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

The Early Functional Abilities-revised may bridge the measurement gap between the disorder of consciousness and the functional independence scales: a Rasch analysis study

Introduction

A measurement gap between the disorder of consciousness (DoC) and functional independence scales is present, as both cannot measure the recovery of early functional changes occurring on emergence from DoC. The Early Functional Abilities scale (EFA) was developed to bridge this gap. It describes clinically observable changes concerning purposeful activities, illness and disability awareness, and the ability to comply with medical, nursing, and therapeutic interventions.

In 2018, Poulsen et al. assessed the internal construct validity (ICV), reliability, and measurement precision of EFA in patients with TBI with Rasch analysis. The analysis rejected unidimensionality and did not recommend summarizing the four subscale measures into an EFA total score.

This study investigated whether selecting a valid content subset of items (EFA-R) from the original EFA was possible, providing an essentially unidimensional measurement of early functional ability.

Methods

In a multicenter observational cross-sectional study, we included three hundred sixty-two adults diagnosed with DoC due to a severe acquired brain injury (sABI) on admission to eleven Italian rehabilitation centers. We excluded patients with pre-existing neurological degenerative pathologies and/or concurrent illnesses likely to compromise survival within six months. Each patient was represented with only one chosen random evaluation in the dataset to avoid the risk of time dependency.

The Italian version of EFA (20 items with a five-point score grouped in 4 subscales) was administered to the sample and then submitted to Mokken analysis (MA), Confirmatory Factor Analysis (CFA), Rasch analysis, Confirmatory Bifactor Analysis (CBA), and external construct validity.

When available, we also collected the Coma Recovery Scale-Revised (CRS-R) and the FIMTM for each person at the same time point for sample description and external validity purposes.

Results

According to MA and CFA, the Italian EFA showed sufficient preliminary unidimensionality. Within Rasch Analysis, a final 12-item solution (EFA-R) was calibrated. EFA-R is “essentially unidimensional” according to 1) analysis of residual correlations supporting item essential local independence; 2) a robust correlation between item subtests (rho=0.950); 3) only 2.1% of cases with significant difference between person parameter estimates by different subscales; 4) an explained common variance equal to 0.916 obtained from a final CBA. The invariance requirement (unconditional χ2df=9.8120; p=0.457, conditional class-interval based χ2df=33.135; P=0.557) and monotonicity were also satisfied (Table 1). The reliability (Person Separation Index=0.887) was adequate for person measurements (Figure 1). A practical raw-score-to-measure conversion table based on the EFA-R calibration was devised (Table 2). Finally, EFA-R strongly correlated with CRS-R (rho=0.922) and motor FIM™ (rho=0.808).

Discussion and Conclusion

EFA-R is an essentially unidimensional subset of 12 items with adequate ICV and sufficient reliability for individual measurement under the Rasch Model Theory framework in patients with sABI. It has the potential to measure people’s functional abilities whose consciousness is improving despite ongoing severe motor-functional impairments during the early stages of rehabilitation. It covers all four original conceptual domains. The item hierarchy was consistent with the theoretical and expected order of functional recovery in these patients. The raw-score-to-measure conversion table provides interval-level estimates of early functional abilities, essential for correctly interpreting change scores and using parametric statistics.

Given the strong correlation with CRS-R and mFIMTM, it provides “a measurement bridge” between the DoC and the functional independence scales in patients with sABI, overcoming the ceiling and floor effects of the two scales (Figure 2).

REFERENCES

  1. Heck G, Steiger-Bächler G, Schmidt T. Early Functional Abilities (EFA) – eine Skala zur Evaluation von Behandlungsverläufen in der neurologischen Frührehabilitation. Neurol Rehabil 2000;6:125–33.
  2. Poulsen I, Kreiner S, Engberg AW. Validation of the Early Functional Abilities scale: an assessment of four dimensions in early recovery after traumatic brain injury. J Rehabil Med 2018;50:165–72.
  3. Tennant A, Conaghan PG. The Rasch measurement model in rheumatology: what is it and why use it? When should it be applied, and what should one look for in a Rasch paper? Arthritis Rheum 2007;57:1358–62.
  4. La Porta F, Caselli S, Ianes AB, Cameli O, Lino M, Piperno R, et al. Can we scientifically and reliably measure the level of consciousness in vegetative and minimally conscious States? Rasch analysis of the coma recovery scale-revised. Arch Phys Med Rehabil 2013;94:527– 535.e1.

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

Mobility Scale for Acute Patients: validity and reliability of the Italian scale

Introduction

Many well-known functional scales include items of mobility and have been validated for assessing functional status in the rehabilitation setting but propose measures of complex items, that would be expected months after an acute event. The Mobility Scale for Acute Stroke Patients (MSAS) by Simondson et al. (1996) was developed to respond to the need for a scale that addresses the specific needs of neurological patients in the acute setting. Although the MSAS was developed to specifically discriminate between the lower levels of mobility in acute stroke patients in the first two weeks post-onset, we thought it could also be a valid tool to be used for the assessment of patients in the early sub-acute phase of stroke. The present study aims to develop and validate a version of the MSAS in Italian.

Methods

The English version of the MSAS was translated into Italian according to international guidelines. Later were tested the internal consistency, concurrent validity, reliability, and responsiveness properties of the scale. The recruited patients were divided into two groups. For the scute (AC) group we recruited patients admitted for rehabilitation within 14 days of the stroke onset, while for the sub-acute (SA) group, we recruited patients admitted for rehabilitation between 15 and 90 days after the stroke. Each patient was tested twice after 24 hours by the same physical therapist to evaluate the test-retest reliability.  To assess inter-rater reliability, two blinded physical therapists independently evaluated the same person.  To investigate the responsiveness the MSAS was administered at the time of admission and two (acute) and seven (sub-acute) weeks later, at the discharge, to a sub-group of 44 patients.

Results

Internal consistency results showed statistically significant data for both groups. Cronbach’s alpha for individuals in AC and SA phases showed values equal to 0.96, and the alpha deleted analysis (Table 1) demonstrates that all the items on the scale have reason to exist. Concurrent validity showed statistically significant data for both populations. Indeed, we obtained statistically significant data for all scales (Table 2). The Italian version of the MSAS showed significant and high intra-rater reliabilities (all ICCs ≥ 0.75) for both the AC and SA sub-groups (Table 3).  The MSAS also showed excellent test-retest reliabilities (all ICCs ≥ 0.90) for the AC and SA sub-groups (Table 4). The reactivity of the scale, evaluated through the Student’s ts for paired samples on the sub-sample of 42 individuals, showed statistically significant improvements over time for all items and the total scale (Table 5).

Discussion and Conclusion

The results show that the scale is stable and reliable both in the evaluation after 24 hours and in the evaluation between different operators. A high internal consistency and a strong correlation between the scales used as Gold Standard and the MSAS were found for both acute and sub-acute samples. The scale has also proved to be able to evaluate the improvement obtained by patients following the rehabilitation treatments carried out.

REFERENCES

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

HOME-BASED EXERGAMES TO IMPROVE COGNITIVE FUNCTION IN MULTIPLE SCLEROSIS: A MULTICENTRE, RANDOMISED, SHAM-CONTROLLED, SINGLE-BLIND, PARALLEL ARM STUDY (EXTREMUS)

Introduction

People with Multiple Sclerosis (PwMS) often experience coexisting cognitive and motor dysfunctions that require both cognitive and motor rehabilitation. The set-up of a tailored approach encompassing two different forms of rehabilitation (for motor and cognitive problems) can be time-consuming and expensive. Therefore, the provision of a single rehabilitation strategy that can address both cognitive and motor issues remains highly desirable.Exergaming is an emerging tool in neurorehabilitation that incorporates goal-based training and gross motor exercise, thus having the potential for improving both cognitive and automatic components of motor control by exploiting adaptive plasticity. The aim of this study was to verify the hypothesis that exergames and working memory trainings were equally superior to a sham intervention on information processing speed and that exergames were superior to both working memory training and sham intervention on walking endurance and dynamic balance.

Methods

We selected 92 PwMS who had a cognitive impairment defined based on Symbol Digit Modalities Test (SDMT) score and with the ability to stand upright for at least 180 seconds.Subjects were randomized in a one-to-one-to-one ratio to sham intervention or working memory training or exergames. Both the sham intervention and the working memory training were delivered by COGNI-TRAcK that is a handheld application for tablets. Exergaming was delivered by the Wii Fit Plus package.All interventions were standardized in terms of setting(at home), intensity(30 minutes per session), frequency(5 sessions per week) and duration(8 weeks).Study assessments were done at baseline (T0) and soon after the end of intervention (T1).The SDMT was the primary endpoint. The secondary outcomes were Brief International Cognitive Assessment for MS (BICAMS), Stroop test, 2 Minute Walk Test (2MWT), Timed Up-and-Go test (TUG), 9-Hole Peg Test (9HPT) and patient-reported

Results

Regarding the primary outcome, both exergames and adaptive COGNI-TRAcK were superior to sham on SDMT after the eight-week intervention (T1).In particular, the Effect Size (ES) by Cohen’s d considering the change between the score at T1 and T0 (T1-T0) was 0.78 and 0.53 respectively in COGNI-TRAcK adaptive and exergames groups,with a p < 0.05 versus sham in both groups.Only the adaptive COGNI-TRAcK was superior to sham intervention on verbal learning and memory (ES= 0.71) and only exergames were superior to sham on executive functions explored with the Stroop test (ES=0.55) with p < 0.05 versus sham.Only the exergames group had significant improvement in both 2MWT (ES=0.54) and TUG (ES=0.71) as compared with the sham intervention(p < 0.05 versus sham).Regarding patient-reported outcomes, we found a beneficial effect only with exergames group that experienced less impact of MS.A significant reduction of the total Modified Fatigue Impact Scale score with an ES=0.55 was found.

Discussion and Conclusion

Exergames can be regarded as a “pay-one-get-two” deal, as they can improve both the motor and cognitive domains, especially attention and executive function. On the other hand, we confirm the beneficial effect of working-memory training on a wide range of cognitive aspects, but we found no effect on motor outcomes or patient-reported outcomes (thereby, there is no far transfer for working-memory training).Moreover, other data analyses are in progress to explore adherence to intervention, the long-term effect of intervention, the safety of exergames with special attention to accidental falls, and several predictors of outcomes including sleep quality, personality trait, cognitive reserve and motor reserve.

REFERENCES

-Stanmore E, Stubbs B, Vancampfort D, de Bruin ED, Firth J. The effect of active video games on cognitive functioning in clinical and non-clinical populations: A meta-analysis of randomized controlled trials. Neurosci Biobehav Rev. 2017 Jul;78:34-43. doi: 10.1016/j.neubiorev.2017.04.011. Epub 2017 Apr 23. PMID: 28442405.

-Prosperini L, Fortuna D, Giannì C, Leonardi L, Marchetti MR, Pozzilli C. Home-based balance training using the Wii balance board: a randomized, crossover pilot study in multiple sclerosis. Neurorehabil Neural Repair. 2013 Jul-Aug;27(6):516-25. doi: 10.1177/1545968313478484. Epub 2013 Mar 11. PMID: 23478168.

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

Psychometric properties of the Fugl-Meyer Assessment (FMA): a systematic review with meta-analysis

Introduction

Stroke is the second cause of death in the world, and the main cause of disability. Using reliable, valid and responsive instrument to assess the sensory and motor function in patients with stroke is crucial in clinical practice and research. Fugl-Meyer Assessment (FMA) is widespread measurement instrument, and it is composed by five domains for Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE), assessing motor activity, sensory response, balance, joint range of motion, and joint pain, for a total of 155 items. Each item is scored by 3-point Likert scale (i..e, 0=unable to perform, 1=performs partially, 2= performs totally) and the maximum score is 226 points. However,  no systematic review is available that summaries evidence on its psychometric properties. Therefore, the aim of this study is to perform a systematic reviews with meta-analysis to assess the psychometric properties (i.e., reliability, validity, responsiveness) of the FMA.

Methods

A literature search was performed in PubMed, EMBASE and CINAHL between the inception to May 2022 with MeSH terms and free words text, according to the COSMIN recommendation. Studies were included if they assessing the psychometric properties of the FMA in patients with stroke. Screening, eligibility, and data extraction processes were performed by two independent reviewers and disagreements were resolved by a third reviewer. Fixed and random effect models were considered for the meta-analysis, and the statistical heterogeneity between the studies was evaluated by I² statistics.

Results

Out of 3193 articles retrieved, 25 met eligibility criteria for systematic review and 23 were included in the meta-analysis (Figure 1). Detailed results of meta-analysis findings are reported in Figure 2 and Figure 3. For intra-rater reliability, the ICC was >0.90, except for some subscales (e.g., FMA joint pain:  ICC=0.79). Also, for inter-rater reliability, the ICC was >0.90 for all scales except one (i.e., FMA-LE Passive joint motion, ICC= 0.87). We found several high values for measurement error ​​for the subscales with few items (e.g. FMA-LE Sensation 0.12 points); on the other hand we found a reasonable measurement for FMA Total Score. For construct validity from weak to strong correlations were found between FMA subscale and different measurement instruments. Few study assessed the responsiveness of two FMA subscales.

Discussion and Conclusion

FMA subscales proved to be reliable and valid; however, the measurement error was high for some subscales. Evidence on FMA subscales responsiveness are limited. FMA subscales can be used to assess the sensory and motor function in patients with stroke in several measurement between the same assessor or with different assessors. However, our findings suggest to use care when using FMA subscales for capture the change of sensory and motor function after a treatment in patients with stroke. Future studies should fill in this gap.

REFERENCES

Fugl-Meyer AR, et al. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7(1):13-31.

Terwee CB, et al. Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Qual Life Res. 2009 Oct;18(8):1115-23.

Terwee CB, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34-42.

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.

Multidisciplinary Approach Based on Frailty Screening in Liver Transplant Candidates at ISMETT: Analysis for Personalized Interventions and Improved Transplant Outcomes

Introduction

Frailty is a debilitating condition in organ transplant candidates. Accurate screening would enhance resource management during the waiting period.

Benefits of screening:

Accurate frailty assessment provides indications for activation of territorial services with preventive measures, such as functional recovery programs and balanced diets.

According to the “National Transplant Center” for 2021 (3), there were 2,679 liver transplant registrations, with 1,388 transplants and 8.7% mortality on the waiting list, with a 15.5% drop-out rate.

Identifying frail patients optimizes resource allocation during the waiting period. The study’s aim was to map the liver transplant candidate population at ISMETT, identifying the most fragile subjects.

Methods

ISMETT is a transplant institute in Palermo. In the 2022 report, 91 liver transplants were performed, including 75 from deceased donors. Transplant activity began in 1998, with cadaveric, living donor, and split liver programs.

For liver transplant candidates, the physiotherapist’s evaluation was introduced into the assessment protocol, complemented by the “Liver Frailty Index” test since April 2021. Patients are stratified into three classes: “frail,” “pre-frail,” and “robust.”

Based on the test, frailty reassessment is scheduled at 1, 3, and 6 months for each class, with specific indications for activities and care settings, including ADI service activation, long-term hospitalization, or self-managed physiotherapy exercises using a brochure provided after patient instruction.

Data were collected in an Excel database, and statistical analysis was performed using means, standard deviations, minimum and maximum values, and stratification by gender

Results

A total of 379 consecutive patients were evaluated, excluding 6 due to inadequate test conditions. Male prevalence: 76.1% (n = 284), mean age: 55.23 years (range: 21-71, SD: 10.36), with no significant gender differences. Frailty assessment: mean 3.74 (range: 1.68-6.74, SD: 0.96), with no significant gender differences.

Distribution of patients by frailty classes: pre-frail (n = 183, 49.1%), frail (18.2%, n = 68), with no gender differences.

Analysis of individual test items: 94.9% passed the single-leg balance test, while 7.8% were unable to perform the tandem position test.

Therapeutic indication: A self-managed recovery exercise program through a brochure with predefined or patient-selected exercises was used for 54.2% of evaluated patients.

18.2% were recommended ADI service activation, with 7 preferably hospitalized if available. 26% received no additional activity indications (robust patients)

Discussion and Conclusion

The conclusions of our study allowed an accurate analysis of frailty in liver transplant candidates at ISMETT. Implementing the physiotherapist evaluation protocol and utilizing the Liver Frailty Index provided valuable insights for personalized interventions and a more detailed understanding of liver transplant recipients’ characteristics

A multidisciplinary approach based on frailty screening proves to be a valuable tool for enhancing management and customization of care for liver transplant candidates, aiming to adopt personalized interventions and improve transplant outcomes. However, the current data are partial and lacking in terms of transplant survival and adherence to therapeutic indications, as well as the actual support of territorial services.

Our study offers a crucial knowledge base, but further research and joint efforts are necessary to ensure optimal and personalized treatment for liver transplant candidates

REFERENCES

Haugen CE, McAdams-DeMarco M, Holscher CM, Ying H, Gurakar AO, Garonzik-Wang J, et al. Multicenter Study of Age, Frailty, and Waitlist Mortality Among Liver Transplant Candidates. Ann Surg. 2020 Jun;271(6):1132–6.

Centro Nazionale Trapianti. Rapporto annuale [ Internet ]. Available from: https://www.trapianti.salute.gov.it/imgs/C_17_cntPubblicazioni_506_allegato.pdf

Kwong AJ, Ebel NH, Kim WR, Lake JR, Smith JM, Schladt DP, et al. OPTN/SRTR 2020 Annual Data Report: Liver. Am J Transplant Off J Am Soc Transplant Am Soc Transpl Surg. 2022 Mar;22 Suppl 2:204–309

Lai JC, Covinsky KE, Dodge JL, Boscardin WJ, Segev DL, Roberts JP, et al. Development of a novel frailty index to predict mortality in patients with end‐stage liver disease. Hepatology. 2017 Aug;66(2):564–74