Posts Tagged cognition

[ARTICLE] Fluid cognitive abilities are important for learning and retention of a new, explicitly-learned walking pattern in individuals after stroke – Full Text



There is significant variability in post-stroke locomotor learning that is poorly understood and impacts individual responses to rehabilitation interventions. Cognitive abilities relate to upper extremity motor learning in neurologically intact adults, but have not been studied in post-stroke locomotor learning.


To understand the relationship between locomotor learning and retention and cognition after stroke.


Participants with chronic (>6 months) stroke participated in three testing sessions. During the first session, participants walked on a treadmill and learned a new walking pattern through visual feedback about their step length. During the second session, participants walked on a treadmill and 24-hour retention was assessed. Physical and cognitive tests, including the Fugl-Meyer-Lower Extremity (FM-LE), Fluid Cognition Composite Score (FCCS) from the NIH Toolbox -Cognition Battery®, and Spatial Addition from the Wechsler Memory Scale-IV®, were completed in the third session. Two sequential regression models were completed: one with learning and one with retention as the dependent variables. Age, physical impairment (i.e., FM-LE), and cognitive measures (i.e., FCCS and Spatial Addition) were the independent variables.


Forty-nine and thirty-four participants were included in the learning and retention models, respectively. After accounting for age and FM-LE, cognitive measures explained a significant portion of variability in learning (ΔR2=0.17, p=0.008; overall model R2=0.31, p=0.002) and retention (ΔR2=0.17, p=0.023; overall model R2=0.44, p=0.002).


Cognitive abilities appear to be an important factor for understanding locomotor learning and retention after stroke. This has significant implications for incorporating locomotor learning principles into the development of personalized rehabilitation interventions after stroke.


Improving one’s walking ability after stroke is a common goal of patients and rehabilitation professionals.1 As a result, significant time and money are spent on improving walking during stroke rehabilitation. Despite this, only 50% of individuals regain the ability to walk independently after their stroke.2 This is in part due to highly variable responses to interventions across individuals.3,4 Since motor learning is the foundation of most rehabilitation interventions, differences in how well individuals learn likely contributes to these varied responses. Thus, understanding sources of individual variability during locomotor learning can improve the field’s understanding of varied responses to rehabilitation interventions and ultimately lead to the delivery of personalized rehabilitation interventions to improve walking after stroke. However, individual differences during locomotor learning have been largely ignored. The few studies that have sought to understand variability in locomotor learning after stroke have focused on a limited number of factors, specifically demographic information and sensorimotor impairment.5,6 These factors are unable to explain a significant portion of the observed variability in locomotor learning. Thus, it remains unclear what factors predict how well an individual will be able to learn and retain a new walking pattern after stroke.

Although cognition has been found to relate to motor outcomes after stroke711, it has been unexplored related to locomotor learning after stroke. In neurologically intact adults, however, lower cognitive abilities have been found to relate to poorer motor learning and retention of upper extremity tasks.1220 Specifically, visuospatial working memory, or one’s ability to temporarily store visual and/or spatial information for manipulation21, has drawn significant attention in past work. In upper extremity sequence learning13,15,16 and visuomotor rotation tasks,12,14,17,18 neurologically intact adults with lower visuospatial working memory scores have been found to learn and retain new motor patterns worse than individuals with higher visuospatial working memory scores. However, visuospatial working memory is highly related to other domains of cognition, specifically attention and executive functions.13,21,22 Additionally, other work has found that nonverbal reasoning,13 processing speed,23 decisionmaking,23 delayed memory,20 and visuospatial construction ability19,24 are related to upper extremity motor learning. Thus, it is unclear if the relationship between motor learning and cognition is specific to visuospatial working memory. All of the domains of cognition that have been found to relate to motor learning can broadly be classified as fluid cognitive abilities, which is a global cognitive measure reflecting one’s abilities to problem solving and learn new things in the absence of prior experience.25 Thus, it is possible that global fluid cognition rather than visuospatial working memory specifically is related to motor learning.

The work described above has all been conducted in upper extremity tasks. Therefore, despite the high prevalence of cognitive impairments after stroke,7 it is unclear if cognition is related to locomotor learning similarly. Because of the unique demands of locomotion (i.e., high levels of postural control and bilateral coordination), it is possible that cognition does not have the same relationship with locomotor learning as it does with motor learning involving upper extremity tasks. However, there is evidence that underlying learning processes that occur in the upper extremity and during locomotion are likely the same. For example, sensorimotor adaptation occurs during upper extremity tasks2629 and locomotion.30,31 Similarly, explicit, strategic learning processes have been observed in both upper extremity tasks28,3234 and locomotion.35,36 Thus, despite the unique demands of walking, the relationship between cognition and locomotor learning may exist due to similar underlying learning processes. Importantly, cognition is believed to relate to explicit motor learning processes in the upper extremity. This is highlighted by the work of Christou et al. (2016), which found that a visuospatial working memory task was specifically related to the explicit, strategic component of visuomotor adapation.17 The involvement of the dorsolateral prefrontal cortex in both visuospatial working memory and explicit, strategic learning is the hypothesized mechanism of this relationship.12,14,37 Although much less is known about the regions of the brain involved in explicit locomotor learning, there is evidence for activity in the prefrontal cortex when learning a new walking pattern through explicit cues38,39 and during complex walking tasks, such as obstacle navigation.40 Therefore, it is possible that cognition, specifically visuospatial working memory, has the same relationship with explicit locomotor learning due to overlapping activation in the prefrontal cortex; however, this is currently unknown.

Thus, the purpose of this work was to understand the relationship between cognition (i.e., visuospatial working memory and fluid cognitive abilities) and explicit locomotor learning and retention after stroke. To do this, we used a visually-guided walking paradigm that primarily results in explicit, strategic learning35,41 to assess locomotor learning abilities after stroke. Additionally, we used a standardized measure of visuospatial working memory and of fluid cognitive abilities to measure cognition. We hypothesized that cognition, specifically visuospatial working memory and fluid cognition, would explain a significant portion of variability in learning and retention of a new, strategically-learned walking pattern after accounting for age and physical impairment.



Community-dwelling stroke survivors were recruited from local physical therapy and physician practices, support groups, and through advertisements. To be included, participants had to meet the following criteria: 1) 18-85 years old, 2) MRI evidence of a single unilateral chronic (>6 months) stroke, 3) able to walk 10 meters without physical assistance, 4) resting heart rate within 40 to 100 beats per minute, and 5) resting blood pressure within 90/60 and 185/100 mmHg. Participants were excluded if they met the following criteria: 1) MRI evidence of a cerebellar stroke, 2) neurologic conditions other than stroke, 3) changes in vision following their stroke via self-report, 4) neglect via clinical observation, or 5) inability to communicate with investigators via questions 1b and c of the NIH Stroke Scale, 6) history of coronary artery bypass graft or myocardial infarction in the past 3 months, 7) unexplained dizziness in the last 6 months, or 8) pain that limited walking. Participants signed an informed consent approved by the Human Subjects Review Board at the University of Delaware.

Experimental Protocol

Participants completed a three-day protocol that included two days of treadmill walking and one day of physical and cognitive testing. The two sessions of treadmill walking where performed 24 hours (± 2 hours) apart, while the third session consisting of clinical and cognitive tests was performed one to seven days after the second treadmill walking session (Figure 1a). Cognitive tests were administered on a separate day to minimize the potential impact of activity before the cognitive assessments. The range of time between Day2 and Day3 (one to seven days) was to ensure that participants were able to complete the three day protocol. On average, subjects completed the cognitive and physical tests 2.4 ± 2.1 days after Day2.Figure 1.

Figure 1.

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Experimental protocol and set up. Participants after stroke completed a three day protocol that included two days of treadmill walking and one day of clinical and cognitive testing (a). During Baseline, Immediate Retention, and 24-hour Retention, no visual feedback was provided (b), while during Orientation and Acquisition1 and 2 a bar graph was displayed on the computer monitor in front of the treadmill (c). During Orientation the feedback was accurate, but during Acquisiton1 and 2, the visual feedback of one of the bars was distorted to make it look as if though that leg was taking a shorter step than they actually were (d). This resulted in participants learning to a new walking pattern where they took a longer than usual step with one leg. During Immediate Retention and 24-hour Retention, participants were instructed to walk with the pattern they had learned during the acquisition phases. The final day included the lower extremity portion of the Fugl-Meyer (FM-LE), the NIH Toolbox Cognitive Battery (NIHTB-CB), and the Wechsler Memory Scale-IV (WMS-IV).



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[Abstract] Commercial videogames in stroke rehabilitation: systematic review and meta-analysis – Review


Objective: The aim of this article was to perform a systematic review of all studies (both observational and experimental) wherein commercial video games were used in comprehensive rehabilitation (both physical and cognitive areas) after stroke.

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed, and all observational and experimental studies that met at least six PEDro scale criteria were included. A total of 50 studies were included in the Meta-Analysis. Data analysis was performed using RevMan 5.3 and the bias with JAMOVI.

Results: In observational studies, results favored intervention with video games in terms of functionality such as Fulg–Meyer Assessment scores [standard mean difference (SMD) = −0.45; 95% CI = −0.74 to −0.15; p = .94; I2 = 0%)] and when measured in the upper limbs using the Wolf Motor Function Test (SMD = 0.41; 95% CI = 0.07 to 0.74; p = .47; I2 = 0%). Other results showed heterogeneity. In the experimental group, most results tended to favor the experimental group and showed homogeneity, but they were not significant. Fail Safe N was calculated, and the results were not biased.

Conclusions: Results tend to favor intervention with commercial video games, but the heterogeneity of the measuring instruments and small sample size do not allow for significant results to be obtained. Future research should provide the number of participants, mean, and standard deviation to facilitate future meta-analyses. Commercial video games appear to be a feasible tool in physical and cognitive stroke rehabilitation


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[Abstract] Cognitive Recovery After Stroke: A Meta-analysis and Metaregression of Intervention and Cohort Studies



Cognition affects poststroke recovery, but meta-analyses of cognition have not yet provided a comparison of observational and intervention evidence.


To describe the trajectory of poststroke cognition and the factors that moderate it across intervention and observational cohorts.


Six databases were searched up to January 2020. Studies describing quantitative changes in cognition in adults poststroke were included. Interventions were classified into pharmacological, therapist-led, nonroutine/alternative, and usual care. Summary estimates were compared via hierarchical mixed-effects models. Age, recovery stage, stroke etiology, cognitive domain targeted in studies, and intervention types were investigated as moderators of cognition. Recovery stage and intervention were further analyzed in a multiplicative metaregression model.


A total of 43 intervention trials and 79 observation cohorts involving 28 222 stroke participants were included. Heterogeneity was significant (τ2 = 0.09; CI = 0.01-0.21, P < .001) with no evidence of publication bias. Cognitive recovery was greater in intervention trials (g = 0.47; CI = 0.37-0.58) than observational cohorts (g = 0.28; CI = 0.20-0.36) across all moderators analyzed. Nonroutine/alternative and pharmacological trials achieved the best overall results (g = 0.57, CI = 0.42-0.73, and g = 0.52, CI = 0.30-0.74, respectively), followed by therapist-led (g = 0.46; CI = 0.17-0.74), and usual care (g = 0.28; CI = 0.11-0.45) interventions. Medium recovery effects (ie, g ≥ 0.5) were observed in examining first-ever stroke, executive function, visuo-perceptual, consciousness, and psychomotor skills, 61 to 180 days poststroke, in participants aged 65 to 70 years.


Cognitive recovery is possible using different controlled interventions in all recovery stages, with smaller benefits ≥2 years poststroke. Longer-term studies are needed to determine the role of nonroutine/alternative therapies and the association between cognitive recovery and performance in everyday activities.


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[ARTICLE] Physical Therapy for Gait, Balance, and Cognition in Individuals with Cognitive Impairment: A Retrospective Analysis


Objectives. The purpose of this study was to determine if a pragmatic physical therapy (PT) program was associated with improved cognition, gait, and balance in individuals with cognitive impairment. This study investigated these associations for individuals with Alzheimer disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), and mild cognitive impairment (MCI) in order to better characterize outcomes to PT for each diagnostic group. 

Methods. Data before and after one month of physical therapy were extracted from patient records (67 with AD, 34 with VaD, 35 with DLB, and 37 with MCI). The mean number of PT sessions over a month was 3.4 (±1.8). Outcomes covered the domains of gait, balance, and cognition with multiple outcomes used to measure different constructs within the balance and gait domains. 

Results. All groups showed improvements in balance and at least one gait outcome measure. Those with MCI improved in every measure of gait and balance performance. Lastly, cognition as measured by Montreal Cognitive Assessment improved in individuals in the AD, VaD, and MCI groups. 

Conclusion. While this retrospective analysis is not appropriate for causal inference, results of one month of physical therapy were associated with decreases in gait, balance, and cognitive impairment in individuals with AD, VaD, DLB<, and MCI. 

Clinical Implications. While physical therapy is not typically a primary treatment strategy for individuals with cognitive impairment, the results of this study are consistent with the literature that demonstrates improvement from physical therapy for other neurodegenerative diseases. Further clinical and research exploration for physical therapy as a primary treatment strategy in these populations is warranted.

1. Introduction

Between 2012 and 2050, the population aged 65 years and older within the United States is expected to nearly double from 43.1 million to 83.7 million [1]. This growth will have wide-ranging implications for healthcare systems and its management of chronic diseases. Of particular concern are disorders resulting in cognitive impairment (CI) including Alzheimer disease (AD), vascular dementia (VaD), dementia with Lewy bodies (DLB), and mild cognitive impairment (MCI). Because of their progressive nature, these disorders can result in the loss of independence which strains individuals, families, and society [2].

Dementia is an umbrella term for a broad range of cognitive symptoms that cause functional impairment [3]. It encompasses a variety of subtypes that are categorized based on disease timing, severity of cognitive symptoms, and other specific diagnostic criteria [3]. With a prevalence of 5.3 million cases in the U.S. in 2015, AD is the most common cause of dementia in older adults and is the most common neurodegenerative disease [4]. It is characterized by beta-amyloid and phosphorylated-tau pathology [5]. In comparison, DLB is the second most diagnosed type of progressive dementia, and it is characterized by a primary synucleinopathy that causes protein deposits, called Lewy bodies, in the brain [3]. The presence of visual hallucinations and spontaneous motor features of parkinsonism makes DLB distinguishable from other dementias [6]. VaD is another type of dementia that is caused by vascular events in the brain [7]. MCI, a potential precursor to dementia, is marked by slight, but detectable, decline in cognitive abilities not reaching the threshold for dementia diagnosis.

Another contributor to functional decline in persons with CI is motor impairment [810]. These motor impairments have received less treatment and research attention compared to the more prominent cognitive impairments. Subsequently, while physical activity programs for the prevention of and management of CI have begun to be implemented, physical therapy (PT) to address the motor impairment has not been considered a primary treatment strategy for individuals with CI [1112]. However, evidence supports that exercise can mitigate some of the cognitive and motor impairment [89]. Hence, there is a need to further explore the most effective circumstances and settings for providing these types of interventions to individuals with CI disorders.

Gait and balance dysfunctions are common in people with dementia [10]. Specifically, individuals with dementia exhibited slower gait speeds compared to healthy controls, and more severe dementia was associated with more severe declines in gait [89]. Recognizing and addressing this connection are crucial as declining gait characteristics have been correlated with decreased survival and independence in older adults [13]. Another important motor impairment in individuals with CI is impaired balance which, combined with the gait deficits, significantly increases risk for falls [1416]. Approximately 60% of individuals with CI fall annually, twice as frequently as their cognitively intact counterparts [1718]. Individuals with CI have higher rates of mortality and institutionalization postfall [1920] and are more likely to have falls resulting in injuries, with up to a threefold increase in hip fracture incidence over individuals without CI [19]. Falls with resultant injuries have been shown to warrant extensive medical care including long-term hospitalization and rehabilitation which not only diminish the quality of life of the individual but also come with significant economic costs [21].

Because CI disorders are associated with loss of independence or future loss of independence, it is important to address potentially mitigable motor impairments which may exacerbate or hasten disability. Targeting motor impairments early may potentially prevent loss of function and also may delay the progression of CI [1022]. While evidence has suggested a connection between diminished mobility and diminished cognition, the opposite is also true: improving mobility has been shown to improve cognition. In fact, evidence suggests that improvements in the Six Minute Walk Test correlated with significantly less decline on the Mini-Mental State Examination in those with AD [23].

Currently, treatments for CI include both pharmacological and nonpharmacological interventions. Appropriate cognitive pharmacotherapy (e.g., cholinesterase inhibitors for AD and other memory enhancers) produces improvements in gait velocity, stride time, and fall risk [24]. Aerobic exercise has been shown to preserve mental speed and attention in individuals with AD [25]. Moreover, dual-task-based training can improve gait and balance in individuals with dementia [2426].

With all this evidence promoting the importance of mobility for individuals with CI, some medical doctors have started prescribing PT. [27] Referral to PT for the primary treatment of motor impairment associated with CI is not currently considered a first-line intervention because there is no consensus on its efficacy. In fact, although several studies have investigated this topic, it remains unclear whether individuals with CI will benefit from individualized PT, as opposed to the more commonly studied exercise programs, with respect to motor performance and fall risk prevention [2830]. Therefore, the first aim of this study was to determine if a pragmatic individualized PT program over the course of four weeks is associated with decreases in gait and balance impairment in different diagnostic groups of individuals with CI. The intent was to investigate associations within each group of diagnoses rather than a between-group comparison. The second aim of this study was to determine if PT was also positively associated with cognition.[…]


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[Abstract] Effects of therapeutic instrumental music performance and motor imagery on chronic post-stroke cognition and affect: A randomized controlled trial


Background: The burden of post-stroke cognitive impairment, as well as affective disorders, remains persistently high. With improved stroke survival rates and increasing life expectancy, there is a need for effective interventions to facilitate remediation of neurocognitive impairments and post-stroke mood disorders.

Objective: To investigate the effects of Therapeutic Instrumental Music Performance (TIMP) training with and without Motor Imagery on cognitive functioning and affective responding in chronic post-stroke individuals.

Methods: Thirty chronic post-stroke, community-dwelling participants were randomized to one of three experimental arms: (1) 45 minutes of active TIMP, (2) 30 minutes of active TIMP followed by 15 minutes of metronome-cued motor imagery (TIMP+cMI), (3) 30 minutes of active TIMP followed by 15 minutes of motor imagery without cues (TIMP+MI). Training took place three times a week for three weeks, using a selection of acoustic and electronic instruments. Assessments, administered at two baselines and post-training, included the Trail Making Test (TMT) – Part B to assess mental flexibility, the Digit Span Test (DST) to determine short-term memory capacity, the Multiple Affect Adjective Checklist – Revised (MAACL-R) to ascertain current affective state, and the General Self-Efficacy Scale (GSE) to assess perceived self-efficacy. The Self-Assessment Maniqin (SAM) was also administered prior to and following each training session.

Results: Thirty participants completed the protocol, ten per arm [14 women; mean age = 55.9; mean time post-stroke = 66.9 months]. There were no statistically significant differences between pooled group baseline measures. The TIMP+MI group showed a statistically significant decrease in time from pre-test 2 to post-test on the TMT. The TIMP group showed a significant increase on MAACL sensation seeking scores, as well as on the Valence and Dominance portions of the SAM; TIMP+cMI showed respective increases and decreases in positive and negative affect on the MAACL, and increases on the Valence, Dominance, and Arousal portions of the SAM. No statistically significant association between cognitive and affective measures was obtained.

Conclusions: The mental flexibility aspect of executive functioning appears to be enhanced by therapeutic instrumental music training in conjunction with motor imagery, possibly due to multisensory integration and consolidation of representations through motor imagery rehearsal following active practice. Active training using musical instruments appears to have a positive impact on affective responding; however, these changes occurred independently of improvements to cognition.


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[Abstract] Comorbidity in traumatic brain injury and functional outcomes: a systematic review

INTRODUCTION: Comorbidities in persons with traumatic brain injury (TBI) may negatively impact injury recovery course and result in long-term disability. Despite the high prevalence of several categories of comorbidities in TBI, little is known about their association with patients’ functional outcomes. We aimed to systematically review the current evidence to identify comorbidities that affect functional outcomes in adults with TBI.

EVIDENCE ACQUISITION: A systematic search of Medline, Cochrane Central Register of Controlled Trials, Embase, and PsycINFO was conducted from 1997 to 2020 for prospective and retrospective longitudinal studies published in English. Three researchers independently screened and assessed articles for fulfillment of the inclusion criteria. Quality assessment followed the Quality in Prognosis Studies tool and the Scottish Intercollegiate Guidelines Network methodology recommendations.

EVIDENCE SYNTHESIS: Twenty-two studies of moderate quality discussed effects of comorbidities on functional outcomes of patients with TBI. Cognitive and physical functioning were negatively affected by comorbidities, although the strength of association, even within the same categories of comorbidity and functional outcome, differed from study to study. Severity of TBI, sex/gender, and age were important factors in the relationship. Due to methodological heterogeneity between studies, meta-analyses were not performed.

CONCLUSIONS: Emerging evidence highlights the adverse effect of comorbidities on functional outcome in patients with TBI, so clinical attention to this topic is timely. Future research on the topic should emphasize time of comorbidity onset in relation to the TBI event, to support prevention, treatment, and rehabilitation. PROSPERO registration (CRD 42017070033).


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[Abstract] A Portable Device for Hand Rehabilitation with Force Cognition: Design, Interaction and Experiment


Introducing interactive system into portable robots for hand rehabilitation has always been a crucial topic. Moreover, hand rehabilitation with force cognition can make patients participate actively and improve rehabilitation effect. In this paper, we design a portable robotic device with interactive system for patients to rehabilitate with force cognition. Firstly, an exoskeleton glove is designed with a compact mechanical structure which is controlled by a real-time feedback system. The portable device allows patients to rehabilitate not only in hospital. Next, an interactive system including virtual environment and force cognition is introduced to detect the hand motion and collision. At last, clinical tests of our portable device is carried out with 9 subjects after tendon injury to show the effective assistance with our device.


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[ARTICLE] The Michelangelo Effect: Art Improves the Performance in a Virtual Reality Task Developed for Upper Limb Neurorehabilitation – Full Text

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 (p = 0.001) and with a lower perception of physical demand (p = 0.049). In experiment 2, only the patients treated with artistic stimuli showed a reduction in the erroneous movements performed orthogonally to the canvas (p < 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.


The human capacity to experience the beauty of things is particularly evident in the creation and appreciation of works of art. Experiencing the aesthetics of artworks is a very intriguing and controversial subject dealt with by philosophers and then by psychologists and neuroscientists (Di Dio et al., 2016). The processes involved in such a capacity include three different levels of aesthetic experience which have been evaluated and discussed: a perceptual, a cognitive and an emotional stage (Di Dio et al., 2016). It has opened a new field of research named neuroaesthetics (Zeki, 2002). Surprisingly, the aesthetic experience of artworks depicting both human subjects and nature scenes seems to involve also brain motor areas. Indeed, it has been demonstrated that the dynamic human figures seem to activate more precuneus, fusiform gyrus, and posterior temporal areas, with respect to nature scenes that activate more occipital and posterior parietal cortex, both involved in visuospatial exploration and pragmatic coding of movement, as well as central insula (Di Dio et al., 2016). Static nature paintings further activated central and posterior insula, probably because they evoke aesthetic processes requiring an additional proprioceptive and sensorimotor component implemented by “motor accessibility” to the represented scenario, which is needed to judge the aesthetic value of the observed painting (Di Dio et al., 2016). It is important to highlight that further results also showed the involvement of the cortical motor system even in the viewing of static abstract artworks (Umilta’ et al., 2012).

The sensorimotor networks activated by viewing an art masterpiece could be related to the recognition of emotions displayed by expressions of painted persons (Adolphs et al., 2000), to the mirror neuron networks activated by the actions performed by painted persons (Freedberg and Gallese, 2007), to the ideal possibility to walk in the scene (Di Dio et al., 2016), and even to the empathetic engagement activating simulation of the motor program that corresponds to the gesture implied by the trace done by the painter into the observer (Knoblich et al., 2002Freedberg and Gallese, 2007).

Artworks would feed into a general feeling of pleasure, motivation, and arousal (Duckworth et al., 2014). Brain arousal and motivation are two fundamental aspects also in neurorehabilitation, together with active participation and treatment intensity (Paolucci et al., 2012). Based on these principles, music-therapy, for example, has been proposed in neurodegenerative diseases such as Parkinson’s disease (De Bartolo et al., 2020a) or stroke (Verna et al., 2020). Furthermore, it was observed that listening to Mozart music improves the performance of subjects during the execution of a task, and it was called “Mozart effect” (Victorino et al., 2020). If Music-therapy could be performed by listening or generating music, Art-therapy was often limited to asking patients to paint, and not to observe art masterpieces. Action-observation neural mechanisms, based on the activations of mirror neuron networks, have been exploited in rehabilitation showing to patients some videos, but it does not involve the above described wide brain activations. The ideal scenario for combining the potential sensorimotor benefits of painting and the wide brain arousal induced by art would be to require the patient to copy a masterpiece. Unfortunately, very few humans are able to do it, so it seems practically impossible for a patient with an affected upper limb. However, virtual reality technology may provide valid support in simulating this task. Furthermore, technological sensors may also provide reliable measures of the subject’s performance during the task (Iosa et al., 2016Tieri et al., 2018).

Virtual reality (VR) is a new technology that can give the illusion to be in another place, thanks to the so-called sense of presence (Sanchez-Vives and Slater, 2005), and to respond in a realistic way to virtual stimuli, including both physiological (Meehan et al., 2002Tieri et al., 2015Fossataro et al., 2020) and neural reactivity (Vecchiato et al., 2015a,bPavone et al., 2016), the so-called sense of agency, and even to do impossible or uncommon things, living unusual experiences, in a safe and controlled situation (Tieri et al., 2015), as often occurs in immersive videogames. Virtual reality has been suggested also as a useful tool in neurorehabilitation of patients because it may increase motivation and enjoy during therapy process (Cho et al., 2013). Undoubtedly, technologically-assisted therapy should favor gaining maximum advantage from the opportunities provided by VR-technology for obtaining significant benefits in terms of rehabilitative outcomes (Tieri et al., 2018). Indeed, VR showed promising results in the therapy process thanks to interactive and direct training opportunities given to patients affected by neurodegenerative diseases, such as those with multiple sclerosis (Calabró et al., 2017). So, despite sometimes VR is used just to replicate the activities of daily living, it can provide the possibility to give the illusion to do something otherwise impossible, such as painting a masterpiece of the history of art. Even though the experience of standing in front of an authentic work of art cannot be replaced in terms of explicit hedonic attributed values by virtual reproductions, it has been shown as faithful high-quality virtual reproductions of artworks could be as arousing as the original works of art (Siri et al., 2018).

In the present study, we immersed healthy participants and a group of patients with stroke in a virtual environment where they had the illusion to paint famous masterpieces. Furthermore, during the task, their performance was assessed by measuring kinematic parameters related to the hand trajectory with respect to the virtual canvas. We also evaluated the acceptability and usability of this VR-system.

The main aim of this study was to validate the hypothesis that the performance of subjects could be improved when they interact with an art masterpiece, with respect to control stimuli, during the execution of the task performed in VR. This approach could open a novel way for rehabilitation programs for multiple users and can be helpful in administering to patients with stroke an art therapy for upper limb recovery.

Materials and Methods

The study was divided in two experiments, one conducted on healthy subjects and one involving a group of four patients with stroke. The research protocol was designed in accordance with the 2013 Declaration of Helsinki and approved by the Ethics Committee of the Santa Lucia Foundation. Each volunteer provided written informed consent to participate in the study.

Hardware and Software Equipment

Each subject sat wearing the Oculus Rift Head Mounted Display and taking into his/her hand (the preferred one for healthy subjects, the paretic one for patients with stroke) an Oculus Controller joystick which allowed to interact with the virtual stimuli. The virtual environment, designed by using 3ds MAX 2018 and implemented in Unity 2018 game engine software, consisted of a large and comfortable room (with a door, a window, two lamps, a sofa; Scale 1:1) in the middle of which there was a canvas on an easel. The subject could interact with the canvas with a virtual sphere, displayed in VR in the same place of the real hand, which could be controlled with the Oculus Controller by means of a customized script in C# (see Supplementary Video 1).

Each virtual canvas was 60 cm × 40 cm and appeared white at the beginning of the task. Subjects were instructed that the sphere can color the canvas when put in contact with it, forming a painting. The illusion is given thanks to a white thin virtual panel (composed by 19 × 13 = 247 pixels, pixel area: 10 cm2) placed in front of the canvas which occluded the visibility of an underlying image. When the subject touched the virtual panel with the sphere, the target pixels were automatically deleted allowing to see a part of the underlay picture. To overcome the missing tactile information concerning the real touch of the virtual canvas, we included visual feedback about the shadow of the virtual sphere on the canvas itself (in order to enhance the visual information about its position in the 3D-space) and also a change in the color of the sphere, from grey to green, when the virtual sphere touched the canvas colliding the panel’s pixels, or becoming red if an erroneous movement was performed beyond the canvas. The dimension of canvas and pixels were chosen according to preliminary tests involving other patients with stroke (not included in the present study). Before the experiment, each participant underwent to a calibration task. Then the participant was asked to color the entire canvas in the shorter time possible, but without missing any pixel. The performance of the subject was recorded through a customized C# script implemented in Unity which allowed to track and record in real-time the position of the virtual sphere/real hand in space. Each subject was also instructed to move their upper limb without moving the trunk. Each trial was controlled by a researcher who monitored what happened into the virtual environment on the computer’s monitor and by a physiotherapist who monitored the movements of the subjects, especially for avoiding trunk compensation strategies of patients. Each experimental session was composed of 10 trials, that could be 10 artistic paintings or 10 control stimuli, during which the participants painted the canvas. After each trial, the colored canvas disappeared and a new white canvas appeared on the easel.

The artistic paintings were chosen according to three criteria: to cover different époques (starting from Renaissance up to the twentieth century), to cover different styles (realism, baroque style, impressionism, post-impressionism, Ukiyo-e style, expressionism, and cubism), and especially to have similar proportions each other that could be matched by the size of the canvas. The following paintings were chosen: The Annunciation (Da Vinci, 1475), The Birth of Venus (Botticelli, 1485), The creation of Adam (Michelangelo, 1511), The Vocation of Saint Matthew (Caravaggio, 1600), The great wave of Kanagawa (Hokusai, 1831), Rowers Breakfast (Renoir, 1882), The bedroom (Van Gogh, 1888), The Night Café (Van Gogh, 1888), The Dance (Matisse, 1910), The Three Musicians (Picasso, 1921). For avoiding possible bias, the same colors and the same amount of brightness of the art masterpieces were maintained into the control stimuli; each masterpiece, was realized by blur-filter for control painting, and then reversing both left-right and up-down the image (GIMP software, Gnu Image Manipulation Program, version 2), as shown in Figure 1.

Figure 1. (A) Experimental setup; Left-side represents an example of the art masterpieces (the Creation of Adam of Michelangelo) presented during the task; Right-side shows a patient with the experimental setting of Oculus Headset and Controller, under the supervision of experimenter. (B) Example of an experimental stimulus of the art masterpieces (the Creation of Adam of Michelangelo) and the relevant control stimuli (below), with superimposed the hand trajectories for a healthy subject (on the left) and a patient (on the right).



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[BOOK] Embodying Tool Use: From Cognition to Neurorehabilitation – Google Books

Front Cover

Mariella Pazzaglia, Giulia Galli, Yusuf Ozgur Cakmak, Jan Babic

Frontiers Media SA, Dec 18, 2020

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[Abstract] Functional Change from Five to Fifteen Years after Traumatic Brain Injury


Few studies have assessed the long-term functional outcomes of traumatic brain injury (TBI) in large, well-characterized samples. Using the Traumatic Brain Injury Model Systems cohort, this study assessed the maintenance of independence between years 5 and 15 post-injury and risk factors for decline. The study sample included 1381 persons with TBI who received inpatient rehabilitation, survived to 15 years post-injury, and were available for data collection at 5 or 10 years and 15 years post-injury. The Functional Independence Measure (FIM) and Disability Rating Scale (DRS) were used to measure functional outcomes. The majority of participants had no changes during the 10-year time frame. For FIM, only 4.4% showed decline in Self-Care, 4.9% declined in Mobility, and 5.9% declined in Cognition. Overall, 10.4% showed decline in one or more FIM subscales. Decline was detected by DRS Level of Function (24% with >1-point change) and Employability (6% with >1-point change). Predictors of decline factors across all measures were age >25 years and, across most measures, having less than or equal to a high school education. Additional predictors of FIM decline included male sex (FIM Mobility and Self-Care) and longer rehabilitation length of stay (FIM Mobility and Cognition). In contrast to studies reporting change in the first 5 years post-TBI inpatient rehabilitation, a majority of those who survive to 15 years do not experience functional decline. Aging and cognitive reserve appear to be more important drivers of loss of function than original severity of the injury. Interventions to identify those at risk for decline may be needed to maintain or enhance functional status as persons age with a TBI.


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