Systemic Inflammatory Changes in Spinal Cord Injured Patients after Adding Aquatic Therapy to Standard Physiotherapy Treatment.

Spinal cord injury (SCI) is a severe medical condition resulting in substantial physiological and functional consequences for the individual. People with SCI are characterised by a chronic, low-grade systemic inflammatory state, which contributes to further undesirable secondary injuries. This study aimed to evaluate the effect of adding aquatic therapy to the standard physiotherapy treatment, implemented in two different schedules, on systemic inflammation in SCI patients. Additionally, the relationship between cytokine blood levels and changes in functionality (measured with the 6MWT, 10MWT, WISCI, BBS, and TUG tests) throughout the study was assessed. A quantitative multiplexed antibody assay was performed to measure the expression level of 20 pro- and anti-inflammatory cytokines in blood samples from SCI patients at three time points: baseline, week 6, and immediately post-intervention (week 12). This study identified a complex signature of five cytokines (IL-12p70, IL-8, MCP-1, IL-1α, and IP10) associated with the time course of the two physiotherapy programs. Two other cytokines (IL-4 and TNF-α) were also associated with the functional recovery of patients. These could be important indicators for SCI prognosis and provide a basis for developing novel targeted therapies.

Effectiveness of Body Weight-Supported Gait Training on Gait and Balance for Motor-Incomplete Spinal Cord Injuries: A Systematic Review with Meta-Analysis.

OBJECTIVE: This review aims to analyse the effectiveness of body weight-supported gait training for improving gait and balance in patients with motor-incomplete spinal cord injuries. METHOD: Relevant articles were systematically searched in electronic databases to identify randomised controlled trials of body weight-supported gait training (either with methods of robotic, manual, and functional electrical stimulation assistance) versus conventional physical therapy or no intervention. Subjects were >16 years-old with motor-incomplete spinal cord injury (AIS C or D). Primary outcomes were gait-related parameters (functionality, endurance, and speed) and balance. Quality of life was included as a secondary outcome. Articles were selected up to 31 December 2023. RESULTS: Fifteen studies met the inclusion criteria (n = 673). Nine studies used robotic assistance, four trials performed manual assistance, one study functional electrical stimulation assistance, and one trial performed the intervention without guidance. Robot-assisted body weight-supported gait training improved walking functionality (SMD = 1.74, CI 95%: 1.09 to 2.39), walking endurance (MD = 26.59 m, CI 95% = 22.87 to 30.31), and balance (SMD = 0.63, CI 95% = 0.24 to 1.02). CONCLUSIONS: Body weight-supported gait training is not superior to conventional physiotherapy in gait and balance training in patients with motor-incomplete spinal cord injury. However, body weight-supported gait training with robotic assistance does improve walking functionality, walking endurance, and balance, but not walking speed.

Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome: A Systematic Review and Meta-analysis of Randomized Clinical Trials.

OBJECTIVE: The aim of the study is to examine the effectiveness of extracorporeal shockwave therapy in reducing pain, improving functionality, joint range of motion, quality of life, fatigue, and health status self-perception in people with myofascial pain syndrome. METHODS: PubMed, the Cochrane Library, CINAHL, the Physiotherapy Evidence Database, and SPORTDiscus were systematically searched for only randomized clinical trials published up to June 2, 2022. The main outcome variables were pain, as reported on the visual analog scale and pressure pain threshold, and functionality. A quantitative analysis was conducted using the inverse variance method and the random effects model. RESULTS: Twenty-seven studies were included ( N = 595 participants in the extracorporeal shockwave therapy group). The effectiveness of extracorporeal shockwave therapy for relieving pain was superior for the extracorporeal shockwave therapy group compared with the control group on the visual analog scale (MD = -1.7 cm; 95% confidence interval = -2.2 to -1.1) and pressure pain threshold (mean difference = 1.1 kg/cm 2 ; 95% confidence interval = 0.4 to 1.7) and functionality (standardized mean difference = -0.8; 95% confidence interval = -1.6 to -0.04) with high heterogeneity. However, no differences were found between extracorporeal shockwave therapy and other interventions as dry needling, exercises, infiltrations, and lasers interventions. CONCLUSIONS: Extracorporeal shockwave therapy is effective in relieving pain and improving functionality in patients with myofascial pain syndrome compared with control and ultrasound therapy. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Determine the effectiveness of radial and focal extracorporeal shockwaves on pain perception, the pressure pain threshold, and functionality in people with myofascial pain syndrome; (2) Describe the intervention protocol of extracorporeal shockwave therapy to improve pain perception in people with myofascial pain syndrome; and (3) Describe the advantages and disadvantages of extracorporeal shockwave therapy versus other intervention such as dry needling. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity. LEVEL: Advanced. ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Assessing the relevance of mental health factors in fibromyalgia severity: A data-driven case study using explainable AI.

BACKGROUND AND OBJECTIVE: Fibromyalgia is a chronic disease that causes pain and affects patients' quality of life. Current treatments focus on pharmacological therapies for pain reduction. However, patients' psychological well-being is also affected, with depression and pain catastrophizing being common. This research addresses the clinicians' need to assess the influence of mental health factors on FM severity compared to pain factors. METHODS: A co-development study between FM clinicians and data scientists analyzed data from 166 FM-diagnosed patients to assess the influence of mental health factors on FM severity in comparison to pain factors. The study used the Polysymptomatic Distress Scale (PDS) and Fibromyalgia Impact Questionnaire (FIQ) as FM severity indicators and collected 15 variables including regarding demographics, pain intensity perceived, and mental health factors. The team used an author's developed framework to identify the optimal FM severity classifier and explainability by selecting a number of features that lead to obtaining the best classification result. Machine learning classifiers employed in the framework were: decision trees, logistic regression, support vector machines, random forests, AdaBoost, extra trees, and RUSBoost. Explainability analyses were conducted using the following explainable AI techniques: SHapley Additive exPlanations (SHAP), Partial Dependence Plot (PDP), and Mean Decrease Impurity (MDI). RESULTS: A balanced random forest with 6 features achieved the best performance with PDS (AUC_ROC, mean = 0.81, std = 0.07). Being FIQ the target variable, due to the imbalance in FM severity levels, a binary and a multiclass classification approaches were considered achieving the optimal performance, respectively, a logistic regression classifier (AUC_ROC, mean = 0.83, std = 0.08) with 6 selected features, and a random forest (AUC_ROC, mean = 0.91, std = 0.04) with 8 selected features. Next, the explainability analysis determined mental health factors were found to be more relevant than pain perceived factors for FM severity. CONCLUSIONS: This study's findings, validated by clinicians, are potentially aligned with FM international guidelines that promote non-pharmacological interventions such as promoting mental well-being of FM patients.

Effectiveness of transcranial direct current stimulation on balance and gait in patients with multiple sclerosis: systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Motor impairments are very common in neurological diseases such as multiple sclerosis. Noninvasive brain stimulation could influence the motor function of patients. OBJECTIVE: The aim of this meta-analysis was to evaluate the effectiveness of transcranial direct current stimulation (tDCS) on balance and gait ability in patients with multiple sclerosis. Additionally, a secondary aim was to compare the influence of the stimulation location of tDCS on current effectiveness. METHODS: A search was conducted for randomized controlled trials published up to May 2023 comparing the application of tDCS versus a sham or control group. The primary outcome variables were balance and gait ability. RESULTS: Eleven studies were included in the qualitative analysis, and ten were included in the quantitative analysis, which included 230 patients with multiple sclerosis. The average effect of tDCS on gait functionality was superior to that of the control group (SMD = -0.71; 95% CI, -1.05 to -0.37). However, the overall results of the tDCS vs. sham effect on static balance did not show significant differences between groups (MD = 1.26, 95% CI, -1.31 to 3.82). No significant differences were found when different locations of tDCS were compared. CONCLUSIONS: These results reveal that tDCS is an effective treatment for improving gait ability with a low quality of evidence. However, the application of tDCS has no effect on static balance in patients with multiple sclerosis with very low quality of evidence. Similarly, there seems to be no difference regarding the stimulation area with tDCS.

Effectiveness of Different Electrical Stimulation Modalities for Pain and Masticatory Function in Temporomandibular Disorders: A Systematic Review and Meta-Analysis.

Temporomandibular disorders comprise a set of conditions that include alterations of the temporomandibular joint and masticatory muscles. Although different modalities of electric currents are widely used for treating temporomandibular disorders, previous reviews have suggested these are ineffective. This systematic review and meta-analysis aimed to determine the effectiveness of different electrical stimulation modalities in patients with temporomandibular disorders for reducing musculoskeletal pain, increasing the range of movement, and improving muscle activity. An electronic search was conducted of randomized controlled trials published until March of 2022 that compared the application of an electrical stimulation therapy versus a sham or control group. The main outcome measure was pain intensity. Seven studies were included in the qualitative analysis and in the quantitative analysis (n = 184 subjects). The overall effect of electrical stimulation on pain reduction was statistically superior to sham/control (MD = -1.12 cm; CI 95%: -1.5 to -0.8), showing moderate heterogeneity of results (I2 = 57%, P = .04). The overall effect on range of movement of the joint (MD = 0.97 mm; CI 95%: -0.3 to 2.2) and muscle activity (SMD = -2.9; CI 95%: -8.1 to 2.3) were not significant. Transcutaneous electrical nerve stimulation (TENS) and high-voltage current stimulation reduces pain intensity clinically in people with temporomandibular disorders with a moderate quality of evidence. On the other hand, there is no evidence of the effect of different electrical stimulation modalities on range of movement and muscle activity in people with temporomandibular disorders with a moderate and low quality of evidence respectively. PERSPECTIVE: TENS and high voltage currents are valid options for the control of pain intensity in patients suffering from temporomandibular disorder. Data suggest clinically relevant changes compared to sham. Healthcare professionals should take this into account as it is inexpensive therapy, has no adverse effects and can be self-administered by patients.

High-Intensity Laser Therapy for Musculoskeletal Disorders: A Systematic Review and Meta-Analysis of Randomized Clinical Trials.

High-intensity laser therapy (HILT) is one of the therapeutic approaches used in the treatment of musculoskeletal disorders (MSD). The main objective of this study was to examine the effectiveness of HILT for reducing pain and improving functionality in people with MSD. Ten databases were systematically searched for randomized trials published up to 28 February 2022. Randomized clinical trials (RCTs) assessing the effectiveness of HILT on MSD were included. The main outcome measures were pain and functionality. In total, 48 RCTs were included in the qualitative synthesis and 44 RCTs in the quantitative analysis. HILT showed a decrease on the pain VAS (mean difference (MD) = -1.3 cm; confidence interval (CI) 95%: -1.6 to -1.0) and an improvement in functionality (standardized mean difference (SMD) = -1.0; CI95%: -1.4 to -0.7), with low and moderate quality of evidence, respectively. A greater effect was observed when compared with control than with other conservative treatments, both on pain (χ2 = 20.6; p < 0.001) and functionality (χ2 = 5.1; p = 0.02). Differences in the effectiveness of HILT were found depending on the location (χ2 = 40.1 p < 0.001), with further improved functionality in MSD of the knee and shoulder. HILT is an effective treatment for improving pain, functionality, range of motion, and quality of life in people with MSD, although these findings must be treated with caution due to the high risk of bias in the studies. Further clinical trials should be well designed to lower the risk of bias.

Capacitive resistive monopolar radiofrequency at 448 kHz plus exercising versus exercising alone for subacromial pain: A sham-controlled randomized clinical trial.

OBJECTIVE: To investigate the effectiveness of thermal and sub-thermal capacitive-resistive monopolar radiofrequency at 448 kHz plus exercising compared to sham radiofrequency plus exercising on pain, functionality, and quality of life in patients with subacromial pain. DESIGN: Randomized, controlled, parallel, double-blind, three-arm clinical trial. SETTING: Hospital and Primary Care. SUBJECTS: Eighty-one participants with subacromial pain in three intervention groups. INTERVENTIONS: Three interventions with capacitive-resistive radiofrequency (thermal, sub-thermal, and sham) over 9 sessions (3 per week) plus an exercising protocol identical for all groups over 15 sessions (5 per week). OUTCOME MEASURES: Visual analogue scale and pressure pain threshold for pain, Shoulder Pain and Disability Index and Quick-Disabilities of the Arm, Shoulder and Hand for functionality, and quality of life via the European Quality of Life-Five Dimensions were assessed at baseline, immediately posttreatment, and 1 month and 3 months post-intervention. RESULTS: No between-group differences were found in the pain visual analogue scale (F = 1.0; P = 0.37), Shoulder Pain and Disability Index (F = 1.0; P = 0.36), European Quality of Life-Five Dimensions (F = 0.76; P = 0.47), and pressure pain (F = 0.14; P = 0.86) outcomes, with a statistical power < 0.30 for all comparisons. Between-group differences were found in the Quick-Disabilities of the Arm, Shoulder and Hand (F = 3.4; P < 0.038), with an improvement of -14.1 points (confidence interval at 95% (95% CI) -28.1 to -0.1) in the thermal versus the sham group at 1 month follow-up. The mobility dimension of European Quality of Life-Five Dimensions improved in a greater proportion of participants in the thermal group (22.2% thermal, 7.4% sub-thermal, and 0.0% sham; P = 0.02). CONCLUSION: Adding thermal radiofrequency to exercising can further improve slightly functionality and mobility in people with subacromial pain in the short term, but not pain perception. Future studies with larger sample sizes are warranted to increase statistical power.

Effectiveness of Transcranial Direct Current Stimulation Combined With Exercising in People With Fibromyalgia: A Randomized Sham-Controlled Clinical Trial.

OBJECTIVE: To evaluate the effectiveness of transcranial direct current stimulation (tDCS) combined with exercising in people with fibromyalgia. DESIGN: Randomized, triple-blind, sham-controlled, clinical trial. SETTING: Primary health care center. PARTICIPANTS: A total of 120 volunteer participants (N=120) between 18 and 65 years old and diagnosed with fibromyalgia. Four participants dropped out of the study for causes unrelated to the intervention. INTERVENTION: Participants were randomized into 3 groups (active tDCS+exercising, sham tDCS+exercising, no-intervention control). The intervention was delivered in 5 sessions over 2 weeks. MAIN OUTCOME MEASURES: Pain intensity and referred pain area after suprathreshold pressure stimulation. RESULTS: Pain intensity further decreased in the active tDCS group vs control (mean, -14.43; 95% confidence interval, -25.27 to -3.58) at post intervention, unlike the sham tDCS group. Both tDCS groups did not achieve greater reductions in referred pain vs control. In the active tDCS group, health status (mean, -14.80; 95% confidence interval, -23.10 to -6.50) and pain catastrophizing (mean, -6.68, 95% confidence interval, -11.62 to -1.73) improved at post intervention, and so did health status (mean, -8.81; 95% confidence interval, -17.11 to -0.51), pain catastrophizing (mean, -7.00; 95% confidence interval, -12.13 to -1.87), and depression (mean, -3.52; 95% confidence interval, -6.86 to -0.19) after 1 month. In the sham tDCS group, improvements were recorded in health status (mean, -13.21; 95% confidence interval, -21.52 to -4.91) and depression (mean, -3.35; 95% confidence interval, -6.35 to -0.35) at post intervention and in health status (mean, -8.77; 95% confidence interval, -17.06 to -0.47), pain catastrophizing (mean, -5.68; 95% confidence interval, -10.80 to -0.55), and depression (mean, -3.98; 95% confidence interval, -7.31 to -0.64) after 1 month. No intergroup differences were observed between active and sham tDCS. CONCLUSIONS: Active and sham tDCS improved health status, pain catastrophizing, and depression vs control, but pain intensity decreased only in the active tDCS group.

A New Approach to Assess Blinding for Transcranial Direct Current Stimulation Treatment in Patients with Fibromyalgia. A Randomized Clinical Trial.

Correct blinding is essential for preventing potential biases. The aim of this study was to assess the blinding of participants and a therapist following treatment with transcranial direct current stimulation in subjects with fibromyalgia using James' and Bang's blinding indexes. Eighty subjects were randomly allocated either active or sham stimulation groups in an intervention of five sessions lasting 20 min each. A questionnaire was delivered to both the therapist and patients after the last session to record their guess of which treatment had been applied. No differences between the groups were noted at baseline in terms of demographic or clinical data. James' BI was 0.83 (CI 95%: 0.76-0.90) for the patients and 0.55 (CI 95%: 0.45-0.64) for the therapist. Bang's BI for subjects was -0.08 (CI 95%: -0.24-0.09) and -0.8 (CI 95%: -0.26-0.1) for the active and sham transcranial direct current stimulation groups, respectively. Bang's BI for the therapist was 0.21 (CI 95%: -0.02-0.43) and 0.13 (CI 95%: -0.09-0.35) for the active and sham transcranial direct current stimulation groups, respectively. Protocols of active and sham transcranial direct current stimulation applied in this study have shown satisfactory blinding of the therapist and subjects with fibromyalgia.

Pressure-Induced Referred Pain as a Biomarker of Pain Sensitivity in Fibromyalgia.

BACKGROUND: Fibromyalgia (FM) syndrome is characterized by widespread pain, fatigue, and generalized increased pain sensitivity. Appropriate and simple pain models are methods employed to assess pain mechanisms that can potentially lead to improved treatments. Pressure pain thresholds (PPTs) or mapping the referred pain area produced by pressure stimulation at suprathreshold intensities are used to assess pain mechanisms. The optimal suprathreshold stimulation intensity to elicit referred pain with minimal discomfort for patients with FM has yet to be determined. OBJECTIVES: The aim of this study was to compare the area and intensity of pressure-induced referred pain in patients with FM as elicited by systematic increases in PPTs, compared with controls. STUDY DESIGN: Observational, crossed-section study. SETTING: Research laboratory. METHODS: Twenty-six patients with FM and 26 healthy controls, age- and gender-matched, were included. Suprathreshold stimulation was applied to the infraspinatus muscle of the dominant side at 4 different intensities (PPT +20%, +30%, +40%, and +50%), after which referred pain was evaluated by measuring the area of pain in pixels using a digital body chart and its intensity on a Visual Analog Scale. Factors related to anxiety condition, pain catastrophizing, depression, and quality of life were recorded. RESULTS: The referred pain areas were larger in the FM group compared with healthy individuals at 120% (P = 0.024), 130% (P = 0.001), 140% (P = 0.001), and 150% (P = 0.001) PPT, however, within the FM group no differences were found between the intensity of suprathreshold stimulation and the size of the referred pain areas (P = 0.135) or pain intensity (P > 0.05). There was a positive correlation between the size of referred pain areas and pain catastrophizing in the FM group (r = 0.457, P = 0.032). LIMITATIONS: This study presents some limitations, among which is the variability found in the referred pain areas. CONCLUSIONS: These findings show that referred pain induced by applying a suprathreshold pressure of 120% PPT can be a useful biomarker to assess sensitized pain mechanisms in patients suffering from FM. KEY WORDS: Referred pain, pain sensitivity, fibromyalgia, central sensitization, suprathreshold, pressure pain threshold, biomarker, facilitated pain mechanisms.

Posterior tibial nerve stimulation in the treatment of fecal incontinence: a systematic review.

Fecal incontinence severely impacts on quality of life, causing stigmatization and social exclusion. Posterior tibial nerve stimulation (PTNS) is one technique used for treatment. This systematic review aims to assess the effectiveness of PTNS for the treatment of fecal incontinence. A literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration. Pubmed, Scopus, Web of Knowledge and PEDro databases were searched for both randomized clinical trials and cases series. The outcome variables were treatment effectiveness, severity of incontinence and quality of life; all were measured in the short, mid and long-term after performing both percutaneous and transcutaneous PTNS. Twenty-three studies met the selection criteria. Two clinical trials found significant differences in treatment effectiveness compared to the placebo response. Fifteen cases series observed significant differences in terms of effectiveness, severity and quality of life. All clinical trials achieved a reduction in the number of incontinence episodes and an increase in the deferral time for defecation. Optimal results were achieved by interventions consisting of one or two weekly sessions of a 30-60 minutes duration and the use of pulse widths of 200 µs and frequencies of 10-20 Hz. Percutaneous stimulation did not demonstrate better results compared to transcutaneous application. PTNS is an effective technique for the treatment of fecal incontinence, although long-term interventions are required in order to prolong its effects in the long-term.