**4. From fNIRS to the definition of a rehabilitation model**

The ability of the brain to reorganize itself and change its activity associated to a given function in order to achieve a neurological control is well supported by studies in neural activation. This is a goal to be kept in mind while using a verified and controlled neuronavigation technique such as fNIRS. Nowadays, everyone is trying to find the best standardized rehabilitation process while the entire scientific community agrees on the brain specific individuality that cannot be encoded. We can claim to know each functional brain area, but the information encoded inside is individual and only in a small part conventional. This is the main starting point in order to set individualized rehabilitation models through the use of neuronavigation techniques such as fNIRS.

In order to allow a cortical reorganization process, there is the need of a specific environmental stimulation, aimed at compensating the impairments. Regardless of which brain area is involved, the aim is to set up a model that can be verified each time with optical imaging techniques. According to this kind of rehabilitation model, the environmental stimulation needs to be grounded on the person's real life experiences so that the choice between different rehabilitation programs is based on the brain activity of a specific area involved during stimulation and verified thanks to NIRS. This choice has to be based not only on customary, logistic and organizational needs but also on cognitive, emotional and motivational patient's needs according to a functional brain activation point of view.

The main goal of the Cerebro rehabilitation model is to improve the functional outcome by supervising rehabilitation choices from time to time and to evaluate the emotional outcome by analyzing Hb-HbO variation in PFC since it is an area involved in emotional control [13].

#### **4.1. Cerebro model's application fields**

This neurofunctional rehabilitation model is applied to patients with behavioral cognitive impairment due to brain injury after a complete neuropsychological assessment.

Neurofunctional impairments are:

Aerobic process and energy consumption associated to muscular contraction may induce significant changes in oxyhemoglobin. However, Schecklmann et al. [2] found no relationship between electromyographic signals and oxyhemoglobin variation during a fluency task. Nevertheless, the influence of peripheric responses was analyzed including limited condition. Further signal falsification is given by neural activation to emotional stimulation since variation in Hb-HbO concentration in this case may be due to vasoconstriction. A solution to this is to elicit two different emotional responses and statistically analyze the differences in

Another problem appears to be the time range (TR) selection that is the time needed for cortical activation to be visually inspected; many studies suggest that oxyhemoglobin drop values indicate cortical activation [3]. Suh et al. [4] claim that cortical direct stimulation induces a rapid increase in deoxyhemoglobin (1–2 s after stimulation) while the total hemoglobin value remains constant. This problem is avoidable by using high temporal resolution in order to

Theories on PFC's role in emotion processing [5–7] agree on PFC being the key area in which

As PFC is important in emotional processing, the evaluation of emotional intensity with NIRS

Studies suggest that individual sensitivity to reward and stress may promote depression disorders [8, 9]; these results induce a deeper analysis of eventual biological predisposition that may lead to specific PFC responses to stimuli-induced emotions. Individual differences in

Using NIRS to analyze PFC activity when stimulated during rehabilitation and the evaluation of the rehabilitation program intensity, considering the abovementioned biological factors,

Primary function of emotion is to guide adaptive motor behavior [10]. Few studies focused on this important statement. It is well known that motor activity directly interacts with emotions and mood [11], and it has been shown that there is a bidirectional relationship that has been

The ability of the brain to reorganize itself and change its activity associated to a given function in order to achieve a neurological control is well supported by studies in neural activation. This is a goal to be kept in mind while using a verified and controlled neuronavigation technique such as fNIRS. Nowadays, everyone is trying to find the best standardized

evaluate statistically significant changes in Hb-HbO concentration variation.

emotional reactions, motivation, attentional processes and behaviors take place.

terms of emotional responses can help in identifying eventual risk factors.

established between motor function and individual emotional experience [12].

**4. From fNIRS to the definition of a rehabilitation model**

may help to select the optimal rehabilitation method for each patient.

Hb-HbO concentration between the two responses.

**3.1. Potential fNIRS application**

becomes crucial.

96 Prefrontal Cortex


Each of these impairments involves directly or indirectly the prefrontal cortex since it is charged with emotional control.

Others that can benefit from this rehabilitation processes are post-stroke patients, cerebrovascular diseases, traumatic brain injuries, multiple sclerosis, encephalitis and post-surgical cancer patients.

Neurodegenerative diseases are excluded from this rehabilitation procedure, apart from multiple sclerosis due to its remittent nature, since there is no evidence yet on how to treat them and due to lack of compliance. However, in case of a motor impairment together with cognitive impairment, that are usually not rehabilitated, our neurofunctional rehabilitation method may be applied in order to monitor brain areas and determine more appropriate choices that would not be taken because of lack of compliance. The most important achievement in order to obtain autonomy in everyday life is being able to perform an adequate motor act and this can be done even if cognitively impaired.

**4.2. Rehabilitation goals**

responses.

cortex.

*4.2.1. Methods*

follows:

life.

riential living.

and behavioral impairments.

program takes it into account.

in order to match patient's life necessities.

no more accessible due to the impairments.

• Proficiency level in coping strategies.

• Cognitive function analysis for goal-oriented activities.

tive functions, therefore it is extremely interesting.

Goals are structured according to three different rehabilitation phases:

Defining the optimal rehabilitation program is the fundamental basis of the Cerebro model. Prefrontal cortex (PFC) activity is indeed one of the most significant areas involved in execu-

Hemoglobin (Hb) - Oxyhemoglobin (HbO) Variation in Rehabilitation Processes Involving…

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99

The main goal is achieved through a variety of subgoals directed to arouse natural daily-life

• First phase must provide deficit awareness through rehabilitation processes based on life experience stimuli. Keep in mind that mirror neurons are everywhere not only in the motor

• Second phase must provide practical skills in order to compensate cognitive, emotional

• Third phase is the conclusive one. It consists in strengthening acquired rehabilitation skills

Experiential living is what makes individuals unique; that is why the Cerebro rehabilitation

The methodology used is based on cognitive and behavioral studies that can be outlined as

• Specific stimulation of a cognitive impaired process. Check of excessive stimulation in the impaired area. The stimulation can facilitate information access that is relatively intact but

Irrespective of the selected technique, cognitive and behavioral deficits must be assessed by

• Deficit assessment of cognitive and behavioral impairment and related impact on everyday

• Individual features assessment like socio-cultural and educational context as well as expe-

• Stimulation and functional reorganization of preserved cognitive processes.

Hb-HbO concentration analysis provided by neuronavigation (fNIRS). Choosing strategies and rehabilitation goal depends on different factors:

#### *4.1.1. Definition and evaluation of neurofunctional impairments*

First, neuropsychological assessment needs to be integrated with neurofunctional measurement of the area involved using neuronavigation techniques such as NIRS and to be combined with the patient life experience and peculiarities such as everyday life, work, family, house, hobbies and emotions experienced.

Next step is to evaluate neuropsychological impairments from a behavioral and cognitive point of view.


Many questionnaires can be handed out and functionally measured with NIRS such as: Quick Exposure Check (QEC) [14], Cognitive Failures Questionnaire (CFQ) [15] and so on.

• Emotional functioning can also be observed with neuronavigation techniques; presence and entity of emotional disorders, such as emotional lability, irritability, depression and anxiety, changes in personality and caregiver relationship quality.

As before, analyzing brain activity while administering standardized questionnaires is very important in order to exclude misunderstanding of items and have a responsive measurement of brain activity while reading the questions. Standardized tests that can be administered are Neuropsychiatric Inventory Questionnaire (NPI-Q) [16], Beck Depression Inventory (BDI) [17], Geriatric Depression Scale (GDS) [18], Minnesota Multiphasic Personality Inventory (MMPI) [19], European Brain Injury Questionnaire (EBIQ) [20] and Big-Five Questionnaire (BFQ) [21].

• Emotional engagement and self-awareness deficits must be assessed through clinical observation and neurofunctional investigation with NIRS. Patient's compliance sometimes does not reflect the undergoing neurofunctional responses; patient may act as collaborative as usual despite his true engagement.

Collected data taken from the neuropsychological assessment allow a faster and more precise identification of neurofunctional impairments.

#### **4.2. Rehabilitation goals**

would not be taken because of lack of compliance. The most important achievement in order to obtain autonomy in everyday life is being able to perform an adequate motor act and this

First, neuropsychological assessment needs to be integrated with neurofunctional measurement of the area involved using neuronavigation techniques such as NIRS and to be combined with the patient life experience and peculiarities such as everyday life, work, family,

Next step is to evaluate neuropsychological impairments from a behavioral and cognitive

• For cognitive impairments, preserved and altered networks reflecting impaired cognitive

• For executive impairments and motivational disorders, direct evaluation of motivational levels is observed by analyzing patient's willingness and effort in taking part in the rehabilitation program together with suitability of social behavior, ability to control and inhibit thoughts and behaviors, static/fluid thinking and problem solving. These observations are measured with NIRS technique in order to set a starting value of Hb and HbO variation that will be taken as a baseline during each rehabilitation session in order to control meta-

Many questionnaires can be handed out and functionally measured with NIRS such as: Quick

• Emotional functioning can also be observed with neuronavigation techniques; presence and entity of emotional disorders, such as emotional lability, irritability, depression and

As before, analyzing brain activity while administering standardized questionnaires is very important in order to exclude misunderstanding of items and have a responsive measurement of brain activity while reading the questions. Standardized tests that can be administered are Neuropsychiatric Inventory Questionnaire (NPI-Q) [16], Beck Depression Inventory (BDI) [17], Geriatric Depression Scale (GDS) [18], Minnesota Multiphasic Personality Inventory (MMPI) [19], European Brain Injury Questionnaire (EBIQ) [20] and Big-Five Questionnaire

• Emotional engagement and self-awareness deficits must be assessed through clinical observation and neurofunctional investigation with NIRS. Patient's compliance sometimes does not reflect the undergoing neurofunctional responses; patient may act as collaborative

Collected data taken from the neuropsychological assessment allow a faster and more precise

Exposure Check (QEC) [14], Cognitive Failures Questionnaire (CFQ) [15] and so on.

anxiety, changes in personality and caregiver relationship quality.

functions are evaluated with psychometric and standardized tests.

can be done even if cognitively impaired.

house, hobbies and emotions experienced.

point of view.

98 Prefrontal Cortex

bolic brain fatigue.

(BFQ) [21].

as usual despite his true engagement.

identification of neurofunctional impairments.

*4.1.1. Definition and evaluation of neurofunctional impairments*

Defining the optimal rehabilitation program is the fundamental basis of the Cerebro model. Prefrontal cortex (PFC) activity is indeed one of the most significant areas involved in executive functions, therefore it is extremely interesting.

The main goal is achieved through a variety of subgoals directed to arouse natural daily-life responses.

Goals are structured according to three different rehabilitation phases:


#### *4.2.1. Methods*

Experiential living is what makes individuals unique; that is why the Cerebro rehabilitation program takes it into account.

The methodology used is based on cognitive and behavioral studies that can be outlined as follows:


Irrespective of the selected technique, cognitive and behavioral deficits must be assessed by Hb-HbO concentration analysis provided by neuronavigation (fNIRS).

Choosing strategies and rehabilitation goal depends on different factors:


Time of monitoring with fNIRS is influenced by patient's hospitalization period. If the prefixed goal has not been achieved or if there are still dysfunctional areas that could be usefully considered for an optimal rehabilitation program, then a day-hospital formula is needed.

Despite technical limitations, NIRS is a reliable method to quantify a stimulus reaction especially in PFC functioning in emotion processing. It allows to establish the optimal rehabilitation program according to a visual inspection of Hb-HbO concentration variation and by

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101

By measuring individual experience-based emotions encoded by PFC, it is possible to choose between different rehabilitation programs according to life experience but also to individual

The author thanks Istituto San Celestino for the clinical support and NIRX Medizintechnick

The authors declare that the research was conducted in the absence of any commercial or

[1] Woods DL, Knight RT. Electrophysiologic evidence of increased distractibility after dor-

[2] Schecklmann M, Ehlis AC, Plichta MM, Fallgatter AJ. Influence of muscle activity on brain oxygenation during verbal fluency assessed with functional near-infrared spec-

[3] Nishitani S, Doi H, Koyama A, Shinohara K. Differential prefrontal response to infant facial emotions in mothers compared with non-mothers. Neuroscience Research. 2011;

financial relationship that could be construed as a potential conflict of interest.

checking the functional area involved.

Hb-HbO variations.

**Acknowledgements**

Gmbh for all the pictures.

**Conflict of interest**

**Author details**

**References**

**70**(2):183-188

Samorindo Peci\* and Federica Peci

\*Address all correspondence to: info@samorindopeci.it

solateral prefrontal lesions. Neurology. 1986;**36**(2):212-212

Centro Ricerca e Formazione Scientifica, Milan, Italy

troscopy. Neuroscience. 2010;**171**(2):434-442

Changing in patient's behavior can be monitored throughout the rehabilitation period because the neuronavigation systems like fNIRS allow to change and adjust the rehabilitation program according to the patient's needs.

At the end of the rehabilitation program, a neuropsychological assessment is necessary to evaluate the improvement or stationarity of the early impairments via neuropsychologic standardized tests, questionnaires and so on. The results obtained are analyzed and serve to establish a long-term rehabilitation program applicable in everyday life.

Neurofunctional rehabilitation is planned by the psychologist in charge with the neuropsychologist experience in test administration according to the reported cognitive impairments. A speech therapist is needed to evaluate speech disorder in case of aphasia.

In addition, other health professionals are needed such as occupational therapists and physiotherapists for motor function disorders in order to improve everyday life autonomy in activities of daily living (ADL) or to discourage maladaptive behaviors.

Finally, care givers are important in order to set proper individual life-based stimuli, which is essential to this kind of rehabilitation model.
