Effects of Action Observation Plus Motor Imagery Administered by Immersive Virtual Reality on Hand Dexterity in Healthy Subjects

Action observation and motor imagery (AOMI) are commonly delivered through a laptop screen. Immersive virtual reality (VR) may enhance the observer's embodiment, a factor that may boost AOMI effects. The study aimed to investigate the effects on manual dexterity of AOMI delivered through immersive VR compared to AOMI administered through a laptop. To evaluate whether VR can enhance the effects of AOMI, forty-five young volunteers were enrolled and randomly assigned to the VR-AOMI group, who underwent AOMI through immersive VR, the AOMI group, who underwent AOMI through a laptop screen, or the control group, who observed landscape video clips. All participants underwent a 5-day treatment, consisting of 12 min per day. We investigated between and within-group differences after treatments relative to functional manual dexterity tasks using the Purdue Pegboard Test (PPT). This test included right hand (R), left hand (L), both hands (B), R + L + B, and assembly tasks. Additionally, we analyzed kinematics parameters including total and sub-phase duration, peak and mean velocity, and normalized jerk, during the Nine-Hole Peg Test to examine whether changes in functional scores may also occur through specific kinematic patterns. Participants were assessed at baseline (T0), after the first training session (T1), and at the end of training (T2). A significant time by group interaction and time effects were found for PPT, where both VR-AOMI and AOMI groups improved at the end of training. Larger PPT-L task improvements were found in the VR-AOMI group (d: 0.84, CI95: 0.09-1.58) compared to the AOMI group from T0 to T1. Immersive VR used for the delivery of AOMI speeded up hand dexterity improvements.

Influence of Backpack Carriage and Walking Speed on Muscle Synergies in Healthy Children

Four to five muscle synergies account for children's locomotion and appear to be consistent across alterations in speed and slopes. Backpack carriage induces alterations in gait kinematics in healthy children, raising questions regarding the clinical consequences related to orthopedic and neurological diseases and ergonomics. However, to support clinical decisions and characterize backpack carriage, muscle synergies can help with understanding the alterations induced in this condition at the motor control level. In this study, we investigated how children adjust the recruitment of motor patterns during locomotion, when greater muscular demands are required (backpack carriage). Twenty healthy male children underwent an instrumental gait analysis and muscle synergies extraction during three walking conditions: self-selected, fast and load conditions. In the fast condition, a reduction in the number of synergies (three to four) was needed for reconstructing the EMG signal with the same accuracy as in the other conditions (three to five). Synergies were grouped in only four clusters in the fast condition, while five clusters were needed for the self-selected condition. The right number of clusters was not clearly identified in the load condition. Speed and backpack carriage altered nearly every spatial-temporal parameter of gait, whereas kinematic alterations reflected mainly hip and pelvis adaptations. Although the synergistic patterns were consistent across conditions, indicating a similar motor pattern in different conditions, the fast condition required fewer synergies for reconstructing the EMG signal with the same level of accuracy.

Early sleep after action observation plus motor imagery improves gait and balance abilities in older adults

Action observation plus motor imagery (AOMI) is a rehabilitative approach to improve gait and balance performance. However, limited benefits have been reported in older adults. Early sleep after motor practice represents a strategy to enhance the consolidation of trained skills. Here, we investigated the effects of AOMI followed by early sleep on gait and balance performance in older adults. Forty-five older adults (mean age: 70.4 ± 5.2 years) were randomized into three groups performing a 3-week training. Specifically, AOMI-sleep and AOMI-control groups underwent observation and motor imagery of gait and balance tasks between 8:00 and 10:00 p.m. or between 8:00 and 10:00 a.m. respectively, whereas Control group observed landscape video-clips. Participants were assessed for gait performance, static and dynamic balance and fear of falling before and after training and at 1-month follow-up. The results revealed that early sleep after AOMI training sessions improved gait and balance abilities in older adults compared to AOMI-control and Control groups. Furthermore, these benefits were retained at 1-month after the training end. These findings suggested that early sleep after AOMI may represent a safe and easy-applicable intervention to minimize the functional decay in older adults.

Action observation plus motor imagery and somatosensory discrimination training are effective non-motor approaches to improve manual dexterity

BACKGROUND

Action observation plus motor imagery (AOMI) and somatosensory discrimination training (SSDT) represent sensory input-based approaches to train the motor system without necessarily asking subjects to perform active movements.

PURPOSE

To investigate AOMI and SSDT effects compared to no intervention on manual dexterity in healthy subjects.

STUDY DESIGN

Randomized controlled study.

METHODS

Sixty healthy right-handed participants were randomized into AOMI, SSDT or Control (CTRL) groups. AOMI observed video-clips including right-hand dexterity tasks and concurrently performed motor imagery, SSDT performed surfaces recognition and 2-point distance discrimination tasks with the right hand, whereas CTRL underwent no intervention. A blinded physiotherapist assessed participants for manual dexterity using the Purdue Pegboard Test (Right hand-R, Left hand-L, Both hands-B, R+L+B and assembly tasks) at baseline (T0) and training end (T1). A mixed-design Analysis of Variance with Time as within-subject factor and Group as between-subject factor was used to investigate between-group differences over time.

RESULTS

A Time by Group interaction and Time effect were found for R task, which increased from T0 to T1 in all groups with very large effect sizes for SSDT (d = 1.8, CI95 2.4-1.0, P < .001) and AOMI (d = 1.7, CI95 2.5-1.0, P < .001) and medium effect size for CTRL (d = 0.6, CI95 1.2-0.2, P < .001). Between-group post-hoc comparison for deltas (T1-T0) showed large effect size (d = 1.0, CI95 1.6-0.3, P = .003) in favor of SSDT and medium effect size (d = 0.7, CI95 1.4-0.1, P = .026) in favor of AOMI compared to CTRL. Time effects were found for L, B, R + L + B and assembly tasks (P < .001).

CONCLUSIONS

AOMI and SSDT induced greater manual dexterity improvements than no intervention. These findings supported the role of visual and somatosensory stimuli in building a motor plan and enhancing the accuracy of hand movements. These non-motor approaches may enhance motor performance in job or hobbies requiring marked manual dexterity.

Telerehabilitation for Stroke: A Personalized Multi-Domain Approach in a Pilot Study

Stroke, a leading cause of long-term disability worldwide, manifests as motor, speech language, and cognitive impairments, necessitating customized rehabilitation strategies. In this context, telerehabilitation (TR) strategies have emerged as promising solutions. In a multi-center longitudinal pilot study, we explored the effects of a multi-domain TR program, comprising physiotherapy, speech therapy, and neuropsychological treatments. In total, 84 stroke survivors (74 analyzed) received 20 tailored sessions per domain, addressing individual impairments and customized to their specific needs. Positive correlations were found between initial motor function, cognitive status, independence in activities of daily living (ADLs), and motor function improvement after TR. A lower initial health-related quality of life (HRQoL) perception hindered progress, but improved ADL independence and overall health status, and reduced depression correlated with a better QoL. Furthermore, post-treatment improvements were observed in the entire sample in terms of fine motor skills, upper-limb functionality, balance, independence, and cognitive impairment. This multi-modal approach shows promise in enhancing stroke rehabilitation and highlights the potential of TR in addressing the complex needs of stroke survivors through a comprehensive support and interdisciplinary collaboration, personalized for each individual's needs.

Joint pressure stimuli increase quadriceps strength and neuromuscular activity in patients with knee osteoarthritis

The study investigated the effects of periarticular knee pressure stimuli on quadriceps strength and neuromuscular activity in subjects with knee osteoarthritis. Twenty-five subjects with knee osteoarthritis and 25 age-matched healthy controls performed maximal voluntary knee extension tasks on an isometric dynamometer. Three different pressure stimuli (no-pressure, 60-mmHg, 120-mmHg) were applied using a sphygmomanometer via the cuff covering the knee joint. Peak torque and root-mean-square peak of rectus femoris (RF), vastus medialis (VM), and vastus lateralis (VL) were collected and normalized for the no-pressure condition (nTorque-peak and nRMS-peak). Normalized Torque-peak increased from no-pressure to 60-mmHg and 120-mmHg in patients, which revealed higher nTorque-peak during 60-mmHg (MD: 10.9%, IC95: 1.8%, 20.1%, p = 0.020) and 120-mmHg (MD: 16.0%, IC95: 4.4%, 27.6%, p = 0.008) conditions than healthy subjects. Moreover, nRMS-peak increased from no-pressure to 60-mmHg for RF, from no-pressure to 120-mmHg for RF, VM and VL, and from 60-mmHg to 120 mm-Hg for VL in patients. Patients revealed higher nRMS-peak of RF and VM during 60-mmHg and 120-mmHg conditions than healthy subjects. Periarticular knee pressure stimuli enhanced quadriceps strength and neuromuscular activity in subjects with knee osteoarthritis. This approach may represent a new strength training modality in patients with neuromuscular activation deficits for knee osteoarthritis.

Thoughts and concerns of patients at hospital discharge after lumbar spine surgery. A qualitative study

PURPOSE

The increased rate of surgical interventions point to the necessity to investigate the patient's experience from a biopsychosocial perspective. The aim of this study was to investigate the thoughts and concerns of patients undergoing spinal surgery for lumbar degenerative disease at the time of their discharge from hospital.

METHODS

Semi-structured interviews were conducted with 28 patients. The questions investigated possible concerns associated to discharging them home. A content analysis was performed by a multidisciplinary group to identify the main themes that emerged from the interviews.

RESULTS

The patients were satisfied with the surgeons' preoperative explanations and description of expected prognosis. However, they were disappointed with the lack of information at hospital discharge, in particular regarding practical and behavioral recommendations. The patients expressed clear concerns about being left alone to deal with possible complications or difficulties they may encounter when returning home.

CONCLUSION

This study underlined the patients' need for a comprehensive psychological guidance and possibly a person of reference during the post-operative process. Discussing discharge with the patient was emphasized as an important issue to improve patients' compliance to the recovery process itself. Putting these elements into practice should help spine surgeons to manage better hospital discharge.IMPLICATIONS FOR REHABILITATIONA comprehensive discussion with the patient at the time of hospital discharge is clearly stressed as an important issue to improve patients' adherence to the recovery process.The patients complained of a lack of information when returning home, in particular regarding practical and behavioral recommendations.The patients expressed clear concerns about possible complications or difficulties they may encounter when returning home and they expressed their need to know whom they can contact for help if needed.A better understanding of the thoughts and concerns of patients undergoing spinal surgery at the time of their discharge from hospital should help spine surgeons to improve the management of hospital discharge and the post-operative recovery.

Reliability of Shoulder Helical Axes During Intransitive and Transitive Upper Limb Tasks

Shoulder complex stability can be estimated in vivo through the analysis of helical axes (HAs) dispersion during upper limb movements. The study aimed at investigating test-retest reliability of shoulder HAs dispersion parameters during upper limb tasks. Twenty healthy volunteers performed 2 intransitive (shoulder flexion and rotation) and one transitive (combing) tasks with the dominant and nondominant upper limbs during 2 recording sessions at 1-week distance. Kinematics was detected through an optoelectronic system. Mean distance and mean angle (MA) were adopted as HAs dispersion indexes. Reliability was excellent for mean distance (intraclass correlation coefficient [ICC]: .91) and MA (ICC: .92) during dominant flexion, and good for MA (ICC: .90) during nondominant flexion. Moderate reliability was found for HAs parameters during rotation (ICCs from .70 to .59), except for MA during dominant rotation where reliability was poor. Reliability was good for mean distance (ICC: .83) and moderate for MA (ICC: .67) during the dominant combing task, whereas no reliability was found during the nondominant combing task. HAs dispersion parameters revealed high reliability during simple intransitive tasks with the dominant limb. Reliability decreased with the increase in task complexity due to the increase in movement variability. HAs dispersion technique could be used to assess shoulder complex stability in patients after rehabilitation or surgery.

What networks in the brain system sustain imagination?

The brain cannot stop elaborating information. While the circuitries implied in processing sensory information, and those involved in programming and producing movements, have been extensively studied and characterized, what circuits elicit and sustain the endogenous activity (which might be referred to as imaginative activity) has not been clarified to a similar extent. The two areas which have been investigated most intensely are visual and motor imagery. Visual imagery mostly involves the same areas as visual processing and has been studied by having the subject face specific visual imagery tasks that are related to the use of the visual sketchpad as a component of the working memory system. Much less is known about spontaneous, free visual imagination, what circuits drive it, how and why. Motor imagery has been studied with several approaches: the neural circuits activated in the brain during performance of a movement have been compared with those involved in visually or kinaesthetically imagining performing the same movement, or in observing another person performing it. Some networks are similarly activated in these situations, although primary motor neurons are only activated during motor execution. Imagining the execution of an action seems unable to activate circuits involved in eliciting accompanying motor adjustments (such as postural adaptations) that are unconsciously (implicitly) associated to the execution of the movement. A more faithful neuronal activation is obtained through kinaesthetic motor imagination-imagining how it feels to perform the movement. Activation of sensory-motor and mirror systems, elicited by observing another person performing a transitive action, can also recruit circuits that sustain implicit motor responses that normally accompany the overt movement. This last aspect has originated the expanding and promising field of action observation therapy (AOT). The fact that the various kinds of motor imagery differentially involve the various brain networks may offer some hints on what neural networks sustain imagery in general, another activity that has an attentive component-recalling a memory, covertly rehearsing a speech, internally replaying a behaviour-and a vague, implicit component that arises from the freely flowing surfacing of internal images, not driven by intentional, conscious control.

Kinematic evaluation and reliability assessment of the Nine Hole Peg Test for manual dexterity

BACKGROUND

The Nine Hole Peg Test (NHPT) is one of the most frequently used tools to assess manual dexterity. However, no kinematic parameters are provided to describe the quality of the motor performance, since time is the only score.

PURPOSE

To investigate test-retest and intra-rater reliability, correlation with clinical test score, and discriminant validity of kinematic indexes during NHPT.

STUDY DESIGN

A clinical measurement study.

METHODS

Twenty-five healthy right-handed volunteers performed the NHPT. An experienced physiotherapist administered two sessions at a 6-hour interval with two trials for dominant and non-dominant upper limbs. An optoelectronic system was used to detect NHPT performance, which was divided into nine consecutive peg-grasp, peg-transfer, peg-in-hole, hand-return phases, and one final removing phase. Outcome measures were total and single phases times, normalized jerk, mean, peak and time-to-peak of velocity, curvature index during peg-grasp and hand-return phases, and trunk 3D displacement. The statistical analysis included Intraclass Correlation Coefficients (ICCs) for test-retest and intra-rater reliability, Pearson's coefficients for correlation with the NHPT score, and paired t-tests for discriminant validity.

RESULTS

Test-retest reliability was excellent for trunk rotation (ICC: 0.91) and good to moderate for the other indexes (ICCs: 0.89-0.61). Intra-rater reliability was excellent for total and removing times (ICCs: 0.91 and 0.94) and good to moderate for the other indexes (ICCs: 0.84-0.66), except for trunk inclination (ICC: 0.37). NHPT phases, normalized jerk, mean velocity, peak of velocity, time-to-peak and curvature index correlated with total time (r-score: 0.8-0.3). NHPT phases and most kinematic indexes discriminated the dominant from non-dominant upper limb, with the greatest effect size for normalized jerk during hand-return (d = 1.16).

CONCLUSIONS

Kinematic indexes during NHPT can be considered for manual dexterity assessment. These indexes may allow for the detection of kinematic changes responsible for NHPT score variations in healthy subjects or patients with upper limb impairments.

Motor resonance to non-visible postural adaptation: A novel aspect of the mirror mechanism

The activation of the Mirror Neuron System (MNS) has been described to reflect visible movements, but not postural, non-visible, adaptations that accompany the observed movements. Since any motor act is the result of a well-tailored dialogue between these two components, we decided to investigate whether a motor resonance to nonvisible postural adaptations could be detected. Possible changes in soleus corticospinal excitability were investigated by eliciting the H-reflex during the observation of three videos, corresponding to three distinct experimental conditions: 'Chest pass', 'Standing' and 'Sitting', and comparing its size with that measured during observation of a control videoclip (a landscape). In the observed experimental conditions, the Soleus muscle has different postural roles: a dynamic role in postural adaptations during the Chest pass; a static role while Standing still; no role while Sitting. The H-reflex amplitude was significantly enhanced in the 'Chest pass' condition compared to the 'Sitting' and 'Standing' conditions. No significant difference was found between 'Sitting' and 'Standing' conditions. The increased corticospinal excitability of the Soleus during the 'Chest pass' condition suggests that the mirror mechanisms produce a resonance to postural components of an observed action, although they may not be visible. This observation highlights the fact that mirror mechanisms echo non intentional movements as well and points to a novel possible role of mirror neurons in motor recovery.

Test-retest reliability of a photographic marker-based system for postural examination

BACKGROUND

The BHOHB system (Bhohb S.r.l., Italy) is a portable non-invasive photographic marker-based device for postural examination.

OBJECTIVE

To assess the test-retest reliability of the BHOHB system and compare its reliability with an optoelectronic system (SMART-DX 700, BTS, Italy).

METHODS

Thirty volunteers were instructed to stand upright with five markers on the spinous processes of C7, T6, T12, L3 and S1 vertebrae to define the dorsal kyphosis and lumbar lordosis (sagittal plane) angles. Three markers were placed on the great trochanter, apex of iliac crest and lateral condyle of the femur to detect pelvic tilt. Finally, to define angles between the acromion and the spinous processes (frontal plane), two markers were placed on the right and left acromion. Postural angles were recoded simultaneously with BHOHB and optoelectronic systems during two consecutive recording sessions.

RESULTS

The BHOHB system revealed excellent reliability for all the angles (ICCs: 0.92-0.99, SEM: 0.78∘-3.33∘) as well as a shorter processing time compared to the optoelectronic system. Excellent reliability was also found for all the angles detected through the optoelectronic system (ICCs: 0.91-0.99, SEM: 0.84∘-2.80∘).

CONCLUSION

The BHOHB system resulted as a reliable non-invasive and user-friendly device to monitor spinal posture, especially in subjects requiring repeat examinations.

Balance improvements in healthy subjects are independent to postural strategies involved in the training

BACKGROUND

Adequate postural strategies have a pivotal role in ensuring balance during the performance of daily or sport activities. These strategies are responsible for the management of center of mass kinematics and depend on the magnitude of perturbations and posture assumed by a subject.

RESEARCH QUESTION

Are there differences in postural performance after a standardized balance training performed in sitting versus standing posture in healthy subjects? Does a standardized unilateral balance training with the dominant or non-dominant limb improve balance on trained and untrained limbs in healthy subjects?

METHODS

Seventy-five healthy subjects reporting a right-leg dominance were randomized into a Sitting, Standing, Dominant, Non-dominant or Control groups. In the Experiment 1, Sitting group performed a 3-week balance training in seated posture, whereas Standing group performed the same training in bipedal stance. In the Experiment 2, Dominant and Non-dominant groups underwent a 3-week standardized unilateral balance training on the dominant and non-dominant limbs, respectively. Control group underwent no intervention and was included in both experiments. Dynamic (Lower Quarter Y-Balance Test with the dominant and non-dominant limbs and trunk and lower limb 3D kinematics) and static (center of pressure kinematics in bipedal and bilateral single-limb stance) balance were assessed before and after the training, and at 4 weeks follow-up.

RESULTS

A standardized balance training in sitting or standing posture improved balance without between-group differences, while a unilateral balance training with the dominant or non-dominant limb improved postural stability on the trained and untrained limbs. Trunk and lower limb joints range of motion increased independently to their involvement in the training.

SIGNIFICANCE

These results may allow clinicians to plan effective balance interventions even when a training in standing posture is not possible or in subjects with restricted limb weight-bearing.

Early sleep after action observation and motor imagery training boosts improvements in manual dexterity

The systematic observation and imagination of actions promotes acquisition of motor skills. Furthermore, studies demonstrated that early sleep after practice enhances motor learning through an offline stabilization process. Here, we investigated behavioral effects and neurodynamical correlates of early sleep after action observation and motor imagery training (AO + MI-training) on motor learning in terms of manual dexterity. Forty-five healthy participants were randomized into three groups receiving a 3 week intervention consisting of AO + MI-training immediately before sleeping or AO + MI-training at least 12 h before sleeping or a control stimulation. AO + MI-training implied the observation and motor imagery of transitive manual dexterity tasks, whereas the control stimulation consisted of landscape video-clips observation. Manual dexterity was assessed using functional tests, kinematic and neurophysiological outcomes before and after the training and at 1-month follow-up. AO + MI-training improved manual dexterity, but subjects performing AO + MI-training followed by early sleep had significantly larger improvements than those undergoing the same training at least 12 h before sleeping. Behavioral findings were supported by neurodynamical correlates during motor performance and additional sleep-dependent benefits were also detected at 1 month follow-up. These findings introduce a new approach to enhance the acquisition of new motor skills or facilitate recovery in patients with motor impairments.

Development of the Italian version of the Consultation and Relational Empathy (CARE) measure: translation, internal reliability, and construct validity in patients undergoing rehabilitation after total hip and knee arthroplasty

PURPOSE

To translate and cross-culturally adapt the Consultation and Relational Empathy (CARE) measure into Italian, examine its internal reliability, and construct validity in a rehabilitation setting.

MATERIALS AND METHODS

The translation process consisted of two forward translations, a pre-final version, a back-translation, and a final version, in accordance with available guidelines. We administered the Italian version of the CARE measure to 101 patients hospitalised for rehabilitation after total hip or total knee arthroplasty (THA and TKA). We assessed face validity, internal reliability, and construct validity.

RESULTS

Face validity was high. Patients answered all questions and the "does not apply" option was never selected. Internal reliability (Cronbach's α = 0.962) resulted in line with the original version. The exploratory factor analysis confirmed the unidimensional structure of the CARE measure with 74.82% of variance explained by the first factor.

CONCLUSIONS

The Italian version of the CARE measure showed high face validity. Internal reliability and construct validity were in line with the original version in patients undergoing rehabilitation after THA and TKA.IMPLICATIONS FOR REHABILITATIONInternal reliability and construct validity of the Italian version of the CARE measure are in line with those of the original version of the CARE measure.The Italian CARE measure can be used to assess patient's perceived therapist's empathy in patients undergoing physical therapy after THA and TKA.Physiotherapists should use the CARE measure with more caution in other rehabilitative contexts.

Translation of surface electromyography to clinical and motor rehabilitation applications: The need for new clinical figures

Advanced sensors/electrodes and signal processing techniques provide powerful tools to analyze surface electromyographic signals (sEMG) and their features, to decompose sEMG into the constituent motor unit action potential trains, and to identify synergies, neural muscle drive, and EEG-sEMG coherence. However, despite thousands of articles, dozens of textbooks, tutorials, consensus papers, and European and International efforts, the translation of this knowledge into clinical activities and assessment procedures has been very slow, likely because of lack of clinical studies and competent operators in the field. Understanding and using sEMG-based hardware and software tools requires a level of knowledge of signal processing and interpretation concepts that is multidisciplinary and is not provided by most academic curricula in physiotherapy, movement sciences, neurophysiology, rehabilitation, sport, and occupational medicine. The chasm existing between the available knowledge and its clinical applications in this field is discussed as well as the need for new clinical figures. The need for updating the training of physiotherapists, neurophysiology technicians, and clinical technologists is discussed as well as the required competences of trainers and trainees. Indications and examples are suggested and provide a basis for addressing the problem. Two teaching examples are provided in the Supplementary Material.

Action Observation and Motor Imagery administered the day before surgery enhance functional recovery in patients after total hip arthroplasty: A randomized controlled trial

OBJECTIVE

To investigate the effects of Action Observation and Motor Imagery administered the day before surgery on functional recovery in patients after total hip arthroplasty.

DESIGN

Randomised controlled trial.

SETTING

Humanitas Clinical and Research Center, Milan, Italy.

PARTICIPANTS

Eighty inpatients with end-stage hip osteoarthritis undergoing total hip arthroplasty.

INTERVENTIONS

All patients followed a standardized postoperative rehabilitation program. Experimental group (AO + MI) performed two 12-minute Action Observation and Motor Imagery sessions on the preoperative day, whereas control group underwent usual care consisting of education without any additional preoperative activity.

OUTCOME MEASURES

A blinded physiotherapist assessed participants for functional mobility (Timed Up and Go - TUG) (primary outcome), maximum walking speed (10-Meter Walk Test - 10MWT), pain (Numeric Pain Rating Scale - NPRS) and fear of movement (Tampa Scale of Kinesiophobia - TSK) the day before and at four days after surgery.

RESULTS

No between-group differences were found at baseline. Although TUG and 10MWT worsened in both groups (p < 0.001), better TUG was found for AO + MI group at four days (mean difference -5.8 s, 95% confidence interval from -11.3 to -0.3 s, p = 0.039). NPRS (p < 0.001) and TSK (p = 0.036 for AO + MI group, p = 0.003 for control group) improved after surgery without between-group differences.

CONCLUSIONS

Patients undergoing Action Observation and Motor Imagery on the day before surgery showed less functional decline than control group in the first days after total hip arthroplasty. This intervention may contribute to a safer discharge with higher functional abilities in patients hospitalized for total hip arthroplasty.

Selecting a pre-processing pipeline for the analysis of EEG event-related rhythms modulation

When deciding how to pre-process EEG data, researchers need to make a choice at each single step of the procedure among different possibilities, equally valid. Therefore, in this work, we illustrate how these decisions may affect the quality of the final cleaned data in an Action Observation/Motor Imagery protocol, using quantitative indices. In particular, we showed the effect of segmenting or not the data in epochs around the stimulus presentation time on the independent component analysis (ICA) used for artifact removal. For ICA analysis, we tested two algorithms (SOBI and Extended Infomax). Finally, three re-reference approaches (Common averaged reference-CAR, robust-CAR and reference electrode standardization technique - REST) were also applied and their effects compared. Results showed that the segmenting method has a prominent effect on the cleaning procedure and consequently on final EEG data quality. Extended Infomax is confirmed as the method of choice for the identification of the artifactual components and, finally, CAR and the REST re-referencing techniques led to similar good results.

Action Observation Therapy Before Sleep Hours: An EEG Study

Action Observation Therapy (AOT) is a rehabilitation method which aims at stimulating motor memory by means of the repetitive observation of motor tasks presented through video-clips. Since sleep seems to have a positive effect on learning processes, it is reasonable to hypothesize that the delivery of AOT immediately before sleep hours could enhance the effects of motor training. The objective of the present work was to test the effect of AOT delivered before the sleep hours in terms of improvements in manual dexterity and changes in cortical activity through Electroencephalography (EEG) on healthy subjects. Specifically, EEG traces acquired on a treatment and on a control group before and after three weeks of training during the execution of a Nine Hole Peg Test were analyzed. The spectral analysis of brain signals showed an increased activation of the motor cortex on a subgroup of the treatment subjects. Moreover, a significantly higher involvement of frontal areas was observed in the treatment group.

Mapping brain structure and function in professional fencers: A model to study training effects on central nervous system plasticity

Brain magnetic resonance imaging (MRI) studies have shown different patterns of structural and functional reorganization in high‐level athletes compared with controls, but little is known about their relationship with interlimb coordination mechanisms. To this aim, we investigated brain structural and functional differences in high‐level fencers compared with nonathlete controls and the MRI substrates of interlimb coordination in elite athletes. Fourteen right‐handed male fencers (median age = 22.3 years) and 15 right‐handed age‐ and sex‐matched healthy subjects (median age = 22.4 years) underwent structural and functional MRI acquisition during the execution of cyclic bimanual‐movements as well as during in‐phase and antiphase hand/foot‐movements of the dominant‐right limbs. No between‐group differences were found in gray matter volumes and white matter architecture. Active‐fMRI showed that controls versus fencers had higher activations in parietal and temporal areas during bimanual‐task; whereas fencers versus controls had higher activations in the basal ganglia. During in‐phase task, controls versus fencers showed higher activation of right cerebellum, whereas fencers had higher activity mainly in frontal areas. The functional‐connectivity (FC) analysis showed that fencers versus controls had an increased FC between left motor cortex and fronto‐temporal areas as well as bilateral thalami during the different tasks. Intensive and prolonged fencing activity is associated with brain functional changes mainly involving frontal regions related to high‐level motor control and planning of complex tasks. These modifications are likely to reflect an optimization of brain networks involved in motor activities, including interlimb coordination tasks, occurring after intensive training.

Effects of a cool classroom microclimate on cardiac autonomic control and cognitive performances in undergraduate students

An inverted U-shape relationship between cognitive performance and indoor temperature with best performance peaking at 21.6 °C was previously described. Little is known on classroom temperature reduction effects on cognitive performances and cardiac autonomic profile, during the cold season. Fifteen students underwent electrocardiogram recording during a lecture in two days in December when classroom temperatures were set as neutral (NEUTRAL, 20-22 °C) and cool (COOL, 16-18 °C). Cognitive performance (memory, verbal ability, reasoning, overall cognitive C-score) was assessed by Cambridge Brain Science cognitive evaluation tool. Cardiac autonomic control was evaluated via the analysis of spontaneous fluctuations of heart period, as the temporal distance between two successive R-wave peaks (RR). Spectral analysis provided the power in the high frequency (HF, 0.15-0.40 Hz) and low frequency (LF, 0.04-0.15 Hz) bands of RR variability. Sympatho-vagal interaction was assessed by LF to HF ratio (LF/HF). Symbolic analysis provided the fraction of RR patterns composed by three heart periods with no variation (0 V%) and two variations (2 V%), taken as markers of cardiac sympathetic and vagal modulations, respectively. The students' thermal comfort was assessed during NEUTRAL and COOL trials. Classroom temperatures were 21.5 ± 0.8 °C and 18.4 ± 0.4 °C during NEUTRAL and COOL. Memory, verbal ability, C-Score were greater during COOL (13.01 ± 3.43, 12.32 ± 2.58, 14.29 ± 2.90) compared to NEUTRAL (9.98 ± 2.26, p = 0.002; 8.57 ± 1.07, p = 0.001 and 10.35 ± 3.20, p = 0.001). LF/HF (2.4 ± 1.7) and 0 V% (23.2 ± 11.1%) were lower during COOL compared to NEUTRAL (3.7 ± 2.8, p = 0.042; 28.1 ± 12.2.1%, p = 0.031). During COOL, 2 V% was greater (30.5 ± 10.9%) compared to NEUTRAL (26.2 ± 11.3, p = 0.047). The students' thermal comfort was slightly reduced during COOL compared to NEUTRAL trial. During cold season, a better cognitive performance was obtained in a cooler indoor setting enabling therefore energy saving too.

Reference theories and future perspectives on robot-assisted rehabilitation in people with neurological conditions: A scoping review and recommendations from the Italian Consensus Conference on Robotics in Neurorehabilitation (CICERONE)

BACKGROUND

Robot-based treatments are developing in neurorehabilitation settings. Recently, the Italian National Health Systems recognized robot-based rehabilitation as a refundable service. Thus, the Italian neurorehabilitation community promoted a national consensus on this topic.

OBJECTIVE

To conceptualize undisclosed perspectives for research and applications of robotics for neurorehabilitation, based on a qualitative synthesis of reference theoretical models.

METHODS

A scoping review was carried out based on a specific question from the consensus Jury. A foreground search strategy was developed on theoretical models (context) of robot-based rehabilitation (exposure), in neurological patients (population). PubMed and EMBASE® databases were searched and studies on theoretical models of motor control, neurobiology of recovery, human-robot interaction and economic sustainability were included, while experimental studies not aimed to investigate theoretical frameworks, or considering prosthetics, were excluded.

RESULTS

Overall, 3699 records were screened and finally 9 papers included according to inclusion and exclusion criteria. According to the population investigated, structured information on theoretical models and indications for future research was summarized in a synoptic table.

CONCLUSION

The main indication from the Italian consensus on robotics in neurorehabilitation is the priority to design research studies aimed to investigate the role of robotic and electromechanical devices in promoting neuroplasticity.

Static and dynamic pelvic kinematics after one-stage bilateral or unilateral total hip arthroplasty

INTRODUCTION

The pelvis rotates simultaneously around both hips along sagittal, frontal and transversal planes and its kinematics change in patients after total hip arthroplasty (THA). Consequently, it is reasonable to expect different pelvic kinematic profiles in bilateral or unilateral THA. Therefore, the aim of this study was to compare pelvic kinematics in patients with bilateral or unilateral THA.

METHODS

40 patients undergoing bilateral (n = 20) or unilateral (n = 20) THA were evaluated for pelvic kinematics during standing and walking tasks using an optoelectronic system. Mean pelvic orientation was assessed during standing, whereas the Gait Variable Score (GVS), maximum and minimum peaks, range and values of pelvic tilt, obliquity and rotation during Heel-Strike and Toe-Off phases of gait cycle were calculated during walking. Data were collected the day before and at seven days after surgery.

RESULTS

At baseline, no between-group differences were found. At 7 days, GVS for pelvic tilt (p = 0.029) and rotation (p = 0.046) were closer to normative data in bilateral patients, who also revealed lower maximum peak of anterior tilt (p = 0.013) and lower range of pelvic tilt during gait (p = 0.031) with respect to unilateral cases. No between-group differences were found for pelvic orientation during standing at any time-point.

CONCLUSIONS

Bilateral patients revealed more physiological pelvic kinematics than unilateral cases. These findings underline the advantage of patients undergoing 1-stage bilateral THA and may be helpful in selecting personalised rehabilitative approaches.

Agreement between the inertial measurement unit and optoelectronic system to measure postural sway

BACKGROUND

Optoelectronic systems and force platforms represent the gold standard for postural sway assessment, but pose disadvantages in terms of equipment, cost and preparation time.

OBJECTIVE

Wearable inertial measurement units (IMUs) have been proposed to overcome these issues, but have never been compared to an optoelectronic system. The study aim was therefore to investigate agreement between inertial measurement unit and optoelectronic system in postural sway assessment.

METHODS

Thirty healthy volunteers performed four balance tasks. IMU was placed on the sacrum (S2) with a retroreflective marker over the sensor and subjects' performance was simultaneously recorded by both systems. Total (TOT), anterior-posterior (AP) and medial-lateral (ML) length of trace, range, speed, root mean squared (RMS), and confidence ellipse were computed.

RESULTS

ICCs revealed excellent correlations for Length-TOT, Length-AP and Speed-AP, good correlation for Length-ML, Speed-ML, Confidence Ellipse, Range-AP and RMS-AP, and moderate correlation for range-ML and RMS-ML. Bland-Altman plot showed greater estimation for Length-TOT, Length-AP, Speed-AP, confidence ellipse and RMS-AP using optoelectronic system, and for Length-ML, Range-AP, Range-ML, Speed-ML, RMS-ML using IMU. Both systems revealed the same differences among tasks.

CONCLUSION

The excellent to good agreement of IMU for length of trace and speed parameters and its user-friendly application suggest its potential implementations in clinical practice.

The role of mirror mechanism in the recovery, maintenance, and acquisition of motor abilities

While it is well documented that the motor system is more than a mere implementer of motor actions, the possible applications of its cognitive side are still under-exploited, often remaining as poorly organized evidence. Here, we will collect evidence showing the value of action observation treatment (AOT) in the recovery of impaired motor abilities for a vast number of clinical conditions, spanning from traumatological patients to brain injuries and neurodegenerative diseases. Alongside, we will discuss the use of AOT in the maintenance of appropriate motor behavior in subjects at risk for events with dramatic physical consequences, like fall prevention in elderly people or injury prevention in sports. Finally, we will report that AOT can help to tune existing motor competencies in fields requiring precise motor control. We will connect all these diverse dots into the neurophysiological scenario offered by decades of research on the human mirror mechanism, discussing the potentialities for individualization. Empowered by modern technologies, AOT can impact individuals' safety and quality of life across the whole lifespan.

Conservative vs. surgical approach for degenerative meniscal injuries: a systematic review of clinical evidence

OBJECTIVE

Analyzing the available evidence by comparing the role of arthroscopic surgery and conservative treatment in the management of degenerative meniscopathy.

MATERIALS AND METHODS

A literature search was carried out on the PubMed, EMBASE, Scopus, and PEDro databases in May 2019 to identify all the randomized controlled trials (RCTs) comparing arthroscopic surgery to conservative management of painful but stable degenerated menisci. The quality of the RCTs was assessed using the Cochrane Risk of Bias Assessment.

RESULTS

A total of 10 studies, including 1525 patients and dealing with conservative treatment vs. arthroscopic surgery were included in this review. In eight studies the effectiveness of exercise therapy was compared to surgery; in one study the effectiveness of intra-articular steroid injection was compared to surgery; in one study the effectiveness of placebo surgery was compared to partial meniscectomy. In all studies, no significant inter-group difference in terms of knee pain and knee function were observed at any follow-up evaluation.

CONCLUSIONS

Degenerative meniscal tears, without symptoms of locking and catching, can be successfully managed by a proper regimen of physical therapy as a first line treatment. Surgical approach might be considered in case of poor response after conservative treatment.

Dispersion of shoulder helical axes during upper limb movements after muscle fatigue

Shoulder complex control of motion is influenced by neuromuscular function and can be quantified through the analysis of helical axes (HAs) dispersion. Muscle fatigue is a variable able to influence neuromuscular control, altering muscle activation timing and proprioception. The aim of the study was to describe shoulder complex HAs dispersion after muscle fatigue during upper limb movements of young healthy subjects. Thirty healthy right-handed volunteers (age 23.2 ± 2.6 years) were asked to perform a test made up of 15 humerothoracic flexion and rotation movements using both upper limbs in two different recording sessions. After each session, muscles of the tested movement were fatigued in isometric condition at dominant side. After fatigue, subjects repeated the test. Kinematics was recorded by an optoelectronic system and HAs dispersion was computed using Mean Distance (MD) and Mean Angle (MA) for the entire Range of Motion (RoM) and in portions of RoM. After fatigue of shoulder flexion muscles, greater MD (p = 0.001) and MA (p = 0.019) were found on the dominant side. After fatigue of shoulder rotation muscles, greater MD and MA were found on the dominant (p = 0.002 for MD; p = 0.047 for MA) and non-dominant (p = 0.038 for MD; p = 0.019 for MA) sides. Independently of fatigue, greater MA was found in portions of RoM with higher external resistance torque in flexion and rotation tasks. Muscle fatigue increases shoulder complex HAs dispersion, probably due to alteration in neuromuscular control. This data should be considered when exercise involving upper arms are proposed to subjects undergoing fatigue.

Dispersion of knee helical axes during walking in young and elderly healthy subjects

Knee joint rotation center displacement can be estimated in vivo through the analysis of helical axis (HAs) dispersion. HAs can be analyzed during walking, providing information on joint stability. The study aim was to describe knee HAs dispersion during walking in dominant and non-dominant legs of young and elderly healthy subjects. Twenty young (YG: age 23.3 ± 2.4 years) and twenty elderly (EG: age 69.3 ± 4.6 years) healthy subjects were asked to walk on a treadmill at a self-selected speed with reflective markers placed bilaterally on thighs and shanks to detect HAs dispersion and knee kinematics with an optoelectronic system. HAs dispersion was described during the following four phases of gait cycle: (1) flexion from 95% of the previous gait cycle to 10% of the subsequent gait cycle, (2) extension from 10% to 40%, (3) flexion from 40% to 75% and (4) extension from 75% to 95% of the gait cycle. Mean Distance (MD) and Mean Angle (MA) were used as HAs dispersion indexes during each gait phase. Participants showed greater MD and MA in sagittal and frontal planes during the first and second phases. EG revealed higher MD (p = 0.001) and MA (p < 0.001) during the first phase and higher MA (p = 0.001) during the fourth phase in both dominant and non-dominant legs on the sagittal plane. HAs dispersion could be related to the amount of forces acting on knee (first two phases) and knee degeneration (elderly). These results may be used as reference data in further studies on HAs dispersion in presence of knee pathologies or after knee surgery or rehabilitation.

Efficacy and Characteristics of the Stimuli of Action Observation Therapy in Subjects With Parkinson's Disease: A Systematic Review

Background: The discovery of the Mirror Neuron System has promoted the development of Action Observation Therapy (AOT) to improve motor and functional abilities in patients with Parkinson's disease (PD). This innovative approach involves observing video-clips showing motor contents, which may vary across the studies influencing AOT efficacy. To date, no studies have systematically summarized the effects of AOT in patients with PD on motor and functional outcomes, underlining the characteristics of visual stimuli in relation to their efficacy.

Objectives: To describe the potential benefits of AOT in patients with PD and discuss the characteristics of visual stimuli used in clinical studies in relation to their efficacy.

Methods: A systematic literature search was carried out using MEDLINE via PubMed, EMBASE, Scopus, and PEDro, from inception until March 2020. Randomized controlled trials that investigated the effects of AOT on motor and functional recovery in patients with PD were included. Two independent reviewers appraised the records for inclusion, assessed the methodological quality, and extracted the following data: number and characteristics of participants, features and posology of the treatments, outcome measures at each follow-up, and main results. Findings were aggregated into a quantitative synthesis (mean difference and 95% confidence interval) for each time point.

Results: Overall, 7 studies (189 participants) with a mean PEDro score of 6.1 (range: 4–8) points were selected. Included studies revealed AOT as effective in improving walking ability and typical motor signs (i.e., freezing of gait and bradykinesia) in patients with PD. Moreover, when this approach incorporated ecological auditory stimuli, changes to functional abilities and quality of life were also induced, which persisted up to 3 months after treatment. However, included studies adopted AOT stimuli with heterogeneous posology (from a single session to 8 weeks) and characteristics of motor contents might be responsible for different motor and functional recovery (person-related and viewing perspectives, transitive or intransitive actions, healthy subjects or patients, and association or not with imitation).

Conclusions: AOT leads to improvements in motor and functional abilities in patients with PD and the characteristics of visual stimuli may play a role in determining AOT effects, deserving further investigations.

A two-year multicenter point prevalence study of older patients with hip fractures admitted to rehabilitation units in Italy

PURPOSE

To date in Italy we do not have sufficient information on the rehabilitation process of older patients with hip fractures especially in the context of dementia. The main aims of the study were to gather information on the characteristics of older patients with hip fracture admitted to rehabilitation units with a specific focus on geriatric syndromes and the rehabilitation process.

METHODS

A national multi-center "point prevalence study" was conducted in Italy over two index days in 2017 and 2018. All patients aged 70 years and older hospitalized on the index day in Rehabilitation Units after a hip fracture were eligible.

RESULTS

A total of 615 patients were included. Most of the hospitals involved were from northern Italy, to a lesser extent from central and from southern Italy. The mean age was 83.08 ± 7.9 years. Almost half of the patients lived alone before the hip fracture. Most of the falls happened at home and while walking. The prevalence of delirium, dementia and malnutrition was 9.1%, 36.6%, and 19.3%, respectively. Antidepressants were prescribed in 27% of the population. The multidisciplinary team was activated as follows: occupational therapist in 18.9% of the cases, psychologists in 14.5%, social workers in 15.3%, and speech therapists in 6.5%.

CONCLUSION

The study allowed the collection of data on a relatively large sample of older patients with hip fracture showing the possible current limitations in the correct management of geriatric syndromes in this frail population. Future multicenter longitudinal studies are required to further study this population.

Conservative Treatment and Percutaneous Pain Relief Techniques in Patients with Lumbar Spinal Stenosis: WFNS Spine Committee Recommendations

BACKGROUND

Degenerative lumbar spinal stenosis (LSS) is a progressive disease with potentially dangerous consequences that affect quality of life. Despite the detailed literature, natural history is unpredictable. This uncertainty presents a challenge making the correct management decisions, especially in patients with mild to moderate symptoms, regarding conservative or surgical treatment. This article focused on conservative treatment for degenerative LSS.

METHODS

To standardize clinical practice worldwide as much as possible, the World Federation of Neurosurgical Societies Spine Committee held a consensus conference on conservative treatment for degenerative LSS. A team of experts in spinal disorders reviewed the literature on conservative treatment for degenerative LSS from 2008 to 2018 and drafted and voted on a number of statements.

RESULTS

During 2 consensus meetings, 14 statements were voted on. The Committee agreed on the use of physical therapy for up to 3 months in cases with no neurologic symptoms. Initial conservative treatment could be applied without major complications in these cases. In patients with moderate to severe symptoms or with acute radicular deficits, surgical treatment is indicated. The efficacy of epidural injections is still debated, as it shows only limited benefit in patients with degenerative LSS.

CONCLUSIONS

A conservative approach based on therapeutic exercise may be the first choice in patients with LSS except in the presence of significant neurologic deficits. Treatment with instrumental modalities or epidural injections is still debated. Further studies with standardization of outcome measures are needed to reach high-level evidence conclusions.

Does walking the day of total hip arthroplasty speed up functional independence? A non-randomized controlled study

Background

Few data address modalities for speeding up functional independence in subjects included in a fast-track approach after total hip arthroplasty (THA). The study aim was to assess short-term effects of mobilization and walking the day of THA (WDS) on independence, pain, function and quality of life.

Methods

Seventy-one patients were allocated in a study (SG: n = 36) or control (CG: n = 35) groups according to time of surgery and recovery from anesthesia. Patients who recovered lower limbs sensitivity (disappearance of sensation deficits) and motility (MRC scale ≥3 at knee, ankle and great toe extension) by 7.00 p.m. made up the SG, whereas patients who underwent surgery later and recovered from anesthesia after 7.00 p.m. made up the CG. SG underwent WDS, whereas CG performed mobilization and walking the day after surgery starting the same physiotherapy program 1 day later. Patients were evaluated for independence (Functional Independence Measure - FIM), pain (Numeric Rating Scale - NRS), hip function (Harris Hip Score - HHS) and quality of life (EuroQoL-5Dimension - EQ. 5D and EQ. 5D-VAS)the day before surgery, at 3 and 7 days in a hospital setting. Analysis of Covariance with age (SG: mean 60.9, SD 9.0; CG: mean 65.5, SD 8.9) and BMI (SG: mean 27.4, SD 2.8; CG: mean 26.7, SD 2.4) as covariates was used to assess between-group differences over time.

Results

Between-groups differences were observed for FIM total and motor scores (p = 0.002, mean difference: 2.1, CI₉₅: 0.64, 3.7) and FIM self-care (p = 0.01, mean difference: 1.7, CI₉₅: 0.41, 3) in favor of SG at 3 days. Between-group differences were found for FIM self-care (p = 0.021, mean difference: 1.2, CI₉₅: 0.18, 2.1) in favor of SG at 7 days. FIM total and motor scores (p <  0.001), FIM self-care (p = 0.027) and transfer-locomotion (p <  0.001) and HHS (p = 0.032) decreased after surgery followed by improvements in postoperative days (p ≤ 0.001). No differences were found for NRS, EQ. 5D and EQ. 5D-VAS.

Conclusions

WDS produces additional benefits in patients’ independence in the first week after THA. Absence of pain aggravation or adverse effects on hip function and quality of life may allow clinicians to recommend WDS to promote discharge with functional independence.

Capsulectomy vs capsulotomy in total hip arthroplasty. Clinical outcomes and proprioception evaluation: Study protocol for a randomized, controlled, double blinded trial

Background

Patients affected by coxarthrosis may be treated surgically with total hip arthroplasty (THA). During the surgical intervention, the hip joint capsule can be completely removed, performing a capsulectomy. Otherwise it's possible to perform a capsulotomy, which allows for capsular conservation. Since there is no scientific evidence demonstrating the superiority of one method over the other, the choice whether to remove or conserve the capsule is at the surgeon's discretion and both procedures are actually accepted.The purpose of our study is to evaluate the differences in functional activities and proprioception in patients who underwent THA and capsulotomy with capsular conservation versus patients who underwent THA with capsulectomy.

Methods

In order to compare the two surgical techniques of capsulotomy with capsular conservation and capsulectomy, we created a randomized, controlled, double-blind, single-centre, non-pharmacological, interventional, superiority, parallel-group trial. The primary outcome of our study is evaluated using the HOOS scale (Hip disability and Osteoarthritis Outcome Score). Secondary outcomes are: the proprioceptive sensitivity, the postoperative bleeding, the surgical time, the active range of motion, and the ability to walk, sit and stand. The proprioception study is carried out through active and passive repositioning tests. THA is performed through the minimally invasive direct anterior approach. The evaluation tests are carried out in the 15 days preceding the intervention (T0), at 50-day post-operative (T1), and finally at three months after surgery (T2).

Discussion

Considering that the hip joint capsule is innervated by proprioceptive nerve endings, while the psuedocapsule that replaces the native capsule following a THA with capsulectomy doesn't have any active neurophysiological role, we hypothesize that capsulotomy with capsular conservation at the time of primary THA may lead to better proprioception and therefore better functional recovery.

Trial registration

ClinicalTrials.gov identifier: NCT02749058. Date of registration: 04/21/2016.

Can strenuous exercise harm the heart? Insights from a study of cardiovascular neural regulation in amateur triathletes

Regular exercise is recommended to improve the cardiovascular risk profile. However, there is growing evidence that extreme volumes and intensity of long-term exertion may increase the risk of acute cardiac events. The aim of this study is to investigate the after-effects of regular, strenuous physical training on the cardiovascular neural regulation in a group of amateur triathletes compared to age-matched sedentary controls. We enrolled 11 non-elite triathletes (4 women, age 24±4 years), who had refrained from exercise for 72 hours, and 11 age-matched healthy non-athletes (3 women, age 25±2 years). Comprehensive echocardiographic and cardiopulmonary exercise tests were performed at baseline. Electrocardiogram, non-invasive blood pressure, respiratory activity, and muscle sympathetic nerve activity (MSNA) were continuously recorded in a supine position (REST) and during an incremental 15° step-wise head-up tilt test up to 75° (TILT). Blood samples were collected for determination of stress mediators. Autoregressive spectral analysis provided the indices of the cardiac sympathetic (LF_RR) and vagal (HF_RR) activity, the vascular sympathetic control (LF_SAP), and the cardiac sympatho-vagal modulation (LF/HF). Compared to controls, triathletes were characterized by greater LF_RR, LF/HF ratio, LF_SAP, MSNA, and lower HF_RR at REST and during TILT, i.e. greater overall cardiovascular sympathetic modulation together with lower cardiac vagal activity. Cortisol and adrenocorticotropic hormone concentrations were also higher in triathletes. In conclusion, triathletes were characterized by signs of sustained cardiovascular sympathetic overactivity. This might represent a risk factor for future cardiovascular events, given the known association between chronic excessive sympathetic activity and increased cardiovascular risk.

Dispersion of helical axes during shoulder movements in young and elderly subjects

The shoulder complex (SC) consists of joints with little congruence and its active and passive structures ensure its stability. Stability of the SC rotation centre during upper arm movements can be estimated through the analysis of Helical Axes (HAs) dispersion. The aim of this study was to describe shoulder HAs dispersion during upper limb movements performed with dominant and non-dominant arms by young and elderly subjects. Forty subjects participated in the study (20 young: age 24.8 ± 2.8 years and 20 elderly: age 71.7 ± 6.3 years). Subjects were asked to perform four cycles of 15 rotations, flexions, elevations and abductions with one arm at a time at constant speed. Reflective markers were placed on participants' arms and trunk in order to detect movements and the HAs dispersion with an optoelectronic system. Mean Distance (MD) from the HAs barycenter and Mean Angle (MA) were used as HAs dispersion indexes. Young subjects showed significant lower MD compared to the elderly during all motion ranges of rotation, flexion and elevation (p < 0.001). Moreover, the MD was lower in the dominant arm compared to the contralateral for rotation (p = 0.049) and flexion (p = 0.019). The results may be due to joint degeneration described in elderly subjects and differences in neuromuscular control of SC stability.

Can action observation modulate balance performance in healthy subjects?

Background

Action observation activates brain motor networks and, if followed by action imitation, it facilitates motor learning and functional recovery in patients with both neurological and musculoskeletal disorders. To date, few studies suggested that action observation plus imitation can improve balance skills; however, it is still unclear whether the simple repetitive observation of challenging balance tasks is enough to modify postural control. Thus, the primary aim of this study was to investigate whether repetitive action observation of balance exercises without imitation has the potential to improve balance performance; the secondary aim was to estimate the different training effects of action observation, action observation plus imitation and balance training relative to a control condition in healthy subjects.

Methods

Seventy-nine healthy young adults were randomly assigned to 4 groups: action observation, action observation plus imitation, balance training and control. The first three groups were trained for about 30 minutes every day for three weeks, whereas the control group received no training. Center of pressure path length and sway area were evaluated on a force platform at baseline and after training using posturographic tests with eyes open and closed.

Results

As expected, both action observation plus imitation and balance training groups compared to the control group showed balance improvements, with a medium to large effect size performing balance tasks with eyes open. Action observation without imitation group showed a balance improvement with eyes open, but without a significant difference relative to the control group.

Conclusions

Both action observation plus imitation and balance training have similar effects in improving postural control in healthy young subjects. Future studies on patients with postural instability are necessary to clarify whether AOT can induce longer lasting effects. Action observation alone showed a trend toward improving postural control in healthy subjects, suggesting the possibility to study its effects in temporarily immobilized diseased subjects.

Functional and structural plasticity following action observation training in multiple sclerosis

BACKGROUND

Hand motor deficits contribute to multiple sclerosis (MS)-related disability. Action observation training (AOT) is promising to improve upper limb function in neurologic patients.

OBJECTIVES

In this preliminary study, we investigated AOT effects on dominant-hand motor performance in MS patients with upper limb motor impairment and performed an explorative analysis of their anatomical and functional magnetic resonance imaging (MRI) substrates.

METHODS

In total, 46 healthy controls (HC) and 41 MS patients with dominant-hand motor impairment were randomized to AOT (HC-AOT = 23; MS-AOT = 20; watching daily-life action videos and execution) or control-training (HC-Control = 23; MS-Control = 21; watching landscapes videos and execution). Behavioral, structural, and functional (at rest and during object manipulation) MRI scans were acquired before and after a 2-week training.

RESULTS

After training, MS groups improved in right upper limb functions, mainly in AOT group (p from 0.02 to 0.0001). All groups showed regional increased and decreased gray matter volume, with specific AOT effects in fronto-temporal areas in MS-AOT (p < 0.001), without white matter (WM) integrity modifications. Increased and reduced recruitments of the action observation matching system and its connections in MS-AOT were found (p < 0.001). Motor improvements were correlated with volumetric and functional MRI modifications (r from -0.78 to 0.77, p < 0.001).

CONCLUSION

The 10-day AOT promotes clinical improvements in MS patients through structural and functional modifications of the action observation matching system.

Action observation training modifies brain gray matter structure in healthy adult individuals

Action observation training (AOT) is thought to facilitate motor system function. We applied voxelwise methods to assess the regional modifications of brain gray matter (GM) volumes and white matter (WM) architecture in healthy subjects following AOT and their correlations with improvements at motor and cognitive functional scales. Forty-two righ-handed healthy subjects were randomized into an experimental (AOT-G, n = 20) and a control (C-G, n = 22) group. The training lasted 2 weeks and consisted of 10 sessions of 45 min each during which subjects watched videos of daily-life actions (AOT-G) or landscapes (C-G), alternated by the execution with the right hand of actions presented in the AOT-G videos. At baseline and follow up, motor and cognitive functional measures as well as brain structural MRI scans were obtained. Tensor-based morphometry and tract-based spatial statistics were used to map longitudinal modifications of GM and WM structures and their correlation with functional scales. After training, both groups improved at cognitive tests, whereas the AOT-G also improved hand motor performance. Following training, no modifications of WM diffusion tensor MRI indexes were detected. After training, compared to C-G, AOT-G had increased volume of the left superior frontal gyrus and decreased volume of the right lingual gyrus. Compared to AOT-G, C-G showed increased volume of the right middle frontal gyrus and left inferior temporal gyrus. In AOT-G, GM volume changes correlated with improvements at cognitive tests. Ten-day AOT in healthy individuals modifies GM structure, promoting structural brain plasticity and functional competence.

Mirror therapy for an adult with central post-stroke pain: a case report

BACKGROUND

Treatment of central post-stroke pain (CPSP) after a thalamic-capsular stroke is generally based on pharmacological approach as it is low responsive to physiotherapy. In this case report, the use of mirror therapy (MT) for the reduction of CPSP in a subject after a stroke involving thalamus is presented.

CASE PRESENTATION

Five years after a right lenticular-capsular thalamic stroke, despite a good recovery of voluntary movement that guaranteed independence in daily life activities, a 50-year-old woman presented with mild weakness and spasticity, an important sensory loss and a burning pain in the left upper limb. MT for reducing arm pain was administered in 45-min sessions, five days a week, for two consecutive weeks. MT consisted in performing symmetrical movements of both forearms and hands while watching the image of the sound limb reflected by a parasagittal mirror superimposed to the affected limb. Pain severity was assessed using visual analogue scale (VAS) before and after the intervention and at one-year follow-up. After the two weeks of MT, the patient demonstrated 4.5 points reduction in VAS pain score of the hand at rest and 3.9 points during a maximal squeeze left hand contraction. At one-year follow-up, pain reduction was maintained and also extended to the shoulder.

CONCLUSION

This case report shows the successful application of a motor training with a sensory confounding condition (MT) in reducing CPSP in a patient with a chronic thalamic stroke.

The effect of action observation/execution on mirror neuron system recruitment: an fMRI study in healthy individuals

Action observation and execution activate regions that are part of the motor and mirror neuron systems (MNS). Using functional magnetic resonance (fMRI), we defined the presence and extent of MNS activation during three different motor tasks with the dominant, right-upper limb in healthy individuals. The influence of the modality of task administration (execution, observation, observation and execution) was also investigated. fMRI scans during the execution (E) of a motor task, the observation (O) of a video showing the same task performed by another person and the simultaneous observation and execution (OE) of the task were obtained from three groups of healthy subjects (15 subjects per group) randomized to perform: a simple motor (SM) task, a complex motor (CM) task and a finalistic motor (FM) task. Manual dexterity was assessed using the 9-hole peg test and maximum finger tapping frequency. MNS activation was higher during FM than SM or CM tasks, independently from the modality of administration (E, O, or OE). Inferior frontal gyrus recruitment was more significant during SM than CM tasks in the E and O conditions. Compared to SM and FM, CM task resulted in increased recruitment of brain regions involved in complex motor task performance. Compared to O and E, OE resulted in the recruitment of additional, specific, brain areas in the cerebellum, temporal and parietal lobes. The modality of administration and the type of task modulated MNS recruitment during motor acts. This might have practical implications for the set-up of individualized motor rehabilitation strategies.

Intra-arterial transplantation of HLA-matched donor mesoangioblasts in Duchenne muscular dystrophy

Intra‐arterial transplantation of mesoangioblasts proved safe and partially efficacious in preclinical models of muscular dystrophy. We now report the first‐in‐human, exploratory, non‐randomized open‐label phase I–IIa clinical trial of intra‐arterial HLA‐matched donor cell transplantation in 5 Duchenne patients. We administered escalating doses of donor‐derived mesoangioblasts in limb arteries under immunosuppressive therapy (tacrolimus). Four consecutive infusions were performed at 2‐month intervals, preceded and followed by clinical, laboratory, and muscular MRI analyses. Two months after the last infusion, a muscle biopsy was performed. Safety was the primary endpoint. The study was relatively safe: One patient developed a thalamic stroke with no clinical consequences and whose correlation with mesoangioblast infusion remained unclear. MRI documented the progression of the disease in 4/5 patients. Functional measures were transiently stabilized in 2/3 ambulant patients, but no functional improvements were observed. Low level of donor DNA was detected in muscle biopsies of 4/5 patients and donor‐derived dystrophin in 1. Intra‐arterial transplantation of donor mesoangioblasts in human proved to be feasible and relatively safe. Future implementation of the protocol, together with a younger age of patients, will be needed to approach efficacy.