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).

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

Introduction

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

Methods

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

Results

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

Discussion and Conclusion

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

REFERENCES

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

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

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

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

Effect of botulinum toxin injection on clinical and instrumental measures of walking ability in post-stroke patients with equinus foot deviation. A prospective cohort study.

Introduction

Equinus foot deviation (EFD) is the most frequent lower limb acquired deformity in stroke survivors. It affects ankle stability during the stance phase of gait and hinders foot clearance during swing, increasing the risk of falling and reducing both participation and quality of life. EFD may result from several factors, including the presence of triceps surae spasticity. Botulinum toxin (BoNT-A) is the first-line treatment for spasticity and is typically associated with adjuvant treatments, inclusive of physiotherapy, to potentiate its effect [ 1 ]. This study aims to describe the effects of BoNT-A injection alone at the triceps surae of post-stroke patients with EFD on ankle ROM and spasticity, loading and propulsive abilities during gait, and on the patient’s overall walking ability.

Methods

Prospective cohort study. Inclusion criteria: hemiparesis consequent to a first stroke, >1 y from the lesion, age <80 y, ability to walk for at least 10 m without help, Modified Tardieu Scale (MTS) ≥ 1 at the calf muscles, treatment by BoNT-A at the triceps surae with no physiotherapy thereafter. Exclusion criteria: cognitive barriers, orthopaedic pathologies at the lower limbs, ongoing antispastic therapy. Patients were assessed 1 week before and 4-6 weeks after BoNT-A injection. Clinical assessment included: ankle maximum passive dorsiflexion with the knee extended and flexed (pDF_KE, pDF_KF), MTS score and spasticity angle (SA), walking speed, FAC, WHS, and RMI. Dynamic loading ability (DLA) and dynamic propulsive ability (DPA) were computed from ground reaction force (GRF) data [ 2 ]. DLA is the mean value of the vertical component of the GRF. DPA is the mean value of the positive part of the fore-aft component [ 2 ]. The Wilcoxon test was used to compare paired variables.

Results

20 adult patients with chronic stroke and EFD, 4F/16M, age 42 (15) years were included. In baseline, pDF_KE was -4 (7)°, pDF_KF was 4 (8)°, median MTS score was 2 in both conditions (KE, KF), spasticity angle was 9 (5)° at the gastro-soleus complex (KE) and 9 (7)° at the soleus (KF). FAC ranged between 3 and 4, WHS between 3 and 6 and RMI between 5 and 15. On average, pDF_KE and pDF_KF did not vary after treatment (p=0.15, p=0.54). MTS score and SA did not vary at the soleus (p=0.23, p=0.18), while a nearly significant improvement was found at the gastro-soleus complex for both MTS score, reduced by 1 point (p=0.065), and SA, reduced by 3° (p=0.053). Walking speed was 33 (12) %height/s before treatment and 36 (14) %height/s after treatment (p=0.173). DLA minimally increased from 66 (8) to 68 (9) %BW (p=0.053). DPA remained stable at 3 (2) %BW (p=0.68). FAC, WHS, and RMI did not vary (p>0.78). Walking speed improved in 6 subjects, was stable in 11, and worsened in 3 cases.

Discussion and Conclusion

A subset of patients only had an improvement after treatment, while the remaining subjects did not vary or even worsened. This explains the lack of statistical significance in the results. In our study, walking speed increased in only 1/3 of the patients after treatment, with limited or no effect on functional scales. On the one hand, this may depend on the lack of adjunctive physiotherapy following BoNT-A, which is instead recommended. On the other hand, a preliminary assessment of calf muscles by sEMG during walking might have modified the treatment selection, as in [ 3 ]. Finally, GRF-based indices can be a valid compromise to obtain an instrumental evaluation over time of the effects of BoNT-A with extremely low evaluation times and costs. Patient recruitment is ongoing to increase the sample size and the consequent statistical power.

REFERENCES

[ 1 ] Picelli A et al. Ann Phys Rehabil Med 2019;62(4):291-296

[ 2 ] Campanini I et al. Gait Posture 2009;30(2):127-31

[ 3 ] Ferrarin M et al. Eur J Phys Rehabil Med 2015;51(2):171-84

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

Introduction

Methods

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

Results

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

Discussion and Conclusion

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

REFERENCES

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Walking and fatigue in People with Multiple Sclerosis: Gait compensatory strategies to control clearance during the mid-swing phase. A qualitative study.

Introduction

People with Multiple Sclerosis (PwMS) commonly experience falls or near falls, of which one-third seem to be associated with fatigue or tripping. Lately, different studies have inquired about changes in gait parameters related to fatigue, but none have depicted the clinical compensations in the swinging limb that PwMS implement when they get fatigued, to reduce the risk of tripping. The present study tries to describe the strategies that PwMS carry out to control the clearance of the swinging limb when they get fatigued.

Methods

Thirty-two PwMS (EDSS 3.0±1.5) and 8 healthy subjects (HS) were recruited. Kinematic data were collected using a SMART-D motion capture system (BTS, Milano, Italy) with LAMB protocol. Subjects were asked to walk continuously at a steady cadence (spontaneous + 15%) suggested by a metronome. Every minute physical exertion was recorded on the Borg scale (RPE); the test ended as the subject reached a score of 17 (very hard).

We estimated the trend over time for clearance, foot drop, and lower limb length (LL), calculated as the distance between the ipsilateral anterior superior iliac spine and lateral malleolus. For each variable, we derived the slope trends and considered the slope coefficient (k) to describe our findings.

Finite mixture models were used to provide a cluster analysis: a) Univariate model of k clearance; b) Multivariate model of k-LL and k-footdrop, considering the subjects with a negative clearance according to the previous univariate analysis.

Results

PwMS walked less time (13.9±10.22 vs 30.0±1 min) HS reaching an RPE of 17, while HS walked 30 minutes reaching an RPE≤11. The cluster analysis of the k clearance showed 2 different patterns (Figure 1): 1a) showing a minimal clearance variability -0.11(0.03)mm/min (light-blue dots); 1b) a higher clearance variability -0.62(1.1)mm/min (red dots).

The multivariate model (Figure 2), considering subjects in 1b) and with a negative k-clearance, showed 3 different patterns related to k-LL and k-footdrop: the first group (green triangles) had an increased LL over time (k-LL=4.8(0.5)mm/min) and a reduction in the foot drop (k-footdrop=-2.0 (0.5)mm/min). The second group (red squares) showed a minimal variation in both parameters (k-footdrop=0.2(1.0)mm/min, k-LL = 0.3(1.0)mm/min). The third group (blue dots) had an increased k-footdrop (5.6(2.8)mm/min) associated with a reduction in the LL (k-LL=-4.8 (2.8)mm/min).

Discussion and Conclusion

The present findings seem to have the potential to better guide gait rehabilitation. In subjects with a stable clearance, the fatiguability seems associated more to deconditioning and general stability. For subjects who increase clearance (over-compensating), the treatment could be aimed toward more energy-conservative strategies. While, for subjects more at risk of tripping we found three different patterns: a group had a progressive deficit in ankle dorsiflexion partially compensated by a shortening of the limb in flight; another group had a slight change in both; finally, a third group had a deficit related to limb length in flight partially compensated by an increase in ankle dorsiflexion. Thus, rehabilitation intervention could be directed to proximal or, distal muscle function or both, and ankle-orthosis prescription could be suggested to subjects with a real need. Other factors (eg. trunk, pelvis) should be explored in future studies.

REFERENCES

Comber L, Galvin R, Coote S. Gait deficits in people with multiple sclerosis: A systematic review and meta-analysis. Gait Posture. 2017 Jan;51:25-35. doi: 10.1016/j.gaitpost.2016.09.026. Epub 2016 Sep 26. PMID: 27693958.

Broscheid KC, Behrens M, Bilgin-Egner P, Peters A, Dettmers C, Jöbges M, Schega L. Instrumented Assessment of Motor Performance Fatigability During the 6-Min Walk Test in Mildly Affected People With Multiple Sclerosis. Front Neurol. 2022 May 9;13:802516. doi: 10.3389/fneur.2022.802516. PMID: 35614920; PMCID: PMC9125148.

Fritz NE, Eloyan A, Baynes M, Newsome SD, Calabresi PA, Zackowski KM. Distinguishing among multiple sclerosis fallers, near-fallers and non-fallers. Mult Scler Relat Disord. 2018 Jan;19:99-104. doi: 10.1016/j.msard.2017.11.019. Epub 2017 Nov 22. PMID: 29182996; PMCID: PMC5803437.