The new biotechnology raises expectations for modifying human behaviour through its use. This article focuses on the ethical analysis of the not so remote possibility of rehabilitating criminals by means of neurotechnological techniques. The analysis is carried out from a synthetic position of, on the one hand, the consequentialist conception of what is right and, on the other hand, the emphasis on individual liberties. As a result, firstly, the ethical appropriateness of adopting a general predisposition for allowing the neurorehabilitation (...) of prisoners only if it is safe and if they give their consent will be defended. But, at the same time, reasons will be given for requiring, in certain circumstances, the exceptional use of neurotechnology to rehabilitate severely psychopathic prisoners, even against their will, from the same ethical perspective. (shrink)

It has been proposed that reoffending could be reduced by manipulating the neural underpinnings of offenders’ criminogenic mental features with what have been called neurocorrectives. The legitimacy of such use of neurotechnology – criminal neurorehabilitation, as the use is called – is usually seen to presuppose valid consent by the offenders subjected to it. According to a central criticism of nonconsensual criminal neurorehabilitation, nonconsensual use of neurocorrectives would express a degrading attitude towards offenders. In this article, I consider (...) this criticism of nonconsensual criminal neurorehabilitation. By using cases of autonomous persons who lead a subservient existence as an example, I propose that nonconsensual criminal neurorehabilitation need not express a more degrading attitude towards offenders than consensual criminal neurorehabilitation. The argument of this article does not show that nonconsensual criminal neurorehabilitation is morally or legally acceptable. Yet, in view of the argument, criticizing nonconsensual criminal neurorehabilitation for expressing a degrading attitude towards offenders is not compatible with simultaneously endorsing consensual criminal neurorehabilitation. (shrink)

Our access to computer-generated worlds changes the way we feel, how we think, and how we solve problems. In this review, we explore the utility of different types of virtual reality, immersive or non-immersive, for providing controllable, safe environments that enable individual training, neurorehabilitation, or even replacement of lost functions. The neurobiological effects of virtual reality on neuronal plasticity have been shown to result in increased cortical gray matter volumes, higher concentration of electroencephalographic beta-waves, and enhanced cognitive performance. Clinical (...) application of virtual reality is aided by innovative brain-computer interfaces, which allow direct tapping into the electric activity generated by different brain cortical areas for precise voluntary control of connected robotic devices. Virtual reality is also valuable to healthy individuals as a narrative medium for redesigning their individual stories in an integrative process of self-improvement and personal development. Future upgrades of virtual reality-based technologies promise to help humans transcend the limitations of their biological bodies and augment their capacity to mold physical reality to better meet the needs of a globalized world. (shrink)

For public health professionals, traumatic brain injury and its possible protracted repercussions are a significant source of worry. In opposed to patient neurorehabilitation with developed brain abnormalities of different etiologies, neurorehabilitation of affected persons has several distinct features. The clinical repercussions of the various types of TBI injuries will be discussed in detail in this paper. During severe TBI, the medical course frequently follows a familiar first sequence of coma, accompanied by disordered awareness, followed by agitation and forgetfulness, (...) followed by return of function. Clinicians must be aware of common medical issues that might occur throughout the various stages of neurorehabilitation, for example, posttraumatic hydrocephalus, paroxysmal sympathetic hyperactivity and posttraumatic neuroendocrine disorders, at each step of the process. Furthermore, we address problems about the scheduling of various rehabilitation programs as well as the availability of current data for comprehensive rehabilitative neuropsychology techniques. (shrink)

We have already had the occasion to study how Goldstein offered his fundamental postulates to neurorehabilitation, enabling it to establish itself as a new disciplinary branch of medicine [Gilart de Keranflec’h 2021]. Now we shall hypothesize that the proposals that Goldstein borrowed from his fellow contemporary neurologists by reformulating them, those he rejected and those he prolonged, were successive acculturations leading to a broader area than neurology alone, namely rehabilitative care. Long before he experienced exile —a major biographical turning (...) point in his life—had Goldstein not already led neurology down the path of exile, by demanding that it take into consideration its necessary hybridization with social and environmental issues? Combining dimensions of care, cures and even healing, rehabilitative care challenges the medical discipline alone for its pre-eminence over positive health outcomes for patients with health problems whose severity leaves them in a situation of disability. (shrink)

Many upper limb amputees experience an incessant, post-amputation “phantom limb pain” and report that their missing limbs feel paralyzed in an uncomfortable posture. One hypothesis is that efferent commands no longer generate expected afferent signals, such as proprioceptive feedback from changes in limb configuration, and that the mismatch of motor commands and visual feedback is interpreted as pain. Non-invasive therapeutic techniques for treating phantom limb pain, such as mirror visual feedback (MVF), rely on visualizations of postural changes. Advances in neural (...) interfaces for artificial sensory feedback now make it possible to combine MVF with a high-tech “rubber hand” illusion, in which subjects develop a sense of embodiment with a fake hand when subjected to congruent visual and somatosensory feedback. We discuss clinical benefits that could arise from the confluence of known concepts such as MVF and the rubber hand illusion, and new technologies such as neural interfaces for sensory feedback and highly sensorized robot hand testbeds, such as the “BairClaw” presented here. Our multi-articulating, anthropomorphic robot testbed can be used to study proprioceptive and tactile sensory stimuli during physical finger-object interactions. Conceived for artificial grasp, manipulation, and haptic exploration, the BairClaw could also be used for future studies on the neurorehabilitation of somatosensory disorders due to upper limb impairment or loss. A remote actuation system enables the modular control of tendon-driven hands. The artificial proprioception system enables direct measurement of joint angles and tendon tensions while temperature, vibration, and skin deformation are provided by a multimodal tactile sensor. The provision of multimodal sensory feedback that is spatiotemporally consistent with commanded actions could lead to benefits such as reduced phantom limb pain, and increased prosthesis use due to improved functionality and reduced cognitive burden. (shrink)

Stroke continues to be a leading cause of disability. Basic neurorehabilitation research is necessary to inform the neuropathophysiology of impaired motor control, and to develop targeted interventions with potential to remediate disability post-stroke. Despite knowledge gained from basic research studies, the effectiveness of research-based interventions for reducing motor impairment has been no greater than standard of practice interventions. In this perspective, we offer suggestions for overcoming translational barriers integral to experimental design, to augment traditional protocols, and re-route the rehabilitation (...) trajectory toward recovery and away from compensation. First, we suggest that researchers consider modifying task practice schedules to focus on key aspects of movement quality, while minimizing the appearance of compensatory behaviors. Second, we suggest that researchers supplement primary outcome measures with secondary measures that capture emerging maladaptive compensations at other segments or joints. Third, we offer suggestions about how to maximize participant engagement, self-direction, and motivation, by embedding the task into a meaningful context, a strategy more likely to enable goal-action coupling, associated with improved neuro-motor control and learning. Finally, we remind the reader that motor impairment post-stroke is a multidimensional problem that involves central and peripheral sensorimotor systems, likely influenced by chronicity of stroke. Thus, stroke chronicity should be given special consideration for both participant recruitment and subsequent data analyses. We hope that future research endeavors will consider these suggestions in the design of the next generation of intervention studies in neurorehabilitation, to improve translation of research advances to improved participation and quality of life for stroke survivors. (shrink)

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 and four patients with stroke 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 and with a lower perception of physical demand. In experiment 2, only the patients treated with artistic stimuli showed a reduction in the erroneous movements performed orthogonally to the canvas. 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. (shrink)

Soon it may be possible to promote the rehabilitation of criminal offenders through _neurointerventions_ (interventions which exert direct physical, chemical or biological effects on the brain). Some jurisdictions already utilise neurointerventions to diminish the risk of sexual or drug-related reoffending. And investigation is underway into several other neurointerventions that might also have rehabilitative applications within criminal justice—for example, pharmacotherapy to reduce aggression or impulsivity. Ethical debate on the use of neurointerventions to facilitate rehabilitation—henceforth ‘neurorehabilitation’—has proceeded on two assumptions: that (...) we have instrumental reasons for employing neurorehabilitation (e.g. because it helps protect the public from crime); and that its permissibility depends upon whether its use unjustifiably infringes offenders’ rights. This paper defends a different, hitherto neglected thought. I argue we have rights-based reasons to offer neurorehabilitation to offenders—in other words, that offenders have a _moral right_ to neurorehabilitation. I identify three considerations which support a moral right to conventional rehabilitative interventions—(1) as a countermeasure to the debilitating side-effects of punishment; (2) as a derivative right of the right to hope for renewed liberty; and (3) as compensation for structural injustice. I argue these considerations extend to support a moral right to neurorehabilitation in the following instance: when neurorehabilitation would be part of the _most effective_ package for facilitating rehabilitation, and can be carried out at reasonable cost. I then defend my argument against potential objections, including the objection that neurorehabilitation is a bad option for offenders to have and the charge of over-medicalisation. (shrink)

BackgroundFrontal brain dysfunction is a major challenge in neurorehabilitation. Neurofeedback (NF), as an EEG-based brain training method, is currently applied in a wide spectrum of mental health conditions, including traumatic brain injury.ObjectiveThis study aimed to explore the capacity of Infra-Low Frequency Neurofeedback (ILF-NF) to promote the recovery of brain function in patients with frontal brain injury.Materials and methodsTwenty patients hospitalized at a neurorehabilitation clinic in Switzerland with recently acquired, frontal and optionally other brain lesions were randomized to either (...) receive NF or sham-NF. Cognitive improvement was assessed using the Frontal Assessment Battery (FAB) and the Test of Attentional Performance (TAP) tasks regarding intrinsic alertness, phasic alertness and impulse control.ResultsWith respect to cognitive improvements, there was no significant difference between the two groups after 20 sessions of either NF or sham-NF. However, in a subgroup of patients with predominantly frontal brain lesions, the improvements measured by the FAB and intrinsic alertness were significantly higher in the NF-group.ConclusionThis is the first double-blind controlled study using NF in recovery from brain injury, and thus also the first such study of ILF NF. Although the result of the subgroup has limited significance because of the small number of participants, it accentuates the trend seen in the whole group regarding the FAB and intrinsic alertness (p = 0.068, p = 0.079, respectively). We therefore conclude that NF could be a promising candidate promoting the recoveryfrom frontal brain lesions. Further studies with larger numbers of patients and less lesion heterogeneity are needed to verify the usefulness of NF in the neurorehabilitation of patients with frontal brain injury (NCT02957695 ClinicalTrials.gov). (shrink)

To offer engaging neurorehabilitation training to neurologic patients, motor tasks are often visualized in virtual reality. Recently introduced head-mounted displays allow to realistically mimic the body of the user from a first-person perspective in a highly immersive VR environment. In this immersive environment, users may embody avatars with different body characteristics. Importantly, body characteristics impact how people perform actions. Therefore, alternating body perceptions using immersive VR may be a powerful tool to promote motor activity in neurologic patients. However, the (...) ability of the brain to adapt motor commands based on a perceived modified reality has not yet been fully explored. To fill this gap, we “tricked the brain” using immersive VR and investigated if multisensory feedback modulating the physical properties of an embodied avatar influences motor brain networks and control. Ten healthy participants were immersed in a virtual environment using an HMD, where they saw an avatar from first-person perspective. We slowly transformed the surface of the avatar from human to stone. We enforced this visual change by repetitively touching the real arm of the participant and the arm of the avatar with a hammer, while progressively replacing the sound of the hammer against skin with stone hitting sound via loudspeaker. We applied single-pulse transcranial magnetic simulation to evaluate changes in motor cortical excitability associated with the illusion. Further, to investigate if the “stone illusion” affected motor control, participants performed a reaching task with the human and stone avatar. Questionnaires assessed the subjectively reported strength of embodiment and illusion. Our results show that participants experienced the “stone arm illusion.” Particularly, they rated their arm as heavier, colder, stiffer, and more insensitive when immersed with the stone than human avatar, without the illusion affecting their experienced feeling of body ownership. Further, the reported illusion strength was associated with enhanced motor cortical excitability and faster movement initiations, indicating that participants may have physically mirrored and compensated for the embodied body characteristics of the stone avatar. Together, immersive VR has the potential to influence motor brain networks by subtly modifying the perception of reality, opening new perspectives for the motor recovery of patients. (shrink)

Wijdicks and colleagues1 recently presented the Full Outline of UnResponsiveness (FOUR) scale as an alternative to the Glasgow Coma Scale (GCS)2 in the evaluation of consciousness in severely brain-damaged patients. They studied 120 patients in an intensive care setting (mainly neuro-intensive care) and claimed that “the FOUR score detects a locked-in syndrome, as well as the presence of a vegetative state.”1 We fully agree that the FOUR is advantageous in identifying locked-in patients given that it specifically tests for eye movements (...) or blinking on command. This is welcomed given that misdiagnosis of the locked-in syndrome has been shown to occur in more than half of the cases (see Laureys and colleagues3 for review). As for the diagnosis of the vegetative state, the scale explicitly tests for visual pursuit, and hence can disentangle the vegetative state from the minimally conscious state (MCS). The diagnostic criteria for MCS have been proposed4 only recently, but Wijdicks and colleagues1 do not mention the existence of this clinical entity in their article. As for the vegetative state, MCS can be encountered in the acute or subacute setting as a transitional state on the way to further recovery, or it can be a more chronic or even permanent condition. The MCS refers to patients showing inconsistent, albeit clearly discernible, minimal behavioral evidence of consciousness (eg, localization of noxious stimuli, eye fixation or tracking, reproducible movement to command, or nonfunctional verbalization).4 The FOUR scale does not test for all of the behavioral criteria required to diagnose MCS.4 It is known from the literature (see Majerus and colleagues5 for review) that about a third of patients diagnosed with vegetative state are actually in MCS, and this misdiagnosis can lead to major clinical, therapeutic, and ethical consequences. We tested the ability of the newly proposed FOUR scale to correctly diagnose the vegetative state in an acute (intensive care and neurology ward) and chronic (neurorehabilitation) setting.. (shrink)

The quality of arm movements typically improves in the sub-acute phase of stroke affecting the upper extremity. Here, we used whole arm kinematic analysis during reaching movements to distinguish whether these improvements are due to true recovery or to compensation. Fifty-three participants with post-acute stroke performed ∼80 reaching movement tests during 4 weeks of training with the ArmeoSpring exoskeleton. All participants showed improvements in end-effector performance, as measured by movement smoothness. Four ArmeoSpring angles, shoulder horizontal rotation, shoulder elevation, elbow rotation, (...) and forearm rotation, were recorded and analyzed. We first characterized healthy joint coordination patterns by performing a sparse principal component analysis on these four joint velocities recorded during reaching tests performed by young control participants. We found that two dominant joint correlations [SH with elbow rotation and SE with forearm rotation] explained over 95% of variance of joint velocity data. We identified two clusters of stroke participants by comparing the evolution of these two correlations in all tests. In the “Recoverer” cluster, both joint correlations converged toward the respective correlations for control participants. Thus, Recoverers relearned how to generate smooth end-effector movements while developing joint movement patterns similar to those of control participants. In the “Compensator” cluster, at least one of the two joint correlations diverged from the corresponding correlation of control participants. Compensators relearned how to generate smooth end-effector movements by discovering various new compensatory movement patterns dissimilar to those of control participants. New compensatory patterns included atypical decoupling of the SE and forearm joints, and atypical coupling of the SH rotation and elbow joints. There was no difference in clinical impairment level between the two groups either at the onset or at the end of training as assessed with the Upper Extremity Fugl-Meyer scale. However, at the start of training, the Recoverers showed significantly faster improvements in end-effector movement smoothness than the Compensators. Our analysis can be used to inform neurorehabilitation clinicians on how to provide movement feedback during practice and suggest avenues for refining exoskeleton robot therapy to reduce compensatory patterns. (shrink)

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration . This withdrawal is deemed necessary because patients in PDOC (...) can survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession. (shrink)

Muscle synergy analysis via surface electromyography is useful to study muscle coordination in motor learning, clinical diagnosis, and neurorehabilitation. However, current methods to extract muscle synergies in the upper limb suffer from two major issues. First, the necessary normalization of EMG signals is performed via maximum voluntary contraction, which requires maximal isometric force production in each muscle. However, some individuals with motor impairments have difficulties producing maximal effort in the MVC task. In addition, the MVC is known to be (...) highly unreliable, with widely different forces produced in repeated measures. Second, synergy extraction in the upper limb is typically performed with a multidirection reaching task. However, some participants with motor impairments cannot perform this task because it requires precise motor control. In this study, we proposed a new isometric rotating task that does not require precise motor control or large forces. In this task, participants maintain a cursor controlled by the arm end-point force on a target that rotates at a constant angular velocity at a designated force level. To relax constraints on motor control precision, the target is widened and blurred. To obtain a reference EMG value for normalization without requiring maximal effort, we estimated a linear relationship between joint torques and muscle activations. We assessed the reliability of joint torque normalization and synergy extraction in the rotating task in young neurotypical individuals. Compared with normalization with MVC, joint torque normalization allowed reliable EMG normalization at low force levels. In addition, the extraction of synergies was as reliable and more stable than with the multidirection reaching task. The proposed rotating task can, therefore, be used in future motor learning, clinical diagnosis, and neurorehabilitation studies. (shrink)

The information theoretic principle of rational adaptation predicts that individuals with aphasia adapt to their language impairments by relying more heavily on comparatively unimpaired non-linguistic knowledge to communicate. This prediction was examined by assessing the extent to which adults with chronic aphasia due to left-hemisphere stroke rely more on conceptual rather than lexical information during verb retrieval, as compared to age-matched neurotypical controls. A primed verb naming task examined the degree of facilitation each participant group received from either conceptual event-related (...) or lexical collocate cues, compared to unrelated baseline cues. The results provide evidence that adults with aphasia received amplified facilitation from conceptual cues compared to controls, whereas healthy controls received greater facilitation from lexical cues. This indicates that adaptation to alternative and relatively unimpaired information may facilitate successful word retrieval in aphasia. Implications for models of rational adaptation and clinical neurorehabilitation are discussed. (shrink)

ObjectiveNoisy galvanic vestibular stimulation (nGVS) is often used to improve postural stability in disorders, such as neurorehabilitation montage. For the safe use of nGVS, we investigated whether arterial pressure (AP) and heart rate vary during static supine and slow whole-body tilt with random nGVS (0.4 mA, 0.1–640 Hz, gaussian distribution) in a healthy elderly population.MethodsThis study was conducted with a double-blind, sham-controlled, cross-over design. Seventeen healthy older adults were recruited. They were asked to maintain a static supine position on (...) a bed for 10 min, and the bed was tilted up (TU) to 70 degrees within 30 s. After maintaining this position for 3 min, the bed was passively tilted down (TD) within 30 s. Real-nGVS or sham-nGVS was applied from 4 to 15 min. The time course of mean arterial pressure (MAP) and RR interval variability (RRIV) were analyzed to estimate the autonomic nervous activity.ResultnGVS and/or time, including pre-/post-event (nGVS-start, TU, and TD), had no impact on MAP and RRIV-related parameters. Further, there was no evidence supporting the argument that nGVS induces pain, vertigo/dizziness, and uncomfortable feeling.ConclusionnGVS may not affect the AP and RRIV during static position and whole-body tilting or cause pain, vertigo/dizziness, and discomfort in the elderly. (shrink)

To maximize brain plasticity after stroke, several rehabilitation strategies have been explored, including the use of intensive motor training, motor imagery, and action observation. Growing evidence of the positive impact of virtual reality (VR) techniques on recovery following stroke has been shown. However, most VR tools are designed to exploit active movement, and hence patients with low level of motor control cannot fully benefit from them. Consequently, the idea of directly training the central nervous system has been promoted by utilizing (...) motor-imagery (MI) based brain-computer interfaces (BCIs). To date, detailed information on which VR strategies lead to successful functional recovery is still largely missing, and very little is known about how to optimally integrate BCI and VR paradigms for stroke rehabilitation. The purpose of this study was to examine the efficacy of a BCI-VR system using a MI paradigm for post-stroke upper limb rehabilitation on functional assessments, and related changes in MI ability and brain imaging. To achieve this, a 60 years old male chronic stroke patient was recruited. The patient underwent a 3-week intervention in a clinical environment, resulting in 10 BCI-VR training sessions. The patient was assessed before and after intervention, as well as on a one-month follow-up, in terms of clinical scales and brain imaging using functional MRI (fMRI). Consistent with prior research, we found important improvements in upper extremity scores (Fugl-Meyer) and identified increases in brain activation measured by fMRI that suggest neuroplastic changes in brain motor networks. This study expands on the current body of evidence as more data are needed on the effect of this type of interventions not only on functional improvement but also through brain imaging to study the effect of the intervention on plasticity. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Accurate Self-Assessment, Autonomous Ignorance, and the Appreciation of DisabilityJoel Anderson (bio) and Warren Lux (bio)In their thoughtful commentaries on our essay, "Knowing your own strength: Accurate self-assessment as a requirement for personal autonomy," George Agich, Ruth Chadwick, and Dominic Murphy (2004) provide both criticisms and insights that give us a context in which to clarify further our claim that one's autonomy is impaired when one is unable to appreciate (...) whether one has the capacities required for tasks one is undertaking. We focus on two issues: the extent to which our account of autonomy suggests a problematically "externalist" or "objective" approach and the issue of whether our talk of accurate self-assessment entails an overdemanding requirement that one know numerous facts about oneself to count as autonomous.The External Point of ViewFor many, the idea that specific regions of the brain might be relevant to a person's autonomy evokes nightmarish, startlingly reductionist visions of a world in which informed consent is decided on the basis of neuroimaging. In arguing that a capacity for self-assessment is essential for autonomy and also presupposes executive function that is often impaired by prefrontal damage, we do not wish to engage in such reductionism by suggesting that there is any straightforward, one-to-one mapping comparable to that presupposed by the nightmare scenarios. Given what we know about the brain's plasticity, the prospects (although limited at present) for neurorehabilitation, the multiplicity of the instantiation of autonomy-related capacities, and, especially, the constitutively moral/normative dimensions of these capacity concepts, such mappings are clearly problematic. This is true even in the easy cases, which, as Murphy points out, include our case of "John." This is all the more true with regard to the more complicated psychiatric cases, including disorders such as depression where the normative dimensions and the greater interpretive leeway in diagnosis preclude reductionist solutions (See Anderson 2004). For these reasons and for independent philosophical reasons, we are uncomfortable with the label "externalist," [End Page 309] although we acknowledge and confirm our view that externally applied neuroscientific notions—and evidence—can inform these matters. Nonetheless, we do not wish to argue for a fully externalist point of view, especially when paired with the idea that we are advocating a "smooth naturalistic picture of the cognitive basis of autonomy" (Murphy 2004, 303). Murphy puts us in some terrific company with the likes of John Doris, Shaun Nichols, and—we would add—himself, and this is welcome and flattering. But, to avoid any misunderstanding of an issue that we do not actually take up in our essay, we should caution that we do not endorse a program of naturalizing the normativity on which many of central autonomy-related concepts are based. The notion, for example, of what it is to assess competently one's chances of success cannot be replaced with a set of nomological regularities or a self-applying list of necessary and sufficient conditions.Appreciating Disability and Knowing the FactsOne of the central challenges we face in presenting our approach is to distinguish our requirement of "accurate self-assessment" from an implausible requirement that one have no false beliefs about one's capacities. In different ways, all three commentaries make it clear that our argument would benefit from further clarification of this distinction.In her commentary, Chadwick suggests that our approach may commit us to requiring too much self-knowledge, specifically, that it seems to require accurate knowledge of things like our genetic makeup as a requirement for autonomy. To begin with, it is worth underscoring again that the requirement we have introduced is explicitly task specific: we are focused here on whether an agent has an understanding of things that are relevant for undertaking an intended task, and declarative knowledge of facts, genetic or otherwise, about oneself is relevant only insofar as they bear on that understanding.But Chadwick's point clearly goes deeper. In that regard, it is particularly important to underscore that ours is actually a requirement that has less to do with knowing facts—even task-specific ones—about oneself and much more to do with having the ability to incorporate available... (shrink)

Introduction: Advantageous effects of biological motion detection, a low-perceptual mechanism that allows the rapid recognition and understanding of spatiotemporal characteristics of movement via salient kinematics information, can be amplified when combined with motor imagery, i.e., the mental simulation of motor acts. According to Jeannerod’s neurostimulation theory, asynchronous firing and reduction of mu and beta rhythm oscillations, referred to as suppression over the sensorimotor area, are sensitive to both MI and action observation of BM. Yet, not many studies investigated the use (...) of BM stimuli using combined AO-MI tasks. In this study, we assessed the neural response in the form of event-related synchronization and desynchronization patterns following the observation of point-light-walkers and concordant MI, as compared to MI alone.Methods: Twenty right-handed healthy participants accomplished the experimental task by observing BM stimuli and subsequently performing the same movement using kinesthetic MI. We recorded an electroencephalogram with 32 channels and performed time-frequency analysis on alpha and beta frequency bands during the MI task. A two-way repeated-measures ANOVA was performed to test statistical significance among conditions and electrodes of interest.Results: The results revealed significant ERD/S patterns in the alpha frequency band between conditions and electrode positions. Post hoc comparisons showed significant differences between condition 1 and condition 3 over the left primary motor cortex. For the beta band, a significantly less difference in ERD patterns was detected only between condition 3 and condition 4.Discussion: Our results confirmed that the observation of BM combined with MI elicits a neural suppression, although just in the case of jumping. This is in line with previous findings of AO and MI eliciting a neural suppression for simulated whole-body movements. In the last years, increasing evidence started to support the integration of AOMI training as an adjuvant neurorehabilitation tool in Parkinson’s disease.Conclusion: We concluded that using BM stimuli in AOMI training could be promising, as it promotes attention to kinematic features and imitative motor learning. (shrink)

Although the neural bases of the brain associated with movement disorders in children with developmental coordination disorder are becoming clearer, the information is not sufficient because of the lack of extensive brain function research. Therefore, it is controversial about effective intervention methods focusing on brain function. One of the rehabilitation techniques for movement disorders involves intervention using motor imagery. MI is often used for movement disorders, but most studies involve adults and healthy children, and the MI method for children with (...) DCD has not been studied in detail. Therefore, a review was conducted to clarify the neuroscientific basis of the methodology of intervention using MI for children with DCD. The neuroimaging review included 20 magnetic resonance imaging studies, and the neurorehabilitation review included four MI intervention studies. In addition to previously reported neural bases, our results indicate decreased activity of the bilateral thalamus, decreased connectivity of the sensory-motor cortex and the left posterior middle temporal gyrus, bilateral posterior cingulate cortex, precuneus, cerebellum, and basal ganglia, loss of connectivity superiority in the abovementioned areas. Furthermore, reduction of gray matter volume in the right superior frontal gyrus and middle frontal gyrus, lower fractional anisotropy, and axial diffusivity in regions of white matter pathways were found in DCD. As a result of the review, children with DCD had less activation of the left brain, especially those with mirror neurons system and sensory integration functions. On the contrary, the area important for the visual space processing of the right brain was activated. Regarding of characteristic of the MI methods was that children observed a video related to motor skills before the intervention. Also, they performed visual-motor tasks before MI training sessions. Adding action observation during MI activates the MNS, and performing visual-motor tasks activates the basal ganglia. These methods may improve the deactivated brain regions of children with DCD and may be useful as conditioning before starting training. Furthermore, we propose a process for sharing the contents of MI with the therapist in language and determining exercise strategies. (shrink)

In this study, we sought to assess the predictors of outcome in patients with disorders of consciousness (DOC) after severe traumatic brain injury (TBI) during neurorehabilitation stay. In total, 96 patients with DOC (vegetative state, minimally conscious state, or emergence from minimally conscious state) were enrolled (69 males; mean age 43.6 ± 20.8 years) and the improvement of the degree of disability, as assessed by the Disability Rating Scale, was considered the main outcome measure. To define the best predictor, (...) a series of demographical and clinical factors were modeled using a twofold approach: (1) logistic regression to evaluate a possible causal effect among variables; and (2) machine learning algorithms (ML), to define the best predictive model. Univariate analysis demonstrated that disability in DOC patients statistically decreased at the discharge with respect to admission. Genitourinary was the most frequent medical complication (MC) emerging during the neurorehabilitation period. The logistic model revealed that the total amount of MCs is a risk factor for lack of functional improvement. ML discloses that the most important prognostic factors are the respiratory and hepatic complications together with the presence of the upper gastrointestinal comorbidities. Our study provides new evidence on the most adverse short-term factors predicting a functional recovery in DOC patients after severe TBI. The occurrence of medical complications during neurorehabilitation stay should be considered to avoid poor outcomes. (shrink)

Brain–machine interfaces combining visual, auditory, and tactile feedback have been previously used to generate embodiment experiences during spinal cord injury rehabilitation. It is not known if adding temperature to these modalities can result in discomfort with embodiment experiences. Here, comfort levels with the embodiment experiences were investigated in an intervention that required a chronic pain SCI patient to generate lower limb motor imagery commands in an immersive environment combining visual, auditory, tactile, and thermal feedback. Assessments were made pre-/ post-, throughout (...) the intervention, and at 7 weeks follow up. Overall, high levels of embodiment in the adapted three-domain scale of embodiment were found throughout the sessions. No significant adverse effects of VR were reported. Although sessions induced only a modest reduction in pain levels, an overall reduction occurred in all pain scales at follow up. A high degree of comfort in the comfort scale for the thermal-tactile sleeve, in both the thermal and tactile feedback components of the sleeve was reported. This study supports the feasibility of combining multimodal stimulation involving visual, auditory, tactile, and thermal feedback to generate embodiment experiences in neurorehabilitation programs. (shrink)

Proprioceptive acuity is of great significance in basic research exploring a possible neural mechanism of fine motor control and in neurorehabilitation practice promoting motor function recovery of limb-disabled people. Moreover, body representation relies on the integration of multiple somatic sensations, including proprioception that is mainly generated in muscles and tendons of human joints. This study aimed to examine two hypotheses: First, different extension positions of wrist joint have different proprioceptive acuities, which might indicate different body representations of wrist joint (...) in the brain. Second, repetitive peripheral magnetic stimulation applied peripherally to the forearm radial nerve and extensors could change proprioceptive acuity at the wrist joint. Thirty-five healthy participants were recruited then randomly divided into the real stimulation group and the sham stimulation group. The participants’ non-dominant side wrist joint position sense was tested at six extension positions within the physiological joint motion range both before stimulation and after stimulation. Results showed that proprioceptive bias among six extension positions could be divided into lower-extension position and higher-extension position. One session rPMS could influence proprioceptive bias in lower-extension position but not in higher-extension position. However, proprioceptive precision was not influenced. To conclude, proprioceptive bias may vary between different wrist extension positions due to different hand postures being related to changes in body representation, and different functions relating to proprioceptive bias and proprioceptive precision may underlie two aspects of body representation. (shrink)

ObjectiveTo prospectively study the cingulate cortex for the localization and role of the grasping action in humans during electrical stimulation of depth electrodes.MethodsAll the patients with intractable focal epilepsy and a depth electrode stereotactically placed in the cingulate cortex, as part of their pre-surgical epilepsy evaluation from 2015 to 2017, were included. Cortical stimulation was performed and examined for grasping actions. Post-implantation volumetric T1 MRIs were co-registered to determine the exact electrode position.ResultsFive patients exhibited contralateral grasping actions during electrical stimulation. (...) All patients had electrodes implanted in the ventral bank of the right cingulate sulcus adjacent to the vertical anterior commissure line. Stimulation of other electrodes in adjacent regions did not elicit grasping.ConclusionGrasping action elicited from a localized region in the mid-cingulate cortex directly supports the concept of the cingulate cortex being crucially involved in the grasping network. This opens an opportunity to explore this region with deep brain stimulation as a motor neuromodulation target for treatment in specific movement disorders or neurorehabilitation. (shrink)

Functional electrical stimulation (FES), a method for inducing muscle contraction, has been successfully used in gait rehabilitation for patients with deficits after neurological disorders and several clinical studies have found that it can improve gait function after stroke and spinal cord injury. However, FES gait training is not suitable for patients with walking difficulty, such as those with severe motor paralysis of the lower limbs. We have previously shown that action observation combined with motor imagery (AO + MI) of walking (...) induces walking-related cortical activity. Therefore, we combined FES, which alternately generates dorsiflexion and plantar flexion, with AO + MI as an alternative to gait training. The present study investigates the transient effects of 20-min of FES simultaneously with and without AO + MI of walking on corticospinal and spinal reflex excitability in able-bodied participants. We measured motor evoked potentials and Hoffmann-reflexes to assess corticospinal and spinal reflex excitability at rest before and after the 20-min FES with and without the AO + MI. Our results show that FES without AO + MI did not change excitability (p > 0.05), while FES with AO + MI facilitated corticospinal excitability (p < 0.05). This facilitation likely occurred due to the synchronization of sensory inputs from FES and cortical activity during AO + MI. Facilitation was observed only in the dorsiflexor but not the plantar flexor muscle (p < 0.05), suggesting muscle specificity of the facilitation. These results demonstrate the effectiveness of combining FES with AO + MI and pave the way for novel neurorehabilitation strategies for patients with neurological gait deficits. (shrink)

Background On December 2017 the Italian Parliament approved law n. 219/2017 “Provisions for informed consent and advance directives” regarding challenging legal and bioethical issues related to healthcare decisions and end-of-life choices. The law does not contain an explicit reference to Ethics Committees (ECs), but they could still play a role in implementing the law. Methods A questionnaire-based survey was performed among the ECs of the Italian Institute for Research and Care belonging to the Network of neuroscience and neurorehabilitation, with (...) the aim of (1) knowing whether the ECs participated and, if so, how in the process of implementation of law n. 219/2017 in the referring institutes; (2) investigating the point of view of the ECs regarding their possible involvement in the process; (3) exploring the contribution ECs can provide to give effective implementation to the law principles and provisions. Results Seventeen ECs out of thirty took part in the survey; the characteristics of the responding and non-responding committees are similar, so the responding ECs can be regarded as representative of all ECs in the Network. Nine ECs did not discuss the law in anyway: the main reason for this is that the referring institutions (6) and the health care professionals (3) did not ask for an EC intervention. Nevertheless, the large majority of the ECs believe that their involvement in the implementation of the law as a whole is appropriate (8) or absolutely appropriate (6), while 3 of them are neutral. No EC believes that the involvement is inappropriate. The aspect of the law on which the 14 ECs converge in considering the EC involvement appropriate/absolutely appropriate is the one related to the health facilities obligation to guarantee the full and proper implementation of the principles of the law. Conclusions Our survey confirms that ECs believe they can play a role in the implementation of law n. 219/2017, although this does not entirely correspond to what the committees have actually done in reality. This role could be better exercised by ECs specifically established for clinical practice, which would have a composition, functioning and a mandate better suited to the purpose. This supports the call for a national regulation of ECs for clinical practice. (shrink)

Reappraisal is a widely investigated emotion regulation strategy, often impaired in those with acquired brain injury (ABI). Little is known, however, about the tools to measure this capacity in patients, who may find traditional reappraisal tasks difficult. Fifty-five participants with ABI, and thirty-five healthy controls (HCs), completed reappraisal tasks with personal and impersonal emotion elicitation components, questionnaires measuring reappraisal (the ERQ-CA), and neuropsychological assessment. The main findings demonstrated that both groups produced more reappraisals, and rated their reappraisal ideas as more (...) effective for personal stimuli. The ABI group were significantly faster to generate reappraisals for personal, compared to impersonal, stimuli. Yet, participants with ABI performed worse than HCs on the majority of reappraisal components, across both reappraisal tasks. Results of regression analyses revealed significant relationships between certain measures of cognitive control and certain reappraisal components, which varied for the personal and impersonal reappraisal task. Notably, while inhibition predicted aspects of reappraisal in both the ABI and HC group, working memory was only related to reappraisal in participants with ABI. The study suggests that personal context plays a key role in reappraisal, and proposes a model to better understand the role of cognitive control across the reappraisal process. (shrink)

Introduction: Neuropsychiatry has generally been regarded as a hybrid discipline that lies in the borderland between the disciplines of psychiatry and neurology. There is much debate on its current and future identity and status as a discipline. Materials and Methods: Taking a historical perspective, the future of neuropsychiatry is placed within the context of recent developments in clinical neuroscience. Results: The authors argue that with the maturation of the discipline, it must define its own identity that is not dependent entirely (...) upon the parent disciplines. The requirements for this are the claiming of neuropsychiatric territory, a strong training agenda, an emphasis on treatments that are uniquely neuropsychiatric, and a bold embrace of new developments in clinical neuroscience. Conclusion: The exponential growth in neuroscientific knowledge places neuropsychiatry in an excellent position to carve out a strong identity. It is imperative that the leaders of the discipline seize the moment. (shrink)

Background: Patients in a vegetative state pose problems in diagnosis, prognosis and treatment. Currently, no prognostic markers predict the chance of recovery, which has serious consequences, especially in end-of-life decision-making. Objective: We aimed to assess an objective measurement of prognosis using advanced electroencephalography (EEG). Methods: EEG data (19 channels) were collected in 14 patients who were diagnosed to be persistently vegetative based on repeated clinical evaluations at 3 months following brain damage. EEG structure parameters (amplitude, duration and variability within quasi-stationary (...) segments, as well as the spatial synchrony between such segments and the strength of this synchrony) were used to predict recovery of consciousness 3 months later. Results: The number and strength of cortical functional connections between EEG segments were higher in patients who recovered consciousness (P < .05 – P < .001) compared with those who did not recover. Linear regression analysis confirms that EEG structure parameters are capable of predicting (P = .0025) recovery of consciousness 6 months post-injury, whereas the same analysis failed to significantly predict patient outcome based on aspects of their clinical history alone (P = .629) or conventional EEG spectrum power (P = .473). Conclusions: The result of this preliminary study demonstrates that structural strategy of EEG analysis is better suited for providing prognosis of consciousness recovery than existing methods of clinical assessment and of conventional EEG. Our results may be a starting point for developing reliable prognosticators in patients who are in vegetative state, with the potential to improve their day-to-day management, quality of life, and access to early interventions. (shrink)