Research Lines

The main results obtained in this line concern the development and application of “mechatronic” systems (integration of mechanics, electronics and information technology) in patients with neurological lesions, which make it possible to integrate the work of traditional physiotherapy with the advantages that these systems offer: repetitiveness of movement that is always the same in terms of speed, strength and range of motion, specificity, interaction with a monitor to increase proprioceptive feedback during rehabilitation sessions, the possibility of quantitatively assessing the recovery rate, and optimisation of resources.

The systems produced are all covered by international patents and the most important are Aramis, Copernicus, Intellibed, already described in the introduction.

All devices made and used on patients are based on neurophysiopathological background and reflect the principles of neurophysiopathology and neurorehabilitation experience gained over the years. In addition, third-party mechatronic devices were acquired for hand recovery and treadmill walking. In particular, through the Amadeo system supplied by TyroMotion, the rehabilitation of the upper limb carried out with Aramis is completed with the treatment of the hand and fingers; with the Geo system supplied by RehaTechnology, it is possible to carry out rehabilitation of the lower limbs in complete safety.

The development and application of robot systems dedicated to the neurorehabilitation of patients with neurological injuries aims to meet all the needs required by the rehabilitation process, from the acute phase in a stroke unit, through the entire rehabilitation pathway, up to the continuation of training at home. In fact, within this line, there is a keen interest in the use of home telerehabilitation systems obtained with the system provided by Khymeia.

When the patient is an in-patient in the rehabilitation facility, he/she carries out neuromotor, cognitive and speech exercises through the VRRS system present in the facility, while once he/she returns home, he/she will continue to carry out the same exercises through a home device connected by video and remote assistance with the therapist in the clinic. This system, which integrates technological devices with traditional therapies, is intended to make the most of the potential of robotics and not limit or supplement the work of the therapist, who assumes a much more differentiated role in that he or she can draw up a customised rehabilitation project according to clinical evolution.

Within this line, several activities are under way with the relevant experimental projects approved by the relevant Ethics Committee and, in the case of mechatronic devices, also approved by the Ministry of Health; in particular, the activities under way concern an RCT study in post-stroke patients for the evaluation of functional recovery of the upper limb with a robotic device, an RCT study with electromyographic evaluation of treatments with a robotic device a study on the feasibility of using Intellibed in a Stroke Unit in collaboration with the Stroke Unit of the Jazzolino Hospital in Vibo Valentia, where the bed is being tested; an RCT study on the feasibility of using Copernicus and its clinical efficacy for early recovery of ambulation; a study on the feasibility and cost/benefit analysis of a multi-domain tele-neurisation treatment in patients with neurological pathologies.

1. Autonomic system. At the S. Anna Institute, this area of research has been active for some time. To date, relations between stimulation and changes in the Autonomic Nervous System (ANS) have been observed and published through the analysis of cardiac variability (HRV) in its temporal, frequency and non-linear components. In particular, differences between aresponsive and minimally conscious patients and correlations between the autonomic system and recovery of consciousness were studied. The Central Autonomic Network (CAN) (a system describing the reciprocal influence present between the heart and brain) is also being studied and published as a useful model for defining and explaining severe disorders of consciousness, including by analysing cardiac variability. To this end, a system for analysing the SNA was created and implemented using a system of devices that record and correlate variations in patients’ biometric signals (heart rate and variability, respiration, temperature and posture) with variations in continuous (24-hour) environmental data. Initial work on the correlation between environmental variability and cardiac variability has already been submitted for publication.
   Ongoing activities concern:
   • Study of HRV correlated with environmental parameters for the study of circadian rhythms in patients with severe disturbance of consciousness;
   • Study of HRV h24 for correlation with dysautonomic syndromes;
   • Study of SNA and correlation with analyses in the neuroendocrine system and proteomic investigations;
   • Study of visual stimulation, in patients with severe disorders of consciousness, with images classified as emotionally significant by means of electroencephalographic and HRV investigations;
   • Analysis of the results obtained on nociceptive learning according to a classical learning scheme, in aresponsive patients, by means of Galvanic Skin Response and potential predictive aspects concerning the recovery of consciousness;

   
   

2. Gait Analysis. The Gait Analysis and Electrophysiology laboratory assesses the kinematic, dynamic and surface electromyography activity of subjects undergoing Gait Analysis, Upper Limb Activity (Reaching and Pointing) and Trunk Stability and Movement. The purpose of these assessments is to offer support to therapists and physicians in order to customise patients’ rehabilitation projects by supplementing the normal assessments of the results of the therapies themselves, both in orthopaedic and neurological patients. In particular, Gait Analysis data are to be used to evaluate the effects of neuromotor rehabilitation, comparing conventional therapy with that assisted with innovative technology instrumentation and equipment. Specifically, the Gait Analysis system is currently used in the following study protocols:
   -for the protocols involving the use of some innovative equipment for the treatment of the upper limb (Aramis, Pablo, Amadeo)
   -for the study protocol on trunk control, using the Copernicus mechatronic system




3. Brain stimulation. This field of study has only recently been activated at the Sant’Anna Institute. A research project was initiated in collaboration with the University of Liege in Belgium to study the clinical potential and application of tDCS in aresponsive patients with severe acquired brain injury.

1. Promotion by Istituto S. Anna of a multicentre prospective study to assess the incidence of Paroxysmal Sympathetic Hyperactivity with internationally shared diagnostic criteria. In addition to the Istituto S. Anna as promoter, 8 Italian Centres, distributed throughout the country, took part. Data collection of 152 patients at admission and at 4 months after the event has been completed; data collection will be completed by 15 September 2019;




2. Participation in the national multicentre study sponsored by Ist. Maugeri di Telese Terme: The effect of clinical complications on the short- and long-term evolution of disorders of consciousness from Severe Acquired Brain Injury. Completed data collection at 24 months (May 2019);




3. Adherence to: “Multicentre longitudinal study of serum levels of neurofilament light chain in patients with disorders of consciousness and collelation with outcome” sponsored by Fondazione G. Giglio di Cefalù (PA). Data collection started April 2019;




4. Participation in a working group on prognostic factors in patients with severe Acquired Cerebral Palsy, promoted by the Mario Negri Institute in Milan, to which 14 centres throughout Italy have adhered. Ongoing work on the definition of prognostic variables for recovery of per os feeding, decannulation and recovery of trunk control;
5. Data from a retrospective study of 96 patients with post-traumatic GCA: comorbidities and outcome;




6. Follow-up study at least 24 months of 180 post-traumatic and non-post-traumatic GCA patients admitted to the S. Anna Institute assessed with weekly CRS-r for the first 2 months during admission to an intensive rehabilitation setting. Correlation of SRC-r with long-term outcome;




7. Promotion of a survey to assess the likelihood of Paroxysmal Sympathetic Hyperactivity Seizures in patients with Chronic Consciousness Disorders admitted to long-term care facilities (LDS of the S. Anna Institute in Crotone and 2-3 other Centres in Italy);




8. In addition, the systematic collection of clinical indicators of outcomes, complications, survival, of patients with severe disorders of consciousness from GCA in the medium and long term (chronic phase) for an optimisation of clinical care and rehabilitation pathways is proposed.

• acquisition of new knowledge and skills in the treatment of cognitive disorders such as attentional deficits, memory, language disorders, executive functions and mood disorders;
• medium- and long-term follow-up aimed at investigating the impact of outcomes on quality of life (family, social, work);
• identification of outcome indicators related to “Activity and Participation” using the ICF;
• study of the abilities that enable the individual to understand the behaviour of others and to act appropriately in the social context (Social Cognition);
• definition of assessment instruments for measuring outcome in cognitive functioning levels;
• identification of correlations between neurophysological parameters and neuropsychological assessment instruments in order to define possible prognostic indicators;
• development of treatment methods and techniques and their application in the clinical setting in order to reduce the interference of cognitive and emotional-behavioural disorders in the rehabilitation pathway.

The following studies are underway at different levels of progress:

1. Review and publication of Rhythmic-Melodic Therapy for the Treatment of Motor Aphasia. This study phase involved adapting the technique to Italian-speaking patients by modifying the melodic structure and rhythmic groups;




2. Study of the nociceptive stimulus response in patients with disorders of consciousness through the use of a trace conditioning paradigm and the Galvanic Skin Response;




3. Visual perception and disorders of consciousness;




4. Collection and systematisation of data on the Wessex Head Injury Scale for the behavioural assessment of changes in levels of consciousness in patients with severe disorders of consciousness;
5. Study on the role of attentional deficits in the evolution of dysphagia;




6. Correlation study between Cognitive Resource and severity levels of aphasic disorders;




7. Thrombolysis: short-, medium- and long-term effects on cognitive functioning;




8. Onset, course and outcome in post-thrombolysis aphasia: a retrospective study;




9. Constructive apraxia and cognitive resource;




10. Identification of predictive characteristics of disability and outcome of patients with acquired brain injuries;




11. Marital stability and relationship quality in GCA;




12. Social support and improvement of quality of life in stroke.