Alfredo Manuli

Background/Objectives: Sexual dysfunction (SD) and broader sexual health problems are common after neurological disorders, yet interventional evidence is fragmented across conditions and outcomes. This umbrella review mapped and appraised systematic review-level evidence on interventions targeting SD and sexual health in neurological populations and qualified conclusions using certainty of evidence. Methods: PubMed, Web of Science, Cochrane Library, Embase, PsycINFO, EBSCOhost, and Scopus were searched from inception to 27 November 2025. Two reviewers screened records, extracted data, assessed review quality with AMSTAR 2, and rated certainty across intervention–outcome pairings using a GRADE-informed approach that integrated review confidence and primary-study risk-of-bias as reported by the source reviews. Results: Twenty-six systematic reviews were included. Overall confidence was frequently limited (17/26 critically low and 6/26 low), with only a small subset rated moderate or higher. Evidence was most coherent for phosphodiesterase type 5 (PDE5) inhibitors improving erectile function in men with spinal cord injury, whereas most other interventions and outcomes were supported by low or very low certainty. Women were represented in 16/26 reviews, yet validated female sexual function outcomes were synthesized in 6/26 reviews and relationship/couple outcomes in 3/26; furthermore, 10/26 reviews restricted inclusion to men, and no review synthesized pediatric intervention trials. Conclusions: Evidence supports PDE5 inhibitors for improving erectile function in men with spinal cord injury, while evidence for other interventions and sexual health domains remains limited. Methodological limitations highlight the need for more inclusive trials, broader standardized outcomes, and longer follow-up within neurorehabilitation pathways.

Central pontine myelinolysis (CPM) is a solitary, symmetric, demyelination in the central pons. This case study aimed to report the effects of an intensive robotic gait training with Lokomat-Pro on...

Chronic disorders of consciousness cause a total or partial and fluctuating unawareness of the surrounding environment. Virtual reality (VR) can be useful as a diagnostic and/or a neurorehabilitation tool, and its effects can be monitored by means of both clinical and electroencephalography (EEG) data recording of brain activity. We reported on the case of a 17-year-old patient with a disorder of consciousness (DoC) who was provided with VR training to improve her cognitive-behavioral outcomes, which were assessed using clinical scales (the Coma Recovery Scale-Revised, the Disability Rating Scale, and the Rancho Los Amigos Levels of Cognitive Functioning), as well as EEG recording, during VR training sessions. At the end of the training, significant improvements in both clinical and neurophysiological outcomes were achieved. Then, we carried out a systematic review of the literature to investigate the role of EEG and VR in the management of patients with DoC. A search on PubMed, Web of Science, Scopus, and Google Scholar databases was performed, using the keywords: “disorders of consciousness” and “virtual reality”, or “EEG”. The results of the literature review suggest that neurophysiological data in combination with VR could be useful in evaluating the reactions induced by different paradigms in DoC patients, helping in the differential diagnosis. In conclusion, the EEG plus VR approach used with our patient could be promising to define the most appropriate stimulation protocol, so as to promote a better personalization of the rehabilitation program. However, further clinical trials, as well as meta-analysis of the literature, are needed to be affirmative on the role of VR in patients with DoC.

The five “W” of cognitive telerehabilitation in the Covid-19 era. Expert Review of Medical Devices. Accepted 28 May 2020.

Social cognition (SC) consists of mental representations of interpersonal relationships, which are used flexibly by the individual to promote functional social behaviors and achieve the goals. SC is a multidimensional construct and is supported by the activity of distributed neural networks in which different cortical and subcortical regions of the brain are involved. The review aims to evaluate the current literature on SC taking into account how it is compromised in acquired brain injury. Studies performed between 2010 and 2019 and fulfilling the selected criteria were searched on PubMed, Scopus, Cochrane and Web of Sciences databases. Impairment of SC is a neglected but common consequence of ABI, often leading to disordered interpersonal functioning and poor regulation of personal behavior with impaired social adaptation and quality of life of both the patient and his/her family. This review supports the idea that SC could have an important role in the management of neurological patients by both clinicians and caregivers.

The assessment of awareness in patients with chronic Disorders of Consciousness (DoC), including Unresponsive Wakefulness Syndrome (UWS) and Minimally Conscious State (MCS), is challenging. The level of awareness impairment may depend on the degree of deterioration of the large-scale cortical-thalamo-cortical networks induced by brain injury. Electrophysiological approaches may shed light on awareness presence in patients with DoC by estimating cortical functions related to the cortical-thalamo-cortical networks including, for example, the cortico-subcortical processes generating motor responses to the perturbation of the peri-personal space (PPS). We measured the amplitude, latency, and duration of the hand-blink reflex (HBR) responses by recording electromyography (EMG) signals from both the orbicularis oculi muscles while electrically stimulating the median nerve at the wrist. Such a BR is thought to be mediated by a neural circuit at the brainstem level. Despite its defensive-response nature, HBR can be modulated by the distance between the stimulated hand and the face. This suggests a functional top-down control of HBR as reflected by HBR features changes (latency, amplitude, and magnitude). We therefore estimated HBR responses in a sample of patients with DoC (8 MCS and 12 UWS, compared to 15 healthy controls −HC) while performing a motor task targeting the PPS. This consisted of passive movements in which the hand of the subject was positioned at different distances from the participant’s face. We aimed at demonstrating a residual top-down modulation of HBR properties, which could be useful to differentiate patients with DoC and, potentially, demonstrate awareness preservation. We found a decrease in latency, and an increase in duration and magnitude of HBR responses, which were all inversely related to the hand-to-face distance in HC and patients with MCS, but not in individuals with UWS. Our data suggest that only patients with MCS have preserved, residual, top-down modulation of the processes related to the PPS from higher-order cortical areas to sensory-motor integration network. Although the sample size was relatively small, being thus our data preliminary, HBR assessment seems a rapid, easy, and first-level tool to differentiate patients with MCS from those with UWS. We may also hypothesize that such a HBR modulation suggests awareness preservation.

Purpose: In the Italian National Health Service, hospital planning has been influenced by two aspects: patients' freedom to choose their healthcare provider and the equal distribution of centers spread throughout country. Unfortunately, while every Italian region should be able to meet the health needs of its own inhabitants, consistent migration among regions exists, especially from the southern areas of the country, including Sicily. As it has been demonstrated that a hub-and-spoke model (HSM) can provide medical care to even the most rural areas, the aim of this study is to propose a new Sicilian model to avoid patients' migration.Design, Methodology, Approach: The IRCCS Centro Neurolesi “Bonino-Pulejo” of Messina, together with the Ministry of Health and the Sicilian government, has incorporated an HSM into a Sicilian healthcare program that provides neurological rehabilitation by means of innovative technologies such as robotics.Findings: The authors expected, thanks to this novel HSM, that patients may benefit from advanced robotic neurorehabilitation even in rural areas, and therefore be properly treated in their own cities, avoiding unnecessary and expensive migrations to other regions and/or countries. Indeed, since the introduction of this model, there has been a reduction in patient migration, especially in the province of Messina, with a reduction of costs for admission outside the region of about 260.000 euros.Originality/value: The use of innovative technology in the context of the promising HSM will help clinicians increase the intensity of therapies and improve working cost/efficacy, with better functional outcomes in patients.