Parkinson rehabilitation and LSVT protocol: toward an interdisciplinary approach. A narrative review

Autori

Bonanno Francesco (Università degli studi di Messina, Messina, Italia)

Cavallaro Filippo (Università degli studi di Messina, Messina, Italia)

Lizio Alice (Università degli studi di Catania, Catania, Italia)

Di Dio Antonio (Università degli studi di Messina, Messina, Italia)

Sposito Francesca (Università degli studi di Messina, Messina, Italia)

Saraceno Silvia (Università degli studi di Messina, Messina, Italia)

Rizzo Vincenzo (Dipartimento di Medicina Clinica e Sperimentale, Università degli studi di Messina, Messina, Italia)

Background and aims

Rehabilitative interventions play a crucial role in all progressive neurological diseases, such as Parkinson’s disease (PD). PD impairs speech, swallowing, limb function, gait, balance, and activities of daily living. For this reason, an interdisciplinary rehabilitative approach can be very useful to improve health outcomes, motor and non-motor functioning. A clear example of interdisciplinary rehabilitation for PD is represented by the Lee Silverman Voice Treatment (LSVT), a treatment protocol addressed to patients with PD. It is possible to distinguish LSVT LOUD and LSVT BIG. The first is a standardized, research-based speech treatment protocol consisting of exercises aimed at voice enhancement and voice perception. The LSVT BIG is a set of exercises based on speed-amplitude regulation to overcome bradykinesia. With this project, we want to highlight the efficacy of LSVT LOUD and LSVT BIG related to an interdisciplinary context.

Methods

Authors searched for English articles published from 2005 to 2025 in the electronic database PubMed using the following search string: (“Parkinson’s disease”) AND (“Parkinson rehabilitation” AND (“LSVT”). Articles were screened by title and abstract, using the following inclusion criteria for selection: (1) randomized controlled trials; (2) written in English; (3) published in indexed journals; and (4) dealing with Parkinson rehabilitation and LSVT protocols. The exclusion criteria were (1) non-randomized trials; (2) reviews; (3) papers written in languages other than English; and (4) other rehabilitative approaches. 8 articles were included in this study.

Results

Of these 8 articles, 3 showed the efficacy of LSVT LOUD for speech and voice disorders in patients with PD, while 4 papers analysed the use of LSVT BIG for gait, balance, and movement disorders. Only one article highlighted how, with a combined use of LSVT LOUD and LSVT BIG protocols, patients with PD could improve their motor, non-motor, and psychological functions.

Conclusion

Nowadays, despite the scientific community well knowing the importance of an interdisciplinary team for the management of pathologies (such as PD), we realized that there is still little scientific literature on this topic. Further studies are needed to strengthen this concept. With this work, we want to raise a small critical issue about the rehabilitation management of chronic degenerative diseases. There are still a few articles in which it is possible to observe an interdisciplinary management of the patients. LSVT is only an example we used to raise this discrepancy. Ours is a call for a future in which there can be a true collaboration between multiple healthcare professionals.

REFERENCES

Fox C et al. LSVT LOUD and LSVT BIG: Behavioral Treatment Programs for Speech and Body Movement in Parkinson Disease

Healing or hurting words: the Power of Language in Pain Perception – A Narrative Review

Autori

Bonanno Francesco (Università degli Studi di Messina, Messina, Italia)

Leonardi Giulia (Department of Physical and Rehabilitation Medicine, University Hospital “G. Martino”, Messina, Italia)

Cucinotta Carmen (Università degli Studi di Messina, Messina, Italia)

Di Dio Antonio (Università degli Studi di Messina, Messina, Italia)

Poli Elisa (Università degli Studi di Messina, Messina, Italia)

Saraceno Silvia (Università degli Studi di Messina, Messina, Italia)

Cavallaro Filippo (Università degli Studi di Messina, Messina, Italia)

Alito Angelo ((Department of Physical and Rehabilitation Medicine, University Hospital “G. Martino”, Messina, Italia))

Background and aims

Pain is a complex experience with both sensory and emotional components¹. Language plays a crucial role in pain perception, interpretation, and communication². In clinical settings, particularly in rehabilitation, verbal communication plays a key role in modulating pain perception. Verbal suggestions—whether positive, negative, or neutral— can influence both pain intensity and the efficacy of therapeutic interventions. This narrative review aims to provide an overview of the current literature on the link between pain and word processing.

Methods

The authors searched PubMed for English articles published within the last ten years using the keywords: “pain”, “acute pain”, “chronic pain”, “musculoskeletal pain”, “neuropathic pain”, “psychogenic pain”, “word processing”, “language”, “semantics”, “cognition”, “NLP”, “pain neuroscience education” and “pain perception”.

Results

The articles included analysed the impact of language on pain perception. They emphasised several key points, such as the role of words in Pain Neuroscience Education. They suggested that a multimodal approach may be necessary to achieve broader effects on the psychological and functional aspects of pain. They also discussed the influence of verbal suggestions and showed that vocal cues can elicit empathic responses and reduce perceived pain. Finally, they highlighted the connection between pain and cognition. They demonstrated how positive expectations, shaped by language prior to a painful stimulus, can trigger nocebo effects.

Conclusion

Pain has a dual nature, involving both physical-biological and mental-cognitive dimensions, both influenced by language. Approaches such as Pain Neuroscience Education use language to educate patients about the neurophysiological basis of pain, helping to reshape their understanding and alleviate the emotional burden of chronic pain. Physiotherapists, as pivotal figures in pain management, can utilize both verbal and non-verbal communication strategies to improve treatment outcomes, enhance placebo effects, and reduce nocebo responses.

REFERENCES

1. Pain terms: a list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy. Pain. 1979 Jun;6(3):249.
2. Swannell ER, Brown CA, Jones AK, Brown RJ. Some Words Hurt More Than Others: Semantic Activation of Pain Concepts in Memory and Subsequent Experiences of Pain. J Pain. 2016 Mar;17(3):336-49. doi: 10.1016/j.jpain.2015.11.004. Epub 2015 Dec 8

“Physiotherapy and beyond: how Contextual Factors Influence Pain and Rehabilitation Outcomes?”

Autori

Francesco Bonanno (Università degli Studi di Messina, Messina, Italia)

Leonardi Giulia (Department of Physical and Rehabilitation Medicine, University Hospital “G. Martino”, Messina, Italia)

Garofalo Alfio (Università degli Studi di Messina, Messina, Italia)

Di Dio Antonio (Università degli Studi di Messina, Messina, Italia)

Sposito Francesca (Università degli Studi di Messina, Messina, Italia)

Saraceno Silvia (Università degli Studi di Messina, Messina, Italia)

Cucinotta Carmen (Università degli Studi di Messina, Messina, Italia)

Cavallaro Filippo (Università degli Studi di Messina, Messina, Italia)

Alito Angelo (Department of Physical and Rehabilitation Medicine, University Hospital “G. Martino”, Messina, Italia)

Background and aims

Contextual factors (CFs) are increasingly recognized as integral components in the modulation of pain perception and the potentiation of both pharmacological and non-pharmacological treatment effects. These factors exert bidirectional influences on both patients and healthcare providers, originating from prior experiences and the interpersonal dynamics established during clinical encounters. CFs encompass multiple domains, including patient-specific characteristics, treatment attributes, the therapeutic alliance, and the broader clinical environment. Their influence may manifest as either placebo-induced analgesia or nocebo-induced hyperalgesia, thereby significantly shaping clinical outcomes. In light of the multifactorial nature of pain and its management, this narrative review synthesizes current evidence regarding the role of CFs within rehabilitation settings, with a focus on their mechanisms of action and their impact on pain perception and therapeutic efficacy.

Methods

The authors searched PubMed for English articles published within the last ten years using the keywords:   “pain”, “acute pain”, “chronic pain”, “musculoskeletal pain”, “neuropathic pain”, “psychogenic pain”, “contextual factors”, “placebo effect”, “healthcare setting”, “verbal communication”, “non-verbal communication”, “patient-physiotherapist relationship”, and “physiotherapy”.

Results

The selected articles consistently highlight the significant influence of CFs on pain management. Notably, nocebo effects in musculoskeletal pain can be mitigated by creating a supportive therapeutic environment, personalizing treatment, managing patient expectations, and fostering effective communication between the patient and physiotherapist. Furthermore, accurately interpreting patients’ non-verbal pain cues is essential for optimizing clinical outcomes. Equally important is the therapeutic alliance, which—through active listening, bidirectional communication, and mutual understanding grounded in patients’ lived experiences and social contexts—plays a crucial role in enhancing pain relief.

Conclusion

This review underscores the pivotal role of contextual factors (CFs) in the rehabilitation process, influencing both the patient and the physiotherapist throughout the course of care. Patients are the main beneficiaries of improvements in these areas, so these should be systematically addressed and incorporated into the core training programmes of rehabilitation professionals to foster a better understanding of their impact on clinical outcomes. Increasing awareness of the impact of CFs on clinical outcomes is essential for fostering more effective, patient-centered care. While the evidence highlights the relevance of CFs in enhancing pain management and overall therapeutic effectiveness, the review is limited by the relatively small number and size of the included studies. An important question remains: to what extent are these factors currently and systematically integrated into everyday clinical practice by physiotherapists?

REFERENCES

1) Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, Keefe FJ, Mogil JS, Ringkamp M, Sluka KA, Song XJ, Stevens B, Sullivan MD, Tutelman PR, Ushida T, Vader K. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982. doi: 10.1097/j.pain.0000000000001939. PMID: 32694387; PMCID:PMC7680716.

2) Rossettini G, Carlino E, Testa M. Clinical relevance of contextual factors as triggers of placebo and nocebo effects in musculoskeletal pain. BMC Musculoskelet Disord. 2018 Jan 22;19(1):27. doi: 10.1186/s12891-018-1943-8. PMID: 29357856; PMCID: PMC5778801.

Quando per la semplificazione il fisioterapista tornò ad essere massaggiatore. Scenari letterari nella divulgazione

Literary scenarios in popularization: when the physiotherapist went back to being a massage therapist.

Autori

Francesco Bonanno (Università degli studi di Messina)

Mariachiara Ceccio (Università degli studi di Messina)

Teresa Pintaudi (Università degli studi di Messina)

Filippo Cavallaro (Università degli studi di Messina)

Introduction

The space for disclosure and professional testimony, thanks to the plot defined by the authors in the novels, takes us to unexpected dimensions and fascinating adventures. Then it happens that one quotes The Radical Chick Census written by Giacomo Papi and is surprised at how it is current and close.

Doing science popularization is an activity of communicating addressed to the general public, consisting in specialized notions and research of a discipline in a form that is easy to understand. The space that has been available in the online journal Messina Medica 2.0,  like so many spaces for discussion, are opportunities to grow as a profession and to improve as professionals.

It is a chance to learn to present ourselves clearly and to relate with other professionals. In this way we can be recognizable for specific expertise and our own disciplinary field.

Writing and discussing leads to being recognized individually, while these activities need to be done by all physiotherapist in order to proclaim our own identity.

Methods

Since 2019, every 15 days a space has been open for discussion and presentation, focusing on novels and essays analyzed by physiotherapist’s point of view (often relating them to clinical episodes).

We analyzed the contents of more than one hundred articles published, to note the aspects correlated with concern or denunciation, evoked by simplification or reductionism.

Results

At the time when the discipline of physiotherapy also entered in our country’s academic sphere with the establishment of university courses, we had the awareness that we would have to know the body of knowledge of the specific profession, the techniques and how the basic sciences served as the foundation of that knowledge. This was a new thing for the world of medicine and for the whole encyclopedic field of knowledge.

In the health knowledge sphere there were those who had studied ways and times that allowed serious and/or incurable diseases not to be survivable (even it was discovered that certain interventions of physiotherapy limited disease outcomes). Early undergraduate students were suggested to write a glossary of terminology in physiotherapy. For some areas it was easier to relate in others not.

In the text and content analysis of the articles published by Messina Medica 2.0 in the bookseller’s “Noterelle riabilitative del padre del libraio” there are some signs that should act as a spur for the profession.

Two problems are most obvious: firstly the simplification which is a specific risk of popularization, then that of reductionism which is a specific risk of the scientific thinking.

Due problemi sono più evidenti in primis quello della semplificazione che è un rischio specifico della divulgazione, poi quello del riduzionismo che è rischio specifico del pensiero scientifico.

Discussion and Conclusion

In the illness filed, the body alone faces in autonomy with suffering with the tools at its disposal. Today, with scientific knowledge, we know the complexity that underlies our lives, so we cannot relegate all to simple word, commonly used, with an etymology and a history.

Alessandro Baricco argues that “whenever we make certain buzzwords of brutal simplicity enough for us, we burn years of collective growth spent not getting screwed by the apparent simplicity of things.”

Culture is not a “smoky thing”. Culture is the streets on which we walk, the houses where we live, the words in our mouths that some other human, time ago, who knows why, invented. With the ”Rehabilitation Noterella” point of view, we can rewrite it this way,: “Physiotherapy is not a smoky or magical thing. Physiotherapy is the roads on which the reasoning of the physiotherapist walks, the spaces where it is practiced, the words that run in our mouths and that some other human, in practicing and describing his interventions has found and used. Culture is a bet that we can eventually understand each other. That is why it sometimes bothers”.

REFERENCES

• Cavallaro F., Fiolo R., Giordano G. Lo Statuto Epistemologico della Fisioterapia, Fisioterapisti 55/2014
• a cura di Ferrari MG., Il Codice Deontologico dei Fisioterapisti, Ed Libreria Cortina 2014
• AA.VV., Linee guida per la formazione del fisioterapista – core competence, Masson 2003
• AA.VV., La formazione “core” del Fisioterapista, Scienza Riabilitativa 13(3) 2011
• https://www.messinamedica.it/
• Papi G., Il censimento dei radical chic, Feltrinelli 2019
• Baricco A., The Game, Einaudi 2018

Tentammo di stimare il settimo: uno studio meta-analitico

We tried testing the seventh cranial nerve: a meta-analysis study

Autori

Francesco Bonanno (Università degli studi di Messina)

Mariachiara Ceccio (Università degli studi di Messina)

Teresa Pintaudi (Università degli studi di Messina)

Filippo Cavallaro (Università degli studi di Messina)

Introduction

Facial nerve palsy is a clinical diagnosis di­fferentiating between central upper motor neuron lesions (e.g., stroke) and peripheral lower motor neuron lesions (e.g., idiopathic or caused by infection or trauma or surgery). Peripheral facial nerve palsy has various causes; the most common is Bell’s palsy (approximately 75% of all cases)¹, which has a better prognosis than secondary causes. Secondary causes include neoplasms, such as acoustic neuroma and facial nerve schwannoma, and/or surgical adverse. It has been reported that after removal of an acoustic nerve schwannoma or neuroma, facial nerve palsy might occur in up to 70 percent of cases¹. Rehabilitation is an important issue in peripheral facial nerve palsy management. Di­fferent approaches have been applied, such as exercise therapy, electrotherapy, massage, lymph drainage, and biofeedback therapy², but there is no evidence that any particular technique is better than others.

Our aim is to conduct a meta-analysis in order to understand and to investigate the therapies, the management and the complexity of pathology.

Methods

A meta-analysis of the literature was conduct on the rehabilitation methods used in facial palsy. We searched English articles published from 2004 to 2024, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles. The electronic databases PubMed, Scopus, Cochrane Library were investigated, using the following key words, which were combined to achieve maximum search strategy sensitivity: (“facial palsy”) AND (“physiotherapy”) AND (“rehabilitation”).

First, articles were screened by title and abstract, using the following inclusion criteria for selection: (1) randomized controlled trials (RCTs); (2) written in English language; (3) published on indexed journals from 2004 to 2024.

The exclusion criteria were: (1) non-randomized trials; (2) reviews; (3) papers written in other languages than English. Second, the full texts of the selected articles were screened with further exclusions according to the previously described criteria. A PRISMA flowchart of the selection and screening method is provided in Figure 1.

Results

Table 1 summaries the principal key point of each article analyzed. All the author proposed different type of therapeutic protocols (Kabat, laser therapy, neuro-mobilisation), showing improvements in all validated score scale (such as House-Brackmann scale and Facial Disability Index) and in somatic and proprioceptive sensitivity, facial symmetry and electrophysiological responses.

These results highlight the central role of the physiotherapist in the management of facial palsy.

Discussion and Conclusion

Little clinical literature is still available on physiotherapy field about the treatment of 7nc injuries. Minimal is that in which the specific physiotherapy techniques of intervention are described.

The work of colleagues who have indicated therapeutic conducts is very important. An interdisciplinary contribution that can give comfort to the active participation of the subject and enhancement to the physiotherapist’s knowledge and skills can be very useful.

REFERENCES

1 Finsterer J. Management of peripheral facial nerve palsy. Eur Arch Otorhinolaryngol. 2008;265(7):743–752

2 Peitersen E. Bell’s palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of different etiologies. Acta Otolaryngol Suppl. 2002;(549):4–30.

3 Cavallaro F, Portaro S, Pintaudi T, Ceccio M, Alito A. Remote Cognitive Therapeutic Exercise in Facial Nerve Palsy Rehabilitation: Pandemic Tips and Tricks. Innov Clin Neurosci. 2023 Jan-Mar;20(1-3):10-12. PMID: 37122569; PMCID: PMC10132273.

COGNITIVE THERAPEUTIC EXERCSES PROPOSAL IN A FINGER INJURY

Introduction

Alba is a 50 year-old woman with a chronic bone lesion of the second phalanx of the left hand. After the surgical reconstruction and after a period of 6 weeks with the brace, she begins a rehabilitation program based on the Cognitive Therapeutic Exercise (CTE), in order to recover the mobility of the finger. To the first evaluation the patient presents: semiflexion of the proximal inter-phalangeal (10°-15°) with the impossibility of reaching passively the extension; a minimum flexion of the distal inter-phalangeal (2°-3°) with a possible passive realignment and little movement of active extension.

Our aim is to describe the importance and the effectiveness of the Cognitive Therapeutic Exercise in a chronic bone lesion management.

Methods

The treatment initially involved stretching and soft tissue massage in order to prepare the hand and the finger to CTE exercises.

These exercises performed by the patient under the supervision of the therapist were:

 

Slingbar: the patient is seated with her forearm leaning on the table. Her index finger is located on one end of the slingbar, while on the other end the therapist places four different weights (with an increasing weight). The aim of this exercise is to recognize the different weights with closed eyes.

Crescent: the patient is seated with her forearm leaning on the table. The four fingers (except the thumb) are placed on a crescent-shaped platform, that is balanced on a tip. The therapist places a weight on one of the previously defined positions. The aim of this exercise is to recognize, with closed eyes, in which position the weight is placed, while keeping the platform in balance.

Results

With stretching and soft tissue massage, the therapist was able to detach the scar adhesion of the areas injured by the trauma, improving the ROM of the finger and the drainage of the area.

With the CTE exercises the patient acquired the management, the control and the consciousness of the volar and dorsal  activities of the hand in the space. At the end of the therapeutic program Alba showed an improvement of active and passive ROM of the distal inter-phalangeal (AROM T0: 7°- 10°; T2: 0°-50°. PROM T0:0°-10°;T2: 0°-60°) and an improvement of active and passive ROM of the proximal inter-phalangeal (AROM T0:10°-80°; T2:0°-80°. PROM T0:5°-85°;T2:0°-90°).

Discussion and Conclusion

In conclusion, we can say that, even if in literature there are few evidences about CTE method, these exercises were be able to improve the passive and active ROM of the finger and the patient independence in ADL.

With this work, we want to highlight the cognitive aspect of every exercise performed by the patient. Although the scar treatment and kinesitherapy are suitable to functional recovery, they do not implicate the same cognitive involvement and sensitive stimulation of CTE exercises.

REFERENCES

The work is unfunded

What measurement tool for “Attentional Fatigue”?

Introduction

Attentional fatigue is experienced as a decreased ability to concentrate, engage in purposeful activity, and maintain social relationships when there are competing demands on attention. According to William James there are two types of attention: involuntary attention, which is effortlessly drawn to nature, things that affect survival, and things that fascinate us; and voluntary attention, which requires effort to direct when there are competing stimuli. Voluntary attention is necessary for concentration, purposeful action, and monitoring one’s behavior in social interactions. Nowadays there is no measuring scale for attentional fatigue that describes its characteristics such as dimensional size, measuring range, principle of operation.

Methods

To measure attentional fatigue we created a scale based on the IPDDAI scale (Identificazione Precoce del Disturbo da Deficit di Attenzione e Iperattività). It is an observational questionnaire composed by 10 items (as a reference of the 17 items of the IPDDAI) whose assessment is based on a 4-point Likert scale (0 = not at all/never, 1 = a little/most of the time, 2 = quite a lot/most of the time, 3 = a lot/always). The first 3 items are aimed at the subject’s behavior, item 4 investigates inattention, the next 4 analyze the impulsivity dimension, and the last two are related to self-esteem and relational aspects that could create interference with attention. The physiotherapist proposed this scale to neurologic patients who did not specifically manifest disorders that impaired the ability to pay attention and concentrate.

Results

Through the administration of this scale, we saw a significant improvement in patients’ consciousness about their attentional fatigue.

Discussion and Conclusion

Although there is no validated scale to measure attentional fatigue, thanks to the scale described before we realized that attentional fatigue is an important dimension that must be monitored. The exercises proposed by the physiotherapist are always calibrated to the person’s attention span. In this exercises, the patient is encouraged to stay focused, in order to develop progressively different components of attentional skill, such as focus, sustained attention, selectivity, divisibility and alternation.

REFERENCES

James, W. The Principles of Psychology. Cambridge, MA: Harvard University Press; 1890/1983;

Marcotto, E., Paltenghi, B., & Cornoldi, C. (2002). La scala IPDDAI: contributo per la costruzione di uno strumento per l’identificazione precoce del disturbo da deficit di attenzione e/o iperattività. Difficoltà di apprendimento, 8 (2), 153-172