Efficacy of telemedicine for musculoskeletal disorders: an umbrella review

Introduction

Telemedicine is a broad term encompassing many applications, such as diagnostic asynchronous evaluation, continuous monitoring using biosensors and synchronous video consultations, including multiple variations on each theme. This definition includes “Telerehabilitation”, “Health Technologies”, “Digital Medicine” and other similar keywords (1, 2). In addition, in recent years, an increasing number of studies use patient-reported outcomes measurements (PROMs) and patient-reported experience measurement (PREMs) to evaluate telemedicine services (3). Several systematic reviews (SRs) assessing the use of telemedicine for musculoskeletal conditions have been published in last years. However, the landscape of evidence on multiple clinical outcomes  remaines unclear. The aim of this overview is to explore the efficacy of telemedicine and rehabilitation in the treatment of musculoskeletal conditions in terms of PROMs, PREMs and objective outcomes.

Methods

We conducted an overview of SRs (PROSPERO n:CRD42022347366) searching PubMed and EMBASE up to July 25, 2022 for SRs of randomized controlled trials assessing patients with any musculoskeletal or orthopedic condition, undergoing any kind of interventions based on advanced technology systems named as “Telemedicine”, “Telerehabilitation”, “Health Technologies” and “Digital Medicine”, delivered both in synchronous and asynchronous modalities, compared to in-person treatment or usual care/no treatment. We collected PROMs regarding pain, HRQoL, physical function, social function, emotional function, cognitive function, health literacy, side effects, adherence; PREMs, categorized into treatment and technology; and objective measures, including direct and indirect costs. We assessed the methodological quality by A Measurement Tool to Assess Reviews 2 (AMSTAR 2). Findings were reported qualitatively.

Results

Overall, 35 SRs published between 2015 and 2022 were included (Figure 1). The majority of reviews assessed “telerehabilitation” (n=29) in patients with osteoarthritis (n=13) using PROMs (n=142 outcomes mapped with 60 meta-analyses). Table 1 shows SRs’ general characteristics. Proportion of PROMs and PREMs by number of review is displayed in figure 2. Most reviews (68.6%) were rated as critically low by AMSTAR 2. A substantive body of evidence meta-analyzed found telemedicine to benefit or being equal in terms of PROMs compared to conventional care (n=57 meta-analyses).  Meta-analyses showed no differences between groups in PREMs (n=4), while objectives measure (i.e. ‘physical function’) were mainly in favour of telemedicine or showing no differences (9 out of 13). Figure 3 shows directions of SRs’ effects and AMSTAR II by outcomes and by type of population. All SRs showed significant lower costs for telemedicine compared to in-person visit.

Discussion and Conclusion

To our knowledge, this is the first overview of reviews encompassing any kind of telemedicine for different musculoskeletal disorders. Telemedicine can provide more accessible tailored health care with non-inferior results in various clinical outcomes in comparison with conventional care. The assessment of telemedicine is largely represented by PROMs, reflecting how relevant is patient-centered care. Clinicians and stakeholders should consider the adoption of the best available telemedicine technologies to meet patients’ acute and chronic conditions; evidence-based exercise and education can be tailored and delivered remotely, for instance, to increase patient’s compliance to treatment. In a cost-effectiveness point of view, future studies should put efforts in investigating PREMs, objective measures and costs filling the gaps on this promising area.

REFERENCES

1. Cottrell MA, Russell TG. Telehealth for musculoskeletal physiotherapy. Musculoskelet Sci Pract. 2020;48:102193.
2. Russell TG. Physical rehabilitation using telemedicine. J Telemed Telecare. 2007;13(5):217-20.
3. Knapp A, Harst L, Hager S, Schmitt J, Scheibe M. Use of Patient-Reported Outcome Measures and Patient-Reported Experience Measures Within Evaluation Studies of Telemedicine Applications: Systematic Review. J Med Internet Res. 2021;23(11):e30042.

 

Evaluation of balance and gait in stroke patients: correlation between stabilometric indices and gait analysis parameters

Introduction

Stroke is the leading cause of disability worldwide. Restoring balance and a more fluid, safe and correct gait is a prerequisite for the patient to recover autonomy in activities of daily life. Furthermore, a consequence of impaired gait recovery in stroke patients is the high risk of falls, which worsens their quality of life [ 1 ]. Since many falls are predictable, early identification of the risk of falls is crucial for developing tailored interventions to prevent such falls. Recently, an instrumental fall risk assessment index was developed using the Hunova® robotic platform with the aim of giving an early indication of this risk using numerical data of both static and dynamic balance [ 2 ]. In order to combine an instrumental assessment of balance and walking with a clinical evaluation, the aim of this study is to evaluate the correlation between the Silver Index and gait analysis parameters in order to be able to propose more personalized rehabilitation training.

Methods

We enrolled 12 stroke patients, aged between 70 and 95 years. The risk of falls evaluation was performed by Hunova® robotic platform computing the Silver Index. The gait was analyzed by an optoelectronic system with 8 infrared cameras (SMART-DX500 – BTS Bioengineering, Milan, IT). We used the Davis protocol that includes 22 markers. For each patient we calculated the mean values as well as the coefficient of variation (CV) and the multiple correlation coefficient (CMC) of spatio-temporal parameters and joint kinematic parameters. We assessed CV and CMC to quantify variability of the discrete and continuous variables, respectively [ 3 ]. We used Spearman test to calculate the correlation between the Silver Index and the gait analysis parameters.

Results

The correlation analysis shows a statistically significant correlation between the Silver Index and the stance phase of the unaffected side (%) (p=0.036, ρ=0.700) and between the Silver Index and the swing phase of the unaffected side (%) (p=0.036, ρ=-0.700). Furthermore, the Silver Index correlates with the variability of step width (p=0.007, ρ=-0.816).

Discussion and Conclusion

These preliminary results show that the risk of falling is higher in patients who have a longer stance phase of the unaffected limb and a shorter duration of the swing phase always of the unaffected limb. Furthermore, our results show that patients who fall more have less variability in step width. This could be an indication that these patients are unable to make the continuous adjustments that occur physiologically during gait and thus fail to produce dynamic adaptation during walking.

REFERENCES

[ 1 ] Cattaneo D, et al. Frontiers in Neurology 2019;10:865.

[ 2 ] Cella A, et al. PLoS One 2020;15:e0234904.

[ 3 ] Serrao M, et al. Cerebellum 2012;11(1):194-211.

PFD-SENTINEL: the first screening tool for pelvic floor dysfunction in female athletes

Introduction

Evidence suggests the prevalence of Pelvic Floor Dysfunction (PFD) among female athletes is high, with urinary incontinence being particularly common.
Female athletes’ knowledge of PFD is low, and few discuss their condition with medical professionals. Many healthcare providers are also unaware of the potential dysfunction and do not screen for it. This lack of recognition can lead to worsening symptoms, negative impact on performance, and athletes withdrawing from sports.
Although screening tools exist for other conditions, there is currently no tool available for PFD screening specifically for sports medicine clinicians.
This study aimed to develop a screening tool for PFD in female athletes for use by sports medicine clinicians (e.g musculoskeletal/sports physiotherapists, sports and exercise medicine physicians) which guides referral to a PFD specialist (e.g., pelvic floor/women’s health physiotherapist, gynecologist, uro-gynecologist, urologist) through a Delphi consensus.

Methods

A team of Italian researchers developed a screening tool using a Delphi modified consensus through a web-based survey. All complete information are available along the published article.
The target population for the tool is female athletes of any age, performance level, and participating in any type of sport. The clinical condition being considered is any type of PFD. Risk factors and sports-related characteristics (items) associated with PFD in female athletes were extracted from a preliminary search in MEDLINE. Experts’ recruitment relied on non-random, purposive sampling through a literature scan of MEDLINE. Then, an online two-round modified Delphi technique was used to establish agreement among experts on the identified items using a 5-point Likert scale. A consensus was set at 67% agreement or disagreement with a proposal.
Item scores were summarised as appropriate (e.g, frequency and proportions) accompanied by a narrative summary of findings and suggestions.

Results

Among 77 experts, forty-one respondents took part in Round 1 and 34 in Round 2, representing 53.2% (41/77) and 44.2% (34/77) of participants.
Females, Italians, and physiotherapists were the most prevalent sex, nationality, and educational background, respectively. Most participants were currently working as clinicians and researchers (n=22; 53.6%) and reported considerable experience.
Six statements gained immediate consensus by Round 1 and twenty-eight out thirty-seven items were included in the tool. Participants agreed to identify 50% of items (n=14) as a benchmark of total item score for suggesting referral to a PFD specialist. Five out of six symptoms reached the minimum agreement. The majority of experts chose the Pelvic Floor Dysfunction – ScrEeNing Tool IN fEmale athLetes (PFD-SENTINEL) as the official name for the tool (n=16; 47.1%).
Figure 1 shows all the items and PFD symptoms that are included in the PFD-SENTINEL, as well as the clinical algorithm (Figure 2).

Discussion and Conclusion

This 2-round Delphi study involving experts worldwide reached a multidisciplinary consensus on the proposal of the first screening tool for PFD in female athletes. The tool aims to address the barriers in identifying the prevalence and burden of PFD in this population.
The PFD-SENTINEL is a simple and user-friendly tool consisting of two sections to screen for symptoms and risk factors associated with PFD and provides a scoring algorithm to determine whether referral to a specialist is necessary. The tool should be administered regularly and can be used during the pre-season, after enforced breaks, and among athletes returning to sport after pregnancy.
However, education of clinicians, as well as a confidential setting for using the tool, may be necessary. The study has strengths in its novelty and transparency, but limitations include the representativeness of the expert panel. Further validation studies are necessary to test the screening tool accuracy.

REFERENCES

Giagio S, Salvioli S, Innocenti T, et al. PFD-SENTINEL: Development of a screening tool for pelvic floor dysfunction in female athletes through an international Delphi consensus [published online ahead of print, 2022 Dec 14]. Br J Sports Med. 2022;bjsports-2022-105985. doi:10.1136/bjsports-2022-105985

Abrams P, Cardozo L, Wagg A, et al. Incontinence. 6th Editio. ICI-ICS. International Continence Society, Bristol UK 2017.

Giagio S, Salvioli S, Pillastrini P, et al. Sport and pelvic floor dysfunction in male and female athletes: A scoping review. Neurourol Urodyn 2021;40:55–64. doi:10.1002/nau.24564

McKenna HP. The Delphi technique: a worthwhile research approach for nursing? J Adv Nurs 1994;19:1221–5. doi:https://doi.org/10.1111/j.1365-2648.1994.tb01207.x

Immediate effects of trunk rotator stretching exercise on gait parameters in subjects with Parkinson’s disease: a randomized clinical trial

Introduction

Reduced trunk rotation and pelvic mobility, which are associated with a higher risk of falling and one of the best predictors of gait improvement following rehabilitation [ 1 ], are characteristics of subjects with Parkinson’s disease (swPD) [ 2 ]. The Progressive Modular Rebalancing System (PMR) proved to be an effective multimodal exercise therapy strategy with a trunk mobility focus that can enhance the effects of cognitive strategies in swPD gait training [ 3 ]. The purpose of this study was to compare the immediate effects of PMR trunk rotator stretching exercise to active upper trunk rotation exercise (Control) on gait parameters in swPD.

Methods

An expert neurologist screened 40 swPD for inclusion before randomly assigning them to the PMR or control exercise groups using sealed envelopes. Gait trials were collected using a magneto-inertial measurement unit placed at the lower back before (T0) and immediately after (T1) a single exercise session. Spatio-temporal parameters, pelvic kinematics, and harmonic ratios (HR) in three spatial directions were calculated. Four physical therapists who were not aware of the gait assessment carried out the PMR or control exercise. The entire procedure took between 10 and 15 minutes. To assess differences between groups, the independent sample t-test or Mann-Whitney test was used. Within-group differences were assessed using the paired sample t-test or the Wilcoxon test.

Results

At T1, there were significant differences in pelvic obliquity and HR in the antero-posterior (AP) direction between the PMR and control groups (Fig. 1). The PMR group improved in pelvic obliquity, pelvic rotation, HR in the AP and medio-lateral directions, gait speed and cadence, and double support time. Pelvic obliquity and cadence improved in the control group (Fig. 1).

Discussion and Conclusion

PMR trunk rotation stretching was more effective than upper trunk rotation exercise in improving pelvic mobility and harmonic ratio during gait in swPD patients in a single exercise session. Implementing a PMR trunk rotation stretching exercise into a gait rehabilitation program may enhance the effects of gait training by improving pelvic mobility and trunk behavior during gait.

REFERENCES

Serrao, Mariano et al. “Progressive Modular Rebalancing System and Visual Cueing for Gait Rehabilitation in Parkinson’s Disease: A Pilot, Randomized, Controlled Trial With Crossover.” Frontiers in neurology vol. 10 902. 29 Aug. 2019, doi:10.3389/fneur.2019.00902

Trabassi, Dante et al. “Machine Learning Approach to Support the Detection of Parkinson’s Disease in IMU-Based Gait Analysis.” Sensors (Basel, Switzerland) vol. 22,10 3700. 12 May. 2022, doi:10.3390/s22103700

Serrao, Mariano et al. “Prediction of Responsiveness of Gait Variables to Rehabilitation Training in Parkinson’s Disease.” Frontiers in neurology vol. 10 826. 2 Aug. 2019, doi:10.3389/fneur.2019.00826

Castiglia, Stefano Filippo et al. “Harmonic ratio is the most responsive trunk-acceleration derived gait index to rehabilitation in people with Parkinson’s disease at moderate disease stages.” Gait & posture vol. 97 (2022): 152-158. doi:10.1016/j.gaitpost.2022.07.235

Prevention and risk factor assessment of secondary oncologic lymphedema

Introduction

Lymphedema(LE) is a chronic condition and is considered one of the main sequelae of Cancer Survivors. In Italy, the total number of living cancer patients with secondary LE (in the various clinical stages) is about 200,000;  oncological treatment for breast, skin (melanoma), gynecologic and urologic cancers[ 1 ]. In view of the developmental tendency of LE toward the development of irreversible organic damage, treatment should begin as early as possible, and prevention should guide the patient’s entire course of treatment beginning with the diagnosis of cancer to identify risk factors(RF) for the development of LE[ 2 ]. Our study aims to detect from the scientific literature what are the RF and clinical signs of subclinical LE so that the physiotherapist can contribute, within a multidisciplinary approach, to patient surveillance and implement all necessary actions to counteract the development of LE

Methods

A scoping review was performed to examine preventive and risk factors in the assessment of secondary oncologic lymphedema by screening MEDLINE (PubMed) and PEDro databases using the following keywords: prospective surveillance, risk factors, lymphedema. Inclusion criteria: clinical studies, randomized controlled trials, review and systematic review, articles written in English and published in the last 10 years.

Results

Forty-nine articles published since 2013 to date were selected, including 33 related to breast cancer, 9 gynecological cancer, 1 melanoma, and 6 was not relevant to the study objective or not in English language. In breast cancer related lymphedema (BCRL), the RF are: axillary lymph node dissection (ALND) (p < .001), taxane-based chemotherapy (p < .001), regional lymph node irradiation (RNI) (p ≤ .001), BMI >30 ( p = .002), rurality (p = .037). Mastectomy, age, hypertension, diabetes, seroma, smoking, and air travel were not statistically associated with the risk of BCRL[ 3 ]. In gynecologic cancer a multivariate analysis confirmed that removal of circumflex iliac lymph nodes (hazard ratio [ HR ], 4.28; 95% confidence interval [ CI ], 2.09-8.77; P < 0.0001), cellulitis (HR, 3.48; 95% CI, 2.03-5.98; P < 0.0001), and number of removed lymph nodes (HR, 0.99; 95% CI, 0.98-0.99; P = 0.038) were independent RF for lower limb lymphedema (LLL)[ 4 ].

Discussion and Conclusion

Many risk factors are common to all oncologic procedures requiring lymph node dissection. The etiology of risk factors is multifactorial, and the association of multiple factors increases the likelihood of developing secondary LE. Stratification according to risk: High Risk – immediate treatment: patients undergoing ALND and regional lymph node irradiation (RLNR); Low Risk – developmental monitoring with clinical examination and measurements: patients undergoing Sentinel lymph node biopsy (SLNB). When patients report symptoms in the absence of RVC ≥ 10%, LE diagnosis should not be ruled out. These patients should be considered at high risk for BCRL development and therefore be followed vigilantly and longitudinally[ 5 ].The studies use different methods to assess and grade LE and often the methodology used for determining LLL is poorly described and lacks baseline measurement. [ 6 ]

REFERENCES

1- Linee di indirizzo sul LE ed altre patologie correlate al sistema linfatico, REP-Atti n. 159/CSR del 15 settembre 2016. 2- Damstra RJ, Halk AB. The Dutch LE guidelines based on the ICFunctioning, Disability, and Health and the chronic care model J of Vascular Surgery: Venous and Lympha Disorders Vol 5, Number 5: 576-765. 3-Koelmeyer LA, Gaitatzis K, Dietrich MS, Shah CS, Boyages J, McLaughlin SA, Taback B, Stolldorf DP, Elder E, Hughes TM, French JR, Ngui N, Hsu JM, Moore A, Ridner SH. Risk factors for breast cancer-related lymphedema in patients undergoing 3 years of prospective surveillance with intervention. Cancer. 2022 Sep 15;128(18):3408-3415.4- Hayes SC, Janda M, Ward LC, Reul-Hirche H, Steele ML, Carter J, Quinn M,Cornish B, Obermair A. Lymphedema following gynecological cancer: Results from a prospective, longitudinal cohort study on prevalence, incidence and risk factors. Gynecol Oncol. 2017 Sep;146(3):623-629.

 

NEURAL CORRELATES OF BRADYKINESIA IN PARKINSON’S DISEASE: A KINEMATIC AND FMRI STUDY

Introduction

Bradykinesia is one of the cardinal signs of Parkinson’s disease (PD) and is usually assessed during repetitive movements [1, 2]. The aim of the study was to investigate the neural correlates of hand tapping performance in patients with PD relative to healthy controls.

Methods

Fifteen PD patients and 15 age- and sex-matched healthy controls were included. All the subjects underwent brain magnetic resonance imaging (MRI) including a hand tapping functional MRI (fMRI) task: subjects were asked to alternatively open and close (hand tapping) their right hand as fast and as ample as possible. Hand tapping speed and amplitude was measured during the fMRI task using an optical fiber data glove.

Results

During the fMRI hand tapping task, patients with PD showed reduced hand tapping amplitude and reduced activity of frontoparietal areas and sensorimotor regions including supplementary motor area (SMA), pre/postcentral gyri, pallidum and cerebellum compared to healthy controls. Decreased activity of SMA, cerebellum lobule VIII and caudate correlated with reduced hand tapping amplitude.

Discussion and Conclusion

As expected, patients with PD showed a worse hand tapping performance in terms of reduced movement amplitude relative to healthy controls. Interestingly, we found a correlation between bradykinesia and brain activity. In particular, areas strongly involved in motor planning such as SMA and caudate correlated with reduced movement amplitude. This study has the major strength of collecting objective motor parameters and brain activity simultaneously, providing a unique opportunity to investigate the neural correlates of bradykinesia in PD. A reduced recruitment of cortical, cerebellar and basal ganglia areas implicated in motor programming is a hallmark of bradykinesia in patients with PD. 

 

Funding: Italian Ministry of Health grant GR-2018-12366005

REFERENCES

[ 1 ] Prange-Lasonder GB, et al. European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation (CAULIN): data synthesis from systematic reviews, clinical practice guidelines and expert consensus. Journal of Neuroengineering and Rehabilitation. 2021. Doi: 10.1186/s12984-021-00951-y

[ 2 ] Holiga S, et al. Accounting for movement increases sensitivity in detecting brain activity in Parkinson’s disease. PLoS One. 2012. Doi: 10.1371/journal.pone.0036271

[ 3 ] Bologna M, et al. Neurophysiological correlates of bradykinesia in Parkinson’s disease. Brain. 2018. Doi: 10.1093/brain/awy155

Early rehabilitation program with augmented reality and gamification after surgery in patients with lower limb fractures

Introduction

The rehabilitative pathway following surgery for lower limb fracture can be lengthy, significantly impacting both quality of life and work [ 1 ]. Weight-bearing guidelines are dependent on the operating surgeon, and typically, physiotherapy and functional retraining begin after a period of immobilization and weight-bearing restriction.

After this period, patients often tend to underutilize the affected limb in functional tasks due to movement-related fear [ 2 ] or excessive control over the injured limb.

Incorporating immersive and gamified exercise through augmented reality allows patients to shift the load correctly between both lower limbs. The challenging context serves as a catalyst in increasing  patient’s motivation to achieve their goals [ 3 ]. Furthermore, rehabilitation exergames contribute to increase patient engagement, thereby reducing the repetitiveness of the exercises.

Methods

Nineteen patients, ranging in age from 18 to 65 years, without severe comorbidities, and who were permitted early weight-bearing after surgery, were enrolled in the study.

Eleven patients (control group) followed the standard rehabilitation protocol provided by the regional healthcare system, which included traditional physiotherapy. Conversely, eight patients (study group) participated in an early rehabilitation program (started on average 5 days post-surgery) that incorporated physiotherapy with exercises using the D-Wall Tecnobody® system. The exergames involved controlled weight transfers through pelvic movement, as well as the simulation of more complex gestures with the upper limbs, requiring proper control of the base of support.

At 6 weeks and 3 months post-surgery, functional clinical questionnaires were administered. Simultaneously, the return to autonomy, work, and sports activities were investigated.

Results

At 6 weeks, the study group achieved complete (100%) return to full weight-bearing and autonomy, while 63% of patients in control group achieved full weight-bearing and 81% autonomy. In the study group, 66% had returned to work and 42% to sports activities, compared to 33% returning to work and 9% returning to sports in the control group. The groups showed statistical differences in NRS (p-value 0,046) and WOMAC (p-value 0,0013) questionnaires, with better scores in the study group. At 3 months, the difference between groups persisted in NRS score (p-value 0,0025), while the results of other questionnaires aligned, indicating functional recovery in both groups. No complications occurred.

Overall, patients undergoing early physiotherapy intervention had an average of 11.42 physiotherapy treatments, while patients in the control group required the prescription of multiple physiotherapy session to achieve complete recovery, with an average of 28.18 (p-value 0,0012).

Discussion and Conclusion

The availability of current rehabilitation technologies, such as gamified exercises in augmented reality, offers the opportunity to transform traditional physiotherapy into a dynamic process. This allows patients to gain immediate awareness of the load-bearing possibilities on the operated limb within more complex movements, without developing protective mechanisms or avoiding the use of the fractured limb. This has the potential to decrease the inactivity period, the number of prescribed physiotherapy sessions, and the economic impact for patients receiving early weight-bearing recommendations after surgery.

REFERENCES

[ 1 ] Black JDJ et al., Early weight-bearing in operatively fixed ankle fractures: A systematic review, The Foot, 2013;23(2):78–85

[ 2 ] Steven JL et al., Pain-related fear, catastrophizing and pain in the recovery from a fracture, Scandinavian Journal of Pain, 2010 ;1(1):38–42

[ 3 ] S. Sandrone et al., Gamification and game-based education in neurology and neuroscience: application, challenges and opportunities, Brain Disorders, Vol. 1, 2021, 100008, ISSN 2666-4593

EFFECTIVENESS OF EXERCISE IN THE CONSERVATIVE TREATMENT OF PERIPHERAL OBLITERANT ARTERIOPATHY: A SYSTEMATIC REVIEW

Introduction

The Peripheral Artery Disease (PAD) is a vascular pathology characterized by a stenosis or a narrowing of the arteries of the lower limb, caused by the atherosclerotic disease with which shares the major risk factor. The primary symptom is claudicatio intermittens (CI), described as cramping pain primarily in the calves, relieved by rest within 10 minutes (1;2). The PAD treatment involves the control of the symptomatology and the interruption of the progression of the atherosclerosis, through prevention and rehabilitation protocols (3). Several studies have demonstrated the fundamental importance of conservative treatment based on supervised exercise training (SET), due to the increased tissue perfusion and angiogenesis it induces, improving circulation to the lower extremities (4). The objective of the study is to evaluate which form of exercise is more specific and effective for the conservative treatment of PAD

Methods

The literature search, conducted following the international PRISMA guidelines using the PICO strategy (Figure 1), was carried out through the Medline (via PubMed), Scopus and PEDro databases between December 2022 and January 2023. Common search strings have been formulated for Medline and Scopus. The string Peripheral artery disease was also used on PEDro (Figure 2). Furthermore, the search for the articles was limited using the following filters: year of publication (between 2012 and January 15, 2023), language (English), type of study (RCT). Relevant articles were selected by title, duplicates were eliminated using EndNote software. The articles were then chosen based on the reading of the abstract and ultimately the full text (Figure 3). After inclusion, the methodological quality of the selected RCTs was assessed using the PEDro scale (Figure 4).

Results

After the search conducted on the multimedia databases, the studies considered useful and relevant and therefore included in this systematic review were 7, composed only of randomized controlled trials (RCTs). Most of the studies included in the revision have predicted, for the intervention group (WTG), intermittent walking exercises on the treadmill, while the training intensity varied in the different protocols. Some of the studies included, not all have a control group. The studies analysed present, as the most shared outcomes, those relating to 2 macro-areas: cardiovascular function and functional capacity (exercise), which were evaluated in almost all of the studies through the use of heterogeneous scales and instruments. When assessing functional capacity, improvements were noted in nearly all groups undergoing a complete rehabilitation program. In the evaluation of cardiovascular function, however, heterogeneous results were obtained

Discussion and Conclusion

According to the AHA/ACC (3) guidelines 2016 on the management of patients with PAD, walking is the first-line therapy. What unites the rehabilitation protocols analyzed is the use of aerobic exercise, based on walking/treadmills and muscle relaxation techniques, to obtain progressive functional improvements and a reduction in the level of disability of the patients. Despite heterogeneous rehabilitation protocols for PAD in the literature, in terms of intensity, timing and duration of exercise, cardiovascular rehabilitation based on the combination of aerobic training at regular or continuous intervals and at high or low intensity, has proved to be able to improve patients’ health, well-being and quality of life (QoL) and enhance the exercise capacity and strength of the walking muscles.

REFERENCES

1. Wennberg PW. Approach to the pa­tient with peripheral arterial disease. Cir­culation 2013; https://doi.org/10.1161/CIRCULATIONAHA.
2. Gerhard-Herman MD, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
3. Aboyans V, et. al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases. European Heart Journal. 2018 Mar
4. Aboyans V., et al. Measurement and interpretation of the ankle-brachial index: A scientific statement from the American Heart Association. Circulation. 2012

ACTION OBSERVATION AND MOTOR IMAGERY IMPROVE MOTOR IMAGERY ABILITIES IN PATIENTS WITH PARKINSON’S DISEASE – A FUNCTIONAL MRI STUDY

Introduction

Motor imagery (MI) is a motor-learning skill that can be affected in patients with Parkinson’s disease (PD) [1, 2]. We aimed at assessing MI and brain functional changes after an action observation training (AOT) and MI training associated with gait/balance exercises in PD patients with postural instability and gait disorders (PD-PIGD).

Methods

Twenty-five PD-PIGD patients were randomized into two groups: the DUAL-TASK+AOT-MI group performed a 6week gait/balance training combined with AOT-MI; the DUAL-TASK group performed the same exercises while watching landscape videos. Before and after training, MI was assessed using the Kinesthetic-and-Visual-Imagery Questionnaire (KVIQ) and a MI functional MRI (fMRI) task. During fMRI, subjects were asked to watch first-person perspective videos representing gait/balance tasks and mentally simulate to perform them. At baseline patients were compared with 23 healthy controls.

Results

At baseline, there were no significant differences between groups in the MI scores. Both patient groups increased kinesthetic MI score after training, while only DUAL-TASK+AOT-MI group improved in visual MI and total KVIQ scores. At baseline, both PD groups showed reduced fMRI activity of sensorimotor, temporal and cerebellar areas relative to controls. After training, DUAL-TASK+AOT-MI patients increased activity of anterior cingulate, fronto-temporal and motor cerebellar areas, and reduced the recruitment of cognitive cerebellar regions. DUAL-TASK group showed increased recruitment of occipito-temporal areas and reduced activity of cerebellum crus-I. DUAL-TASK+AOT-MI relative to DUAL-TASK group had increased activity of cerebellum VIII-IX. In DUAL-TASK+AOT-MI group, KVIQ improvement correlated with increased activity of cerebellum IX and anterior cingulate, and with reduced activity of crus-I.

Discussion and Conclusion

AOT-MI improves MI abilities in PD-PIGD patients, promoting the functional plasticity of brain areas involved in MI processes and gait/balance control.

REFERENCES

[ 1 ] G. Abbruzzese, et al. Action Observation and Motor Imagery: Innovative Cognitive Tools in the Rehabilitation of Parkinson’s Disease, Parkinson’s Disease. 2015. Doi: 10.1155/2015/124214

[ 2 ] E. Sarasso, et al. Action Observation and Motor Imagery Improve Dual Task in Parkinson’s Disease: A Clinical/fMRI Study. Movement Disorders. 2021. Doi: 10.1002/mds.28717

Performance of ChatGPT compared to clinical practice guidelines in making informed decisions for low back pain and sciatica: A cross-sectional study

Introduction

ChatGPT is a language model developed by OpenAI that is trained to generate human-like text based on large amounts of data and has the potential for role-playing during informed decisions. We aim to assess internal consistency, reliability, and accuracy of ChatGPT compared to recommendations from international clinical practice guidelines (CPGs) in providing answers to a complex clinical question on low back pain and sciatica.

Methods

This cross-sectional study compares ChatGPT answers to CPGs recommendations in diagnosis and treatment of low back pain and sciatica. All eligible recommendations were classified into ‘should do’, ‘could do’, ‘do not do’, or ‘uncertain’ categories by consensus recommendations across CPGs. Using existing CPGs’ recommendations, relative clinical questions were developed and queried to ChatGPT. We assessed (i) internal consistency of text ChatGPT answers when a clinical question was posed three times, (ii) reliability between two independent reviewers in grading ChatGPT answers into the following categories ‘should do’, ‘could do’, ‘do not do’, or ‘uncertain’, and (iii) accuracy of ChatGPT answers compared to CPGs recommendations in classifying the correct categories. Reliability was calculated using Fleiss’ kappa (κ) coefficients, whereas accuracy was measured by inter-observer agreement (IOA) as frequency of the agreements among all judgements.

Results

We found modest internal consistency of text ChatGPT answers across all three trials in all clinical questions (mean percentage of 49%, standard deviation of 15). Intra (reviewer 1: κ=0·90 standard error (se)=0·09; reviewer 2: κ=0·90 se=0·10) and inter-reliability (κ=0·85 se=0·15) between the two reviewers was “almost perfect”. Accuracy between ChatGPT answers and CPGs recommendations was slight, showing agreement in only 33% of recommendations.

Discussion and Conclusion

ChatGPT showed internal consistency in their text answers but their indications were inappropriate compared to the CPGs’ recommendations in diagnosing and treating low back pain and sciatica. Clinicians and patients should use this AI model cautiously because the system provides misleading indications on average.

REFERENCES

Collaborators GBDLBP. Global, regional, and national burden of low back pain, 1990-2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. Lancet Rheumatol 2023; 5(6): e316-e29

Dave T, Athaluri SA, Singh S. ChatGPT in medicine: an overview of its applications, advantages, limitations, future prospects, and ethical considerations. Front Artif Intell 2023; 6: 1169595.

Khorami AK, Oliveira CB, Maher CG, et al. Recommendations for Diagnosis and Treatment of Lumbosacral Radicular Pain: A Systematic Review of Clinical Practice Guidelines. J Clin Med 2021; 10(11).

Sallam M. ChatGPT Utility in Healthcare Education, Research, and Practice: Systematic Review on the Promising Perspectives and Valid Concerns. Healthcare (Basel) 2023; 11(6).