Physical Therapy in patient with cervical mielopathy following cervical microdiscectomy, gait analysis and stabilometry results: a case report

Introduction

Degenerative cervical myelopathy (DCM) is a progressive, degenerative condition, which is a consequence of degeneration and structural changes of the intervertebral disks that may lead to structural and vascular changes to the spinal cord.¹ Symptoms may present as hyperreflexia, clumsiness in gait,neck stiffness, shoulder pain, paresthesias, or radiculopathic signs.¹ Surgical intervention is recommended for patients with moderate and severe DCM.² There are no rigorous studies evaluating if physiotherapy causes benefit or harm after surgical decompression in patients with DCM.³
With this case report we describe the results obtained in a patient with DCM after surgical decompression who received standard physiotherapy for trunk control according to the Bobath concept, global muscle strengthening especially in the lower limbs and balance training and gait training associated to Virtual Reality.

Methods

A 68 year old man, with severe DCM, MJOA 12 (modified Japanese Orthopaedic Association scale), arrived after surgical intervention. At T0 the patients had a slight left hemiparesis, Mingazzini positive for LL levelling, F4 proximal sthenic deficit, reported left hand paraesthesia. He could walk with a 4-wheeled walker, had reduced LL major control on the left. The tests included: open/closed eyes balance with stabilometric platform (D-Wall, Tecnobody), the outcomes included parameters of center of pressure (COP) during quiet standing; Gait Analysis (WALKER VIEW, Tecnobody) was possible leaning on the handrail, the outcomes included velocity, stride length and joints Range of Motion. The treatment (lasted 3 months, three days a week) focused on balance training with real time biofeedback on stabilometric platform, stable and unstable surfaces; gait training through treadmill with real-time feedback.

Results

The stabilometric parameters have improved: there was reduction of the oscillation area OE 21% and 57% in OE and CE test (mm²: T0 OE 945.92 CE 2959.33 – T1 OE 742.99 CE 1263.97). Romberg index decreased (Area CE/OE T0 313, T1 170). The average speed AP decrease about 34% OE and 17% EC (mm/s T0 OE 17,78 CE 28,24 T1 OE 12,58 CE 23,60). The average speed LL decrease about 17% OE and 8% CE (mm/s T0 OE 15,55 CE 23,09 T1 OE 12,99 CE 21,24) Gait analysis shows better trunk position in the sagittal plane (flex-ext T0 14.7°, T1 6 ,5°) and less oscillation in the frontal plane (lat-flex T0 -2.5°, T1 -0.8). An increased of the 180% of the speed (km/h: T0 1.2, T1 2.2). Improved length gait of 130% for the left, 32% right (cm: T0 l 19 r 28, T1 l 44 r 37). Improvement of parameters of step (flex-ext in stance [°] T0 l 0.5 r 4.4 T1 l 13.3 r 10 ,7, flex-ex in toe off [°] T0 l -38,5 r -30,0 T1 l -34,8 r -44,6. MJOA improved from 12 to 15.

Discussion and Conclusion

Gait impairment constitutes the most prominent clinical manifestation of cervical myelopathy, and thus its amelioration may have tremendous impact on the recovery of patients’ functionality.⁴ Individuals with DCM shown a greater postural sway with increased muscle activation in the trunk and lower extremities during quiet standing.The treatment through a real time biofeedback stabilometric platform, and through gait training led to an improvement in the kinematic parameters of the gait and in the parameters related to the COP. All this has allowed the rehabilitation team and the patient himself to objectively verify the changes obtained throughout the training to direct the treatment towards the limits identified during the sessions and allowing the patient to establish active coping strategies. Future works may provide follow-ups to verify the maintenance of the obtained results.

REFERENCES

1. Cook, Chad E., et al. “Clinical tests for screening and diagnosis of cervical spine myelopathy: a systematic review.” Journal of manipulative and physiological therapeutics 34.8 (2011): 539-546.

2. Fehlings, Michael G., et al. “A clinical practice guideline for the management of patients with degenerative cervical myelopathy: recommendations for patients with mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord compression.” Global spine journal 7.3_suppl (2017): 70S-83S.

3. Tetreault, Lindsay, et al. “Significant predictors of outcome following surgery for the treatment of degenerative cervical myelopathy: a systematic review of the literature.” Neurosurgery Clinics 29.1 (2018): 115-127.

4. Siasios, Ioannis D., et al. “The role of gait analysis in the evaluation of patients with cervical myelopathy: a literature review study.” World Neurosurgery 101 (2017): 275-282.

Tele-Rehabilitation for Knee Osteoarthritis: Evaluating Efficacy, Compliance, and Patient Outcomes

Introduction

The COVID-19 pandemic has brought significant challenges to the healthcare system, including the care of individuals with osteoarthritis (OA)[ 1 ]. Tele-rehabilitation (TR) has emerged as a valuable tool for managing OA through remote exercise interventions, offering potential benefits in reducing costs. This study aims to evaluate the efficacy of TR in managing knee OA, hypothesizing that evidence-based exercise programs delivered through TR can achieve comparable outcomes to traditional clinic-based interventions while potentially reducing overall healthcare costs. By improving adherence and providing a familiar, protected environment for patients, TR has the potential to enhance chronic disease management and quality of life while also offering cost-saving advantages. Understanding the effectiveness of TR in OA care can inform decision-making and help optimize healthcare resources in the post-pandemic era.

Methods

This randomized controlled trial included 50 participants with knee osteoarthritis. They were randomly assigned to either the experimental or control group (25 participants each). Both groups performed the same exercise interventions, including seated knee exercises, isometric quadriceps exercises, sit-to-stand exercises, and wall squats [ 2 ][ 3 ]. The intervention consisted of 12 sessions, three times a week. In the experimental group, participants received home-based rehabilitation through tele-rehabilitation supervised by a dedicated physiotherapist. The control group received conventional rehabilitation at the institute, also supervised by a dedicated physiotherapist. Assessments were conducted at baseline, post-treatment, and at a 1-month follow-up, measuring pain reduction using the Numeric Pain Rating Scale (NRPS)[ 4 ] and secondary outcomes.

Results

In the independent samples t-tests, conducted to compare the two groups, the results showed the following: At the Baseline assessment, there was no statistically significant difference between the groups in terms of NPRS scores (t = 0.170, df = 53, p = 0.865), with a mean difference of 0.070 (SE = 0.413, Cohen’s d = 0.046). Similarly, at the End of Treatment assessment, no significant difference was found in NPRS scores between the groups (t = -0.333, df = 53, p = 0.741), with a mean difference of -0.167 (SE = 0.502, Cohen’s d = -0.090). The results at the After 3-month assessment also revealed no significant difference between the groups in terms of NPRS scores (t = 0.337, df = 53, p = 0.737), with a mean difference of 0.186 (SE = 0.551, Cohen’s d = 0.091). These findings suggest that there were no significant differences in pain levels between the two groups at any of the assessment points.

Discussion and Conclusion

This study compared the effectiveness of home-based tele-rehabilitation and hospital-based rehabilitation in reducing knee osteoarthritis-related pain. Both groups showed significant pain improvement after one month of targeted exercises. No significant difference was found between the groups, indicating that home-based tele-rehabilitation was as effective as hospital-based rehabilitation. Pain improvement was sustained at the three-month follow-up. These findings suggest that home-based tele-rehabilitation can be a viable alternative to hospital-based rehabilitation, improving accessibility and convenience. In conclusion, both treatment modalities effectively reduce knee osteoarthritis-related pain, with home-based tele-rehabilitation offering comparable benefits and the potential to revolutionize care delivery.

REFERENCES

[ 1 ] Ragni, E., Mangiavini, L., Viganò, M., Brini, A.T., Peretti, G.M., Banfi, G., de Girolamo, L., 2020. Management of Osteoarthritis During the COVID‐19 Pandemic. Clin Pharmacol Ther 108, 719–729. https://doi.org/10.1002/cpt.1910

[ 2 ] Janssen, W.G.M., Bussmann, H.B.J., Stam, H.J., 2002. Determinants of the sit-to-stand movement: a review. Phys Ther 82, 866–879.

[ 3 ] Skou, S.T., Pedersen, B.K., Abbott, J.H., Patterson, B., Barton, C., 2018. Physical Activity and Exercise Therapy Benefit More Than Just Symptoms and Impairments in People With Hip and Knee Osteoarthritis. J Orthop Sports Phys Ther 48, 439–447. https://doi.org/10.2519/jospt.2018.7877

[ 4 ] Childs, J.D., Piva, S.R., Fritz, J.M., 2005. Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976) 30, 1331–1334. https://doi.org/10.1097/01.brs.0000164099.92112.29

Effectiveness of Robotic Balance Rehabilitation in Elderly Patients with Stroke Outcomes

Introduction

Stroke is one of the major socio-health problems, the second leading cause of death, and the primary cause of disability worldwide. Due to the aging of the population, the incidence of this condition is constantly increasing, leading to a rise in the demand for care. In recent years, the rehabilitation landscape has been enriched with new technologies to improve the quality and efficiency of functional recovery after an acute event. Regarding balance, in particular, a robotic device has been developed for the functional sensorimotor evaluation and rehabilitation of lower limbs and trunk. Literature works have shown how this tool, the Hunova® robotic platform, is effective in balance rehabilitation for adults with stroke outcomes. The aim of this study is to evaluate the effects of technological rehabilitation using the Hunova® robotic platform on static and dynamic balance in a group of elderly patients with stroke outcomes

Methods

12 elderly patients with stroke outcomes were randomized into two groups: the experimental group (GH) received specific balance disorder rehabilitation on the Hunova® platform for 45 minutes per day, 3 days a week, for 4 weeks, in addition to conventional rehabilitation treatment; the control group (GC) only received the rehabilitation treatment as planned in the rehabilitation project. All patients were clinically and instrumentally assessed at the beginning (T0) and the end (T1) of the treatment. The assessment included the Motricity Index Lower Limb (MI-LL), the Berg Balance Scale (BBS), the Time Up&Go (TUG), Short Physical Performance Battery (SPPB), the Hauser Ambulation Index (HAI), the Functional Ambulation Classification (FAC), and the Walking Handicap Scale (WHS). The instrumental assessment of balance was performed using the Hunova® robotic platform, both in static and dynamic conditions

Results

Intra-group analysis in GH shows significant improvement in the MI-LL on both the affected and unaffected sides, and in GC for the MI-LL,TUG,BBS,SPPB,HAI,FAC and WHS on the affected side. Between the groups there is greater improvement in GH compared to GC in the TUG,BBS and HAI. Instrumental assessment reveals statistically significant differences in GH under static conditions with open eyes(OA), in CenterOfPressure(COP) displacement, and in trunk movements; for the closed-eye(OC) evaluation significant differences are observed in trunk movements. Dynamic assessment there is improvement in COP displacement during OA and in trunk movements.Intergroup analysis in static evaluation there is greater improvement in GH compared to GC in COPAreaOC, COPAreaOA and M-L range of trunk oscillations during OA. In dynamic evaluation with OA improvements are seen in COPArea and trunk movement quantity

Discussion and Conclusion

From an analysis of preliminary data, it emerges that the group of elderly patients with stroke outcomes who underwent technological balance treatment using the Hunova® robotic platform in combination with conventional therapy, showed greater improvement in both static and dynamic balance, with eyes open and eyes closed, compared to the group that underwent conventional rehabilitation alone

REFERENCES

Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009; 8, 741-54.

FUNCTIONAL MRI AND GAIT ANALYSIS CHARACTERISTICS IN PATIENTS WITH ISOLATED REM SLEEP BEHAVIOR DISORDER

Introduction

Clinical, gait analysis, and MRI features might predict the conversion from idiopathic REM sleep behavioral disorder (iRBD) to clinically manifested alpha-synucleinopathies [1, 2]. The aims of this study were to assess gait analysis, neurological, neuropsychological and resting-state functional MRI (RS-fMRI) functional connectivity (FC) characteristics in iRBD patients and to study the correlations between clinical features and RS-fMRI alterations.

Methods

Ten patients with a polysomnography-confirmed iRBD underwent clinical, cognitive, and RS-fMRI evaluations. Ten age/sex-matched healthy controls underwent neuropsychological evaluation and RS-fMRI. Gait analysis was performed using a stereophotogrammetric system to assess asymmetry of spatio-temporal gait parameters during a four-meter walking test with and without a cognitive dual-task.

Results

IRBD patients showed mild asymmetry of spatio-temporal gait parameters, particularly during dual-task gait. IRBD patients showed an increased FC in the right executive control, sensorimotor and dorsal default mode networks compared to healthy controls. Basal ganglia and cerebellar networks showed reduced FC. Correlation analyses showed that an increased asymmetry in the lower limb swing time during gait correlated with an increased FC in the right executive control network, whereas an increased asymmetry of lower limb stride length during dual-task gait correlated with an increased FC in the sensorimotor network.

Discussion and Conclusion

This study suggested that RS-fMRI and gait analysis characteristics could be promising biomarkers for early alpha-synucleinopathy detection and prediction. The collection of longitudinal data in a larger sample will allow the assessment of conversion from iRBD to parkinsonian syndromes and to test a multifactorial prediction model combining fMRI, gait analysis, clinical and neuropsychological data.

Funding: Italian Ministry of Health [grant number # RF-2018-12366746]

REFERENCES

[ 1 ] Ferini-Strambi L, et al. REM sleep Behaviour Disorder. Parkinsonism and Related Disorders. 2016. Doi: 10.1016/j.parkreldis.2015.09.002

[ 2 ] Galbiati A, et al. The risk of neurodegeneration in REM sleep behavior disorder: A systematic review and meta-analysis of longitudinal studies. Sleep Medicine Reviews. 2019. Doi: 10.1016/j.smrv.2018.09.008

VALIDATION OF THE 5DT DATA GLOVE FOR THE ASSESSMENT OF HAND MOVEMENT AMPLITUDE IN HEALTHY SUBJECTS

Introduction

Finger and hand movements are fundamental in many daily-life activities and many studies focus on the assessment of neural correlates of hand tasks using functional magnetic resonance imaging (fMRI) [ 1 ]. However, when task-based fMRI investigates the neural correlates of hand movements, it would be important to contextually measuring motor performance, considering that brain activity is strictly connected to movement-dependent modifications [ 2 ]. The 5DT Data Glove is an MRI-compatible hand motion capture device allowing evaluation of finger movements using optic fibre sensors embedded in a stretch lycra glove.

The aim of this study was to assess the reliability of the 5DT Data Glove in assessment of direction and quantity of movement in open and close hand task (hand tapping).

Methods

Validation study of the 5DT Data Glove movement assessment using a stereophotogrammetric system (BTS, SMART DX 7000) with six optoelectronic cameras as gold standard. Fifteen healthy volunteers wore on their left hand a 5DT Data Glove on which we placed three reflective markers (base and head of the second metacarpal bone and proximal phalanx of the second finger) to allow the assessment of metacarpophalangeal joint movements with the stereophotogrammetric system. Volunteers were asked to perform left hand tapping movements at comfortable (1HZ) and fast (3Hz) speed. Spearman’s correlation coefficient was used to assess the strength of the association between data obtained from 5DT Data Glove and from the stereophotogrammetric system.

Results

We found an overall strong significant positive correlation between data acquired by the two systems during the hand tapping task, both at 1Hz (r=0.79, p<0.001) and 3Hz (r=0.81, p<0.001). Each subject in each condition showed a strong significant positive correlation (r ranging from 0.7 to 0.9; p<0.001).

Discussion and Conclusion

The 5DT Data Glove is a reliable tool for the assessment of hand kinematics in fMRI environment giving the possibility to acquire hand tapping movement parameters fundamental to study the neural mechanisms underlying behavioural data. These data yield the floor to further studies on neural correlates of hand movements.

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

REFERENCES

[ 1 ] Witt ST, et al. Functional neuroimaging correlates of finger-tapping task variations: an ALE meta-analysis. Neuroimage. 2008. Doi: 10.1016/j.neuroimage.2008.04.025

[ 2 ] Martinez M, et al. MRI-compatible device for examining brain activation related to stepping. IEEE Trans Med Imaging. 2014. Doi: 10.1109/TMI.2014.2301493

Harmonic ratio is the most responsive trunk-acceleration derived gait index to rehabilitation in people with Parkinson’s disease at moderate disease stages.

Introduction

Harmonic ratios (HRs), recurrence quantification analysis in the antero-posterior direction (RQA_detAP), and stride length coefficient of variation (CV) have recently been shown to characterize gait abnormalities and fall risk in people with Parkinson’s disease (pwPD) at moderate disease stages. This study aimed to i) assess the internal and external responsiveness to rehabilitation of HR, RQAdetAP, and CV, ii) identify the baseline predictors of normalization of the gait stability indexes, and iii) investigate the correlations between the gait indexes modifications (∆) and clinical and kinematic ∆s in pwPD at Hoehn and Yahr disease staging classification 3.

Methods

The trunk acceleration patterns of 21 pwPD and 21 age- and speed-matched healthy subjects (HS) were acquired during gait using an inertial measurement unit at baseline (T0). pwPD were also assessed after a 4-week rehabilitation period (T1). Each participant’s HR in the antero-posterior (HR_AP), medio-lateral (HR_ML), and vertical directions, RQA_detAP, CV, spatio-temporal, and kinematic variables were calculated. Unpaired t-test or Mann-Whitney test and Cohen’s d were used to identify significant differences between pwPD and HS at T0 and normalization at T1. Multiple linear regression analysis was performed to identify the predictors of improvement. Partial correlation analysis adjusting for Δgait speed was performed between the Δs. Area under the ROC curves (AUCs) and minimally clinically important differences (MCID) were calculated to assess external responsiveness.

Results

After rehabilitation, pwPD improved in HR_AP, HR_ML, gait speed, stride length, cadence, pelvic obliquity, pelvic rotation, and UPDRS-III, with medium-to-large effect sizes (0.52 > d < 0.82). At T1, HR_AP, HR_ML, stride length, and pelvic rotation were no longer different from HS, suggesting a normalization of these parameters (Fig. 1). Lower HRs and higher pelvic rotation values at baseline predicted ∆HRs. ΔHR_AP correlated with ΔHR_ML, Δstride length and Δpelvic rotation, regardless of Δgait speed (Fig. 2). ΔHR_AP ≥ 21.47 %, Δstride length ≥ 10.09 %, and Δpelvic rotation ≥ 8.59 %, respectively, were required to normalize HR_AP with 95 %, 88 %, 74 %, and 81 % probability. ΔHR_ML ≥ 36.94 %, Δstride length ≥ 22.67 %, and Δpelvic rotation ≥ 37.67 %, were required to normalize HR_ML with 92 %, 71 %, 73 %, and 90 % probability. RQA_detAP and step length CV were not responsive to rehabilitation.

Discussion and Conclusion

HR_AP and HR_ML improved to normative values after rehabilitation and showed high internal and external responsiveness. When using inertial measurement units, HR_AP and HR_ML can be considered as responsive outcome measures for assessing the effectiveness of rehabilitation on trunk smoothness during walking in pwPD at moderate disease stages. Subjects with reduced trunk mobility at baseline were more likely to improve their HRs and focusing on exercise programs on pelvic rotation and stride length (Fig. 3) could optimize the rehabilitative planning in order to tailor gait interventions in pwPD at moderate disease stages.

REFERENCES

Castiglia, Stefano Filippo et al. “Ability of a Set of Trunk Inertial Indexes of Gait to Identify Gait Instability and Recurrent Fallers in Parkinson’s Disease.” Sensors (Basel, Switzerland) vol. 21,10 3449. 15 May. 2021, doi:10.3390/s21103449

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

Hubble, Ryan P et al. “Trunk Exercises Improve Gait Symmetry in Parkinson Disease: A Blind Phase II Randomized Controlled Trial.” American journal of physical medicine & rehabilitation vol. 97,3 (2018): 151-159. doi:10.1097/PHM.0000000000000858