Cognitive telerehabilitation in neurological patients: systematic review and meta-analysis.

Telerehabilitation (TR) seems to be an encouraging solution for the delivery of cognitive treatments in patients with neurological disorders. This study was aimed to analyze and synthesize the evidence on the efficacy of cognitive TR interventions in patients with neurological diseases, compared with conventional face-to-face rehabilitation. From a total of 4485 records, 9 studies met the inclusion criteria for qualitative analysis. At the end of the process, 7 studies remained for quantitative analysis. By comparing TR with face-to-face treatments for cognitive impairments, we assessed improvements in global cognitive domain (Mini Mental State Exam) (MD = -0.86; 95% CI -2.43, 0.72, I2 = 0%), in learning and memory domains (SMD = 0.26, 95% CI -0.22, 0.74, I2 = 24%), in verbal fluency (SMD = 0.08, 95% CI -0.47, 0.62, I2 = 0%), and in executive functions (i.e., problem-solving, central processing speed and working memory) (SMD = 0.38, 95% CI 0.06, 0.71, I2 = 0%). In all the included studies, improvement in the performance of the TR groups was comparable to that achieved through face-to-face intervention. Significant differences between those two modalities of providing treatments were observed for working memory and total executive function comparison, in favor of TR. The results of this study can sustain the efficacy of TR and its application for the treatment of neurological patients, especially when treated for executive function impairments.

Retrospective study 2005-2015 of all cases of fetal death occurred at ≥23 gestational weeks, in Friuli Venezia Giulia, Italy.

BACKGROUND: Intrauterine fetal death (IUFD) is a tragic event and, despite efforts to reduce rates, its incidence remains difficult to reduce. The objective of the present study was to examine the etiological factors that contribute to the main causes and conditions associated with IUFD, over an 11-year period in a region of North-East Italy (Friuli Venezia Giulia) for which reliable data in available. METHODS: Retrospective analysis of all 278 IUFD cases occurred between 2005 and 2015 in pregnancies with gestational age ≥ 23 weeks. RESULTS: The incidence of IUFD was 2.8‰ live births. Of these, 30% were small for gestational age (SGA), with immigrant women being significantly over-represented. The share of SGA reached 35% in cases in which a maternal of fetal pathological condition was present, and dropped to 28% in the absence of associated pathology. In 78 pregnancies (28%) no pathology was recorded that could justify IUFD. Of all IUFDs, 11% occurred during labor, and 72% occurred at a gestational age above 30 weeks. CONCLUSION: The percentage of IUFD cases for which no possible cause can be identified is quite high. Only the adoption of evidence-based diagnostic protocols, with integrated immunologic, genetic and pathologic examinations, can help reduce this diagnostic gap, contributing to the prevention of future IUFDs.

Relationship Between Observational Wisconsin Gait Scale, Gait Deviation Index, and Gait Variability Index in Individuals Poststroke.

OBJECTIVE: To compare results of the observational Wisconsin Gait Scale (WGS) and global gait indexes such as Gait Deviation Index (GDI) and Gait Variability Index (GVI), constituting an objective method of assessing gait, and taking into account parameters identified during 3-dimensional gait analysis (3DGA). DESIGN: A validation study. SETTING: Rehabilitation clinic. PARTICIPANTS: A total of 50 individuals poststroke and 50 individuals without stroke and without gait disorders (N=100). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Gait was evaluated using the WGS. GDI and GVI values were acquired using a movement analysis system. The global gait indexes GDI and GVI were determined based on the kinematic and spatiotemporal parameters, respectively. RESULTS: The study showed statistically significant correlations between the parameters of GDI affected leg and WGS total score (R=-0.87), GVI affected leg and WGS total score (R=-0.93), GVI unaffected leg and WGS total score (R=-0.88), GVI affected/unaffected leg and the total score in the assessment of spatiotemporal parameters on the WGS (R=-0.81) as well as GDI affected leg and the total score in the assessment of kinematics parameters on the WGS (R=-0.85). All correlations were strong (0.7<|R|<0.9) or very strong (0.9<|R|<1). CONCLUSIONS: WGS scores have a strong or very strong correlation with GDI and GVI. The WGS may be recommended as a substitute tool to be used when 3DGA is unavailable, as it is a useful ordinal scale, enabling simple and accurate observational assessment of gait in patients poststroke, with effectiveness that is comparable to the GDI and GVI.

Virtual Reality for Upper Limb Rehabilitation in Subacute and Chronic Stroke: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the effectiveness of reinforced feedback in virtual environment (RFVE) treatment combined with conventional rehabilitation (CR) in comparison with CR alone, and to study whether changes are related to stroke etiology (ie, ischemic, hemorrhagic). DESIGN: Randomized controlled trial. SETTING: Hospital facility for intensive rehabilitation. PARTICIPANTS: Patients (N=136) within 1 year from onset of a single stroke (ischemic: n=78, hemorrhagic: n=58). INTERVENTIONS: The experimental treatment was based on the combination of RFVE with CR, whereas control treatment was based on the same amount of CR. Both treatments lasted 2 hours daily, 5d/wk, for 4 weeks. MAIN OUTCOME MEASURES: Fugl-Meyer upper extremity scale (F-M UE) (primary outcome), FIM, National Institutes of Health Stroke Scale (NIHSS), and Edmonton Symptom Assessment Scale (ESAS) (secondary outcomes). Kinematic parameters of requested movements included duration (time), mean linear velocity (speed), and number of submovements (peak) (secondary outcomes). RESULTS: Patients were randomized in 2 groups (RFVE with CR: n=68, CR: n=68) and stratified by stroke etiology (ischemic or hemorrhagic). Both groups improved after treatment, but the experimental group had better results than the control group (Mann-Whitney U test) for F-M UE (P<.001), FIM (P<.001), NIHSS (P≤.014), ESAS (P≤.022), time (P<.001), speed (P<.001), and peak (P<.001). Stroke etiology did not have significant effects on patient outcomes. CONCLUSIONS: The RFVE therapy combined with CR treatment promotes better outcomes for upper limb than the same amount of CR, regardless of stroke etiology.

Prediction of Falls in Subjects Suffering From Parkinson Disease, Multiple Sclerosis, and Stroke.

OBJECTIVE: To compare the risk of falls and fall predictors in patients with Parkinson disease (PD), multiple sclerosis (MS), and stroke using the same study design. DESIGN: Multicenter prospective cohort study. SETTING: Institutions for physical therapy and rehabilitation. PARTICIPANTS: Patients (N=299) with PD (n=94), MS (n=111), and stroke (n=94) seen for rehabilitation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Functional scales were applied to investigate balance, disability, daily performance, self-confidence with balance, and social integration. Patients were followed for 6 months. Telephone interviews were organized at 2, 4, and 6 months to record falls and fall-related injuries. Incidence ratios, Kaplan-Meier survival curves, and Cox proportional hazards models were used. RESULTS: Of the 299 patients enrolled, 259 had complete follow-up. One hundred and twenty-two patients (47.1%) fell at least once; 82 (31.7%) were recurrent fallers and 44 (17.0%) suffered injuries; and 16%, 32%, and 40% fell at 2, 4, and 6 months. Risk of falls was associated with disease type (PD, MS, and stroke in decreasing order) and confidence with balance (Activities-specific Balance Confidence [ABC] scale). Recurrent fallers were 7%, 15%, and 24% at 2, 4, and 6 months. The risk of recurrent falls was associated with disease type, high educational level, and ABC score. Injured fallers were 3%, 8%, and 12% at 2, 4, and 6 months. The only predictor of falls with injuries was disease type (PD). CONCLUSIONS: PD, MS, and stroke carry a high risk of falls. Other predictors include perceived balance confidence and high educational level.

Muscle synergy patterns as physiological markers of motor cortical damage.

The experimental findings herein reported are aimed at gaining a perspective on the complex neural events that follow lesions of the motor cortical areas. Cortical damage, whether by trauma or stroke, interferes with the flow of descending signals to the modular interneuronal structures of the spinal cord. These spinal modules subserve normal motor behaviors by activating groups of muscles as individual units (muscle synergies). Damage to the motor cortical areas disrupts the orchestration of the modules, resulting in abnormal movements. To gain insights into this complex process, we recorded myoelectric signals from multiple upper-limb muscles in subjects with cortical lesions. We used a factorization algorithm to identify the muscle synergies. Our factorization analysis revealed, in a quantitative way, three distinct patterns of muscle coordination-including preservation, merging, and fractionation of muscle synergies-that reflect the multiple neural responses that occur after cortical damage. These patterns varied as a function of both the severity of functional impairment and the temporal distance from stroke onset. We think these muscle-synergy patterns can be used as physiological markers of the status of any patient with stroke or trauma, thereby guiding the development of different rehabilitation approaches, as well as future physiological experiments for a further understanding of postinjury mechanisms of motor control and recovery.

ExoBand, A Passive Wearable Device as a Walking Aid in Neuromuscular Patients: First Quantitative Assessment.

Objective: Exoband (by Moveo, Padova, Italy) functions as a walking brace, comprising a belt and two leg loops connected by a mechanism that stores energy during the initial phase of the gait cycle and releases it in the subsequent phase. This enhances hip flexor thrust, leading to functional improvement in walking for individuals with conditions characterized by proximal weakness. It has been approved as a passive wearable device for individuals with impaired walking abilities. Objective of this study was to establish a protocol to assess the use of Exoband in patients with various neuromuscular disorders. Methods: This exploratory retrospective study includes consecutive patients diagnosed with neuromuscular disorders (CIDP, motor polyneuropathy, MND), exhibiting a proximal involvement and gait abnormalities. The evaluation protocol incorporated specific walking-related outcome measures, the 10-meter walk test (10mWT), Time-up-and-go test (TUG), and 2-minute walking test (2MWT). The assessments were conducted both with and without the Exoband under standard conditions. Results: Eight patients (6 males, aged 60-78 years) were tested. An increase in velocity was observed in the 10mWT (median 13.4 sec, IQR 12.0-15.7 vs. 12.2 sec, IQR 11.3-14.2 seconds, p < 0.05) and the TUG (14.0 sec, IQR 13-16.2 vs 13.35 sec, IQR 11-13.8; p < 0.05, by non-parametric Wilcoxon test), and a trend of increase in 2MWT (median 88.2 vs 92.6 m, n.s.). Six out of 8 patients reported subjective benefits from the very first use, including improved walking stability, speed, confidence, and reduced fatigue. Conclusions: Our protocol provides a quantitative assessment of Exoband usefulness for patients affected by neuropathies with gait abnormalities. Further investigations are warranted to assess the long-term effects of its regular Exoband use, its efficacy in specific neuromuscular diseases, and its potential role as a rehabilitation device.

Telerehabilitation for Neurological Motor Impairment: A Systematic Review and Meta-Analysis on Quality of Life, Satisfaction, and Acceptance in Stroke, Multiple Sclerosis, and Parkinson's Disease.

Telerehabilitation (TR) seems to be a viable and feasible solution to face the rehabilitative challenges posed by neurological impairments and to improve patients' quality of life (QoL). This review aims to synthesize and analyze the evidence on the impact of physiotherapy intervention through TR on QoL in patients with stroke, Parkinson's disease (PD), and multiple sclerosis (MS), together with an evaluation of their satisfaction and technology acceptance levels. Through a systematic search of the literature and a screening process, treatment effects were assessed with meta-analyses using the standardized mean difference, setting the confidence interval at 95%. We included 28 studies in the review, which were analyzed for methodological quality, whereas 16 studies were included in the meta-analyses. The results suggest a significant improvement in QoL in patients who underwent TR. We were unable to perform analyses for satisfaction and technology acceptance outcomes due to insufficient data. Overall, motor TR has a positive impact on the QoL of patients with neurological diseases, especially in stroke patients; although caution is needed in the interpretation of the results due to the high heterogeneity found. For PD and MS, TR seems to yield comparable results to in-person treatment.

Neurophysiological, balance and motion evidence in adolescent idiopathic scoliosis: A systematic review.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is a spinal deformity that affects approximately 4% of the world's population. Several hypotheses regarding the etiology of AIS have been investigated. In the last decades, impaired visual-spatial perception, alterations in spatial body orientation and sensory integration deficits have been documented. OBJECTIVE: We aimed to summarize the neurophysiological, balance, and motion evidence related to AIS published in the last fifteen years, between January 2008 and April 2023. Both observational and interventional studies were considered. Only studies using quantitative assessment methods, such as electroencephalography (EEG), electromyography (EMG), magnetic resonance imaging (MRI), somatosensory evoked potentials, force platform, or motion capture, were included. METHODS: 1250 eligible records identified from online database searching were filtered by duplicate removal, title and abstract screening, and qualitative analysis. 61 articles met the inclusion criteria (i.e., Cobb range 10°-35°, age range 10-18 years) and were summarized. RESULTS: We found significant evidence of impaired standing balance in individuals with AIS who greatly rely on visual and proprioceptive information to stay upright. EMG studies frequently reported an increased activity on the convex side of the intrinsic spinae muscles. EEG data show increased delta and theta power, higher alpha peak frequencies, and significant suppression in the alpha and beta bands in subjects with AIS during standing tasks. MRI studies report changes in white matter structures, differences in the vestibular system, and abnormal cortical activations over motor-related areas in subjects with AIS. Bracing appears to be an effective treatment for AIS, leading to improvements in static balance and gait. Methodological issues prevent reliable conclusions about the effects of other treatment options. CONCLUSIONS: This review underscores the importance of quantitative assessment methods to explore the etiology and pathophysiology of AIS. Further research is needed to measure the impact of physical therapy and orthotic treatments on the neurophysiological mechanisms of the disease.

Does a more refined assessment of exposure to bitumen fume and confounders alter risk estimates from a nested case-control study of lung cancer among European asphalt workers?

OBJECTIVE: To investigate whether a refined assessment of exposure to bitumen fume among workers in the European asphalt industry within a nested case-control study resulted in a different interpretation pertaining to risk of lung cancer mortality compared with the cohort study. METHODS: Pearson correlation coefficients between refined and original estimates were calculated. Logistic regression and generalised additive models (penalised splines) were fitted to estimate ORs for exposure to bitumen fume using the refined and original exposure estimates, respectively, while adjusting for potential confounding. RESULTS: 1555 subjects included in the nested case-control study had both refined and original estimates for exposure to bitumen fume. Exposure assessment in the nested case-control study (compared with the cohort phase) increased the number of subjects never-exposed to bitumen fume from 18% to 32%. From the 1282 subjects originally considered exposed in the cohort phase, 309 (24%) became unexposed after the nested case-control exposure assessment. From the 273 subjects originally considered non-exposed in the cohort phase, 87 (32%) became exposed in the nested case-control study. The majority (75%) of subjects however did not change exposure status and changes were similar among cases and controls. Correlation coefficients between refined and original exposure estimates were moderate overall (range 0.42-0.46), but varied considerably among countries. The ORs and exposure-response curves for exposure to bitumen fume were not meaningfully different between analyses that used refined and original exposure estimates. Adjustment for tobacco smoking and exposure to coal tar did not change these patterns. CONCLUSIONS: Our results showed that more detailed data collection and exposure assessment in the nested case-control study compared with the cohort study did change exposure status of many subjects, but did not alter results of the exposure-response analysis. Adjustment for tobacco smoking did not have a noticeable effect on risk estimates either.

Virtual reality for the rehabilitation of the upper limb motor function after stroke: a prospective controlled trial.

BACKGROUND: Recent evidence has demonstrated the efficacy of Virtual Reality (VR) for stroke rehabilitation nonetheless its benefits and limitations in large population of patients have not yet been studied. OBJECTIVES: To evaluate the effectiveness of non-immersive VR treatment for the restoration of the upper limb motor function and its impact on the activities of daily living capacities in post-stroke patients. METHODS: A pragmatic clinical trial was conducted among post-stroke patients admitted to our rehabilitation hospital. We enrolled 376 subjects who had a motor arm subscore on the Italian version of the National Institutes of Health Stroke Scale (It-NIHSS) between 1 and 3 and without severe neuropsychological impairments interfering with recovery. Patients were allocated to two treatments groups, receiving combined VR and upper limb conventional (ULC) therapy or ULC therapy alone. The treatment programs consisted of 2 hours of daily therapy, delivered 5 days per week, for 4 weeks. The outcome measures were the Fugl-Meyer Upper Extremity (F-M UE) and Functional Independence Measure (FIM) scales. RESULTS: Both treatments significantly improved F-M UE and FIM scores, but the improvement obtained with VR rehabilitation was significantly greater than that achieved with ULC therapy alone. The estimated effect size of the minimal difference between groups in F-M UE and FIM scores was 2.5 ± 0.5 (P < 0.001) pts and 3.2 ± 1.2 (P = 0.007) pts, respectively. CONCLUSIONS: VR rehabilitation in post-stroke patients seems more effective than conventional interventions in restoring upper limb motor impairments and motor related functional abilities. TRIAL REGISTRATION: Italian Ministry of Health IRCCS Research Programme 2590412.

Experimental protocol to investigate cortical, muscular and body representation alterations in adolescents with idiopathic scoliosis.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) is the most common form of scoliosis. AIS is a three-dimensional morphological spinal deformity that affects approximately 1-3% of adolescents. Not all factors related to the etiology of AIS have yet been identified. OBJECTIVE: The primary aim of this experimental protocol is to quantitatively investigate alterations in body representation in AIS, and to quantitatively and objectively track the changes in body sensorimotor representation due to treatment. METHODS: Adolescent girls with a confirmed diagnosis of mild (Cobb angle: 10°-20°) or moderate (21°-35°) scoliosis as well as age and sex-matched controls will be recruited. Participants will be asked to perform a 6-min upright standing and two tasks-named target reaching and forearm bisection task. Eventually, subjects will fill in a self-report questionnaire and a computer-based test to assess body image. This evaluation will be repeated after 6 and 12 months of treatment (i.e., partial or full-time brace and physiotherapy corrective postural exercises). RESULTS: We expect that theta brain rhythm in the central brain areas, alpha brain rhythm lateralization and body representation will change over time depending on treatment and scoliosis progression as a compensatory strategy to overcome a sensorimotor dysfunction. We also expect asymmetric activation of the trunk muscle during reaching tasks and decreased postural stability in AIS. CONCLUSIONS: Quantitatively assess the body representation at different time points during AIS treatment may provide new insights on the pathophysiology and etiology of scoliosis.

Stability of muscle synergies for voluntary actions after cortical stroke in humans.

Production of voluntary movements relies critically on the functional integration of several motor cortical areas, such as the primary motor cortex, and the spinal circuitries. Surprisingly, after almost 40 years of research, how the motor cortices specify descending neural signals destined for the downstream interneurons and motoneurons has remained elusive. In light of the many recent experimental demonstrations that the motor system may coordinate muscle activations through a linear combination of muscle synergies, we hypothesize that the motor cortices may function to select and activate fixed muscle synergies specified by the spinal or brainstem networks. To test this hypothesis, we recorded electromyograms (EMGs) from 12-16 upper arm and shoulder muscles from both the unaffected and the stroke-affected arms of stroke patients having moderate-to-severe unilateral ischemic lesions in the frontal motor cortical areas. Analyses of EMGs using a nonnegative matrix factorization algorithm revealed that in seven of eight patients the muscular compositions of the synergies for both the unaffected and the affected arms were strikingly similar to each other despite differences in motor performance between the arms, and differences in cerebral lesion sizes and locations between patients. This robustness of muscle synergies that we observed supports the notion that descending cortical signals represent neuronal drives that select, activate, and flexibly combine muscle synergies specified by networks in the spinal cord and/or brainstem. Our conclusion also suggests an approach to stroke rehabilitation by focusing on those synergies with altered activations after stroke.

Virtual Feedback for Arm Motor Function Rehabilitation after Stroke: A Randomized Controlled Trial.

A single-blind randomized controlled trial was conducted to compare whether the continuous visualization of a virtual teacher, during virtual reality rehabilitation, is more effective than the same treatment provided without a virtual teacher visualization, for the recovery of arm motor function after stroke. Teacher and no-teacher groups received the same amount of virtual reality therapy (i.e., 1 h/d, 5 dd/w, 4 ww) and an additional hour of conventional therapy. In the teacher group, specific feedback ("virtual-teacher") showing the correct kinematic to be emulated by the patient was always displayed online during exercises. In the no-teacher group patients performed the same exercises, without the virtual-teacher assistance. The primary outcome measure was Fugl-Meyer Upper Extremity after treatment. 124 patients were enrolled and randomized, 62 per group. No differences were observed between the groups, but the same number of patients (χ2 = 0.29, p = 0.59) responded to experimental and control interventions in each group. The results confirm that the manipulation of a single instant feedback does not provide clinical advantages over multimodal feedback for arm rehabilitation after stroke, but combining 40 h conventional therapy and virtual reality provides large effect of intervention (i.e., Cohen's d 1.14 and 0.92 for the two groups, respectively).

Effectiveness of robot-assisted arm therapy in stroke rehabilitation: An overview of systematic reviews.

BACKGROUND: Robot-assisted arm therapy (RAT) has been used mainly in stroke rehabilitation in the last 20 years with rising expectations and growing evidence summarized in systematic reviews (SRs). OBJECTIVE: The aim of this study is to provide an overview of SRs about the effectiveness, within the ICF domains, and safety of RAT in the rehabilitation of adult with stroke compared to other treatments. METHODS: The search strategy was conducted using search strings adapted explicitly for each database. A screening base on title and abstract was realized to find all the potentially relevant studies. The methodological quality of the included SRs was assessed using AMSTAR-2. A pre-determined standardized form was used to realize the data extraction. RESULTS: 18 SRs were included in this overview. Generally, positive effects from the RAT were found for motor function and muscle strength, whereas there is no agreement for muscle tone effects. No effect was found for pain, and only a SR reported the positive impact of RAT in daily living activity. CONCLUSION: RAT can be considered a valuable option to increase motor function and muscle strength after stroke. However, the poor quality of most of the included SRs could limit the certainty around the results.

Effects of robotic upper limb treatment after stroke on cognitive patterns: A systematic review.

BACKGROUND: Robotic therapy (RT) has been internationally recognized for the motor rehabilitation of the upper limb. Although it seems that RT can stimulate and promote neuroplasticity, the effectiveness of robotics in restoring cognitive deficits has been considered only in a few recent studies. OBJECTIVE: To verify whether, in the current state of the literature, cognitive measures are used as inclusion or exclusion criteria and/or outcomes measures in robotic upper limb rehabilitation in stroke patients. METHODS: The systematic review was conducted according to PRISMA guidelines. Studies eligible were identified through PubMed/MEDLINE and Web of Science from inception to March 2021. RESULTS: Eighty-one studies were considered in this systematic review. Seventy-three studies have at least a cognitive inclusion or exclusion criteria, while only seven studies assessed cognitive outcomes. CONCLUSION: Despite the high presence of cognitive instruments used for inclusion/exclusion criteria their heterogeneity did not allow the identification of a guideline for the evaluation of patients in different stroke stages. Therefore, although the heterogeneity and the low percentage of studies that included cognitive outcomes, seemed that the latter were positively influenced by RT in post-stroke rehabilitation. Future larger RCTs are needed to outline which cognitive scales are most suitable and their cut-off, as well as what cognitive outcome measures to use in the various stages of post-stroke rehabilitation.

Assessment of dermal exposure to bitumen condensate among road paving and mastic crews with an observational method.

OBJECTIVE: To assess dermal exposure to bitumen condensate among road pavers and indoor mastic workers in multiple crews using a semi-quantitative observational method [DeRmal Exposure Assessment Method (DREAM)]. METHODS: Two skilled observers assessed dermal exposure to bitumen condensate among 85 asphalt workers from 12 crews from nine companies active within four European countries using the DREAM methodology, which produces an estimate of exposure expressed in dimensionless DREAM units. Both observers independently evaluated each crew member's job (N = 14 jobs) for road paving and mastic applications. Potential and actual dermal exposures were estimated for hands and for the rest of the body separately, taking into account the effect of protective clothing. To evaluate the reproducibility of the observational method intra-class correlation coefficients (ICCs) were estimated. The exposures in DREAM units were modelled using linear mixed models to estimate average relative scores for each job. Correlations between dermal exposure parameters were evaluated by estimating Pearson correlation coefficients. RESULTS: A total of 170 observations were completed by two observers independently (n = 118 and n = 52 for 59 road pavers and 26 mastic workers, respectively) in 11 days. The mean ICCs (for potential and actual exposure in DREAM units) varied between 0.74 and 0.80 with values for actual units being slightly higher. Geometric mean potential dermal exposure units of mastic workers were higher than for road pavers (factor 3 for hands and factor 4 for rest of the body). Differences for actual dermal exposure units were smaller for hands (factor 2) and larger for actual exposure units of rest of the body (factor 5). Differences in dermal exposure at the hands between jobs within a paving crew were much larger than between jobs within a mastic crew. Within paving crews, a consistent pattern for all exposure units emerged with 'screed man' and 'raker' as the two highest exposed jobs. Within mastic crews, 'driver dumper truck' and 'spreader of mastic' were scored as the two jobs with the highest exposure units. Potential and actual exposure units were highly correlated. Hands were more profoundly exposed than the rest of the body, with transfer from contaminated surface to the hands as the most important route. CONCLUSIONS: DREAM observations were reproducible and showed a consistent dermal exposure pattern among the observed crews. The study provided a clear picture of dermal exposure among road pavers and indoor mastic workers, with the mastic workers being considerably more highly exposed. The most important route of exposure appeared to be transferred from contaminated surfaces to the hands.

Effects of vibratory stimulation on balance and gait in Parkinson's disease: a systematic review and meta-analysis.

INTRODUCTION: Among the different rehabilitative approaches to Parkinson's disease, there is conflicting evidence about the effects of vibratory stimulation and its capability to modulate the central elaboration of proprioceptive stimuli. The hypothesis is that the vibration-induced sensorial perturbation (through whole body vibration [WBV] or localized vibration) can influence the motor response in complex tasks such as postural control and gait. Thus, the objective of this review was to evaluate the effect of different modalities of vibratory stimulation treatment on balance, gait signs and symptoms, and quality of life, in patients with Parkinson's disease. EVIDENCE ACQUISITION: From the initial 1249 records, 10 of them which compared Whole Body Vibration (WBV) or localized vibration to conventional physiotherapy were included (i.e. randomized controlled trials, crossover trials, and quasi-experimental trials). Finally, five papers on WBV were included in quantitative synthesis (meta-analysis), while for three studies on localized vibrations a qualitative synthesis was performed. Two independent reviewers selected potentially relevant studies based on the inclusion criteria, extracted data, and evaluated the methodological quality. EVIDENCE SYNTHESIS: Meta-analysis was performed among five studies on WBV treatment, whose effect was found to be significantly better than standard treatment for improving gait (measured by Timed Up and Go test and Stand-walk-sit test: standardized mean difference = -0.51; 95% CI=-1.00 to -0.01). Conversely, WBV was not significantly better than standard treatment for all the other outcomes. Due to high heterogeneity it was not possible to conduct a quantitative meta-analysis on studies of localized vibration. CONCLUSIONS: Results of the review show that WBV can improve gait performance in patients with Parkinson's disease.

Telerehabilitation for people with aphasia: A systematic review and meta-analysis.

OBJECTIVES: To evaluate effectiveness or non-inferiority of telerehabilitation for people with aphasia when compared to conventional face-to-face speech and language therapy. MATERIALS AND METHODS: Five electronic databases (PUBMED, EMBASE, WEB OF SCIENCE, SCOPUS and the Cochrane Library) were searched. We extrapolated data from the included studies and evaluated the methodological quality using the Revised Cochrane risk-of-bias tool for Randomized Trials (RoB 2) and the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). A meta-analysis compared effects of intervention, and it was conducted using the Review Manager 5.3 software. GRADE profile to assess overall quality of evidence was carried out. RESULTS: Out of a total of 1157 records, five studies met the inclusion criteria and were eligible for meta-analysis with a total of 132 participants with post-stroke aphasia. DISCUSSION: Results revealed that telerehabilitation and face-to-face speech and language treatment are comparable with respect to the gains achieved in auditory comprehension (SMD = -0.02; 95% CI -0.39, 0.35), naming accuracy (SMD = -0.09; 95% CI -0.44, 0.25), Aphasia Quotient (MD = -2.18; 95% CI -16.00, 11.64), generalization (SMD = 0.77; 95% IC -0.95, 2.49) and functional communication skills (SMD = -0.08; 95% IC -0.54, 0.38). CONCLUSION: Although evidence is still insufficient to guide clinical decision making due to the relatively low quality of the evidence identified, the analysis of the results suggest that telerehabilitation training for aphasia seems to be as effective as the conventional face-to-face treatment.