Qualitative Characteristics of Vulvodynia: A Cross-Sectional Study on Women’s Vulvar Pain Patterns

Introduction

Vulvodynia is a condition characterized by chronic pain in vulvar region, with a significant impact on women’s quality of life. [1] Its etiology remains poorly understood, and diagnosis is often challenging, relying on the exclusion of other specific causes of genital pain (e.g. infectious, neoplastic, neurological, etc.). [2] The identification of vulvodynia based on type of pain and symptomatic characteristics is crucial for appropriate clinical management. Previous studies have primarily focused on quantitative aspects of  pain, but research on its qualitative characteristics is underexplored. This study aims to address this gap by examining the qualitative features of pain experienced by women with diagnosed vulvodynia using a body chart.

Methods

Following the STROBE guidelines , we conducted an observational cross-sectional study to analyze the qualitative pain characteristics in a population of women with a diagnosis of vulvodynia. Between December 2021 and May 2022, 82 women were recruited from patients attending FISIOS Pelvic-Perineal Disorders Rehabilitation Clinic. Among them, 72 participants met the inclusion criteria (according to the 2015 consensus of ISSVD, ISSWSH, and IPPS) [2] and were informed about the study’s nature before providing written informed and privacy consent forms.

Each participant completed a questionnaire to investigate intensity of pain using the Numeric Pain Rating Scale (NPRS) and associated symptoms. A pain drawing scale was utilized to explore the pain’s qualitative aspects.

Results

The study involved 72 women with vulvodynia presenting comorbidities, e.g. endometriosis (Table 1d). Among them, 19% had provoked vulvodynia, 28% had unprovoked, and 53% had mixed type. Among the participants, 61% underwent the Swab Test, a diagnostic procedure for vulvodynia, resulting in 44% positive and 17% negative outcomes (Figure 1). The body chart was valuable in visualizing pain patterns, revealing a prevalence of burning, stabbing, and dull pain rather than the commonly depicted “pins and needles” sensation (Figure 2, Table 1b and 1c). Concerning pain perception, 39% of patients reported pain in the lumbar region (Table 1a), but only 4.2% mentioned pre-existing low back pain before vulvodynia onset. The NPRS score indicated a significant intensity of pain experienced by the participants (M t0 = 8.667, SD t0 = 1.163).

Discussion and Conclusion

The study found a high percentage of non-execution of the SWAB test, possibly due to confusion regarding different execution methods reported in the literature or doubts about its relevance in confirming vulvodynia. [3] The qualitative presentation of pain differs from the common descriptions. Identifying the pain quality helps understand its type (nociceptive, neuropathic, nociplastic), so physical therapists should be aware that distinct pain types require tailored multimodal and patient-centered treatments.  The experience of referred pain in distant areas and the occurrence of comorbidity suggests potential sensitization (Figure 2 and Table 1d). [ 4 ] In conclusion, this study underscores the importance of a comprehensive assessment of vulvodynia, considering both quantitative and qualitative aspects of pain, to enhance diagnosis and management strategies for affected women.

REFERENCES

1. Chalmers KJ, Catley MJ, Evans SF, Moseley GL. Clinical assessment of the impact of pelvic pain on women. Pain. 2017;158(3):498-504. doi:10.1097/J.PAIN.0000000000000789
2. Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. Obstet Gynecol. 2016;127(4):745-751. doi:10.1097/AOG.0000000000001359
3. Vieira-Baptista P, Lima-Silva J, Beires J, Donders G. Women without vulvodynia can have a positive ‘Q-tip test’: a cross sectional study. Journal of Psychosomatic Obstetrics & Gynecology. 2017 Oct 2;38(4):256-9
4. Torres-Cueco R, Nohales-Alfonso F. Vulvodynia—It Is Time to Accept a New Understanding from a Neurobiological Perspective. Int J Environ Res Public Health. 2021;18(12). doi:10.3390/IJERPH18126639

Shock waves modulate corticospinal excitability: a proof of concept for further rehabilitation purposes?

Introduction

Focused extracorporeal shock wave therapy (fESWT) is a physical therapy consisting in the application of a rapid sequence of single acoustic pulses directed to a target area¹. The mechanisms of action has been vastly studied for various musculoskeletal disorders². However, despite this considerable knowledge, the effect of fESWT on the central nervous system is still to be determined³, and the current knowledge comes mainly from studies on spasticity⁴. In this study, we try to elucidate possible neurophysiological mechanisms of fESWT action, both spinal and supra-spinal level, in order to widen the spectrum of its clinical applications.

Methods

In this proof-of-concept clinical study, ten healthy subjects were assessed before (T0), after (T1) and seven days after (T2) a single session of fESWT (1000 impulses to the right tibialis anterior belly muscle). Motor evoked potentials (resting motor threshold – RMT, maximal motor evoked potential and maximal compound muscle action potential ratio – MEP_max/CMAP_max ratio, cortical silent period – cSP, total conduction motor time – TMCT, direct and indirect central motor conduction time – dCMCT and iCMCT) and H-reflex (threshold, amplitude, maximal H reflex and maximal compound muscle action potential ratio – H_max/CMAP_max amplitude ratio, latency) were considered as outcomes. RM-ANOVA with Holm-Bonferroni Post Hoc test was used to assess the effect of the treatment, and Pearson correlation coefficient to evaluate the relationship between the variation of RMT, cSP and Hr threshold.

Results

RMT significantly decreased from T1 (0.53 ± 0.02, mean ± S.E.) to T2 (0.49 ± 0.01, mean ± S.E.) (p < 0.05, Holm-Bonferroni Post Hoc test). H-reflex threshold increase from T0 (10.46 ± 1.64, mean ± S.E.) to T1 (12.61 ± 1.85, mean ± S.E.) (p < 0.05, Holm-Bonferroni Post Hoc test). Analysis disclosed a strong negative correlation between ∆3 cSP (i.e., T2 – T1 recordings) and ∆1 Hr threshold (i.e., T1 – T0 recordings) (r= – 0.66, p< 0.05), and a positive strong relationship between ∆3 cSP and ∆3 Hr threshold (r=0.63, p < 0.05).

Discussion and Conclusion

fESWT modulated the corticospinal tract excitability in healthy volunteers, possibly driving cortical effects as suggested by changes in RMT over time. Overall, from a functional perspective, the excitability of corticospinal pathways seems to have an early inhibition immediately after fESWT with a later facilitation after one week, as suggested by the correlation between Hr and cSP variations among different time intervals. Although preliminary, these results might expand the mechanisms knowledge and clinical use of fESWT.

REFERENCES

1 Choi, M. J. et al. Ultrasonics 110, 106238 (2021)

2 Romeo, P. et al. Med. Princ. Pract. Int. J. Kuwait Univ. Health Sci. Cent. 23, 7–13 (2014)

3 Dymarek, R. et al. Clin. Interv. Aging 15, 9–28 (2020)

4 Yang, E. et al. J. Clin. Med. 10, 4723 (2021)

Agreement among multiple meta-analyses on the effectiveness and safety of virtual reality rehabilitation after stroke: an overview of systematic reviews

Introduction

Worldwide, stroke is the second leading cause of death and a major cause of disability, with over 12 million new strokes reported each year. With advances in health technologies, the range of interventions for stroke survivors is in continuous expansion. Among these, virtual reality (VR) in neurorehabilitation has proved an engaging, interactive, patient-centred, and relatively inexpensive modality to enhance functional recovery. We aim to conduct an overview of systematic reviews exploring the agreement on the effectiveness and the safety of VR technologies for clinical outcomes in stroke survivors to give a comprehensive balance of effects.

Methods

We searched multiple databases up to 17 January 2023 for systematic reviews comparing any kind of VR technology (with or without conventional therapy) versus conventional therapy alone. The primary outcome was upper limb function and activity. The secondary outcomes were gait, mobility and balance, limitation of activities, participation, cognitive and mental function and adverse events. Methodological quality was assessed using the A MeaSurement Tool to Assess systematic Reviews (AMSTAR 2) and the certainty of evidence (CoE) using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. Considering reviews assessing the same clinical questions on the same outcome measurement, we examined concordance and discordance of meta-analyses effects sizes (i.e., effective intervention vs no difference) using a conceptual framework based on the Jadad algorithm.

Results

We included 58 reviews of 345 unique primary studies. Overall, 42 (72.4%) had conducted meta-analysis  Many reviews assessed mixed (e.g., both subacute and chronic) (69%) or chronic onset of stroke (17.2%) and were judged critically low in quality by AMSTAR 2 (77.2%). For the primary outcome, meta-analyses reported discordant findings in the direction of effects. Applying the Jadad algorithm, VR with or without conventional therapy seems to be more effective than conventional therapy alone on upper limb function (Fugl-Meyer Assessment for Upper Extremity [ FMA-UE ]), with low to moderate CoE and possible to definite clinical relevance (Figure 1). For secondary outcomes there was uncertainty about the superiority or no difference between groups due to substantial heterogeneity of measurement scales (Figure 2). A few reviews (n=6) reported the occurrence of mild adverse events.

Discussion and Conclusion

Current evidence suggests that multiple meta-analyses agreed on the superiority of VR combined or not with conventional therapy over conventional therapy on FME-UE. These findings support the hypothesis that VR may help to improve the recovery of upper limb motor function and quality of movement. As a safe intervention, clinicians should consider embed VR technologies into their practice and adapt them according to patients’ needs and preferences. Caution in the interpretation of findings is warranted given the poor methodological quality of the reviews.

REFERENCES

Collaborators, G. B. D. Stroke. “Global, Regional, and National Burden of Stroke and Its Risk Factors, 1990-2019: A Systematic Analysis for the Global Burden of Disease Study 2019.” Lancet Neurol 20, no. 10 (Oct 2021): 795-820.

Imbimbo, I., D. Coraci, C. Santilli, C. Loreti, G. Piccinini, D. Ricciardi, L. Castelli, et al. “Parkinson’s Disease and Virtual Reality Rehabilitation: Cognitive Reserve Influences the Walking and Balance Outcome.” Neurol Sci 42, no. 11 (Nov 2021): 4615-21.

Jadad, A. R., D. J. Cook, and G. P. Browman. “A Guide to Interpreting Discordant Systematic Reviews.” [In eng]. Cmaj 156, no. 10 (May 15 1997): 1411-6.

Prevention and risk factor assessment of secondary oncologic lymphedema

Introduction

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

Methods

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

Results

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

Discussion and Conclusion

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

REFERENCES

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

 

COGNITIVE-MOTOR INTERFERENCE DURING DUAL-TASK IN PATIENTS WITH PARKINSON’S DISEASE

Introduction

Most activities of daily living involve performing several tasks at once: for example, walking while talking or carrying an object requires attention to be divided between competing tasks^1,2.

Patients with Parkinson’s Disease (PD) are characterised by loss of automaticity of gait, along with deficits of executive functions and attention; thus, performing concomitant tasks (i.e., dual-task, DT) may cause Cognitive-Motor Interference (CMI).

According to Plummer³, Dual-Task Effect (DTE) is the percentage of change in performance of a task during dual-task, with negative values reporting a decrease in performance under DT conditions and positive values reporting an improvement.

Interference exerted by cognitive tasks on motor performance received attention in the literature, but little is known about motor over cognitive interference.

The current study investigates the prioritisation strategy during cognitive-motor DT in PD through the theoretical framework proposed by Plummer³.

Methods

A cross-sectional analysis of 12 participants (7 women) with mild PD (modified Hoehn and Yahr stages <3.0) was performed. Anamnestic and clinical information was collected. All participants underwent the 3-meter Timed Up and Go test (TUG) and a serial number subtraction cognitive task. Both tasks were performed in single-task and dual-task conditions. Total TUG Duration (TTD, s) and the number of correct subtractions made during the countdown were recorded. The corresponding results were compared between conditions. For the TTD, the Minimal Detectable Change (MDC) in a single subject (a 15% change) was available. Arbitrarily, the same MDC was assumed for the cognitive task.

The cognitive and motor DTE were calculated for each task and then cross-plotted on a Performance Operating Characteristic (POC) type diagram² (Figure 1).

Results

4 patients worsened their cognitive DTE beyond MDC (range -22% to -46%); 4 patients worsened their motor DTE (rage -18% to -53%); 2 patients worsened in both their cognitive (range -17% to -27%) and motor (range -23% to -24%) tasks; in 1 patient the motor DTE worsened (-21%) while the cognitive DTE improved (+67%); in 1 patient the cognitive DTE only, improved (+20%).

Discussion and Conclusion

At least 4 different sub-samples emerge from the POC analysis of the DTE: i) subjects who prioritise the motor task at the expenses of the cognitive one; ii) subjects who worsen in their motor performance with no change in cognitive performance; iii) subjects who improved in their cognitive task as if it was facilitated by the motor one; iv) subjects improving in both cognitive and motor DTE.

While it is recognized that DT exercise may be beneficial in PD⁴, better understanding of the individual mechanisms underlying motor and cognitive performance in DT may lead to the development of more specific treatment approaches in PD.

REFERENCES

1. McIsaac TL, Fritz NE, Quinn L, Muratori LM. Cognitive-Motor Interference in Neurodegenerative Disease: A Narrative Review and Implications for Clinical Management. Front Psychol. 2018;9.
2. Kelly VE, Janke AA, Shumway-Cook A. Effects of instructed focus and task difficulty on concurrent walking and cognitive task performance in healthy young adults. Exp Brain Res. 2010;207:65–73.
3. Plummer P, Eskes G. Measuring treatment effects on dual-task performance: A framework for research and clinical practice. Front Hum Neurosci. 2015;9.
4. Xiao Y, Yang T, Shang H. The Impact of Motor-Cognitive Dual-Task Training on Physical and Cognitive Functions in Parkinson’s Disease. Brain Sci . 2023;13:437.

Patient-Reported Outcome Measures to implement routine assessment of cancer survivors’ unmet needs: an overview of reviews and COSMIN analysis

Introduction

The number of cancer survivors (CSs) is increasing worldwide and is expected to reach 75 million by 2030 thanks to advances in treatments, screening techniques, and the ageing of the population.

Cancer care has traditionally focussed on diagnosis and life-saving treatments. However, research has shown that focusing on helping CSs cope with life beyond their acute treatment, i.e. cancer survivorship care, is just as important.

CSs experience a range of physical, psychosocial, spiritual, informational, and practical issues that may result in unmet needs, which are often neither identified nor addressed. Providing services relevant to their specific, unmet needs is crucial.

Patient-reported outcome measures (PROMs) are standardized, validated tools that give value to the information that comes from patients. There are currently various PROMs whose aim is to identify the unmet needs of CSs. Still, limited guidance supports choosing the most appropriate ones for this purpose.

Methods

An Overview of Reviews was conducted to analyse systematic reviews (SRs) focusing on the psychometric properties of PROMs created to identify the unmet needs of adult CSs suffering from non-cutaneous cancer with a 5-year survival of ≥ 65% and an incidence of ≥ 5%.

A literature search was performed on the MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and CINAHL databases to identify SRs published between 2012 and January 2023.

The quality assessment of the included SRs was conducted by two independent reviewers using the AMSTAR-2 checklist and that of the primary studies using the COSMIN Risk of Bias checklist; the psychometric properties of all identified PROMs were evaluated according to the COSMIN updated quality criteria for good measurement properties.

These findings were then summarised, and their quality graded by means of the modified GRADE approach for grading the quality of the evidence in SRs of PROMs.

Results

Two SRs, one of “moderate” and one of “low” quality according to the AMSTAR-2, were included. They covered 14 PROMs targeting our population of interest, described in 19 different articles, and tested on 19151 patients.

The methodological quality used to develop all the PROMs was rated as “inadequate”, primarily for not calculating measurement error (93% of the PROMs), since COSMIN Risk of Bias score applies the ‘worst score count’ rule.

Primary studies were inconsistent in reporting the psychometric properties of PROMs. However, those that did were judged positively, resulting “insufficient” in only 3% of the cases.

According to the GRADE approach, the level of evidence ranged from “very low” to “low”, with better grading for the Cancer Rehabilitation Evaluation System, followed by its short form (CARES-SF), and the Needs Evaluation Questionnaire.

Discussion and Conclusion

To exhaustively clarify the quality of psychometric properties of these PROMs, further studies are needed to investigate their incomplete aspects. However, the use of these PROMs in clinical practice and research is supported for those psychometric properties for which we have reliable reporting.

However, we recognize that the selection of the most appropriate PROMs to assess a domain of interest should be informed by the psychometric properties but should go beyond statistics, considering above all the context in which they will be applied.

Context refers not only to the pathology stage and environmental factors, but also to the geographical location, age, language, educational and socioeconomic level, and cultural background of the target population. The present descriptions of the contexts in which these tools have been developed and validated provides additional support in selecting specific PROMs based on content comparison.

REFERENCES

Rimmer B, Crowe L, Todd A, Sharp L. Assessing unmet needs in advanced cancer patients: a systematic review of the development, content, and quality of available instruments. J Cancer Surviv. 2021.

Tian L, Cao X, Feng X. Evaluation of psychometric properties of needs assessment tools in cancer patients: A systematic literature review. PLoS ONE. 2019;14.

Prinsen CAC, Mokkink LB, Bouter LM, Alonso J, Patrick DL, de Vet HCW, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Quality of life research. 2018;27:1147-57.

Cieza A, Fayed N, Bickenbach J, Prodinger B. Refinements of the ICF Linking Rules to strengthen their potential for establishing comparability of health information. Disabil Rehabil. 2019;41:574-83.

Di Maio M, Basch E, Denis F, Fallowfield LJ, Ganz PA, Howell D, et al. The role of patient-reported outcome measures in the continuum of cancer clinical care: ESMO Clinical Practice Guideline. Ann Oncol. 2022;33:878-92.

Comparative assessment of dynamic motor abilities in patients with neurological disorders during straight, curved and blindfolded paths: an instrumented approach

Introduction

Neurological disorders such as stroke, Parkinson’s disease (PD), and traumatic brain injury (TBI) are often associated with balance and gait disorders that lead to an increased risk of falling [ 1-3 ]. In the last decades, wearable sensor-based technologies have been used, to objectively quantify different gait domains (i.e., stability, symmetry, and smoothness) [ 4-8 ]. Several studies reported the usefulness of the sensors-based in characterizing dynamic motor abilities impairments in patients with neurological disorders.  [ 9 ]. Therefore, this study aims to quantify dynamic stability through straight, curved, and blindfolded paths of people particularly exposed to the risk of falling to support the implementation of personalized rehabilitation training and the evaluation of the effectiveness of neurorehabilitation treatments.

Methods

Sixty patients with neurological disorders (20 people with TBI (PwTBI) (7 F; 37.1±14.42; y); 20 stroke survivors (PwS) (6 F; 59.55±12.86 y) in sub-acute phase, 20 patients with PD (PwPD) (8 F; 69.15±7.55 y) and 20 healthy participants (9F; 37.35±13.94 y) were involved in the study. Gait and balance evaluations were performed with both clinical and IMU-based assessments. Participants were equipped with five synchronized inertial measurement units All participants were asked to perform three different motor tasks in a randomized order: the 10-Meter-Walk Test (10MWT) (Figure 3-a), the Figure-of-8-Walk Test (Fo8WT) (Figure 3-b), and the Fukuda-Stepping Test (FST) (Figure 3-c). A set of spatiotemporal and gait quality parameters describing stability, symmetry, and smoothness of gait were computed in all directions.

Results

The IMU-based assessment revealed significant differences during linear, curved, and blindfolded walking among PwTBI, PwPD and PwS as well as in the comparison between the control group. Focusing on the former, PwS showed significantly less symmetry and less smoothness (p < 0.017) than both groups PwTBI and PwPD during all dynamic tasks. 

Moreover, significant results emerged for the stability domain (p < 0.017) where accelerations were higher in PwS than in PwTBI and PwPD, highlighting the fact that stroke patients suffer of reduced stability. Interestingly, significant differences emerge between PwTBI and PwPD, where PwTBI demonstrates lower stride frequency and higher nRMS (AP)  during the execution of the straight walk task. In addition, from the results it is possible to see significantly lower LDLJv (AP) values (p < 0.017) of PwTBI compared to PwPD, highlighting a less smooth path in both the straight and curvilinear tasks.

Discussion and Conclusion

The use of IMU-based assessments allowed for objective and quantitative measurements of gait symmetry, postural stability, and smoothness during straight, curved, and blindfolded walking tasks. PwS shows the least symmetry and smoothness during all dynamic tasks compared to PwTBI and PwPD, probably due to the typical hemiparetic asymmetrical gait. Furthermore, these gait impairments could support also the instability significantly higher in PwS compared to the other two groups. Our results can inform the development of personalized rehabilitation programs and interventions to improve the dynamic postural stability and gait characteristics of patients with neurological disorders. Further research and clinical implementation of such assessments could lead to better outcomes and enhanced quality of life for individuals affected by these conditions.

REFERENCES

1. Silva-Batista C 2017 Resistance Training Improves Sleep Quality in Subjects With Moderate Parkinson’s Disease
2. Cattaneo 2019 Educational and Exercise Intervention to Prevent Falls and Improve Participation in Subjects With Neurological Conditions: The NEUROFALL Randomized Controlled Trial
3. Dever A 2022 Gait Impairment in Traumatic Brain Injury: A Systematic Review
4. Mazzà C2008. Control of the upper body accelerations in young and elderly women during level walking
5. Pasciuto I Overcoming the limitations of the Harmonic Ratio for the reliable assessment of gait symmetry
6. Kavanagh JJ 2008 Accelerometry: A technique for quantifying movement patterns during walking
7. Balasubramanian S2015. On the analysis of movement smoothness
8. Melendez-Calderon A 2021. Estimating Movement Smoothness From Inertial Measurement Units
9. Hendriks, M.M.S Using Sensor Technology to Measure Gait Capacity and Gait Performance in Rehabilitation Inpatients with Neurological Disorders

Efficacy of telemedicine for musculoskeletal disorders: an umbrella review

Introduction

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

Methods

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

Results

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

Discussion and Conclusion

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

REFERENCES

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

 

EFFECTS OF MANUAL SUBOCCIPITAL MUSCLES “RELEASE” ON PAIN AND DISABILITY IN ADULTS WITH TENSIVE/CERVICOGENIC HEADACHE OR NECK PAIN: SYSTEMATIC LITERATURE REVIEW AND META-ANALYSIS

Introduction

The Suboccipital Muscle Inhibition Technique (MSIT) induces muscle relaxation in the area between occiput and cervical spine. The technique applies a pressure on suboccipital area while the patient lies supine. Suboccipital muscles are involved in the control of posture and head movements[ 1 ]. Several studies proposed the use of this technique to treat pain caused by tension-type/cervicogenic headaches and neck pain[ 2 ]. The clinical effects are thought to be mediated by the autonomic nervous system. Indeed, MSIT seems to release neurotransmitters with both psycho-emotional and general well-being effects[ 3 ]. This systematic review and meta-analysis aims to investigate the effectiveness of MSIT on pain and disability in adults with tensive/cervicogenic headaches or neck pain.

Methods

The review was conducted following the PRISMA statement 2020. Adults with head-neck dysfunction (tension-type/cervicogenic headaches and neck pain) were included. The MSIT had to be performed as follows: subject supine, therapist with hands placed below the patient’s head to create pressure at the level of the suboccipital muscles. Secondary research was excluded. A search was conducted in the PubMed, Scopus, Epistemonikos, PEDro, and Web of Science databases. Two blinded reviewers checked the studies for adherence to inclusion and exclusion criteria. A third reviewer addressed any conflict. The outcomes related to pain and disability were extracted. Table ROB-2, was used to assess risk of bias. The meta-analysis was conducted following standard guidelines using the R statistical environment and the meta and metasens packages.

Results

From a total of 3844 records, 13 randomized controlled clinical trials (RCTs) involving 745 subjects were included. MSIT was applied with varying frequency and duration: from 1 to 5 times weekly, for 1 to 8 weeks with sessions lasting from 4 to 20 minutes. Specifically, 8 out of 13 RCTs proposed 1/2 sessions per week for 4 weeks of treatment while 10 out of 13 RCTs applied MSIT lasting 5/10 minutes. In addition, 8 out of 13 RCTs investigated the effects of MSIT I addition to exercises or cervical manipulation. Most of the studies showed significant effect of MSIT on pain and disability (reduction in headache frequency and intensity). These improvements increased when MSIT was associated with other treatment. The studies showed overall uncertain risk of bias. The meta-analysis involved 9 RCTs, showing moderate significance (P=0.04, RR=0.59, 95% CI 0.53-0.67; substantial heterogeneity I2=51%) in favor of using the treatment over control groups on pain.

Discussion and Conclusion

The results suggest that MSIT can reduce pain and disability in subjects with head-neck dysfunction. However, the study has some limitations including the lack of uniformity of measurement scales used in the studies to assess different outcomes such as pain and disability. Future studies with long-term follow-up are needed to identify the optimal effects of manual therapy approaches in terms of number of sessions, duration of treatment and interaction with other interventions. The application of this technique in combination with other manipulative techniques and cervical exercise is recommended.

REFERENCES

1. Cho SH, Kim SH, Park DJ. The comparison of the immediate effects of application of the suboccipital muscle inhibition and self-myofascial release techniques in the suboccipital region on short hamstring. J Phys Ther Sci, 2015 Jan;27(1):195-7.
2. Kuchera ML. Applying osteopathic principles to formulate treatment for patients with chronic pain. J Am Osteopath Assoc 2007;107(10 Suppl 6):Es28–38.
3. Santos G.J.B., Severiano M.I.R. A importância do toque terapêutico. FIEP Bulletin, 2011, 81: 1-7.

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

Introduction

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

Methods

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

Results

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

Discussion and Conclusion

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

REFERENCES

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

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

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

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