Publications by authors named "Stefano Paolucci"

129 Publications

Continuity of Care During COVID-19 Lockdown: A Survey on Stakeholders' Experience With Telerehabilitation.

Front Neurol 2020 13;11:617276. Epub 2021 Jan 13.

Neurorehabilitation Outpatient Department, Santa Lucia Foundation (Scientific Institute for Research and Health Care), Rome, Italy.

To explore professionals', adult patients', and children's caregivers' perception and satisfaction with telerehabilitation during COVID-19 lockdown. An observational transversal study on a web-based survey was conducted in order to explore participants' perception and satisfaction of telerehabilitation during COVID-19 lockdown. The study was conducted at our Outpatient Neurorehabilitation Service. All rehabilitation professionals, adult patients, and children's caregivers who accepted telerehabilitation were recruited. Participants had to respond to the Client Satisfaction Questionnaire-8 and to a purpose-built questionnaire on their perception and satisfaction of the service provided. Data were analyzed by qualitative statistics and logistic regression models. All 144 caregivers, 25 adult patients, and 50 professionals reported a medium-high level of perception and a high level of satisfaction. Results showed a correlation among caregivers of children aged 0-3 and feeling overwhelmed with remote care (OR = 3.27), a low perception of telerehabilitation for enhancing goals (OR = 6.51), and a high perception of feeling helped in organizing daily activity (OR = 2.96). For caregivers of children aged over 6 years, changes in the therapy plan were related to a low perception of feeling in line with the in-person therapy (OR = 2.61 and OR = 9.61) and a low satisfaction (OR = 5.54 and OR = 4.97). Changes in therapy were related to concern (OR = 4.20). Caregivers under 40 and professionals showed a high probability to perceive telerehabilitation as supportive (OR = 2.27 and OR = 5.68). Level of experience with remote media was shown to influence perception and satisfaction. Telerehabilitation can be a useful practice both during a health emergency and in addition to in-presence therapy.
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http://dx.doi.org/10.3389/fneur.2020.617276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838679PMC
January 2021

The Michelangelo Effect: Art Improves the Performance in a Virtual Reality Task Developed for Upper Limb Neurorehabilitation.

Front Psychol 2020 7;11:611956. Epub 2021 Jan 7.

IRCCS Fondazione Santa Lucia, Rome, Italy.

The vision of an art masterpiece is associated with brain arousal by neural processes occurring quite spontaneously in the viewer. This aesthetic experience may even elicit a response in the motor areas of the observers. In the neurorehabilitation of patients with stroke, art observation has been used for reducing psychological disorders, and creative art therapy for enhancing physical functions and cognitive abilities. Here, we developed a virtual reality task which allows patients, by moving their hand on a virtual canvas, to have the illusion of painting some art masterpieces, such as The Creation of Adam of Michelangelo or The birth of Venus of Botticelli. Twenty healthy subjects (experiment 1) and four patients with stroke (experiment 2) performed this task and a control one in which they simply colored the virtual canvas. Results from User Satisfaction Evaluation Questionnaire and the NASA Task Load Index highlighted an appropriate level of usability. Moreover, despite the motor task was the same for art and control stimuli, the art condition was performed by healthy subjects with shorter trajectories ( = 0.001) and with a lower perception of physical demand ( = 0.049). In experiment 2, only the patients treated with artistic stimuli showed a reduction in the erroneous movements performed orthogonally to the canvas ( < 0.05). This finding reminds the so-called Mozart effect that improves the performance of subjects when they listen to classic music. Thus, we called this improvement in the performance when interacting with an artistic stimulus as Michelangelo effect.
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http://dx.doi.org/10.3389/fpsyg.2020.611956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817887PMC
January 2021

Efficacy of Vestibular Rehabilitation in Patients With Neurologic Disorders: A Systematic Review.

Arch Phys Med Rehabil 2020 Dec 28. Epub 2020 Dec 28.

Fondazione Santa Lucia IRCCS, Rome, Italy. Electronic address:

Objective: The aim of this systematic review is to critically assess the effectiveness of vestibular rehabilitation (VR) administered either alone or in combination with other neurorehabilitation strategies in patients with neurologic disorders.

Data Sources: An electronic search was conducted by 2 independent reviewers in the following databases: MEDLINE (PubMed), the Physiotherapy Evidence Database, and the Cochrane Database of Systematic Reviews.

Study Selection: All clinical studies carried out on adult patients with a diagnosis of neurologic disorders who performed VR provided alone or in combination with other therapies were included.

Data Extraction: Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using a modified version of the Newcastle-Ottawa Scale.

Data Synthesis: The summary of results was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Twelve studies were included in the review. All the included studies, with 1 exception, report that improvements provided by customized VR in subject affected by a central nervous system diseases are greater than traditional rehabilitation programs alone.

Conclusions: Because of the lack of high-quality studies and heterogeneity of treatments protocols, clinical practice recommendations on the efficacy of VR cannot be made. Results show that VR programs are safe and could easily be implemented with standard neurorehabilitation protocols in patients affected by neurologic disorders. Hence, more high-quality randomized controlled trials of VR in patients with neurologic disorders are needed.
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http://dx.doi.org/10.1016/j.apmr.2020.11.017DOI Listing
December 2020

An Italian Neurorehabilitation Hospital Facing the SARS-CoV-2 Pandemic: Data From 1207 Patients and Workers.

Front Neurol 2020 9;11:584317. Epub 2020 Oct 9.

Fondazione Santa Lucia, IRCCS, Rome, Italy.

The aim of the present observational study is to report on the data from a large sample of inpatients, clinical staff and other workers at an Italian neurorehabilitation hospital dealing with SARS-CoV-2 infections, in order to analyze how it might have affected the management and the effectiveness of neurorehabilitation. The data on infection monitoring, obtained by 2,192 swabs, were reported and compared among 253 patients, 722 clinical professionals and 232 other hospital workers. The number of admissions and neurorehabilitation sessions performed in the period from March-May 2020 was compared with those of the same period in 2019. Four patients and three clinical professionals were positive for COVID-19 infection. Six out of these seven people were from the same ward. Several measures were taken to handle the infection, putting in place many restrictions, with a significant reduction in new admissions to the hospital ( < 0.001). However, neither the amount of neurorehabilitation for inpatients ( = 0.681) nor the effectiveness of treatments ( = 0.464) were reduced when compared to the data from 2019. Our data show that the number of infections was contained in our hospital, probably thanks to the protocols adopted for reducing contagion and the environmental features of our wards. This allowed inpatients to continue to safely spend more than 3 hours per day in neurorehabilitation, effectively improving their independence in the activities of daily living.
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http://dx.doi.org/10.3389/fneur.2020.584317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7581710PMC
October 2020

Incidence and Persistence of Viral Shedding in COVID-19 Post-acute Patients With Negativized Pharyngeal Swab: A Systematic Review.

Front Med (Lausanne) 2020 28;7:562. Epub 2020 Aug 28.

Santa Lucia Foundation, Rome, Italy.

After the global spread of a severe acute respiratory syndrome caused by a coronavirus (SARS-CoV-2), factors that influence viral diffusion have gained great attention. Human-to-human transmission mainly occurs through droplets, but viral RNA clearance in different biological fluids in coronavirus disease 2019 (COVID-19) remains unclear. We aimed to correlate the presence and the relevant temporal patterns of SARS-CoV-2 viral RNA in biological specimens (stool, urine, blood, and tears) of the transmission with clinical/epidemiological features in patients with COVID-19. We focused on the time window between the positivity of reverse transcriptase-polymerase chain reaction (RT-PCR) tests from different specimens. We used the Mantel-Cox log rank test to verify the differences in terms of viral shedding duration, while we employed the Mann-Whitney -test for subgroup analysis. This review protocol was registered with PROSPERO number: CRD42020183629. We identified 147 studies; we included 55 (1,348 patients) for epidemiological analysis, of which we included 37 (364 patients) for statistical analysis. The most frequently used specimens other than respiratory tract swabs were stool samples (or anal/rectal swabs), with a positivity rate of 48.8%, followed by urine samples, with a positivity rate of 16.4%; blood samples showed a positivity rate of 17.5%. We found that fecal positivity duration (median 19 days) was significantly ( < 0.001) longer than respiratory tract positivity (median 14 days). Limited data are available about the other specimens. In conclusion, medical and social communities must pay close attention to negativization criteria for COVID-19, because patients could have longer alternative viral shedding.
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http://dx.doi.org/10.3389/fmed.2020.00562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7483760PMC
August 2020

Sensorized Assessment of Dynamic Locomotor Imagery in People with Stroke and Healthy Subjects.

Sensors (Basel) 2020 Aug 13;20(16). Epub 2020 Aug 13.

SMART Lab, Santa Lucia Foundation, Via Ardeatina 306, 00179 Rome, Italy.

Dynamic motor imagery (dMI) is a motor imagery task associated with movements partially mimicking those mentally represented. As well as conventional motor imagery, dMI has been typically assessed by mental chronometry tasks. In this paper, an instrumented approach was proposed for quantifying the correspondence between upper and lower limb oscillatory movements performed on the spot during the dMI of walking vs. during actual walking. Magneto-inertial measurement units were used to measure limb swinging in three different groups: young adults, older adults and stroke patients. Participants were tested in four experimental conditions: (i) simple limb swinging; (ii) limb swinging while imagining to walk (dMI-task); (iii) mental chronometry task, without any movement (pure MI); (iv) actual level walking at comfortable speed. Limb swinging was characterized in terms of the angular velocity, frequency of oscillations and sinusoidal waveform. The dMI was effective at reproducing upper limb oscillations more similar to those occurring during walking for all the three groups, but some exceptions occurred for lower limbs. This finding could be related to the sensory feedback, stretch reflexes and ground reaction forces occurring for lower limbs and not for upper limbs during walking. In conclusion, the instrumented approach through wearable motion devices adds significant information to the current dMI approach, further supporting their applications in neurorehabilitation for monitoring imagery training protocols in patients with stroke.
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http://dx.doi.org/10.3390/s20164545DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7472606PMC
August 2020

Return to Work and Quality of Life after Stroke in Italy: A Study on the Efficacy of Technologically Assisted Neurorehabilitation.

Int J Environ Res Public Health 2020 07 20;17(14). Epub 2020 Jul 20.

IRCCS Fondazione Santa Lucia, Via Ardeatina 306, 00179 Rome, Italy.

Cerebrovascular diseases, including stroke, are historically considered diseases of old adults so only in a few studies has "return to work" (RTW) been considered as an index of rehabilitative outcome. At the moment, data on RTW in patients with stroke are highly variable: four different reviews reported the following ranges: 11-85%, 19-73%, 22-53%, and 40-45%. The absence of re-integration to work after a stroke is shown to be associated with an increase of cardiac disorders and depression, with a higher level of mortality, with social isolation and with insufficient adaptive skills. The aim of this study was to verify the effectiveness of technological treatment, performed with optic (SonicHand) and wearable (Riablo™) systems providing auditory and visual biofeedback, on RTW in patients with stroke. RTW was found to be associated with a higher independence in the activities of daily living (assessed by the Modified Barthel Index). No significant differences were found between technological versus conventional rehabilitation in terms of RTW, despite the former showing a higher odds ratio than the latter (OR = 9 vs. 6). Assistive devices were mainly used in patients who had not returned to work. Finally, quality of life was found higher in those patients who returned to work with the same conditions (work duties and time) as before stroke.
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http://dx.doi.org/10.3390/ijerph17145233DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7399919PMC
July 2020

Visuomotor Integration for Coupled Hand Movements in Healthy Subjects and Patients With Stroke.

Front Bioeng Biotechnol 2020 30;8:591. Epub 2020 Jun 30.

Department of Biomedical Sciences, University of Sassari, Sassari, Italy.

Many studies have investigated the bilateral upper limb coordination during movements under different motor and visual conditions. Bilateral training has also been proposed as an effective rehabilitative protocol for patients with stroke. However, the factors influencing in-phase vs. anti-phase coupling have not yet been fully explored. In this study, we used a motion capture device based on two infrared distance sensors to assess whether the up and down oscillation of the less functional hand (the non-dominant one in healthy younger and older subjects and the paretic one in patients with stroke) could be influenced by in-phase or anti-phase coupling of the more functional hand and by visual feedback. Similar patterns were found between single hand movements and in-phase coupled movements, whereas anti-phase coupled movements were less ample, less sinusoidal, but more frequent. These features were particularly evident for patients with stroke who showed a reduced waveform similarity of bilateral movements in all conditions but especially for anti-phase movements under visual control. These results indicate that visuomotor integration in patients with stroke could be less effective than in healthy subjects, probably because of the attentional overload required when moving the two limbs in an alternating fashion.
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http://dx.doi.org/10.3389/fbioe.2020.00591DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7339959PMC
June 2020

Spasticity Treatment During COVID-19 Pandemic: Clinical Recommendations.

Front Neurol 2020 23;11:719. Epub 2020 Jun 23.

Physical and Rehabilitation Medicine Department, Università di Foggia, Foggia, Italy.

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http://dx.doi.org/10.3389/fneur.2020.00719DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7324716PMC
June 2020

The Promotoer, a brain-computer interface-assisted intervention to promote upper limb functional motor recovery after stroke: a study protocol for a randomized controlled trial to test early and long-term efficacy and to identify determinants of response.

BMC Neurol 2020 Jun 27;20(1):254. Epub 2020 Jun 27.

Fondazione Santa Lucia, IRCCS, Rome, Italy.

Background: Stroke is a leading cause of long-term disability. Cost-effective post-stroke rehabilitation programs for upper limb are critically needed. Brain-Computer Interfaces (BCIs) which enable the modulation of Electroencephalography (EEG) sensorimotor rhythms are promising tools to promote post-stroke recovery of upper limb motor function. The "Promotoer" study intends to boost the application of the EEG-based BCIs in clinical practice providing evidence for a short/long-term efficacy in enhancing post-stroke hand functional motor recovery and quantifiable indices of the participants response to a BCI-based intervention. To these aims, a longitudinal study will be performed in which subacute stroke participants will undergo a hand motor imagery (MI) training assisted by the Promotoer system, an EEG-based BCI system fully compliant with rehabilitation requirements.

Methods: This longitudinal 2-arm randomized controlled superiority trial will include 48 first ever, unilateral, subacute stroke participants, randomly assigned to 2 intervention groups: the BCI-assisted hand MI training and a hand MI training not supported by BCI. Both interventions are delivered (3 weekly session; 6 weeks) as add-on regimen to standard intensive rehabilitation. A multidimensional assessment will be performed at: randomization/pre-intervention, 48 h post-intervention, and at 1, 3 and 6 month/s after end of intervention. Primary outcome measure is the Fugl-Meyer Assessment (FMA, upper extremity) at 48 h post-intervention. Secondary outcome measures include: the upper extremity FMA at follow-up, the Modified Ashworth Scale, the Numeric Rating Scale for pain, the Action Research Arm Test, the National Institute of Health Stroke Scale, the Manual Muscle Test, all collected at the different timepoints as well as neurophysiological and neuroimaging measures.

Discussion: We expect the BCI-based rewarding of hand MI practice to promote long-lasting retention of the early induced improvement in hand motor outcome and also, this clinical improvement to be sustained by a long-lasting neuroplasticity changes harnessed by the BCI-based intervention. Furthermore, the longitudinal multidimensional assessment will address the selection of those stroke participants who best benefit of a BCI-assisted therapy, consistently advancing the transfer of BCIs to a best clinical practice.

Trial Registration: Name of registry: BCI-assisted MI Intervention in Subacute Stroke (Promotoer).

Trial Registration Number: NCT04353297 ; registration date on the ClinicalTrial.gov platform: April, 15/2020.
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http://dx.doi.org/10.1186/s12883-020-01826-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7320550PMC
June 2020

Dealing with ethical issues in rehabilitation medicine: The relationship between managerial support and emotional exhaustion is mediated by moral distress and enhanced by positive affectivity and resilience.

J Nurs Manag 2020 Jul 23;28(5):1114-1125. Epub 2020 Jun 23.

Department of Brain and Behavioural Sciences, Unit of Applied Psychology, University of Pavia, Pavia, Italy.

Aims: To analyse whether managerial support and ethical vision of patient care would be related to emotional exhaustion directly or through moral distress and whether these relationships would be conditional on individual levels of positive affectivity and resilience.

Background: Although some studies described the effects of ethical climate, moral distress, resilience and positive affectivity on emotional exhaustion, there are no attempts of explicative models containing these variables.

Methods: A total of 222 Italian professionals employed in neuro-rehabilitation medicine units participated in this cross-sectional study. Descriptive statistics, mediation and moderated mediation analyses were conducted using SPSS.

Results: Managerial support and ethical vision of patient care were negatively related to emotional exhaustion, directly and through moral distress. Professionals high in resilience and positive affectivity benefited more from the protective effect of managerial support on emotional exhaustion through moral distress.

Conclusion: Ethical climate represents a protective factor against moral distress and emotional exhaustion. Moreover, individual levels of positive affectivity and resilience may increase the beneficial effects deriving from managerial support in dealing with ethical issues.

Implication For Nursing Management: Health organisations may consider developing strategies to improve ethical climate, enhance managers' ability to support team in dealing with ethical issues and foster employees' positive affectivity and resilience.
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http://dx.doi.org/10.1111/jonm.13059DOI Listing
July 2020

Adipokines as Potential Biomarkers in the Neurorehabilitation of Obese Stroke Patients.

Curr Neurovasc Res 2020 ;17(4):437-445

Department of Life, Health and Environmental Sciences, University of L'Aquila-67100, L'Aquila, Italy.

Background: Limited studies concern the influence of obesity-induced dysregulation of adipokines in functional recovery after stroke neurorehabilitation.

Objective: To investigate the relationship between serum leptin, resistin, and adiponectin and functional recovery before and after neurorehabilitation of obese stroke patients. The adipokine potential significance as prognostic markers of rehabilitation outcomes was also verified.

Methods: Twenty obese post-acute stroke patients before and after neurorehabilitation and thirteen obese volunteers without-stroke, as controls, were examined. Adipokines were determined by commercially available enzyme-linked immunosorbent assay (ELISA) kits. Functional deficits were assessed before and after neurorehabilitation with the Barthel Index (BI), modified Rankin Scale (mRS), and Functional Independence Measure (FIM).

Results: Compared to controls, higher leptin and resistin values and lower adiponectin values were observed in stroke patients before neurorehabilitation and no correlations were found between adipokines and clinical outcome measures. Neurorehabilitation was associated with improved scores of BI, mRS, and FIM. After neurorehabilitation, decreased values of Body Mass Index (BMI) and resistin together increased adiponectin were detected in stroke patients, while leptin decreased but not statistically. Comparing adipokine values assessed before neurorehabilitation with the outcome measures after neurorehabilitation, correlations were observed for leptin with BI-score, mRS-score, and FIM-score. No other adipokine levels nor BMI assessed before neurorehabilitation correlated with the clinical measures after neurorehabilitation. The forward stepwise regression analysis identified leptin as prognostic factor for BI, mRS, and FIM.

Conclusion: Our data show the effectiveness of neurorehabilitation in modulating adipokines levels and suggest that leptin could assume the significance of biomarker of functional recovery.
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http://dx.doi.org/10.2174/1567202617666200603150901DOI Listing
January 2020

From movement to thought and back: a review on the role of cognitive factors influencing technological neurorehabilitation.

Funct Neurol 2019 Jul/Sep;34(3):131-144

In recent years, cognitive theories have increasingly influenced the approach to motor rehabilitation. The connection between different aspects of cognitive and motor function is increasingly documented, underlining the importance of developing rehabilitation projects that take cognitive aspects into account. The aim of this non-systematic review is to highlight the relationship between cognition and motion and, in the light of new rehabilitation technologies, to better define how aspects of cognition can affect motor rehabilitation.
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May 2020

Covid-19: A Dynamic Analysis of Fatality Risk in Italy.

Front Med (Lausanne) 2020 30;7:185. Epub 2020 Apr 30.

Clinical Laboratory of Experimental Neurorehabilitation, IRCCS Fondazione Santa Lucia, Rome, Italy.

Italy was the second country in the world to face a wide epidemic of Covid-19 after China. The ratio of the number of fatalities to the number of cases (case fatality ratio, CFR) recorded in Italy was surprisingly high and increased in the month of March. The older mean age of population, the changes in testing policy, and the methodological computation of CFR were previously reported as possible explanations for the incremental trend of CFR, a parameter theoretically expected to be constant. In this brief report, the official data provided by the Italian Ministry of Health were analyzed using fitting models and the linear fit method approach. This last methodology allowed us to reach two findings. The trend of the number of deaths followed a 1-3-day delay of positive cases. This delay was not compatible with a biological course of Covid-19 but was compatible with a health management explanation. The second finding is that the Italian number of deaths did not increase linearly with the number of positive cases, but their relationship could be modeled by a second-order polynomial function. The high number of positive cases might have a direct and an indirect effect on the number of deaths, the latter being related to the overwhelmed bed capacity of intensive care units.
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http://dx.doi.org/10.3389/fmed.2020.00185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7203466PMC
April 2020

Urgent Measures for the Containment of the Coronavirus (Covid-19) Epidemic in the Neurorehabilitation/Rehabilitation Departments in the Phase of Maximum Expansion of the Epidemic.

Front Neurol 2020 30;11:423. Epub 2020 Apr 30.

Department of Rehabilitation, USL Umbria 2, Foligno, Italy.

COVID-19 has rapidly become a pandemic emergency, distressing health systems in each affected country. COVID-19 determines the need for healthcare in a large number of people in an extremely short time and, like a tsunami wave, overruns emergency, infectious diseases, and pneumology departments as well as intensive care units, choking healthcare services. Rehabilitation services are also affected by this epidemic which forces radical changes both in the organization and in the operating methods. In the absence of reference literature on this issue, this report aims to provide a background documentation to support physicians and healthcare personnel involved in neurorehabilitation and rehabilitation care.
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http://dx.doi.org/10.3389/fneur.2020.00423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7205014PMC
April 2020

Assistive products and childhood neurodisability: a retrospective study on factors associated with aids/orthoses prescription.

Eur J Phys Rehabil Med 2020 Aug 14;56(4):412-420. Epub 2020 May 14.

Department of Pediatric Neurorehabilitation, Scientific Institute for Research and Health Care Santa Lucia Foundation, Rome, Italy.

Background: Children affected by pathologies causing neurodisability go through motor, cognitive, sensory and other limitations. The selection of assistive products can influence their level of independence and quality of life.

Aim: The present study investigated the possibility to assess the equipment needs of children with neurodisabilities, based on their clinical characteristics.

Design: A retrospective observational study.

Setting: Outpatients.

Population: Inclusion criteria: diagnosis of cerebral palsy or genetic/chromosomal/syndromic disorders, age range 0-18 years, intelligence quotient evaluation, medical history of positive or negative presence of epilepsy and of communication disorders, admission at our neurorehabilitation service between 2007 and 2017, and registration of all equipment prescribed to each child.

Methods: In 192 children (111 males, 57.81%) we evaluated the relationship between several independent variables (diagnosis, sex, Gross Motor Function Classification System level, intelligence quotient, history of epilepsy and communication disorders) and equipment prescription by means of logistic regression models.

Results: Our data showed significant correlation between the Gross Motor Function Classification System level and the equipment prescribed. A history of seizures was negatively correlated with walker prescriptions (the log odds of prescription decreases by -2.156; CI: -4.16 to -0.65) and positively with those of stroller (the log odds increases by 1.427; CI: 0.22 to 2.69). Stroller and knee-ankle-foot orthoses and hip-knee-ankle-foot orthoses prescriptions were negatively correlated with the cerebral palsy diagnosis. The prescription of foot orthoses was positively correlated with mental retardation (the log odds increases by 0.358; CI: 0.12 to 0.61). A negative correlation between communication disorders and the prescription of ankle-foot orthoses and communication/learning devices was also found (the log odds decreases by -0.833; CI -1.66 to -0.01).

Conclusions: Several clinical characteristics correlate with specific equipment needs.

Clinical Rehabilitation Impact: The definition of the clinical characteristics with a potential predicting value, may facilitate the task of physician on choosing what is more appropriate to prescribe, as well as the authorizing office responsible for evaluating the appropriateness of prescriptions. Furthermore, it could be possible to foresee the care needs in terms of type and number of aids/orthoses and to guarantee every disabled child the possibility to take advantage of the same opportunities.
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http://dx.doi.org/10.23736/S1973-9087.20.06224-3DOI Listing
August 2020

Clinical features of fallers among inpatient subacute stroke: an observational cohort study.

Neurol Sci 2020 Sep 7;41(9):2599-2604. Epub 2020 Apr 7.

Clinical Laboratory of Experimental Neurorehabilitation, IRCCS Santa Lucia Foundation, Via Ardeatina, 306, 00179, Rome, Italy.

Background And Purpose: The aim of this study is to observe the differences between fallers, common fallers, and non-fallers in stroke patients compared with the global ability in a rehabilitation setting.

Materials And Methods: An observational and prospective study has been carried out. A total of 476 subacute stroke patients have been observed. The main outcome measures were assessed using the Canadian Neurological Scale (CNS), Barthel Index (BI), Functional Ambulatory Category (FAC), and Trunk Control Test (TCT) at admission to the rehabilitation unit and after 90 days of the rehabilitation treatment (nearly 3 h for day for 5 days for week) at the discharge with intermediate evaluations after the first and second months.

Results: Out of 397 patients, 109 reported 1 or more falls (27.5%), of whom 67 fell 1 time (fallers) in the hospital (16.9%) and 42 fell 2 or more times (common fallers) (10.6%). For fallers, BI and FAC scores had a significant effect (p = 0.003 for both). Common fallers had statistically significant differences in BI (p = 0.002), FAC (p = 0.012), and TCT scores (0.023) compared with non-fallers.

Conclusions: The severity of stroke may directly increase the risk of fall, and also indirectly, lengthening the hospitalization. Our study seems to suggest that patients with BI scores of between 21 and 30 on admission are more prone to fall in the first period of hospitalization, whereas in the second month, those with scores of between 11 and 20 on admission have a higher risk of falls. In the third month, patients with BI scores below 10 on admission are more susceptible to falls.
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http://dx.doi.org/10.1007/s10072-020-04352-2DOI Listing
September 2020

Robot-assisted therapy for arm recovery for stroke patients: state of the art and clinical implication.

Expert Rev Med Devices 2020 Mar 28;17(3):223-233. Epub 2020 Feb 28.

Clinical Laboratory of Experimental Neurorehabilitation, Fondazione Santa Lucia IRCCS, Rome, Italy.

: Robot-assisted therapy is an emerging approach that performs highly repetitive, intensive, task oriented and quantifiable neuro-rehabilitation. In the last decades, it has been increasingly used in a wide range of neurological central nervous system conditions implying an upper limb paresis. Results from the studies are controversial, for the many types of robots and their features often not accompanied by specific clinical indications about the target functions, fundamental for the individualized neurorehabilitation program.: This article reviews the state of the art and perspectives of robotics in post-stroke rehabilitation for upper limb recovery. Classifications and features of robots have been reported in accordance with technological and clinical contents, together with the definition of determinants specific for each patient, that could modify the efficacy of robotic treatments. The possibility of combining robotic intervention with other therapies has also been discussed.: The recent wide diffusion of robots in neurorehabilitation has generated a confusion due to the commingling of technical and clinical aspects not previously clarified. Our critical review provides a possible hypothesis about how to match a robot with subject's upper limb functional abilities, but also highlights the need of organizing a clinical consensus conference about the robotic therapy.
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http://dx.doi.org/10.1080/17434440.2020.1733408DOI Listing
March 2020

Upper limb motor improvement in chronic stroke after combining botulinum toxin A injection and multi-joints robot-assisted therapy: a case report.

Oxf Med Case Reports 2019 Oct 31;2019(10):omz097. Epub 2019 Oct 31.

Laboratory of Experimental Neurorehabilitation, Scientific Institute for Research, Hospitalisation and Health Care (IRCCS) Santa Lucia Foundation, Rome, Italy.

Spasticity is one of the major complications after stroke. Botulinum toxin type A (BoNT-A) injection is commonly used to manage focal spasticity. However, it is uncertain whether BoNT-A can improve activities of daily living function of paretic arm. The recovery of functions of the affected arm is also the aim of robotic upper limb (UL) therapy. The motorized exoskeleton assists the patient in a large 3D work environment by promoting movement for the UL (shoulder, elbow, wrist, hand). The combination of the BoNT-A injection and the robotic therapy might enhance functional recovery after stroke. We reported the case of a chronic stroke patient in which the injection of BoNT-A was combined with multi-joint exoskeleton training. The patient showed improvement in the motor control of the UL, supporting the feasibility of this approach.
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http://dx.doi.org/10.1093/omcr/omz097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822606PMC
October 2019

The nine circles of EBM hell.

Funct Neurol 2019 Apr/Jun;34(2):63-64

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February 2020

Post-stroke Depression Increases Disability More Than 15% in Ischemic Stroke Survivors: A Case-Control Study.

Front Neurol 2019 27;10:926. Epub 2019 Aug 27.

Fondazione Santa Lucia-IRCCS, Rome, Italy.

We performed a retrospective, case-control study in consecutive ischemic stroke patients admitted to our stroke rehabilitation unit. Patients were matched for severity of neurological impairment (evaluated with the Canadian Neurological Scale, CNS), age (difference within 1 year), and onset admission interval (difference within 3 days). Participants were divided into two subgroups according to the presence or absence of PSD. Aim was to assess the specific influence of post-stroke depression (PSD) and antidepressant treatment on both basal functional status and rehabilitation outcomes. All PSD patients were treated primarily with serotoninergic antidepressants (AD). The final sample included 280 patients with depression (out of 320 found in a whole case series of 993 ischemic patients, i.e., 32.25%) and 280 without depression. Forty patients with depression were excluded because they had a history of severe psychiatric illness or aphasia, with a severe comprehension deficit. On one hand, PSD patients obtained lower Barthel Index (BI) and Rivermead Mobility Index (RMI) scores at both admission and discharge, with minor effectiveness of rehabilitative treatment and longer length of stay; on the other hand, this group had a lower percentage of dropouts. Lastly, PSD patients showed a different functional outcome, based on their response to antidepressant therapy, that was significantly better in responders than in non-responders (13.13%). Our results confirm the unfavorable influence of PSD on functional outcome, despite pharmacological treatment.
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http://dx.doi.org/10.3389/fneur.2019.00926DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6718567PMC
August 2019

Neuropsychological disorders in non-central nervous system cancer: a review of objective cognitive impairment, depression, and related rehabilitation options.

Neurol Sci 2019 Sep 2;40(9):1759-1774. Epub 2019 May 2.

IRCCS Fondazione Santa Lucia, Rome, Italy.

Aim: The objective of the present review was to systematically characterize the types of cognitive impairment that are found in different non-brain types of cancer as measured by objective and validated tests, and also to further examine depression and cognitive function in cancer patients and explore their available rehabilitation treatments.

Results: A total of 29 articles were reviewed. Most of these studies suggest that chemotherapy as well as the combination of chemotherapy and hormonal therapy can influence cognition in different types of cancer patients. Breast cancer patients appear to be the most affected in neuropsychological function, specifically in terms of cognitive impairment and reduced quality of life, as compared to other non-brain solid tumours. Overall, the most impaired functions were verbal ability, memory, executive function, and motor speed.

Conclusion: Chemotherapy-related cognitive dysfunction remains under-recognized and undertreated. The various studies reported differing and non-homogenous findings with mixed results, obtained by self-reporting and web-assisted assessment, with other confounding factors such as age and depression during both cancer diagnosis and treatment. An objective neuropsychological assessment is fundamental to avoid underestimation of the extent of chemobrain. Self-reported and web-assisted assessment may ultimately result in confusion between the neuropsychological signs of chemobrain versus those of depression.
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http://dx.doi.org/10.1007/s10072-019-03898-0DOI Listing
September 2019

Relationship Between Body Mass Index and Rehabilitation Outcomes in Subacute Stroke With Dysphagia.

Am J Phys Med Rehabil 2019 07;98(7):608-612

From the Clinical Laboratory of Experimental Neurorehabilitation, IRCCS Santa Lucia Foundation, Rome, Italy (GM, MI, LM, SP); and Complex Operative Unit in Physical Medicine and Rehabilitation, Azienda Policlinico Umberto I, Sapienza University of Rome, Rome, Italy (TP).

Objective: The aim of the study was to investigate the association between body mass index and rehabilitation outcome in hemiparetic patients with stroke in subacute phase.

Design: This was a prospective study testing the correlation between body mass index and the effectiveness of rehabilitation, measured using Barthel Index scores. We enrolled patients with subacute stroke (n = 664; age, 68 ± 14 yrs; length of hospital stay, 84 ± 34 days). We assessed the body mass index and Barthel Index both at admission and discharge. The effectiveness of rehabilitation was computed as the percentage increment in Barthel Index score with respect to the maximum achievable improvement.

Results: Effectiveness of rehabilitation was significantly correlated with the body mass index at discharge (R = 0.111, P = 0.004) and percentage change in body mass index (R = 0.253, P < 0.001), but not with body mass index at admission (R = 0.006, P = 0.869).

Conclusions: In addition to body mass index value, our findings suggest that rehabilitation outcomes can be influenced by the change in body mass index during rehabilitation.
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http://dx.doi.org/10.1097/PHM.0000000000001159DOI Listing
July 2019

Left hemispatial neglect and overt orienting in naturalistic conditions: Role of high-level and stimulus-driven signals.

Cortex 2019 04 14;113:329-346. Epub 2019 Jan 14.

Neuroimaging Laboratory, Santa Lucia Foundation, Rome, Italy; ImpAct Team, Lyon Neuroscience Research Center, Lyon, France.

Deficits of visuospatial orienting in brain-damaged patients affected by hemispatial neglect have been extensively investigated. Nonetheless, spontaneous spatial orienting in naturalistic conditions is still poorly understood. Here, we investigated the role played by top-down and stimulus-driven signals in overt spatial orienting of neglect patients during free-viewing of short videos portraying everyday life situations. In Experiment 1, we assessed orienting when meaningful visual events competed on the left and right side of space, and tested whether sensory salience on the two sides biased orienting. In Experiment 2, we examined whether the spatial alignment of visual and auditory signals modulates orienting. The results of Experiment 1 showed that in neglect patients severe deficits in contralesional orienting were restricted to viewing conditions with bilateral visual events competing for attentional capture. In contrast, orienting towards the contralesional side was largely spared when the videos contained a single event on the left side. In neglect patients the processing of stimulus-driven salience was relatively spared and helped orienting towards the left side when multiple events were present. Experiment 2 showed that sounds spatially aligned with visual events on the left side improved orienting towards the otherwise neglected hemispace. Anatomical scans indicated that neglect patients suffered grey and white matter damages primarily in the ventral frontoparietal cortex. This suggests that the improvement of contralesional orienting associated with visual salience and audiovisual spatial alignment may be due to processing in the relatively intact dorsal frontoparietal areas. Our data show that in naturalistic environments, the presence of multiple meaningful events is a major determinant of spatial orienting deficits in neglect patients, whereas the salience of visual signals and the spatial alignment between auditory and visual signals can counteract spatial orienting deficits. These results open new perspectives to develop novel rehabilitation strategies based on the use of naturalistic stimuli.
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http://dx.doi.org/10.1016/j.cortex.2018.12.022DOI Listing
April 2019

A stimulus for eating. The use of neuromuscular transcutaneous electrical stimulation in patients affected by severe dysphagia after subacute stroke: A pilot randomized controlled trial.

NeuroRehabilitation 2019 ;44(1):103-110

Clinical Laboratory of Experimental Neurorehabilitation, I.R.C.C.S. Santa Lucia Foundation, Rome, Italy.

Background: Oropharyngeal dysphagia is a common problem in subacute stroke patients leading to aspiration pneumonia and malnutrition. Non-invasive neuromuscular electrical stimulation (NMES) coupled with traditional therapy could be best treatment option for patients with post-stroke dysphagia, however results are still inconclusive and more studies are requested.

Objective: The aim of the study was to investigate the effect of laryngopharyngeal neuromuscular electrical stimulation on dysphagia caused by stroke.

Methods: Thirty-three patients affected by subacute stroke and dysphagia participated in this study. The subjects were divided into NMES plus traditional dysphagia training (n = 17) and traditional dysphagia training alone in a time matched condition (n = 16). Both groups were treated 5 days/week for 8 weeks. All patients were evaluated before and after the treatment. The study was designed as a single blind randomized controlled trial. Primary outcomes were considered the status of swallowing function according to the Functional Oral Intake Scale (FOIS), the instrumental Fiberoptic Endoscopic Examination of Swallowing examination, the Penetration Aspiration Scale and the Pooling score and the presence of oropharyngeal secretion. Secondary outcomes were the type of diet taken by mouth; the need for postural compensations and the duration of the dysphagia training.

Results: A functional improvement was observed in both groups but treatment group showed a significant improvement for primary outcome with the exception of the pooling Score (p = 0.015, p = 0.203; p = 0.003; p = 0.048 respectively) and for secondary outcome p <0.005. The results confirm that laryngopharyngeal neuromuscular electrical stimulation in post-stroke patients with dysphonia improve outcome of the training.

Conclusions: Laryngopharyngeal neuromuscular electrical stimulation may be considered as an additional and effective treatment option for dysphagia after stroke.
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http://dx.doi.org/10.3233/NRE-182526DOI Listing
April 2019

Gait phase proportions in different locomotion tasks: The pivot role of golden ratio.

Neurosci Lett 2019 04 30;699:127-133. Epub 2019 Jan 30.

IRCCS Fondazione Santa Lucia, Italy.

Walking is a repeatable and cyclic locomotor act, presenting standardized biomechanical patterns within the gait cycle in healthy humans. Specifically, both stance and swing durations exhibit high reliability at comfortable speed, maintaining the same proportion between the twos with respect to different contextual features in forward walking. Recently, it was found that this proportion is close to the "golden ratio" (a well-known irrational number equal to 1.618…). While few studies analysed how this ratio is modified due to different contextual factors, no studies are available about different locomotor acts. Thus, aim of the study is to verify whether and how the stance-to-swing ratio is modified during the execution of different locomotor tasks. Twenty healthy young subjects were asked to perform different tasks: forward walking, backward walking, lateral walking, stepping in place, stair ascending and descending, while wearing baropodometric shoe insoles. All tests were performed at comfortable speed, while forward walking was also tested at slow and fast speed. The stance-to-swing ratio did not differ significantly from the golden ratio in forward comfortable walking, backward walking and stair descending. A cluster analysis identified the most frequent cluster centered at 1.63, a value close to the golden ratio. These results supported the idea that golden ratio is the preferred stance-to-swing ratio modality, but at the same time this ratio could be adapted in response to particular contextual requests.
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http://dx.doi.org/10.1016/j.neulet.2019.01.052DOI Listing
April 2019

Rehabilitative devices for a top-down approach.

Expert Rev Med Devices 2019 03 6;16(3):187-195. Epub 2019 Feb 6.

b Clinical Laboratory of Experimental Neurorehabilitation , Santa Lucia Foundation IRCCS , Rome , Italy.

Introduction: In recent years, neurorehabilitation has moved from a 'bottom-up' to a 'top down' approach. This change has also involved the technological devices developed for motor and cognitive rehabilitation. It implies that during a task or during therapeutic exercises, new 'top-down' approaches are being used to stimulate the brain in a more direct way to elicit plasticity-mediated motor re-learning. This is opposed to 'Bottom up' approaches, which act at the physical level and attempt to bring about changes at the level of the central neural system.

Areas Covered: In the present unsystematic review, we present the most promising innovative technological devices that can effectively support rehabilitation based on a top-down approach, according to the most recent neuroscientific and neurocognitive findings. In particular, we explore if and how the use of new technological devices comprising serious exergames, virtual reality, robots, brain computer interfaces, rhythmic music and biofeedback devices might provide a top-down based approach.

Expert Commentary: Motor and cognitive systems are strongly harnessed in humans and thus cannot be separated in neurorehabilitation. Recently developed technologies in motor-cognitive rehabilitation might have a greater positive effect than conventional therapies.
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http://dx.doi.org/10.1080/17434440.2019.1574567DOI Listing
March 2019

From paper to informatics: the Post Soft Care-App, an easy-to-use and fast tool to help therapists identify unmet needs in stroke patients.

Funct Neurol 2018 Oct/Dec;33(4):200-205

Even after rehabilitation, post stroke patients remain disabled. The Post Stroke Checklist (PSC) was developed to highlight unmet needs of community-dwelling stroke patients. The present study set out to validate Post Soft Care-App, designed to administer the PSC using smartphones and tablets, in order to monitor unmet needs in chronic patients. Fifty-three patients and fifteen physiotherapists were enrolled. The therapists administered the PSC to patients using the app, and then completed a structured questionnaire on its usability and utility. The Post Soft Care-App highlighted the following unmet needs: increased spasticity (56.6%), reduced independence in activities of daily living (47.2%), reduced mobility (45.3%), absence of secondary prevention (45.3%). Therapists positively evaluated Post Soft Care-App as useful, practical, quick to complete (96.2%), and effective in helping improve communication with patients (75.5%). The Post Soft Care-App can be considered a valid assessment tool for helping therapists to monitor functional outcomes in chronic patients.
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April 2019

Effect of Cerebellar Stimulation on Gait and Balance Recovery in Patients With Hemiparetic Stroke: A Randomized Clinical Trial.

JAMA Neurol 2019 02;76(2):170-178

Non Invasive Brain Stimulation Unit/Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy.

Importance: Gait and balance impairment is associated with poorer functional recovery after stroke. The cerebellum is known to be strongly implicated in the functional reorganization of motor networks in patients with stroke, especially for gait and balance functions.

Objective: To determine whether cerebellar intermittent θ-burst stimulation (CRB-iTBS) can improve balance and gait functions in patients with hemiparesis due to stroke.

Design, Setting, Participants: This randomized, double-blind, sham-controlled phase IIa trial investigated efficacy and safety of a 3-week treatment of CRB-iTBS coupled with physiotherapy in promoting gait and balance recovery in patients with stroke. Thirty-six patients with consecutive ischemic chronic stroke in the territory of the contralateral middle cerebral artery with hemiparesis were recruited from a neuro-rehabilitation hospital. Participants were screened and enrolled from March 2013 to June 2017. Intention-to-treat analysis was performed.

Interventions: Patients were randomly assigned to treatment with CRB-iTBS or sham iTBS applied over the cerebellar hemisphere ipsilateral to the affected body side immediately before physiotherapy daily during 3 weeks.

Main Outcomes And Measures: The primary outcome was the between-group difference in change from baseline in the Berg Balance Scale. Secondary exploratory measures included the between-group difference in change from baseline in Fugl-Meyer Assessment scale, Barthel Index, and locomotion assessment with gait analysis and cortical activity measured by transcranial magnetic stimulation in combination with electroencephalogram.

Results: A total of 34 patients (mean [SD] age, 64 [11.3] years; 13 women [38.2%]) completed the study. Patients treated with CRB-iTBS, but not with sham iTBS, showed an improvement of gait and balance functions, as revealed by a pronounced increase in the mean (SE) Berg Balance Scale score (baseline: 34.5 [3.4]; 3 weeks after treatment: 43.4 [2.6]; 3 weeks after the end of treatment: 47.5 [1.8]; P < .001). No overall treatment-associated differences were noted in the Fugl-Meyer Assessment (mean [SE], baseline: 163.8 [6.8]; 3 weeks after treatment: 171.1 [7.2]; 3 weeks after the end of treatment: 173.5 [6.9]; P > .05) and Barthel Index scores (mean [SE], baseline: 71.1 [4.92]; 3 weeks after treatment: 88.8 [2.1]; 3 weeks after the end of treatment: 92.2 [2.4]; P > .05). Patients treated with CRB-iTBS, but not sham iTBS, showed a reduction of step width at the gait analysis (mean [SE], baseline: 16.8 [4.8] cm; 3 weeks after treatment: 14.3 [6.2] cm; P < .05) and an increase of neural activity over the posterior parietal cortex.

Conclusions And Relevance: Cerebellar intermittent θ-burst stimulation promotes gait and balance recovery in patients with stroke by acting on cerebello-cortical plasticity. These results are important to increase the level of independent walking and reduce the risk of falling.

Trial Registration: ClinicalTrials.gov Identifier: NCT03456362.
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http://dx.doi.org/10.1001/jamaneurol.2018.3639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439971PMC
February 2019