Autore: Andrea Baroni

  • Rieducazione robotica del cammino nella persona con sclerosi multipla e disabilità severa del cammino, confronto tra protocolli di intervento. Risultati preliminari e follow-up a tre mesi

    Rieducazione robotica del cammino nella persona con sclerosi multipla e disabilità severa del cammino, confronto tra protocolli di intervento. Risultati preliminari e follow-up a tre mesi

    Traditional versus progressive robot-assisted gait training in people with multiple sclerosis and severe gait disability: preliminary results with a three-month follow-up.

    Autori

    Baroni Andrea (Ferrara University, Ferrara, Italy)

    Peracchiotti Gabriele (Ferrara University, Ferrara, Italy)

    Lamberti Nicola (Ferrara University, Ferrara, Italy)

    Manfredini Fabio (Ferrara University, Ferrara, Italy)

    Straudi Sofia (Ferrara University, Ferrara, Italy)

    Introduction

    Gait disorders are frequent in people with multiple sclerosis (PwMS) and the use of robotic devices has been proposed as an effective treatment for gait rehabilitation1. The use of exoskeletons for gait rehabilitation seems to be effective in PwMS, without showing significant superiority compared to intensive overground gait training (OGT), affected by inter-individual variability of response and problems related to fatigue and spasticity2. This study aims to evaluate the effects of a low-intensity RAGT at progressively increasing intensity compared to conventional RAGT and OGT in PwMS and moderate to severe walking impairment3.

    Methods

    All PwMS afferent to our Department from September 2022 to nowadays were screened for eligibility. Inclusion criteria were men and women aged 18-65 years with diagnosis of MS and disability rate defined by an Expanded Disability Status Scale (EDSS) score from 6 to 7. Patients meeting inclusion criteria were assigned to one of the three treatment groups through a block randomization approach. All participants received three weekly treatment sessions of 3 hours each for 4 weeks. In the first two hours of treatment, each patient received a program characterized by personalization, intensity, and task-specificity of the rehabilitative intervention. During the last hour, subjects will undergo specific gait training according to the assignment group. Subjects allocated to low-intensity RAGT at progressively increasing intensity group will receive gait rehabilitation on the Lokomat device. The device was set at 60% robotic assistance, 50% load suspension, and a speed initially set at 1.0 km/h, with progressive increments of 0.1 km/h at each training session. The working time consisted of bouts of 3 minutes of work alternated by 1 minute of recovery, to be repeated 8 times. Subjects allocated to conventional RAGT group will receive gait rehabilitation on the Lokomat device, and the parameters for setting the machine was determined by a physiotherapist based on patient’s characteristics; the effective duration of treatment was 30 minutes. Subjects allocated to OGT group received one hour walking training session supervised by a physiotherapist. During this time, the subject performed a 40-minute walk on a flat surface with appropriate recovery breaks. Mobility, walking function, balance, and patient-reported outcomes measures (PROMs) were assessed before and after treatment and at the three-month follow-up.

    Results

    Ninety-five PwMS were screened and twenty-one were enrolled. The three groups were similar in demographic and clinical characteristics at the baseline. All the enrolled subjects completed the study protocol. Significative improvements in walking function, mobility, and balance were recorded at post-treatment evaluation for all three groups, without differences between them. Significative post-treatment changes in PROMs were recorded only for people who received OGT. No improvement was retained at the three-month follow-up.

    Discussion and Conclusion

    Mobility and gait improvements represent a realistic and achievable goal in PwMS and severe walking impairment. Our preliminary results show that OGT is an effective approach in improving walking function, mobility, and balance, at least as RAGT regardless of the performed training protocol. Changes in PROMs highlighted the superiority of OGT in the subjective perception of disability related to MS. The lack of retention of treatment effects at the three-month follow-up makes it necessary to identify useful strategies to maintain positive changes over time also outside the rehabilitation setting.

    REFERENCES

    1. Calabrò RS, Cassio A, Mazzoli D, et al. What does evidence tell us about the use of gait Robotic devices in patients with multiple sclerosis? A comprehensive systematic review on functional outcomes and clinical recommendations. Eur J Phys Rehabil Med 2021;57:841–9.
    2. Straudi S, Manfredini F, Lamberti N, et al. Robot-assisted gait training is not superior to intensive overground walking in multiple sclerosis with severe disability (the RAGTIME study): a randomized controlled trial. Mult Scler 2020;26:716–24.
    3. Baroni A, Lamberti N, Gandolfi M, et al. Traditional versus progressive robot- assisted gait training in people with multiple sclerosis and severe gait disability: study protocol for the PROGR-EX randomised controlled trial. BMJ Open Sport & Exercise Medicine 2024;10:e002039.

  • Valutazione della funzione motoria da remoto nella persona con disordine neurologico: una revisione sistematica.

    Valutazione della funzione motoria da remoto nella persona con disordine neurologico: una revisione sistematica.

    Remote assessment of motor performance in neurological disorders: a systematic review.

    Autori

    Baroni Andrea (Ferrara University, Ferrara, Italy)

    Carpineto Andrea (Ferrara University, Ferrara, Italy)

    Fregna Giulia (Ferrara University, Ferrara, Italy)

    Antonioni Annibale (Ferrara University, Ferrara, Italy)

    Peracchiotti Gabriele (Ferrara University, Ferrara, Italy)

    Flacco Maria Elena (Ferrara University, Ferrara, Italy)

    Straudi Sofia (Ferrara University, Ferrara, Italy)

    Introduction

    Interest in telerehabilitation has continuously grown in recent years due to the possibility of increasing patients’ accessibility to rehabilitation services and continuity of care1. Clinical evaluation of motor performance represents a crucial point of the rehabilitative process, allowing the identification of patient needs and the planning of personalized treatment2. Several methods have been studied to remotely investigate motor performance of people with neurological disorders using wearable devices and sensors, making the assessment expensive and dependent on the clinician to provide the necessary device. For these reasons, with this systematic review, we aim to synthesize the evidence about the available assessment tools for the evaluation of motor performance that can be administered remotely. Furthermore, we aim to collect data about the reliability, validity, feasibility, and acceptability of their use in the clinical setting.

    Methods

    This systematic review was conducted following the updated version of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines3. The study was registered in the “International Prospective Register of Systematic Reviews” (PROSPERO, CRD42024549094). The search was carried out in MEDLINE (via PubMed), EMBASE, CINAHL, and ScienceDirect. We included all observational and interventional studies that assess motor performance remotely in adults (18 years or older) with neurological disorders, including, but not limited to stroke, multiple sclerosis (MS), Parkinson’s disease (PD), acquired brain injury (ABI), and spinal cord injury (SCI). The assessment had to be conducted by a clinician on real patients via video recording or video conferencing (synchronous or asynchronous). The primary outcome had to be the reliability of the remote assessment tool compared to a reference standard of any kind performed through a validated measure or carried out in person. Secondary outcomes could be the validity, feasibility, and acceptability of the motor assessment tools performed remotely.

    Results

    Database searching identified 2541 records. After removing duplicates, 2390 were screened for title and abstract, and 2069 were excluded. Among the 321 remaining papers, 296 didn’t meet the inclusion criteria and were excluded from the collection. We included 25 papers in our systematic review. Of the included studies, 11 evaluated people with PD and 9 people with stroke; the remaining 5 remotely evaluated mixed neurological populations, including MS and SCI. Looking at PD, 6 studies used the Unified Parkinson’s Disease Rating Scale (MDS-UPDRS); upper and lower limb function was evaluated in 3 and 2 studies respectively, and gait and balance were evaluated in 5 studies. Looking at studies on people with stroke, upper and lower extremity function were evaluated in 5 and 4 studies respectively. Balance was evaluated in 4 studies, walking function in 2. The remaining 5 studies evaluated different aspects of motor performance. All studies on people with PD showed high levels of reliability and validity, representing a feasible resource for PD remote evaluation. Studies on people with stroke suggest good applicability of remote assessment, although data on upper limb function have shown poor reliability. The high heterogeneity of the remaining studies didn’t allow us to draw general conclusions on the other populations.

    Discussion and Conclusion

    Remote assessment represents a valuable option for the evaluation of rehabilitative needs and the definition of achievable rehabilitative goals. People with PD and people with stroke seem to be those who could benefit from remote evaluation of motor performance without using wearable devices and sensors, showing levels of reliability and validity comparable to in-person assessment. The acceptability and safety of remote assessment represent an added value to improve accessibility to care of people with neurological disorders. A comprehensive analysis of the results and the evaluation of the quality of the studies might confirm our preliminary results.

    REFERENCES

    1. Brennan DM, Tindall L, Theodoros D, et al. A blueprint for telerehabilitation guidelines–October 2010. Telemed J E Health. 2011;17(8):662-665. doi:10.1089/tmj.2011.0036
    2. O’Neil J, Barnes K, Morgan Donnelly E, Sheehy L, Sveistrup H. Identification and description of telerehabilitation assessments for individuals with neurological conditions: A scoping review. Digit Health. 2023;9:20552076231183233. Published 2023 Jun 22. doi:10.1177/20552076231183233
    3. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Published 2021 Mar 29. doi:10.1136/bmj.n71

  • Circuito task-oriented ad alta intensità supportato da teleriabilitazione: efficacia e fattibilità in soggetti con sclerosis multipla e disabilità lieve-moderata del cammino.

    High-intensity task-oriented circuit training empowered with telerehabilitation: effectiveness and feasibility in people with multiple sclerosis and mild-to-moderate walking impairment.

    Autori

    Baroni Andrea (Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy)

    Perachiotti Gabriele (Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy)

    Carpineto Andrea (Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy)

    Presti Carmelo Pio (School of Physiotherapy, University of Ferrara, Ferrara, Italy)

    Straudi Sofia (Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy)

    Background and aims

    Mobility and balance disorders are frequent in people with Multiple Sclerosis (PwMS) (1) and are present from the earliest stages of the disease. Physical exercise plays a crucial role in improving motor function and reducing fatigue in PwMS, particularly when performed at high intensity (2). Task-oriented circuit training (TOCT) allows to combine the features of exercise training with motor control skills (3). This study aims to evaluate feasibility and effects of a high intensity (TOCT) in PwMS and mild-to-moderate gait impairment, followed by a three-month asynchronous telerehabilitation intervention.

    Methods

    We planned to recruit 18 PwMS with EDSS  6. All subjects received 10 one-hour TOCT sessions where they performed 2 rounds of five exercise stations targeting specific motor skills: walking (speed and adaptability), supine-to-stand, stepping, stair climbing. Stations were graded across 10 difficulty levels to permit progression of exercise. Perceived exertion, technical challenge and stability were assessed after each station. At the end of the in-hospital rehabilitation, each subject received three months of asynchronous telerehabilitation. Mobility, balance, walking function, fatigue and patient-reported outcome measures (PROMs) were evaluated before (T0) and after (T1) in-hospital treatment, after telerehabilitation intervention (T2) and at three-month follow-up. Acceptability of the intervention was evaluated at T1.

    Results

    Fifteen PwMS completed the in-hospital protocol (6 male, median age 51y, median EDSS 4.5). During each session, every subject performed a median of: 257 meters at the highest possible speed in the walking speed station; 67 meters in the walking adaptability station; 18 repetitions in supine-to-stand station; 165 repetitions in the stepping station; 54 steps in the stair climbing station. All subjects significantly improved in mobility (Timed Up and Go Test -0.71s, p<0.05), walking speed (Timed 25-Foot Walk test -0.36s, p<0.05), walking endurance (6-Minute Walk Test +52m, p<0.05), dynamic balance (Dynamic Gait Index +4pts, p<0.05). No significant changes were observed in fatigue and PROMs. Nine subjects completed the telerehabilitation treatment and retained improvement at T2. Retention was observed for 6 subjects at T3. Despite high exertion and balance challenge levels, the intervention was rated acceptable (5/5), safe (5/5) and appropriate (5/5). No adverse events were observed.

    Conclusion

    Our preliminary results showed that a high intensity TOCT seems to be effective for improving mobility, balance and walking function in PwMS and mild-to-moderate gait impairment. Our protocol was safe and well accepted. A higher number of subjects may confirm our findings.

    REFERENCES

    1. Parsaei M, Amanollahi M, TaghaviZanjani F, Khanmohammadi S, Jameie M, Naser Moghadasi A. Effects of non-pharmacological interventions on gait and balance of persons with Multiple Sclerosis: A narrative review. Mult Scler Relat Disord. 2024;82:105415. doi:10.1016/j.msard.2023.105415
    2. Callesen J, Cattaneo D, Brincks J, Kjeldgaard Jørgensen ML, Dalgas U. How do resistance training and balance and motor control training affect gait performance and fatigue impact in people with multiple sclerosis? A randomized controlled multi-center study. Mult Scler. 2020;26(11):1420-1432. doi:10.1177/1352458519865740
    3. Cardini R, Corrini C, Bertoni R, Anastasi D, Cattaneo D, Gervasoni E. Exploring the effectiveness of circuit training rehabilitation on balance, gait, and fatigue in multiple sclerosis: a systematic review and meta-analysis. Physiotherapy. 2024;125:101413. doi:10.1016/j.physio.2024.101413

  • La fatica può influenzare l’insorgenza di dolore tardivo nella sindrome post COVID-19. Uno studio osservazionale

    Fatigue can influence the development of late-onset pain in post COVID-19 syndrome. An observational study.

    Introduction

    Coronavirus disease (COVID-19) is an infection caused by the SARS-CoV-2 virus resulting in various pathology phenotypes characterized by different symptom severities. Pain is one of the most described persistent symptoms following SARS-CoV-2 infection (Bakılan et al., 2021; Fernandez-de-Las-Penas et al., 2022; Soares et al., 2021). Causes of pain persistence after COVID-19 infection are poorly established, and different pathogenetic mechanisms have been proposed. Identifying the main features of post-COVID-19 pain is necessary to provide tailored rehabilitative interventions (Fernández-de-las-Peñas et al., 2022). For these reasons, the primary aim of this paper is to identify possible demographic-pathological features and/or clinical signs related to late-onset pain in people one year after COVID-19 infection.

    Methods

    This observational study was approved by the local Ethical Committee and registered on Clinicaltrials.gov. We enrolled patients with a diagnosis of COVID-19 with rehabilitation needs during the acute phase, and with an increase in pain intensity at 52 weeks from the infection’s onset compared to the pre-COVID-19 condition. All the subjects were monitored through periodic screening of post-COVID syndrome using C19-YRS at 12, 26, and 52 weeks. The subjects were evaluated with the Numeric Pain Rating Scale (NPRS), the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS), the Central Sensitization Inventory (CSI), the Pain Catastrophizing Scale (PCS), the Tampa Scale of Kinesiophobia (TSK). The evaluation of the pressure pain threshold (PPT) and temporal summation (TS) was performed in COVID-19 patients and age- and sex-matched controls.

    Results

    Sixty-seven patients completed the evaluation for post-COVID-19 symptoms at 52 weeks. Twenty subjects presented increased in pain intensity >= 2 points at the 52-week C19-YRS pain assessment (Fig. 1). Subjects with and without pain were similar in demographic and clinical characteristics. Comparison of C19-YRS domains at the threetime points (12, 26, 52 weeks) revealed significantly worse outcomes in fatigue, anxiety, mobility, ability to perform usual daily activities and generally health perception. Reduction in all these domains was retained at the 52-week evaluation (Fig. 2). Multiple linear regression revealed that fatigue at 26 weeks significantly predicted pain onset (b = 0.51, p = 0.006). A mean intensity of pain of 6.0 ± 1.9 was recorded; most of the sample did not show possible neuropathic or nociplastic mechanisms (Fig. 4). No differences were found in PPT and TS between subjects with pain and healthy subjects.

    Discussion and Conclusion

    Our study found that almost one out of three patients hospitalized for COVID-19 developed pain 52 weeks after symptom resolution. Pain intensity seems to fluctuate during the first year following COVID-19 infection. Probably the development of pain long after COVID-19 resolution may be due to new mechanisms developed months after infection, not imputable to nociceptive pathway stimulation or central sensitization (Fernandez-de-Las-Penas et al., 2022). Pain perception seems to be influenced by fatigue. This causal relationship may open the doors to new treatment approaches in pain management, targeting fatigue for late-onset pain treatment. Distinguishing between mechanisms of pain is challenging, and an overlapping is frequent. A comprehensive approach following a biopsychosocial model must consider all possible factors related to pain development, acting on the components of a vicious circle where fatigue and mood disorders play a crucial role in pain development and maintenance.

    REFERENCES

    – Bakılan F, Gökmen İG, Ortanca B, et al. Musculoskeletal symptoms and related factors in postacute COVID-19 patients. Int J Clin Pract. 2021;75(11):e14734. doi:10.1111/ijcp.14734

    – Fernández-de-Las-Peñas C, Cancela-Cilleruelo I, Moro-López-Menchero P, et al. Exploring the trajectory curve of long-term musculoskeletal post-COVID pain symptoms in hospitalized COVID-19 survivors: a multicenter study. Pain. 2023;164(2):413-420. doi:10.1097/j.pain.0000000000002718

    – Fernández-de-Las-Peñas C, Nijs J, Neblett R, et al. Phenotyping Post-COVID Pain as a Nociceptive, Neuropathic, or Nociplastic Pain Condition. Biomedicines. 2022;10(10):2562. Published 2022 Oct 13. doi:10.3390/biomedicines10102562

    – Soares FHC, Kubota GT, Fernandes AM, et al. Prevalence and characteristics of new-onset pain in COVID-19 survivours, a controlled study. Eur J Pain. 2021;25(6):1342-1354. doi:10.1002/ejp.1755

  • La gestione fisioterapica del paziente con dolore nociplastico: consenso tra esperti italiani tramite metodo Delphi

    Physiotherapy management of nociplastic pain: A Delphi study of Italian specialists.

    Introduction

    Pain is a significant health problem for people with musculoskeletal disorders, particularly when it lasts over 3 months1. In many cases, the transition from acute to chronic pain seems to be related to neuroplastic changes occurring in the Central Nervous System (CNS), a process called Central Sensitization (CS)2. Although CS is not the only cause, mechanisms of sensitizations of the CNS play an essential role in nociplastic pain3. Early identification of people with suspected CS mechanisms is necessary due to higher severity of pain, reduced quality of life and poor prognosis4. Despite this, no clinical practice guidelines are available to manage people with suspected CS in rehabilitative settings5. For this reason, this Delphi study aims to reach a consensus on the physiotherapy management of people with pain and suspected CS mechanisms in the Italian scenario.

    Methods

    A web-based Delphi process was employed. Experts in the rehabilitation field were recruited following pre-defined eligibility criteria. Consensus criteria were defined for each round to establish the agreement between participants. Panellists evaluated the usefulness of physical therapist competences in managing people with signs of CS through closed-ended questions. For every competence included, panellists have to explain how they act in their clinical practice every time they approach people where a CS mechanism is suspected. Following completion of three Delphi rounds the final list of competencies was generated.

    Results

    23 participants were recruited for the web-based Delphi process. They all completed Round 1 (23/23, 100%), twenty Round 2 and Round 3 (20/23, 87%). Following Round 1, seven areas were identified by the panel as crucial for CS physiotherapy management; 19 competencies out of 40 reached the consensus between experts, and nine additional competencies were added to Round 2 following literary review. Round 2 identified the agreement for all the 29 competencies. During Round 3, all the experts confirmed the final list generated through the consensus process.

    Discussion and Conclusion

    An agreement between experts was found for the final list of competencies that a physiotherapist should implement every time it approaches people with suspected CS mechanisms. A detailed list of steps was defined to better characterize the physiotherapy process applicable in clinical practice. These steps derived from existing procedures described in the literature and were integrated with additional behaviors identified by the participants in this web-based Delphi process. Our results can open the door to a new way to decline the physiotherapy approach to specific health conditions where theory and practice struggle to find a meeting point. Further research is needed to support the clinical utility of the final list of physiotherapy behaviors and its applicability in daily practice.

    REFERENCES

    1. Treede RD, Rief W, Barke A, et al. Chronic pain as a symptom or a disease: the IASP Classification of Chronic Pain for the International Classification of Diseases (ICD-11). Pain. 2019;160(1):19-27.
    2. Camfferman D, Moseley GL, Gertz K, Pettet MW, Jensen MP. Waking EEG Cortical Markers of Chronic Pain and Sleepiness. Pain Med. 2017;18(10):1921-1931.
    3. Shraim MA, Massé-Alarie H, Hall LM, Hodges PW. Systematic Review and Synthesis of Mechanism-based Classification Systems for Pain Experienced in the Musculoskeletal System. The Clinical Journal of Pain. 2020;36(10):793-812.
    4. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10(4):287-333.
    5. Nijs J, Goubert D, Ickmans K. Recognition and Treatment of Central Sensitization in Chronic Pain Patients: Not Limited to Specialized Care. J Orthop Sports Phys Ther. 2016;46(12):1024-1028.