Il sistema dei neuroni specchio: ricadute in riabilitazione

Il sistema dei neuroni specchio: ricadute in riabilitazione GIOVANNI BUCCINO Dipartimento di Scienze Mediche e Chirurgiche, Università Magna Graecia, Catanzaro

Gallese et al, 1996

Umiltà et al., 2004

Kohler et al, 2002

Buccino et al, 2001

Dalla Volta et al., 2015

Buccino et al, 2004

Buccino et al, 2004

Vogt et al, 2007

Tettamanti et al, 2005

Nelissen et al, 2011

Action observation (AO) Motor imagery (MI) Control group (CO) p Time error 3.3±7.6 20.1±14.5 16.9±14.6 0.002 Frequency right hand (Hz) 1.00±0.00 0.93±0.00 0.79±0.27 0.008 Frequency right foot (Hz) 0.99±0.00 0.94±0.00 0.88±0.14 0.011 Frequency left hand (Hz) 0.96±0.00 0.97±0.15 0.76±0.27 0.009 Frequency left foot (Hz) 0.96±0.00 0.94±0.13 0.89±0.18 NS Range of motion right hand (degree) Range of motion right foot (degree) Range of motion left hand (degree) Range of motion left foot (degree) 58.0±10.9 57.2±11.3 59.5±12.5 NS 49.1±10.3 45.4±13.2 31.8±12.9 0.002 61.1±7.0 51.9±15.2 59.9±17.7 NS 39.9±10.0 38.4±17.2 25.4±11.0 0.031 Absolute error (degree) 20.9±12.8 23.5±12.1 29.6±14.2 NS Gatti et al, 2013

Action observation treatment What is it? When does it work? Why does (or should) it work?

Action observation treatment in neurorehabilitation Buccino et al, 2006

In a typical rehabilitation session Patients observe carefully common actions (e.g. having an espresso; reading a newspaper) presented through video-clips (observation phase) Actions are complex: they are divided into motor segments (e.g. putting some sugar, stirring). Each motor segment is seen for three minutes

In the videos daily life actions are presented as carried out by different actors and from different perspectives. Patients reproduce the observed motor segment at the best of their motor abilities for two minutes (execution phase).

During the execution phase patients are provided with the required objects (those used in the video) at hand They are advised the focus is on action observation. They should not worry about the quality of their motor performance As a whole the session is 20 minutes long

When does Action Observation Treatment work? Recovery of upper limb motor functions in chronic stroke patients (Ertelt et al., 2007; Franceschini et al., 2010) Recovery of daily living activities and freezing of gait in Parkinson s disease patients (Buccino et al., 2011; Pelosin et al, 2010) Recovery of lower limb motor functions in orthopedic patients (Bellelli et al., 2010) Recovery of upper limb motor functions in children with cerebral palsy (Buccino et al., 2012; Sgandurra et al., 2013)

Patients Patient Sex Age Stroke onset 1 m 61 2/1992 2 m 66 8/ 2000 3 f 38 8/2003 4 f 64 6/2000 5 m 55 1/ 2000 Localisation of lesion Left large frontoparieto-temporal (media territory) Right basal ganglia, capsula Right parietotemporo-occipital, going into the intraparietal sulcus Right basal ganglia, capsula Right frontal operculum Duration of former therapies (days) 84 112 140 142 113 6 m 54 7/2002 Left basal ganglia 238 7 m 60 3/2002 8 F 63 8/1999 Right primary sensorimotor cortex Right parietal (media territory) 50 74

Stable baseline no statistical difference between the two baseline measurements (3 weeks apart) Wilcoxon Signed Ranks Test FAT WMFT SIS Z 0,000(a) -0,840(b) -0,339(b) Asymp.Sig. (2-tailed) 1,000 0,401 0,735 FAT Frenchay Arm Test WMFT Wolf Motor Function Test SIS Stroke Impairment Scale

When does Action Observation Treatment work? Recovery of upper limb motor functions in chronic stroke patients (Ertelt et al., 2007; Franceschini et al., 2010) Recovery of daily living activities and freezing of gait in Parkinson s disease patients (Buccino et al., 2011; Pelosin et al, 2010) Recovery of lower limb motor functions in orthopedic patients (Bellelli et al., 2010) Recovery of upper limb motor functions in children with cerebral palsy (Buccino et al., 2012; Sgandurra et al., 2013)

Significant effect of treatment FAT WMFT SIS Z -3.252-1.680-2.684 Significance 0,0005 0,05 0,0025 FAT Frenchay Arm Test WMFT Wolf Motor Function Test SIS Stroke Impairment Scale Ertelt et al, 2007

Ertelt et al, 2007

Action observation treatment in Parkinson s disease (1) Randomized controlled study, two centers (Milan, Parma) Twenty video-clips each presenting a daily action (i.e walking) Each action subdivided into four motor segments Each motor segment presented for 3 minutes Patients were required to actually execute the observed motor segment for 2 minutes

Action observation treatment in Parkinson s disease (2) In the control group observation of non action related video- clips (videos related to scientific or geographical matters) Patients and controls were evaluated by means of functional scales (UPDRS, FIM) at baseline and at the end of treatment Patients with cognitive impairment were not enrolled

Case Group (EXG) Control Group (CG) EXG vs. CG p p p UPDRS -25.8±8.7 0.018-11.1±7.3 0.042 0.002 FIM 11.1±4.2 0.043 3.8±3.6 0.043 0.004 Buccino et al, 2011

Groups Experimental (n=30) Control (n=30) p Age, years 71.9 ± 8.4 71.8 ± 6.9.96 Sex female, n (%) 21 (70.0) 16 (53.3).14 Type of orthopedic surgical intervention Hip arthroplasty, n (%) 15 (50.0) 10 (33.3) Knee arthroplasty, n (%) 12 (40.0) 18 (60.0).30 Hip fracture repair, n (%) 3 (10.0) 2 (6.7) Time from surgery to randomization (days) 7.7+2.2 7.3+2.4.49 Mini Mental State Examination (0-30) 26.4 ± 3.0 26.3 ± 3.3.94 Geriatric Depression Scale (0-15) 3.0 ± 3.1 3.1 ± 2.8.92 BMI (Kg/cm 2 ) 24.9 ± 6.8 24.7 ± 4.4.87 CIRS severity 1.3 ± 0.3 1.3 ± 0.4.61 CIRS comorbidity 1.7 ± 1.1 1.6 ± 0.9.67 Albumin serum levels (gr/dl) 3.2 ± 0.4 3.2 ± 0.3.95 Transferrin serum levels (mg/dl) 189.6 ± 47.4 180.1 ± 32.5.38 Length of stay, days 20.1 ± 2.9 21.0 ± 3.6.29

Two crutches 1 (3.3) 8 (26.7).01 Groups Experimental (n=30) Control (n=30) Functional status FIM total score on admission (0-126) 86.7 ± 16.6 93.6 ± 11.8.07 FIM total score at discharge (0-126) 109.1 ± 11.9 109.6 ± 6.8.85 FIM AFG 22.4 ± 11.9 16.0 ± 9.3.02 FIM AFE 1.0 ± 0.5 0.7 ± 0.4.01 FIM RFG 57.7 ± 21.5 47.7 ± 14.7.04 Motor FIM* subscore on admission (13-91) 14.7 ± 5.6 17.9 ± 3.5.01 Motor FIM* subscore at discharge (13-91) 26.6 ± 3.4 25.4 ± 2.0.09 Motor FIM* subscores AFG 11.9 ± 5.6 7.5 ± 3.4.001 Tinetti (gait and balance) on admission (0-28) 12.7 ± 6.9 15.7 ± 4.7.06 Tinetti (gait and balance) at discharge (0-28) 22.4 ± 4.0 23.2 ± 1.6.32 Tinetti AFG 9.6 ± 4.2 7.4 ± 4.2.04 Walking aids on admission Two crutches 18 (60.0) 24 (80.0) Walker 12 (40.0) 6 (20.0).08 Walking aids at discharge One crutch 29 (96.7) 22 (73.3)

Action observation treatment in children with cerebral palsy (1) Randomized controlled study Fifteen video-clips each showing upper limb daily actions within the motor repertoire of children Each action divided into three/four motor segments Children in the case group look carefully at the video sequences and imitate the observed action

Action observation treatment in children with cerebral palsy (2) Children in the control group look at video-clips on geographical, scientific or historical topics suitable for children All children evaluated by means of Melbourne Assessment of Upper Limb Function before and at the end of the treatment. Long term follow-up at two months.

Inclusion criteria: Children with cerebral palsy Aged 6-11 IQ>/= 70 No visual and/or auditory deficits Exclusion criteria: Drug treatment Epilepsy

Buccino et al, 2012

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