Multimodal exercises integrated with cognitive-behavioural therapy improve disability of patients with failed back surgery syndrome: a randomized controlled trial with one-year follow-up.

PURPOSE: To evaluate the effect of multimodal exercises integrated with cognitive-behavioural therapy on disability, pain, and quality of life in patients suffering from failed back surgery syndrome (FBSS), and to appraise its extent in the long term. METHODS: By means of a parallel-group superiority-controlled trial, 150 outpatients were randomly assigned to a 10-week individual-based multimodal programme of task-oriented exercises integrated with cognitive-behavioural therapy (experimental group, 75 patients) or individual-based general physiotherapy (control group, 75 patients). Before treatment, 10 weeks later (post-treatment), and 12 months after the end of treatment, the Oswestry Disability Index (primary outcome), the Tampa Scale for Kinesiophobia, the Pain Catastrophising Scale, a pain intensity numerical rating scale and the Short-Form Health Survey were evaluated. Linear mixed model analysis for repeated measures was carried out for each outcome measure. RESULTS: Significant group (p < 0.001), time (p < 0.001), and time-by-group interaction (p < 0.001) effects were found for all outcome measures. Concerning disability, between-group differences (95% confidential interval) in favour of the experimental group of -9 (-10.7; -7.3) after training and of -13.2 (-14.7; -11.7) at follow-up were found. Also, kinesiophobia, catastrophising and pain showed significant between-group differences of 9, 12.5 and 1.7 points, respectively. CONCLUSION: The multimodal intervention proposed was superior to general physiotherapy in reducing disability, kinesiophobia, catastrophising, and enhancing the quality of life of patients with FBSS. The effects were reinforced one year after the programme ended.IMPLICATIONS FOR REHABILITATIONMultimodal exercises integrated with cognitive-behavioural therapy induced significant improvements in disability, pain, kinesiophobia, catastrophising, and quality of life of subjects with Failed Back Surgery Syndrome.A well-integrated rehabilitative team which contributes towards reaching intervention goals is advised.Physiotherapists should adopt task-oriented exercises to promote an earlier return to common activities of disabled patients.Psychologists should explain how to modify useless beliefs and support adequate behaviours, in order to produce constructive attitudes towards perceived disability.

Reshaping cortical connectivity in traumatic spinal cord injury: a novel effect of hyperbaric oxygen therapy.

INTRODUCTION: Spinal cord injuries (SCIs) represent a severe neuro-traumatic occurrence and an excruciating social burden. Though the hyperbaric oxygen (HBO2) has been credited as a first line therapeutic resource for SCIs, its mechanism of action in the spine is only partially known, while the impingement upon other areas of the nervous system deserves additional investigation. In this study we deem to describe a novel effect of HBO2 in a subject affected by SCI who, along with the clinical improvement, showed a reshaped connectivity in cortical sensory-motor areas. CASE PRESENTATION: A 45 years male presenting severe sensory-motor symptoms following a spinal lesion partially involving the C1 segment was successfully treated with HBO2 cycles. After the dramatic improvement reflected by an excellent optimization of the single performances, it has been investigated whether this result would reveal not only an intrinsic effect upon the spinal cord, but also a better connectivity strength in sensory-motor cortical regions. The results obtained by implementing EEG recordings with EEGLAB auto regressive vector plugins indeed suggest a substantial reshaping of cortico-cortical connectivity after HBO2. DISCUSSION: These results show a correlation between positive clinical evolution and a new modulation of cortical connectivity. Though further clinical investigations would clarify as to whether HBO2 might be directly or epiphenomenally involved in this aspect of the network architecture, our report suggests that a comparison between clinical results and the study of brain connectivity represent a holistic approach in investigating the physiopathology of SCIs and in monitoring the treatment.

The effectiveness of biofeedback for improving pain, disability and work ability in adults with neck pain: A systematic review and meta-analysis.

BACKGROUND: Biofeedback is used to optimise muscle activation patterns in people with neck pain. OBJECTIVES: To evaluate the safety and efficacy of electromyographic and pressure biofeedback on pain, disability and work ability in adults with neck pain. DESIGN: Systematic review and meta-analysis. METHODS: We searched key databases and trial registries to September 2020, using terms synonymous with 'neck pain' and 'biofeedback'. We included randomised controlled trials (RCTs) evaluating biofeedback (against any comparison) for adults with neck pain. Outcomes included pain, disability, work ability and adverse events. Two authors independently selected the studies, extracted data, and evaluated risk of bias. GRADE was applied to each meta-analysis. Data were pooled using random-effects models to determine the standardised mean change (SMC). RESULTS: We included 15 RCTs (n = 990). Moderate-quality evidence suggests biofeedback has a moderate effect on reducing short-term disability (SMC = -0.42, 95%CI: 0.59 to -0.26, nine trials, n = 627), and a small effect on reducing intermediate-term disability (SMC = -0.30, 95%CI: 0.53 to -0.06, five trials, n = 458). Biofeedback had no effect on pain or work ability in the short- and intermediate-term (low-to moderate-quality evidence). One study reported headaches in 6.7% of participants, but headache frequency was not reported by group. LIMITATIONS: There were a variety of control interventions across studies. Few studies compared biofeedback with no treatment or placebo. CONCLUSION: Biofeedback appears to have a small-to-moderate effect on reducing neck pain disability in the short- and intermediate-term, but no effect on pain or work ability. More trials reporting adverse events and comparing biofeedback to placebo are needed.

A multimodal training with visual biofeedback in subacute stroke survivors: a randomized controlled trial.

BACKGROUND: Early interventions maximizing patient's involvement are essential to promote gait restoration and motor recovery after stroke. AIM: The aim of this study is to evaluate the effects of a multimodal biofeedback training involving cycling augmented by functional electrical stimulation (FES) and balance exercises on walking ability and motor recovery. DESIGN: Randomized controlled trial (NCT02439515). SETTING: Inpatient rehabilitation facility. POPULATION: Subacute stroke survivors (less than 6 months from the first event) aged up to 90 years old. METHODS: Sixty-eight participants were randomly allocated to an experimental group, performing 15 sessions of biofeedback FES-cycling training followed by 15 sessions of biofeedback balance training (20 minutes each) in addition to usual care (70 minutes), and a control group performing 30 sessions (90 minutes) of usual care. Participants were evaluated before training, after 15 sessions, after 30 sessions, and at 6-month follow-up through: gait speed (primary outcome), spatiotemporal gait parameters, Six-Minute Walking Test, Functional Independence Measure, Motricity Index, Trunk Control Test, Berg Balance Scale, and Fall Efficacy Scale. RESULTS: Both groups significantly improved over time, but no group and interaction effects were found for any outcomes. The 73% of the experimental group achieved a clinically meaningful change in gait speed compared to the 38% of the control group (P=0.048). These percentages were even more unbalanced for patients with a moderate to severe gait impairment at baseline (91% versus 36%; P=0.008). CONCLUSIONS: The multimodal biofeedback training was not statistically superior to usual care, showing only a positive trend in favor of the experimental group on locomotion recovery. Patients initially not able to walk might be the best candidates for such a training. CLINICAL REHABILITATION IMPACT: The multimodal biofeedback training is a task-specific, repetitive and intensive training requiring a minimal supervision, which might result in a lower staff to patient ratio if organized in group sessions. Therefore, it can represent a good alternative for early stroke rehabilitation.

How many physical therapy sessions are required to reach a good outcome in symptomatic lumbar spondylolisthesis? A retrospective study.

BACKGROUND: There is a lack of conclusive information about the optimal dosage of physical therapy treatments in Spondylolisthesis (SPL) patients. PURPOSE: The present study attempted to evaluate the comparative effectiveness of two different doses in reaching similar clinical outcomes. METHODS: A retrospective cohort study of 64 consecutive patients admitted for physical therapy with symptomatic lumbar grade I SPL (42 ± 15years, 57% female) was conducted. At the end of the treatment, all participants were retrospectively assigned to one of two groups, receiving either 5-8 or 9-12 sessions (experimental or control group, respectively) of physical therapy treatments. The Prone Bridge Test (PBT) and the Supine Bridge Test (SBT) were used to measure muscular endurance. RESULTS: The area under the ROC curve for the PBT was 0.64 (95% CI 0.45-0.83) and for the SBT was 0.57 (95% CI 0.33-0.80). The optimal cutoff points were 25.5s for the PBT and 55.0s for the SBT. Logistic regression revealed that PBT (OR = 1.062) was associated with SPL. The final regression model explained 77.4% (R2 = 0.341; p = 0.024) of the variability. CONCLUSIONS: In this sample, the number of sessions required to achieve satisfactory outcomes ranged from 5 to 12. The clinical results of the subjects in the 5-8 sessions group were similar to the 9-12 sessions group. Individual's coping mechanisms could be considered in future studies to understand which patients will require more therapeutic sessions.

Group-based multimodal exercises integrated with cognitive-behavioural therapy improve disability, pain and quality of life of subjects with chronic neck pain: a randomized controlled trial with one-year follow-up.

OBJECTIVE: To evaluate the effect of a group-based multidisciplinary rehabilitation programme on disability, pain and quality of life in subjects with chronic neck pain. DESIGN: Randomized controlled trial. SETTING: Specialized rehabilitation centre. SUBJECTS: A total of 170 patients (mean age of 53 years (13); 121 females). INTERVENTIONS: The multidisciplinary group underwent a multidisciplinary rehabilitation programme combining multimodal exercises with psychologist-lead cognitive-behavioural therapy sessions. The general exercise group underwent general physiotherapy. Both groups followed group-based programmes once a week for ten weeks. Additionally, the multidisciplinary group met with the psychologist once a week for a 60-minute session. MAIN MEASURES: The Neck Disability Index (primary outcome), the Tampa Scale for Kinesiophobia, the Pain Catastrophizing Scale, a pain numerical rating scale and the Short-Form Health Survey. The participants were evaluated before, after training and after 12 months. RESULTS: A linear mixed model for repeated measures was used for each outcome measure. Significant effects ( p-value <0.001) were found over time and between groups for all outcome measures. After training, significant improvements were found for both groups for all outcome measures except kinesiophobia and catastrophizing, which did not change in the control group; however, the improvements were significantly greater for the multidisciplinary group. At 12-month follow-up a clinically meaningful between-group difference of 12.4 Neck Disability Index points was found for disability. CONCLUSIONS: A group-based multidisciplinary rehabilitation programme including cognitive-behavioural therapy was superior to group-based general physiotherapy in improving disability, pain and quality of life of subjects with chronic neck pain. The effects lasted for at least one year.

A multi-channel biomimetic neuroprosthesis to support treadmill gait training in stroke patients.

This study presents an innovative multi-channel neuroprosthesis that induces a biomimetic activation of the main lower-limb muscles during treadmill gait training to be used in the rehabilitation of stroke patients. The electrostimulation strategy replicates the physiological muscle synergies used by healthy subjects to walk on a treadmill at their self-selected speed. This strategy is mapped to the current gait sub-phases, which are identified in real time by a custom algorithm. This algorithm divides the gait cycle into six sub-phases, based on two inertial sensors placed laterally on the shanks. Therefore, the pre-defined stimulation profiles are expanded or stretched based on the actual gait pattern of each single subject. A preliminary experimental protocol, involving 10 healthy volunteers, was carried out to extract the muscle synergies and validate the gait-detection algorithm, which were afterwards used in the development of the neuroprosthesis. The feasibility of the neuroprosthesis was tested on one healthy subject who simulated different gait patterns, and a chronic stroke patient. The results showed the correct functioning of the system. A pilot study of the neurorehabilitation treatment for stroke patients is currently being carried out.

Pain, disability, and diagnostic accuracy of clinical instability and endurance tests in subjects with lumbar spondylolisthesis.

OBJECTIVE: The aims of this study were (1) to investigate the relationship between the main clinical tests to detect spinal instability, the perceived pain and disability, and symptomatic spondylolisthesis (SPL) characteristics, (2) to investigate the relationship between endurance and instability tests, and (3) to measure the diagnostic accuracy of these tests in unstable SPL diagnosed against dynamic radiographs. METHODS: Four instability tests were evaluated on 119 subjects: aberrant movements, active straight leg raising (ASLR), prone instability test, and passive lumbar extension test (PLE); and 2 endurance tests, prone bridge test and supine bridge test (SBT). The results were compared with the numeric rating scale for pain and the Oswestry Disability Index for disability. These tests were used as index tests and compared with dynamic radiographs as reference standard on 64 subjects. RESULTS: A significant relationship between disability and all the clinical tests but ASLR was observed. The relation between tests and pain was weaker, not significant for prone instability test and aberrant movement and critical for ASLR (P = .05). There was a low relationship between endurance tests and instability tests. Only PLE showed a significant association with dynamic radiographs (P = .017). CONCLUSION: Endurance and instability tests appear to be weakly related to the amount of pain but significantly related to the disability in symptomatic SPL. Of the tests evaluated, PLE exhibited the best ability to predict positive dynamic radiographs.

The Italian Society of Physical and Rehabilitation Medicine (SIMFER) recommendations for neck pain.

The paper represents the Italian Society of Physical " and Rehabilitation Medicine (SIMFER) recommendations to Neck Pain. We searched the principal scientific databases for papers concerning the main approaches to NP, including international guidelines, clinical trials of high methodological value and systematic reviews without any temporal limits. The recommendations were graded on the basis of the National Plan for Guidelines of the Italian Istituto Superiore di Sanità, which includes the level of evidence and strength of the recommendation. The principal sections of the recommendations deal with the Evaluation and Therapy for Neck Pain. The first describes the main evidence concerning the evaluation of patients with NP with or without limb involvement and/or headache: medical history, physical examination, neurological examination, laboratory tests, electrodiagnostics, diagnostic imaging and self-administered questionnaires. The second describes the best evidence synthesis concernig the therapy for Neck Pain: education, exercise, medical therapy, manual therapy, traction, physical therapy, acupuncture, orthoses, multimodal treatment, behavioural treatment.

Development of the Italian version of the Tampa Scale of Kinesiophobia (TSK-I): cross-cultural adaptation, factor analysis, reliability, and validity.

STUDY DESIGN: Evaluation of the psychometric properties of a translated and culturally adapted questionnaire. OBJECTIVE: Translating, culturally adapting, and validating the Italian version of the Tampa Scale of Kinesiophobia (TSK-I) to allow its use for Italian-speaking patients with low back pain. SUMMARY OF BACKGROUND DATA: Increasing attention is being given to standardized outcome measures as a means of improving interventions for low back pain. A translated form of the TSK in patients with low back pain has never been validated in the Italian population. METHODS: The development of the TSK-I questionnaire involved its translation and back-translation, a final review by an expert committee, and testing of the prefinal version to establish its correspondence to the original English version. Psychometric testing included factor analysis, reliability by internal consistency (Cronbach's alpha) and test-retest repeatability (Intraclass Coefficient Correlation), discriminant validity (Pearson correlation) by comparing TSK-I to a visual analogue scale, the Roland Morris Disability Questionnaire, Beck's Depression Inventory and Anxiety Inventory. RESULTS: It took the authors 5 months to achieve a shared version of the TSK-I, which proved to be satisfactorily acceptable when administered to 178 subjects. Factor analysis indicated a 2-factor 13-item solution (38% of explained variance). The questionnaire showed acceptable internal consistency (alpha = 0.772) and high test-retest reliability (ICC = 0.956). Discriminant validity showed moderate to low correlations with visual analogue scale (r = 0.345), the Roland Morris Disability (r = 0.337), and Beck's Depression Inventory and Anxiety Inventory (r = 0.258 and r = 283). The subscales were also psychometrically analyzed. CONCLUSION: The TSK was successfully translated into Italian, showing a good factorial structure and psychometric properties, and replicating the results of existing English versions of the questionnaire. Its use is recommended for research purposes.