improve the cognitive and affective domains, also aiding in the long-term maintenance of cognitive outcomes.

Efficacy of non-immersive virtual reality-based telerehabilitation on postural stability in Parkinson's disease: a multicenter randomized controlled trial

BACKGROUND

The implementation of regular prolonged, and effective rehabilitation in people with Parkinson's disease is essential for ensuring a good quality of life. However, the continuity of rehabilitation care may find barriers related to economic, geographic, and social issues. In these scenarios, telerehabilitation could be a possible solution to guarantee the continuity of care.

AIM

To investigate the efficacy of non-immersive virtual reality-based telerehabilitation on postural stability in people with Parkinson's disease, compared to at-home self-administered structured conventional motor activities.

DESIGN

Multicenter randomized controlled trial.

SETTING

Five rehabilitation hospitals of the Italian Neuroscience and Rehabilitation Network.

POPULATION

Individuals diagnosed with Parkinson's disease.

METHODS

Ninety-seven participants were randomized into two groups: 49 in the telerehabilitation group (non-immersive virtual reality-based telerehabilitation) and 48 in the control group (at-home self-administered structured conventional motor activities). Both treatments lasted 30 sessions (3-5 days/week for, 6-10 weeks). Static and dynamic balance, gait, and functional motor outcomes were registered before and after the treatments.

RESULTS

All participants improved the outcomes at the end of the treatments. The primary outcome (mini-Balance Evaluation Systems Test) registered a greater significant improvement in the telerehabilitation group than in the control group. The gait and endurance significantly improved in the telerehabilitation group only, with significant within-group and between-group differences.

CONCLUSIONS

Our results showed that non-immersive virtual reality-based telerehabilitation is feasible, improves static and dynamic balance, and is a reasonably valuable alternative for reducing postural instability in people with Parkinson's disease.

CLINICAL REHABILITATION IMPACT

Non-immersive virtual reality-based telerehabilitation is an effective and well-tolerated modality of rehabilitation which may help to improve access and scale up rehabilitation services as suggested by the World Health Organization's Rehabilitation 2030 agenda.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part III: Executive Functions

INTRODUCTION

Moderate-to-severe traumatic brain injury (MS-TBI) causes debilitating and enduring impairments of executive functioning and self-awareness, which clinicians often find challenging to address. Here, we provide an update to the INCOG 2014 guidelines for the clinical management of these impairments.

METHODS

An expert panel of clinicians/researchers (known as INCOG) reviewed evidence published from 2014 and developed updated recommendations for the management of executive functioning and self-awareness post-MS-TBI, as well as a decision-making algorithm, and an audit tool for review of clinical practice.

RESULTS

A total of 8 recommendations are provided regarding executive functioning and self-awareness. Since INCOG 2014, 4 new recommendations were made and 4 were modified and updated from previous recommendations. Six recommendations are based on level A evidence, and 2 are based on level C. Recommendations retained from the previous guidelines and updated, where new evidence was available, focus on enhancement of self-awareness (eg, feedback to increase self-monitoring; training with video-feedback), meta-cognitive strategy instruction (eg, goal management training), enhancement of reasoning skills, and group-based treatments. New recommendations addressing music therapy, virtual therapy, telerehabilitation-delivered metacognitive strategies, and caution regarding other group-based telerehabilitation (due to a lack of evidence) have been made.

CONCLUSIONS

Effective management of impairments in executive functioning can increase the success and well-being of individuals with MS-TBI in their day-to-day lives. These guidelines provide management recommendations based on the latest evidence, with support for their implementation, and encourage researchers to explore and validate additional factors such as predictors of treatment response.

Innovative Technologies in the Neurorehabilitation of Traumatic Brain Injury: A Systematic Review

Motor and cognitive rehabilitation in individuals with traumatic brain injury (TBI) is a growing field of clinical and research interest. In fact, novel rehabilitative approaches allow a very early verticalization and gait training through robotic devices and other innovative tools boosting neuroplasticity, thanks to the high-intensity, repetitive and task-oriented training. In the same way, cognitive rehabilitation is also evolving towards advanced interventions using virtual reality (VR), computer-based approaches, telerehabilitation and neuromodulation devices. This review aimed to systematically investigate the existing evidence concerning the role of innovative technologies in the motor and cognitive neurorehabilitation of TBI patients. We searched and reviewed the studies published in the Cochrane Library, PEDro, PubMed and Scopus between January 2012 and September 2022. After an accurate screening, only 29 papers were included in this review. This systematic review has demonstrated the beneficial role of innovative technologies when applied to cognitive rehabilitation in patients with TBI, while evidence of their effect on motor rehabilitation in this patient population is poor and still controversial.

Acute traumatic brain injury in frail patients: the next pandemic

PURPOSE OF REVIEW

To highlight recent findings on the evaluation and impact of frailty in the management of patients with traumatic brain injury (TBI).

RECENT FINDINGS

Frailty is not a direct natural consequence of aging. Rather, it commonly results from the intersection of age-related decline with chronic diseases and conditions. It is associated with adverse outcomes such as institutionalization, falls, and worsening health status. Growing evidence suggests that frailty should be a key consideration both in care planning and in adverse outcome prevention. The prevalence of elderly patients with TBI is increasing, and low-energy trauma (i.e., ground or low-level falls, which are typical in frail patients) is the major cause. Establishing the real incidence of frailty in TBI requires further studies. Failure to detect frailty potentially exposes patients to interventions that may not benefit them, and may even harm them. Moreover, considering patients as 'nonfrail' purely on the basis of their age is unacceptable. The future challenge is to shift to a new clinical paradigm characterized by more appropriate, goal-directed care of frail patients.

SUMMARY

The current review highlights the crucial importance of frailty evaluation in TBI, also given the changing epidemiology of this condition. To ensure adequate assessment, prevention and management, both in and outside hospital, there is an urgent need for a valid screening tool and a specific frailty-based and comorbidity-based clinical approach.

Is the "Family Glass Cabin" Useful to Safely Allow Inpatient-Caregiver Interaction in the COVID-19 Era? A Pilot Study on Severe Acquired Brain Injury

Acquired Brain Injury (ABI) is a life-changing event that can have a devastating impact on all aspects of a person’s functioning. Patients with ABI present several behavioral problems that have worsened during the COVID-19 pandemic. This study aimed at investigating the role of a “Family Glass Cabin” (FGC) both in improving cognitive function and communicative abilities of people with ABI and in potentiating the mental health of their caregivers. Fifteen subjects affected by ABI and their caregivers were enrolled in this experimental study. Training was performed through the FGC and was based on either psychoeducational sessions for the caregivers or cognitive stimulations for the patients. The participants attended biweekly meetings for 12 consecutive weeks. Each participant was assessed by means of a complete psychometric and clinical battery, before (T0) and after (T1) the training. We found significant changes in all patients’ outcomes, including global cognitive function and communication abilities (p < 0.01), as well as an improvement in caregivers’ well-being. Our data suggest that the physical presence of the caregiver in the rehabilitation setting, using a safe setting such as the FGC, can be a valuable means to increase ABI patients’ functional recovery and reduce caregivers’ anxiety and emotional burden.

Is intensive gait training feasible and effective at old age? A retrospective case-control study on the use of Lokomat Free-D in patients with chronic stroke

BACKGROUND

In the last decade, the number of people over 60 has increased, leading to various healthcare problems. The aim of this retrospective study is to evaluate the effects of robotic rehabilitation in elderly patients as well as their perception of usability and adaptation to intensive robotic neurorehabilitation.

METHODS

This is a retrospective case-control study. Eighty elderly stroke patients were included in the analysis using an electronic data retrieval system. The enrolled patients were divided into two groups: the experimental group (EG) underwent rehabilitation training with Lokomat FreeD, equipped with a VR screen, while the control group (CG) performed traditional rehabilitation training. The two groups matched for age, sex, education, brain injury, stroke interval. The rehabilitation protocol included a total of 40 training sessions.

RESULTS

Both types of rehabilitation led to an improvement in the perceived level of disability (FIM) and in the performance in gait and balance (TT), highlighting a significant improvement especially in the EG. However, only in the EG, Lokomat training had induced an increase in the distance covered in 10 min (10 m walk test), and a significant improvement in mood (HRS-D). Moreover, Lokomat-FreeD was well tolerated by patients with high levels of usability.

CONCLUSIONS

Our results suggest that elderly patients may benefit from high-intensity robotic neurorehabilitation using the Lokomat-Pro FreeD.

Cycling: how can we activate care-dependent older adults with a mild cognitive impairment?

PURPOSE

In residential care, 50% of older adults are sedentary in most of their time, regardless of the positive impact of physical exercise on health. This study analysed whether television images positively impact the motivation and exercise intensity of cycling exercises of older adults in residential care.

METHODS

In this randomised controlled cross-over study, 10 residential older adults (mean age 85.0 ± 5.7 years) with Mild Cognitive Impairment (MCI) participated in 3 different cycling exercise interventions (TV off, TV turned on the National Geographic channel (NG) and TV with MemoRide software (Activ84Health^®, Leuven, Belgium) (MR) (cybercycling)) compared with a rest condition.

RESULTS

The participants cycled significantly more distance during NG compared with TVoff (p = 0.024). In comparison to the rest condition, the mean heart rate was significantly higher in all exercise conditions while the maximal heart rate was only higher during NG (p = 0.022). There was no difference in the Borg scale between the different exercise interventions. Interest and enjoyment scored significantly higher during NG (p = 0.014) and MR (p = 0.047) compared to the rest condition and in the NG versus TVoff (p = 0.018). No significant differences were observed in the emotions of the participants.

CONCLUSIONS

This study has shown indications that the addition of television images may increase the exercise intensity and motivation to exercise in residential older adults with MCI. However, the overall levels of physical activity were insufficient to meet the recommendations for moderate-intense aerobic exercise according to the International Association of Gerontology and Geriatrics and Global Ageing Research Network.Implications for rehabilitationCycling in front of a television increases the exercise volume and motivation to exercise in residential (pre)frail older adults with MCICybercycling had no additional effect in comparison to television images not linked to the exercise.Even with television images (pre)frail older adults with MCI did not meet the recommendations for moderate-intense aerobic exercise for residential older adults according to the IAGG-GARN.