Balance and visual reliance in post-COVID syndrome patients assessed with a robotic system: a multi-sensory integration deficit.

The symptoms of SARS-CoV-2 infection are not limited to the acute phase, with vertigo, peripheral neuropathies, headache, fatigue, memory loss, and depression being the most common post-acute clinical manifestations. Such post-COVID syndrome is a new clinically relevant challenge for diagnosis and therapy. Our goal was to quantify deficit in balance and proprioception related to post-COVID syndrome and, in this sense, we prospectively analyzed data of 66 post-COVID-19 outpatients (mean age 47.3 ± 11.1 years, 50 females, 25 hospitalized), evaluated using the robotic device hunova. The dynamic balance was assessed with open (OE) and closed eyes (CE) and three indexes, proportional to subject instability, were measured: the sway path and two oscillation ranges. Hospitalized group showed the worst performance with respect to non-hospitalized patients and normality range in both visual conditions for the sway path and the oscillation ranges, with the worst performance being with CE. When compared to normality ranges, post-COVID patients were significantly more distant from normality in the OE condition compared to the CE condition. These results suggest that independently from the severity of the disease experienced, post-COVID syndrome makes the elastic balance test performances more distant from the normality when the subject integrates vision, somatosensory information, and vestibular information. In the absence of visual feedback, patients seem to implement compensatory strategies, presumably seeking more significant feedback from the lower limbs, which improve their performance. These data suggest a new mechanism of the post-COVID syndrome that deserves further investigation for its potential impact on activities of daily living.

20 years of neuromuscular electrical stimulation in COPD.

Although a lung disease, COPD is also associated with extrapulmonary manifestations including, among others, limb muscle dysfunction. Limb muscle dysfunction is a key systemic consequence of COPD that impacts patients' physical activity, exercise tolerance, quality of life and survival. Deconditioning is the main mechanism underlying the development of limb muscle dysfunction in COPD, which can be partially improved with exercise. However, some patients may not be able to tolerate exercise because of incapacitating breathlessness or unwillingness to undertake whole-body exercise. Alternative training modalities that do not give rise to dyspnoea, such as neuromuscular electrical stimulation (NMES), are urged. Over the past 20 years, NMES in COPD has presented conflicting conclusions in meta-analysis. In this review, we try to understand the reason for this result by analysing possible biases and factors that brought conflicting conclusions. We discuss the population (the intervention group, but also the control group), the outcome measures, the frequency of stimulation, the rehabilitation protocol (i.e. NMES alone versus standard care/rehabilitation or NMES plus conventional exercise training versus conventional exercise training alone or NMES versus sham treatment) and the trial design. The main reason for this discrepancy is the lack of dedicated guidelines for NMES. Further research is urged to determine the optimal parameters for an NMES programme. Despite this, NMES appears to be an effective means of enhancing quadriceps strength and exercise capacity in COPD with the potential to break the vicious circle induced by the disease and COPD patients' lifestyle.

Sarcopenia and Multisensory Integration Deficit in Post-COVID Syndrome Patients: The Clinical, Ultrasound and Robotic Evaluation Protocol in a Cross-sectional Study.

INTRODUCTION: Post-COVID syndrome affects relatively young outpatients with fatigue as the mostly reported symptom. We wondered whether sarcopenia could play a role. METHODS: Seventy-four outpatients (median age: 53.8 yrs, 45 females), reporting fatigue and persistent mild neurological/motor deficits, completed the Clinical, Ultrasound and Robotic Evaluation protocol 4.8 mos after the infection. RESULTS: The incidence of sarcopenia was 41%. Sarcopenic patients were older (62.7 vs. 46.4 yrs, P < 0.001), they experienced longer infection (33 vs. 24 days, P = 0.006) and higher incidence of hospitalization (86.6 vs. 29.5%, P < 0.001), they did not report more fatigue (44.5 vs. 48, P = 0.424), but they walked slower (1.27 vs. 1.5 m/sec, P = 0.027).After multivariable adjustment using multiple logistic regression, sarcopenia was dependent on age (odds ratio = 1.09) and on the duration of the disease (odds ratio = 1.04).When expressed as z score, in 79% of patients, the sway path during elastic balance shifted significantly toward negative values with closed eye, indicating multisensory integration deficit. CONCLUSIONS: Post-COVID syndrome in relatively young outpatients complaining mild motor deficit is associated with high incidence of sarcopenia. In addition, they have multisensory integration deficit that further contributes to symptoms. The Clinical, Ultrasound and Robotic Evaluation protocol is able to objectivize symptoms that common diagnostic tool cannot reveal. 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 best diagnostic algorithm for the diagnosis of sarcopenia; (2) Identify and treat two additional factors that help to explain and understand the symptoms reported by relatively young post-COVID syndrome patients; and (3) Extend their diagnostic capability through the use of technology. 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.

From Histoanatomy to Sonography in Myofascial Pain Syndrome: A EURO-MUSCULUS/USPRM Approach.

ABSTRACT: Myofascial pain is a common clinical condition, whereby accurate physical examination is usually considered as the cornerstone to identify/diagnose the "trigger point complex," that is, the characteristic finding of this syndrome. Considering the emerging role of ultrasound examination as the natural extension of physical assessment for musculoskeletal disorders, we briefly revise the histological/anatomical features of trigger points and propose a standardized, multistep sonographic approach to myofascial pain. We also imply that the integrated clinical-ultrasound evaluation could be considered as a potential tool to discriminate different phases/subsets of this challenging pathology.

Musculoskeletal Pain Management and Thermotherapy: An Exploratory Analysis of Italian Physicians' Attitude, Beliefs, and Prescribing Habits.

Purpose: In Italy, musculoskeletal (MSK) disorders are pervasive with one-third of adults seeking medical consultation for a MSK issue in the past year. MSK pain is often treated with local heat applications (LHAs) which can be integrated into MSK care by different specialists and in different settings. Compared to analgesia and physical exercise, LHAs have been less evaluated, and the quality of randomized clinical trials is generally low. The aim of the survey is to assess the knowledge, attitude, perception/practices of general practitioners (GPs), physiatrists and sports medicine doctors towards thermotherapy as delivered by superficial heat pads or wraps. Patients and Methods: The survey was conducted between June and September 2022 in Italy. An online questionnaire with 22 multiple-choice questions was administered to explore the demographics and prescribing habits of the participants; the clinical profile of MSK patients; and physicians' attitude and beliefs about the use of thermotherapy/superficial heat applications in MSK pain management. Results: GPs are at the forefront of the MSK patient journey and preferentially select NSAIDs as first-line option in arthrosis, muscle stiffness, and strain while prescribing heat wraps as preferred choice in presence of muscle spasm/contracture. Similar pattern of prescribing habits was found among specialists who, in contrast to GPs, adopted more frequently ice/cold therapy to relieve pain due to muscle strain and limited paracetamol use. Generally, survey participants agreed on the benefits of thermotherapy in MSK care management, namely increased blood flow and local tissue metabolism as well as connective tissue elasticity and pain relief which all may be of help in attaining pain control and improvement of function. Conclusion: Our findings provided the basis for further investigations aimed at optimizing the MSK patient journey while building up additional evidence supporting the benefit of using superficial heat applications to effectively manage patients with MSK disorders.

Urologic latency time during uroflow stop test with electromyography: an incontinence detector in rehabilitation after robotic radical prostatectomy.

BACKGROUND: Stress urinary incontinence (UI) is the most common presentation following robot-assisted radical prostatectomy (RARP), but a postoperative non-invasive and objective test is still lacking. To assess pelvic floor integrity after RARP, we recently proposed Uroflow Stop Test (UST) with surface electromyography (EMG). AIM: Here we provide two new clinical parameters: the neurologic latency time (NLT) and the urologic latency time (ULT) derived from UST-EMG Test. Principal outcome was to evaluate their variation during one year follow-up and ULT ability to predict post-RARP UI. DESIGN: Observational and longitudinal study. SETTING: Interdivisional Urology Clinic (Perugia-Terni, Italy). POPULATION: Patients with prostate cancer treated with a full nerve-sparing RARP who underwent postoperative pelvic floor muscles training (PFMT): a diurnal functional home program and a weekly hospital program with the use of biofeedback, between 1 and 3 months postoperatively. METHODS: All patients consecutively performed a UST-EMG test at one, three, six, and twelve months after surgery. At each follow-up visit we collected NLT values, ULT values, 5-item 26-Expanded Prostate Cancer Index (EPIC), Incontinence Developed on Incontinence Questionnaire (ICIQ-UI) Short Form and International Prostate Symptom Score (IPSS). We analysed statistically significant differences in NLT and ULT between continent and incontinent patients and we evaluate the diagnostic ability of 1-month post-surgery ULT value to diagnose the presence of postoperative UI. RESULTS: Sixty patients were enrolled. The mean time to PFMT was 31.08 (range: 30-35) days. Overall IPSS, NLT and ULT had similar trends: progressive decrease until the six months after surgery (1-month vs. 3 months vs. 6 months, P<0.05) to plateau thereafter. When considering the two group of patients, IPSS and NLT were significantly higher in the incontinent group only one month after surgery, while ULT became similar between the two groups at 6 months after surgery. The best cut-off of 1-month ULT values that maximized the Youden function at 12-months resulted 3.13 second. CONCLUSIONS: NLT and ULT may respectively account for the nerve and the urethral closure system integrity post-RARP. In the first month after RARP, both NLT and ULT differs between incontinent vs. continent patients. NLT become similar between two group after one month, confirming the recovery from neuropraxia, but ULT remains statistically significant different until 3 months postoperatively. The value of 1-month ULT resulted a valid tool to predict incontinence status at 12 months. CLINICAL REHABILITATION IMPACT: ULT and NLT may be also useful tools to monitor the continence progressive recovery after RARP and they may help rehabilitation specialists to evaluate the ongoing results during postoperative follow-up.

Ultrasound Imaging and Guidance for Cervical Myofascial Pain: A Narrative Review.

Cervical myofascial pain is a very common clinical condition in the daily practice of musculoskeletal physicians. Physical examination is currently the cornerstone for evaluating the cervical muscles and identifying the eventual presence of myofascial trigger points. Herein, the role of ultrasound assessment in precisely localizing them is progressively mounting in the pertinent literature. Moreover, using ultrasound, not only the muscle tissue but also the fascial and neural elements can be accurately located/evaluated. Indeed, several potential pain generators, in addition to paraspinal muscles, can be involved in the clinical scenario of cervical myofascial pain syndrome. In this article, the authors extensively reviewed the sonographic approach for cervical myofascial pain in order to better diagnose or guide different procedures that can be performed in the clinical practice of musculoskeletal physicians.

From histo-anatomy to sonography in lymphedema: EURO-MUSCULUS/USPRM approach.

Lymphedema is a disorder characterized by the accumulation of protein-rich lymphatic fluid in the cutaneous and subcutaneous tissue. Based on the underlying causes, it is classified into primary and secondary forms. The use of ultrasound has recently become widespread in the field of lymphedema - especially for its diagnosis and treatment planning. In this study, we briefly reviewed the anatomy and histology of the skin and subcutaneous tissue - to propose a standardized ultrasound assessment of the superficial tissues in patients with upper-/lower-limb lymphedema. We believe that identification of the sono-histological patterns of the dermo-epidermal complex and subcutaneous tissue has place to serve as a simple and reproducible strategy to evaluate their edema diseases that are often subject to an inaccurate diagnosis in daily clinical practice.

Role of frailty in functional recovery after hip fracture, the variable impact in restoring autonomy.

BACKGROUND: In an old or very older adult, frailty is a common geriatric syndrome resulting from aging-associated decline including loss of autonomy related to multiple pathologies. AIM: The study aims to evaluate the frailty affects on functional and rehabilitative recovery of the elderly patient. DESIGN: This is a retrospective study of subjects over 65 years old who underwent hip surgery following a traumatic femoral fracture. SETTING: Patients admitted to intensive rehabilitation department after hip fracture event. POPULATION: The sudy include records of 350 patients over-65-year-old with hip fracture treated in hospital with surgery. METHODS: Patients enrolled were classified into three groups: youngest-old, ages 65 to 74 years; middle-old, 75 to 84 years; and oldest-old, ≥85 years. Each patient underwent a multidimensional evaluation capable of identifying the deficient domains, defining the presence of frailty, and the different degrees of severity. All patients underwent a project and rehabilitation program according to the literature protocol. RESULTS: The average age of the enrolled patients was 73.2 ± 5.6, 38.6% were over 75 years of age, mostly females (58.9%). The prevalence of frailty increased with age, and cognitive functions were associated with both the frailty measured with the Rockwood and Lacks scales. The recovery of Barthel and Tinetti scores correlates to the level of fragility. CONCLUSION: The approach based on the diagnosis and treatment of the individual disease should be radically changed to a culture and an assessment capacity of elderly persons that take into account the indicators which characterize it as comorbidity, psychological, cultural factors, and environmental health status. Frailty is the sum of these conditions, and it is the most impacting variable in the recovery of autonomy. CLINICAL REHABILITATION IMPACT: The approach based on the diagnosis and treatment of the individual disease should include comorbidity, psychological condition, cultural factors, and environmental health status.

From physical to ultrasound examination in lymphedema: a novel dynamic approach.

In daily practice, medical history and physical examination are commonly coupled with anthropometric measurements for the diagnosis and management of patients with lymphatic diseases. Herein, considering the current progress of ultrasound imaging in accurately assessing the superficial soft tissues of the human body; it is noteworthy that ultrasound examination has the potential to augment the diagnostic process. In this sense/report, briefly revisiting the most common clinical maneuvers described in the pertinent literature, the authors try to match them with possible (static and dynamic) sonographic assessment techniques to exemplify/propose an 'ultrasound-guided' physical examination for different tissues in the evaluation of lymphedema.

Histopathology and high-resolution ultrasound imaging for peripheral nerve (injuries).

BACKGROUND: Neuropathies are commonplace in clinical practice and ultrasound assessment of the peripheral nerves is increasingly becoming a valuable diagnostic tool to support the physical and electrophysiological examinations. In the pertinent literature, several sonographic approaches have been proposed to evaluate the peripheral nerve tissue-mainly based on (semi)-quantitative measures. OBJECTIVE: To define a standardized sonographic approach aiming to evaluate the different sono-histological sections of the peripheral nerve also in a qualitative way. METHODS: Using high-frequency ultrasound probes and high-level ultrasound machines, we matched the histopathological features of the peripheral nerve (in acute and chronic phase) and the different sonographic patterns. Moreover, high-sensitive power Doppler assessments have been performed to assess the microcirculation of the peripheral nerve in physiological and pathological conditions. RESULTS: Modern ultrasound equipment allows a "real-time dissection" of the peripheral nerve evaluating the sonographic patterns of its different histological compartments in physiological and pathological conditions. Moreover, high-sensitive power Doppler allows clear visualization of the microcirculation of the peripheral nerve both in the acute and chronic phases of the neuropathy. CONCLUSION: In clinical practice, using adequate technological equipment, (semi)-quantitative measurements of the peripheral nerve can be coupled with different sonographic patterns of its histological components-both in the acute and chronic phase of the peripheral neuropathy. This way, better/prompt diagnosis and optimal management of the patients would be possible.

Respiratory function assessment at the time of a new respiratory virus pandemic.

We must be aware that new respiratory virus pandemic can happen frequently. Standard lung function tests should keep their crucial role to assist the clinicians in the decision-making process, but they are at risk for the spread of infection because of the generated droplets. We used opto-electronic plethysmography to investigate the post-COVID-19 syndrome on 12 patients after ICU. We found normal ventilatory pattern at rest, a restrictive pattern located in the ribcage during vital capacity and surgical mask to significantly increase minute ventilation. The attention on unconventional respiratory function tests should be sponsored for the important information they can provide.

Mortality and clinical outcomes in patients with COVID-19 pneumonia treated with non-invasive respiratory support: A rapid review.

INTRODUCTION AND AIM: Non-invasive ventilation (NIV) and continuous positive airway pressure (CPAP) have been widely employed to treat acute respiratory failure secondary to COVID-19 pneumonia, but their role in terms of efficacy and safety are still debated. The aim of this review was to analyse mortality and intubation rates in COVID-19 patients treated with NIV/CPAP. METHODS: Rapid review methodology was applied to include all the studies published since December-2019 until November-2020 with available data on in-hospital mortality in COVID-19 patients treated with NIV or CPAP. RESULTS: 23 manuscripts were included (4776 patients, 66% males, 46% with hypertension). 46% of patients received non-invasive respiratory support, of which 48.4% with CPAP, 46% with NIV, and 4% with either CPAP or NIV. Non-invasive respiratory support failed in 47.7% of patients, of which 26.5% were intubated and 40.9% died. In-hospital mortality was higher in patients treated with NIV compared with CPAP (35.1% vs. 22.2%). Complications were under-reported, but mostly not related to CPAP/NIV treatment. CONCLUSION: CPAP and NIV appear equally and frequently applied in patients with COVID-19 pneumonia, but associated with high mortality. Robust evidence is urgently needed to confirm the clinical efficacy of non-invasive respiratory support in COVID-19-related ARDS.