Sensorimotor Perceptive Rehabilitation Integrated (SPRInt) program: exercises with augmented movement feedback associated to botulinum neurotoxin in idiopathic cervical dystonia-an observational study.

BACKGROUND: Idiopathic cervical dystonia (ICD) is a focal dystonia affecting neck muscles. Botulinum neurotoxin (BoNT) is the first-line treatment of ICD and different physical therapies (including exercise) are often proposed as adjunct treatments. However, the actual effectiveness of exercise in ICD is unclear. The aim of the current work is to assess the potential effectiveness of the Sensorimotor Perceptive Rehabilitation Integrated (SPRInt) exercise program as adjunct therapy for ICD. METHODS: Fifteen ICD patients received BoNT injections in the neck muscles and, 12 weeks later, received BoNT a second time and SPRInt started. SPRInt consists in 18 exercise sessions in which augmented feedback of movement (including visual and acoustic feedback) is extensively used. Dystonia burden was measured by the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Patients were evaluated immediately before, 6 and 12 weeks after each BoNT injection. RESULTS: Six weeks after the first BoNT injection (i.e., at BoNT peak effect), TWSTRS total score was better than baseline and remained improved at 12 weeks. TWSTRS disability domain slightly improved 6 weeks after the first BoNT injection, but after 6 more weeks returned to its baseline level. Disability improved more at SPRInt end (i.e., 6 weeks after the second BoNT injection), being even lower than after toxin alone. With a single-subject analysis, 4/10 patients who did not improve disability after BoNT improved after SPRInt plus BoNT. CONCLUSIONS: SPRInt plus BoNT can be more effective than BoNT alone in improving cervical dystonia patients' difficulties in the activities of daily living. TRIAL REGISTRATION: www.ClinicalTrials.gov, identifier NCT03247868 (https://register.clinicaltrials.gov).

lower limbs kinematic assessment of the effect of a gym and hydrotherapy rehabilitation protocol after knee megaprosthesis: a case report.

[Purpose] To quantitatively assess the effect of a personalized rehabilitation protocol after knee megaprosthesis. [Subject and Methods] The gait patterns of a 33-year-old male patient with knee synovial sarcoma were assessed by a computerized analysis before and after 40 rehabilitation sessions. [Results] The rehabilitation protocol improved the gait pattern. After rehabilitation, hip flexion was nearly symmetric, with normalized affected limb hip flexion, and improved ankle flexion. Ankle in/eversion was asymmetric and did not improve after physiotherapy. Before physiotherapy, the hip flexion on the affected side anticipated the movement but nearly normalized in the follow-up assessment. Hip abduction range of motion increased, with wider movements and good balance. Knee range of motion nearly symmetrized, but maintained an anticipated behavior, without shock absorption at heel-strike. [Conclusion] Instrumental gait analysis allowed us to gain evidence about the training and how to expand rehabilitative interventions to improve efficacy. In particular, we recommend quadriceps and gastrocnemius eccentric contraction training (to improve the shock absorption phase, preventing early failures of the prosthesis); one-leg standing performance (to improve the support phase of the affected limb); adductor strength training (to aid in hip control during the swing phase); and peroneus strength training (to increase ankle joint stabilization).

Squat exercise to estimate knee megaprosthesis rehabilitation: a pilot study.

[Purpose] This study evaluated a specific rehabilitation protocol using a half squat after total knee reconstruction with distal femur megaprosthesis and tibial allograft-prosthesis composite. [Subject and Methods] Squat execution was recorded by a three-dimensional system before and after a specific rehabilitation program on a 28-year-old patient. Squat duration, body center of mass trajectory, and vertical range of motion were determined. Step width and joint angles and symmetry (hip flexion, extension, and rotation, knee flexion, and ankle dorsal and plantar flexion) were estimated. Knee and hip joint symmetry was computed using a bilateral cyclogram technique. [Results] After rehabilitation, the squat duration was longer (75%), step width was similar, and vertical displacement was higher. Hip flexion increased by over 20%, and ankle dorsiflexion diminished by 14%. The knee had the highest symmetry gain (4.1-3.4%). Angle-angle plot subtended areas decreased from 108° to 40°(2) (hip) and from 204° to 85°(2) (knee), showing improvement in movement symmetry. [Conclusion] We concluded that the squat is an effective multifactorial exercise to estimate rehabilitation outcomes after megaprosthesis, also considering that compressive and shear forces are minimal up to 60-70° of knee flexion.

Infiltrative Type I Collagen in the Treatment of Morton's Neuroma: A Mini-Series.

Morton's neuroma (MN) is a compressive neuropathy of the common plantar digital nerve, most commonly affecting the third inter-digital space. The conservative approach is the first recommended treatment option. However, other different approaches have been proposed, offering several options of treatments, where, several degrees of efficacy and safety have been reported. We treated five consecutive patients affected by MN through three indirect ultrasound-guided injections of type I porcine collagen at weekly intervals. All patients were assessed before the treatment, after the treatment and up to 6 months after the last injection via AOFAS and VNS scores for pain, in which the function and pain were evaluated, respectively. In all patients, both analyzed variables progressively ameliorated, with benefits lasting until the last follow-up. The trend of the scores during the follow-up showed significant statistical differences. No side effects occurred. To our knowledge, this is the first study on injections of type I porcine collagen for the treatment of Morton's neuroma. Future research is needed to confirm the positive trend achieved in this MN mini-series.

Case Report: Postacute Rehabilitation of Guillain-Barré Syndrome and Cerebral Vasculitis-Like Pattern Accompanied by SARS-CoV-2 Infection.

Introduction: The main clinical manifestation of the novel Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) is respiratory issues. Neurological manifestations are being increasingly recognized, including febrile seizures, headache, dizziness, and myalgia, as well as encephalopathy, encephalitis, stroke, and acute peripheral nerve diseases. Cerebral vasculitis is rarely reported. We describe a case of SARS-CoV-2 interstitial pneumonia complicated by flaccid tetraplegia due to Guillain-Barré Syndrome (GBS) associated with a cerebral vasculitis-like pattern. Case description: A 62-year-old man was hospitalized for cough, fever, and severe respiratory failure requiring tracheal intubation and invasive ventilation. The chest Computerized Tomography (CT) showed images related to interstitial pneumonia and the subsequent nasopharyngeal swab confirmed the presence of SARS-CoV-2 infection. During the hospitalization, there was a progressive deterioration of the senses associated with areflexic flaccid tetraplegia. The treatment with high doses of immunoglobulin G (IgG) led to the immediate improvement of the general conditions and a partial response in terms of recovery of the upper limb and of the distal lower limb movements. Subsequently the patient was admitted to our Rehabilitation Unit, where he received an intensive rehabilitation treatment consisting of physiotherapy and occupational therapy. Two months later the patient was discharged at home and able to walk independently even for long distances thanks to the use of Ankle-Foot Orthosis (AFO). Conclusion: In this report, we present the case of a patient with peripheral and central neurological damage occurred later severe pneumonia induced by SARS-CoV-2. The Immunoglobulin G therapy allowed the patient to benefit considerably from early rehabilitation, reaching the walking, increasing the independence in daily living tasks, and enabling safe discharge from hospital to home. Related neurologic complications of SARS-CoV-2 infection suffer a lack of understanding and further investigations should be conducted.

Rehabilitation After Urgent or Elective Orthopedic Surgery: The Role of Resilience in Elderly Patients.

PURPOSE: The aim of this investigation was to assess resilience within an elderly population during postacute rehabilitation for orthopedic surgery and to identify the role of resilience on rehabilitation outcomes by comparing hip fracture and elective patients (total knee and hip arthroplasty). DESIGN: We conducted a prospective study in an orthopedic rehabilitation department. METHODS: On admission and on discharge, 80 patients aged over 60 years underwent a multidimensional evaluation with the Resilience Scale, the Functional Independence Measure (FIM), the Multidimensional Prognostic Index, and the World Health Organization Quality of Life-BREF. FINDINGS: Hip-fractured patients had a lower level of resilience. High-resilient fracture patients achieved higher FIM scores. For elective patients, no differences on FIM score occurred for different resilience levels. CONCLUSIONS AND CLINICAL RELEVANCE: Resilience plays a significant role in reaching optimal functional recovery in hip-fractured elderly people. Results suggest the introduction of early routine assessment of resilience in future outcome studies in rehabilitation.

Criterion validity of the instrumented Timed Up and Go test: A partial least square regression study.

The Timed Up and Go (TUG) test is a common mobility measure in rehabilitation. With the instrumental TUG test (ITUG; i.e. the TUG measured by inertial measurement units, IMUs), several movement measures are newly available. However, the clinical meaning of these new measures is not totally clear. Aim of the current work is to evaluate the validity of different ITUG parameters as a measure of balance. Neurological patients (n = 122; 52 females; 89 older than 65 years) completed the TUG test with IMUs secured to their back. IMUs signals were used to split the TUG test in five phases (sit-to-stand, walk1, turn1, walk2 and turn-and-sit) and twelve movement parameters were obtained. Experienced clinicians administered the Mini-BESTest (MB) scale, a sound balance measure. The partial least square regression (PLSR) was used to explore the association between the ITUG variables and the MB measure. A PLSR model with twelve ITUG variables had satisfactory fit parameters (RMSEP: 11%; R2: 0.41, 95% CI: 0.28-0.54; regression line: 1, 95% CI: 0.78-1.22). Three ITUG variables (i.e. turn1 vertical angular velocity, turn1 duration and turn2 vertical angular velocity) were found to be the most important predictors of the MB measure. A PLSR model with the turning variables only had fit parameters comparable to that of the twelve variables model. Turning parameters from the TUG test are good predictors of the MB scale. The mean angular velocity during turning and the duration of the turning phase are thus proposed as a valid, ratio-level measures of balance in neurological patients.

Is my patient actually getting better? Application of the McNemar test for demonstrating the change at a single subject level.

PURPOSE: The aim of the current work is to provide a novel method for demonstrating the modification of a single patient's performance on questionnaires and scales. The minimal detectable change (MDC), a statistics indicating the minimal change in measure not attributable to random variation, is commonly used in rehabilitation for this purpose. However, the MDC has some important drawbacks (e.g. it cannot be calculated on scores from ordinal tests and it can be only used for full questionnaire). METHOD: Review of the MDC and its limitations and application of the McNemar test on simulated data from single subjects. RESULTS: We propose to use the McNemar test to check if the proportion of test items affirmed by a patient after rehabilitation is significantly different from the same proportion before rehabilitation. A significant McNemar test would indicate a non-random modification of the patient's score and thus a true modification of his/her performance. CONCLUSIONS: The application of the McNemar test to questionnaires and scales offers a simple method for demonstrating the modification of a single patient's performance. This use of the McNemar test overcomes the weaknesses of the MDC and gives support to the clinician in assisting him/her to convincingly communicate a non-negligible modification of the patient's status. IMPLICATIONS FOR REHABILITATION Measuring the change in patients' status is of paramount importance in medicine and rehabilitation. However, tracking the change in rehabilitation is difficult. For example, the minimal detectable change cannot be calculated on scores from ordinal questionnaires and tests, which are widely used as rehabilitative outcome measures. We propose here to use a McNemar test to check if the proportion of test items affirmed or passed by is significantly different between two conditions (e.g. before vs. after rehabilitation). Similar to the minimal detectable change, the significant McNemar test would indicate a non-random modification of the patient's test score. In addition, the McNemar test can be calculated on ordinal data, thus overcoming some of the minimal detectable change weaknesses.

ISYQOL: a Rasch-consistent questionnaire for measuring health-related quality of life in adolescents with spinal deformities.

BACKGROUND CONTEXT: Spinal deformities are commonly associated with poor health-related quality of life (HRQOL). Several questionnaires (eg, Scoliosis Research Society-24 [SRS-24] and Scoliosis Research Society-22 [SRS-22]) have been developed to evaluate HRQOL in these conditions. In adults as well as during growth, the HRQOL is considered one of the most relevant outcomes of both conservative and surgical treatments. Rasch analysis is a powerful statistical technique for developing high-quality and valid questionnaires. The SRS-24 and SRS-22 have been evaluated using the Rasch analysis but showed poor measurement properties. Thus, a proper measure of HRQOL in people with a spine condition is still missing. PURPOSE: This study aimed to develop a new questionnaire that is totally Rasch consistent for measuring the HRQOL in young people with a spine condition. STUDY DESIGN: This is a cross-sectional study for developing a new HRQOL measure. PATIENT SAMPLE: A total of 402 participants with adolescent idiopathic scoliosis or Scheuermann juvenile kyphosis were included in the study. OUTCOME MEASURE: The outcome measure used was the Italian Spine Youth Quality of Life (ISYQOL) questionnaire. MATERIALS AND METHODS: The study consisted of different stages: a conventional approach content analysis, an opinion poll among clinicians trained in spine deformities, and the Rasch analysis (partial credit model). RESULTS: The Rasch analysis showed that all items of the ISYQOL questionnaire had ordered thresholds and a good fit to the model. Differential item functioning was present for Item 1, with bracing only, and was solved with a conventional items splitting procedure. The ISYQOL item map spans an adequate range of HRQOL. The principal component analysis for Rasch residuals showed, in practical terms, the ISYQOL unidimensionality. The reliability of ISYQOL was high enough so that approximately three significantly different levels of HRQOL could be discerned. Two questionnaire versions were provided for patients with and without the brace, respectively. CONCLUSIONS: ISYQOL is the first HRQOL questionnaire developed according to the Rasch analysis. It was developed in a conservative treatment setting for all types of spinal deformities, including also patients with surgical curves. Validation in many languages is already under way.

Mirror Movements After Stroke Suggest Facilitation From Nonprimary Motor Cortex: A Case Presentation.

When stroke occurs in adulthood, mirror movements (MMs; involuntary movements occurring in 1 hand when performing unilateral movements with the contralateral hand) in the paretic hand rarely occur. We present a case of an apparently healthy 54-year-old man presenting with MMs in his left (nondominant) hand. Further evaluation revealed diminished strength and dexterity in left hand, increased spinal excitability, decreased corticospinal excitability, occurrence of ipsilateral motor responses, enlarged cortical motor representation, and imaging findings consistent with a previously undiagnosed right-subcortical stroke. MMs and ipsilateral motor responses may reflect the increased spinal motor neurons' excitability sustained by the spared nonprimary ipsilesional motor areas.