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So welcome Michele and Marialuisa.
[00:00:36] Dr. Michele Tinazzi: Thank you so much for inviting us.
[00:00:38] Dr. Marialuisa Gandolfi: Thank you.
[00:00:39] Dr. Sarah Lidstone: All right, so we'll get started. So I'd like to have our listeners first understand a little bit about the rationale for the study. So can you give us the background and why did you want to do a study using virtual reality and balance in FMD?
[00:00:53] Dr. Michele Tinazzi: Yes, we know that the people with the functional motor disorders often report gait and [00:01:00] balance disorders, along with the dystonia weakness and other movement disorders, just a tremor and which increase the risk of force and disability. But FMD functional motor disorder involuntary but learned altered movement patterns caused by abnormal self directed attention and movement prediction resulting in a movement generated without a normal sense of agency.
So retraining movement through diverted attention and changing maladaptive symptoms related behaviors can reduce the disability and improve the patient's quality of life. So this can be achieved through virtual reality technology, which offers a promising avenue to optimize motor learning in a challenging, safe, and motivated environment.
Stimulating sensory motor and cognitive processes simultaneously. In particular, the use of immersive virtual reality is [00:02:00] particularly relevant because it allows the interaction with the virtual environment and the visually manipulated condition. Its for this reason that our hypothesis is that the application of immersive virtual reality associated with progressive attention demanding condition would promote more effective use of postural control strategies in patients with the functional motor disorders and as measured by posturography. So this is the rationale of our study.
[00:02:32] Dr. Sarah Lidstone: That's so interesting. And for those of you who may not be actively doing work in this area, I think the the approach generally in treating these patients is to take advantage of the features on the positive signs, such as distractibility and symptom enhancement with attention and actually use that therapeutically.
So this is the area that you guys are working in and very well known for. So Marialuisa, could you just describe the [00:03:00] experimental setup? So for those of you who haven't read the paper just so we can picture what your lab kind of looks like and how you set up your experiment.
[00:03:07] Dr. Marialuisa Gandolfi: Yes, we use an instrumental assessment of a balance, which is a stabilometric platform, which is a very simple platform where the patients or the subject have to stand with the upper limb along with the body, and we have the possibility to record, to quantify the postural control assessment by using very simple postural stabilometric outcomes.
So the patient stands on the platform, and we ask the patient to maintain this position for 180 seconds. And then the platform records the sway area, the length of the COP, and the sway in the medial lateral anterior posterior displacement velocity. So while standing in this position, we [00:04:00] focus on different focus of attention without or with using or without using virtual reality.
The setting was very comfortable. The patients had not to move. And of course, if any concerns came, we stopped the experimental setup and we performed the setting again.
[00:04:24] Dr. Sarah Lidstone: So the, so the patient is standing on this little circle and then the circle of the platform is measuring all of their postural kinematics. So can you describe to us the, the four conditions that you studied in the experiment?
[00:04:38] Dr. Marialuisa Gandolfi: Yes, we did the VR scenario thanks to the collaboration with factory, which is a very expert in the field. And so the, the first the first information is that we use custom made virtual reality setting because we feel that this is the only way to focus on this [00:05:00] kind of symptoms and we can't use other devices that are not custom made for functional motor disorders patients. Then we use three scenarios based on VR. The first was a very simple scenario that was a room like a real scene. in which the patients have to stand on the platform without doing anything. The other two scenarios was custom made and consisted of a city like scenarios in which we reproduce all the features not only visual feature, but also acoustic vision features of the real city. So we have pedestrian, we have buildings, we have tree, we have cars, and we have also sounds of the real city. And we ask the patient to perform a different kind of cognitive dual task during this scenario. The first [00:06:00] was to Avoid the pedestrian, and so don't pay attention to the pedestrian that are moving in the environment.
And the second, we ask the patient to count them. And so we ask the patient to perform a double cognitive dual task to show the pedestrian and to keep in memory the number that the elements that they saw.
[00:06:26] Dr. Sarah Lidstone: So it was almost like a passive attention and an active attention condition in a way.
[00:06:34] Dr. Marialuisa Gandolfi: Yes, in the first one, we look at the effect of the environment by themselves without any other task, while in the second, we included another cognitive task that we would focus on external focus of attention more than the previous one.
[00:06:51] Dr. Sarah Lidstone: So more internally directed attention maybe, or just a little bit of external directed attention and then a much more robust externally directed attention task. [00:07:00] Can you tell us about the sample of patients that participated in the, in the study?
[00:07:06] Dr. Marialuisa Gandolfi: Yes, we selected 17 patients with functional motor disorders, mainly affected by tremor, and weakness in the lower limb. They all complained of postural control disorders, of course. And they were mainly female, as the literature says that the disease is mainly focused on females with an average of 40 years.
So they were very young women with balance and postural control disorders. Of course, we compare our data on This sample with healthy control, age matched healthy control to have normative data to compare results.
[00:07:49] Dr. Sarah Lidstone: So, so quite representative of what we see in clinic. What are the baseline just either in, in, in your study, your findings, or even just your other work that, like what are the baseline [00:08:00] differences already in task performance between patients and healthy controls when it comes to posture imbalance?
[00:08:07] Dr. Marialuisa Gandolfi: Yes. We, as expected, we found that patients had a worse performance on the balance test compared to healthy control. So they were very, very unstable and they suffered from severe balance control in static position. And this was very clear because they had higher outcomes measured than control in all the outcomes we collected.
So they had the higher sway area, higher length CoP, and higher sway velocity. So they were really impaired compared to the control.
[00:08:44] Dr. Sarah Lidstone: And so, so what did you find on the task performance between the FMD patients and the controls?
[00:08:51] Dr. Marialuisa Gandolfi: Yes, we found that when we use on a specific setting of virtual reality, which is the [00:09:00] the virtual reality room without the city, we have no differences in the balance control in FMD and we have no differences in the each measure we collected. But when we use the city like virtual reality condition with the cognitive dual task. And so we challenged the patient not only in the real that the virtual reality environment, but we also added a new attentional demanding task. We found that the postural control improved and improved a lot in all outcome measures. So as we found was that this sway area became smaller, which means that the postural control was better during the virtual environment condition than the real condition.
And we were surprised by the fact that the simple [00:10:00] virtual environment was not effective. And so we confirmed that we need to have a specific custom made scenario for this kind of patient because it's not a useful using a, common virtual reality device. And the second was that the city-like condition without the cognitive dual task was not so powerful.
Like the virtual reality with the cognitive dual task. So we have to consider that this patient the need to be strongly. focused on another function, focus of attention, because it's very challenging to find the best solution to move the attention from the inside to the outside of the body.
[00:10:46] Dr. Sarah Lidstone: And so, and so was it that the, the patient group, just to ask a follow up question around that was the, is it the patient group? And I understand how their balance improved under the hardest conditions. So when they had to be in the immersive [00:11:00] environment and then count what they were seeing in their environment.
But was it also, what happened to the control group under that condition? Did the control group stay the same and no impairment or did they get worse?
[00:11:12] Dr. Marialuisa Gandolfi: Okay. They had a little changes, but they were not significant from a statistical point of view, but we found a trend, a Little bit worse in the best attentional, demanding condition for healthy controls instead of a better performance in FMD. So we didn't find a real interaction from a statistical point of view, but we noticed this trend on the healthy control in the most demanding condition was not so, was a little bit worse than FMD.
[00:11:51] Dr. Sarah Lidstone: So, yeah, so interesting. And it links to what we see in the clinic, right? When we give patients a competing task, a more attentionally demanding task, we can [00:12:00] demonstrate distractibility in their movement. And often in tremor, for example, you know, if the task isn't challenging enough, It's not sufficiently distracting or sufficiently attention demanding, then that distractibility may not actually come out, which your study, I think, really shows very nicely.
And it's important for us clinically. What advantages do you think that virtual reality offers in FMD, like above regular rehab that, that we're doing all the time?
[00:12:26] Dr. Marialuisa Gandolfi: Yes, first of all, it's it's very helpful to have to quantify by using instrumental assessment the different behavior of these patients under different conditions. And so, of course, we have positive sign that are based on clinical assessment, but sometimes to understand better the pathophysiology of these disturbances and to understand why some rehab approaches are more useful than the other ones, we have to use instrumental assessment.
So first of all, a very is a helpful message for a [00:13:00] clinician that they can, they can use also stabilometric assessment to quantify, to quantify disorders and to quantify what distraction improve in these problems. And for rehab, it could be useful at the beginning when the patient is very impaired and maybe it's not completely aware of her possibility.
And so we can use as a positive signs. To describe the patient that her performance can improve in this special situation. So it could be used for rehabilitation, especially at the beginning of the multidisciplinary treatment that we do.
[00:13:45] Dr. Sarah Lidstone: Almost like a biofeedback mechanism or like giving someone an actual number to change is always very helpful when it comes to treatment. And can I ask, you know, It's well documented across many studies that there is a poor correlation between [00:14:00] patient's task performance with FMD in general.
and their experience of how they did, right? There's a number of studies that show that patients very often feel that they performed very poorly, but in fact, their, their measures could be good or even normal. I know that you didn't explicitly measure the subjective experience of the patients, but do you have a sense of, of what they said and how they thought that they did on the task?
[00:14:23] Dr. Marialuisa Gandolfi: Yes, as a feasibility study, we ask the patients what was the feeling and what was the perspective of the patient during the experience. And we have positive experience, have positive feeling. And the most interesting was that the patients didn't think about her body, but was focused on the environment and so on in the task that we asked to perform.
And so it was very helpful for us because we understand that the environment was was adapted for the disease and was effective in the inducing this [00:15:00] change in the focus of attention. And the, the fact that the patient was focused Fully engaged. It was that our primary aim to discuss our results.
And so we have a positive feeling and we were happy about this.
[00:15:16] Dr. Sarah Lidstone: Yes. You confirmed that they, they truly were engaged and fully distracted, if you will, just mechanistically, you know, it was kind of gets in more into the pathophysiology of FMD. But why do you think that you have any hypotheses around why external attention or extension attention off of the body reduces the symptoms of FMD?
[00:15:37] Dr. Marialuisa Gandolfi: Yes, it's related to the pathophysiology that we have non organic lesion. We have not a real disconnection from the brain and the midbrain and the, and the muscle and periphery, but simply we have a dysfunctional function. And so if we use a particular setting in which the patients can rely on the [00:16:00] physiological mechanism for control of posture.
We can have a more normal and physiological performance. So our view is that attention is abnormally focused on the on the mechanisms that control balance, and they work. And in this condition, we can have the patient to don't care on this hyper control on these mechanisms. And so then the function can recovery.
And this is why we use this approach also at the beginning of the rehabilitation, because we can provide to the patient's evidence about this integrity of the structural way that control balance.
[00:16:46] Dr. Sarah Lidstone: Yeah, the taking the attention off the body in some ways releases the ability to just have the nervous system do what's automatic reflexes that it knows how to do. So how do you hope these results will contribute [00:17:00] to the diagnosis and or the treatment going forward in FMD.
[00:17:04] Dr. Marialuisa Gandolfi: I think that our work will help will help a lot of clinicians to improve diagnosis that of course is based on the positive clinical assessment, but we think that instrumental assessment is useful in specific subgroup of patients to understand better their problem, their symptoms, and also to correlate some symptoms with performance.
And so it could be very helpful. For rehab, this approach could be very useful in patients, in all patients, but it could be that the patient's most important to study and to investigate with this approach. Will be patients that have a very strong belief about the disease and so they need the special environment to use to change the focus of attention.
So we can use the environment as a very powerful tool to manipulate not [00:18:00] also feedback, visual feedback and the cognitive performance, but also the belief of the patient.
[00:18:07] Dr. Sarah Lidstone: And I also think the patients would enjoy putting on a custom VR set. I think it would make rehab really fun and engaging and interesting for them. And, Michele did you want to add anything like are you, is there anything you want to say kind of at the end?
[00:18:22] Dr. Michele Tinazzi: I think that this is important. I learned from a physiotherapist of doctor rehabilitation that is very important for gait and posture to examine patients with posturography and gait right. This is very important because its nicer to categorize for example, the different kind of gate in a different function motor disorder.
But at the end it's difficult because we don't have a special temporal parameters that are very, very important and we are exploring both posterography and both with both using different special and temporal parameters to [00:19:00] better categorize posture and gait in this population of patients.
[00:19:06] Dr. Sarah Lidstone: Yeah. You know, we talked at the conference recently in Verona about this, about the urgent need to get some different types of metrics, right, more objective data that doesn't rely simply on a clinical categorization for diagnosis for these patients.
So, so thank you both very much for joining us today and, and talking about your study and we look forward to seeing what, what comes next out of these data.
Thank you.
[00:19:32] Dr. Michele Tinazzi: Thank you. Thank you so much.
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