Efficacy of telerehabilitation with digital and robotic tools for the continuity of care of people with chronic neurological disorders: The TELENEURO@REHAB protocol for a randomized controlled trial.

Context: Chronic Neurological Disorders (CNDs) are among the leading causes of disability worldwide, and their contribution to the overall need for rehabilitation is increasing. Therefore, the identification of new digital solutions to ensure early and continuous care is mandatory. Objective: This protocol proposes to test the usability, acceptability, safety, and efficacy of Telerehabilitation (TR) protocols with digital and robotic tools in reducing the perceived level of disability in CNDs including Parkinson's Disease (PD), Multiple Sclerosis (MS), and post-stroke patients. Design Setting and Subjects: This single-blinded, multi-site, randomized, two-treatment arms controlled clinical trial will involve PD (N = 30), MS (N = 30), and post-stroke (N = 30). Each participant will be randomized (1:1) to the experimental group (20 sessions of motor telerehabilitation with digital and robotic tools) or the active control group (20 home-based motor rehabilitation sessions according to the usual care treatment). Primary and secondary outcome measures will be obtained at the baseline (T0), post-intervention (T1, 5 weeks after baseline), and at follow-up (T2, 2 months after treatment). Main Outcome Measures: a multifaceted evaluation including quality of life, motor, and clinical/functional measures will be conducted at each time-point of assessment. The primary outcome measures will be the change in the perceived level of disability as measured by the World Health Organization Disability Assessment Schedule 2.0. Conclusion: The implementation of TR protocols will enable a more targeted and effective response to the growing need for rehabilitation linked to CNDs, ensuring accessibility to rehabilitation services from the initial stages of the disease.

Classification and Quantification of Physical Therapy Interventions across Multiple Neurological Disorders: An Italian Multicenter Network.

Despite their relevance in neurorehabilitation, physical therapy (PT) goals and interventions are poorly described, compromising a proper understanding of PT effectiveness in everyday clinical practice. Thus, this paper aims to describe the prevalence of PT goals and interventions in people with neurological disorders, along with the participants' clinical features, setting characteristics of the clinical units involved, and PT impact on outcome measures. A multicenter longitudinal observational study involving hospitals and rehabilitation centers across Italy has been conducted. We recruited people with stroke (n = 119), multiple sclerosis (n = 48), and Parkinson's disease (n = 35) who underwent the PT sessions foreseen by the National Healthcare System. Clinical outcomes were administered before and after the intervention, and for each participant the physical therapists completed a semi-structured interview to report the goals and interventions of the PT sessions. Results showed that the most relevant PT goals were related to the ICF activities with "walking" showing the highest prevalence. The most used interventions aimed at improving walking performance, followed by those aimed at improving organ/body system functioning, while interventions targeting the cognitive-affective and educational aspects have been poorly considered. Considering PT effectiveness, 83 participants experienced a clinically significant improvement in the outcome measures assessing gait and balance functions.

Complementary use of statistical parametric mapping and gait profile score to describe walking alterations in multiple sclerosis: a cross-sectional study.

Gait analysis is often used to study locomotor alterations in people with multiple sclerosis (PwMS), but the large number of extracted variables challenges the interpretability. In this paper, we analysed gait alterations by combining the Gait Profile Score (GPS), which summarizes kinematic locomotor deviations, and Statistical Parametric Mapping (SPM), which compares kinematics and kinetics over the whole gait cycle. Eleven PwMS and 11 speed-matched Healthy Controls (HC) underwent overground gait analysis. GPS were compared through independent-samples t-tests; sagittal-plane kinematics and power at hip, knee, and ankle were compared through SPM Hotelling's-T2 and SPM t-tests. Spearman's correlation coefficients (r) between GPS and clinical outcomes were also calculated. PwMS had higher GPS than HC (PwMS = 8.74 ± 2.13°; HC = 5.01 ± 1.41°;p < 0.001). Multivariate SPM found statistically significant differences at 0-49%, 70-80%, and 93-99% of stride (p < 0.05) and univariate analysis showed reduced ankle dorsiflexion, and lower knee flexion during pre-swing and swing. GPS correlated with Expanded Disability Status Scale (r = 0.65; 95%C.I.[0.04,0.91]; p = 0.04) and 2-Minute Walking Test (r = -0.65; 95%C.I.[-0.91,-0.04]; p = 0.04). GPS in conjunction with SPM revealed multi-joint kinematic alterations on sagittal plane involving distal joint angles, ankle and knee, during the stance phase with no changes at the proximal level. Gait deviations were more pronounced in PwMS with higher disability and walking limitations.

Fallers after stroke: a retrospective study to investigate the combination of postural sway measures and clinical information in faller's identification.

Background: Falls can have devastating effects on quality of life. No clear relationships have been identified between clinical and stabilometric postural measures and falling in persons after stroke. Objective: This cross-sectional study investigates the value of including stabilometric measures of sway with clinical measures of balance in models for identification of faller chronic stroke survivors, and the relations between variables. Methods: Clinical and stabilometric data were collected from a convenience sample of 49 persons with stroke in hospital care. They were categorized as fallers (N = 21) or non-fallers (N = 28) based on the occurrence of falls in the previous 6 months. Logistic regression (model 1) was performed with clinical measures, including the Berg Balance scale (BBS), Barthel Index (BI), and Dynamic Gait Index (DGI). A second model (model 2) was run with stabilometric measures, including mediolateral (SwayML) and anterior-posterior sway (SwayAP), velocity of antero-posterior (VelAP) and medio-lateral sway (VelML), and absolute position of center of pressure (CopX abs). A third stepwise regression model was run including all variables, resulting in a model with SwayML, BBS, and BI (model 3). Finally, correlations between independent variables were analyzed. Results: The area under the curve (AUC) for model 1 was 0.68 (95%CI: 0.53-0.83, sensitivity = 95%, specificity = 39%) with prediction accuracy of 63.3%. Model 2 resulted in an AUC of 0.68 (95%CI: 0.53-0.84, sensitivity = 76%, specificity = 57%) with prediction accuracy of 65.3%. The AUC of stepwise model 3 was 0.74 (95%CI: 0.60-0.88, sensitivity = 57%, specificity = 81%) with prediction accuracy of 67.4%. Finally, statistically significant correlations were found between clinical variables (p < 0.05), only velocity parameters were correlated with balance performance (p < 0.05). Conclusion: A model combining BBS, BI, and SwayML was best at identifying faller status in persons in the chronic phase post stroke. When balance performance is poor, a high SwayML may be part of a strategy protecting from falls.

Validity of 2 Fall Prevention Strategy Scales for People With Stroke, Parkinson's Disease, and Multiple Sclerosis.

BACKGROUND AND PURPOSE: Falls are a common and persistent concern among people with neurological disorders (PwND), as they frequently result in mobility deficits and may lead to loss of functional independence. This study investigated the ceiling and floor effects, internal consistency, and convergent validity of 2 patient-reported fall prevention strategy scales in PwND. METHODS: This is a prospective cohort study. Two-hundred and ninety-nine PwND (111 people with multiple sclerosis, 94 people with Parkinson's disease, and 94 people with stroke) were seen for rehabilitation and assessed. The number of retrospective and prospective falls, use of walking assistive devices, scores on the Fall Prevention Strategy Survey (FPSS), Falls Behavioural Scale (FaB), and balance and mobility scales (Berg Balance Scale, Dynamic Gait Index, Timed Up and Go, 10-m walking test, and Activities-specific Balance Confidence) were analyzed. RESULTS: Total score distributions showed negligible ceiling and floor effects for both the FPSS (ceiling: 0.3%, floor: 0.3%) and the FaB (ceiling: 0%, floor: 0%). The Cronbach α (CI) was of 0.87 (0.85-0.89) for the FPSS and 0.86 (0.84-0.88) for the FaB. In terms of convergent validity, the FPSS and FaB were moderately correlated (Spearman correlation coefficient = 0.65). Moreover, the correlations between the FPSS and FaB and balance and mobility scales ranged from 0.25 to 0.49 ( P < .01). Both scales are slightly better able to distinguish between retrospective fallers/nonfallers [area under the curve, AUC (95% CI): FPSS: 0.61 (0.5-0.7); FaB: 0.60 (0.5-0.6)] compared with prospective fallers/nonfallers [AUC (95% CI): FPSS: 0.56 (0.4-0.6); FaB: 0.57 (0.4-0.6)]. Both scales accurately identified individuals who typically required the use of a walking assistive device for daily ambulation [AUC (95% CI): FPSS: 0.74 (0.7-0.8); FaB: 0.69 (0.6-0.7)]. Multiple regression analysis showed that previous falls, use of an assistive device, and balance confidence significantly predicted participants' prevention strategies (FPSS: R2 = 0.31, F(8,159) = 10.5, P < .01; FaB: R2 = 0.31, F(8,164) = 10.89, P < .01). CONCLUSION: The FPSS and the FaB appear to be valid tools to assess fall prevention strategies in people with neurological disorders. Both scales provide unique and added value in providing information on individual behavior for fall prevention.

Effects of immersive virtual reality on upper limb function in subjects with multiple sclerosis: A cross-over study.

BACKGROUND: Upper limb dysfunctions are common in people with multiple sclerosis (PwMS) and lead to limitations in activities of daily living. In this study, we investigated the feasibility and effects of an immersive commercial virtual reality system for upper limb bilateral rehabilitation. METHODS: A total of 20 participants were included in a cross over study with two arm sequences: Treatment-Waiting List (T-WL; N = 9) and Waiting List-Treatment (WT-T; N = 11). T-WL sequence performed 12 sessions of bilateral UL rehabilitation over a 4-week period, based on the use of a commercially VR immersive platform (Oculus Rift), followed by a 4-week wash-out period and a 4-week waiting list period. WL-T sequence followed the protocol in the reverse order. Participants were tested at baseline (T0), after the end of the first 4-week period (T1), at the end of the wash-out period and finally at the end of the third 4-week period (T2). The primary outcome was the Box and Blocks test (BBT). Secondary outcome measures were: Nine Hole Peg Test (NHPT), Maximal isometric handgrip strength, Manual Ability Measure-36 (MAM-36), Modified Fatigue Impact Scale (MFIS), and the System Usability Scale (SUS). In absence of carryover effects, we analyzed primary and secondary outcome measures with mixed linear effect models. Treatment efficacy was assessed on the within-subject differences. Specifically, we used the intra-individual differences at the end of treatment and waiting-list periods (T1 and T2) as dependent variables and sequences (T-WL or WL-T) as independent variable. In presence of carryover effects (p-value <0.05), we assessed between sequence differences by an unpaired t-test considering T0 and T1 as time points, and sequence as group factor. RESULTS: We observed clinical and statistical improvements for BBT, with an overall between-sequence difference of 8.6 ± 2.6 blocks (p < 0.01) favoring treatment period in the less affected side, and a not significant change of 3.0 ± 2.6 blocks (p = 0.28) in the most affected side. Small and not significant between-sequence differences were found for 9HPT, and handgrip strength in both sides. Similarly, no differences were found for patient reported outcomes, MFIS and MAM-36. Finally, mean SUS score was 45.9 ± 11.1 points, representing a moderate usability of the system. CONCLUSION: An immersive VR-based approach resulted useful to improve gross manual dexterity in the less affected limb in PwMS. However, such improvement did not translate into modifications in terms of self-reported ability to carry out activities of daily living nor went along with improvement in fine hand dexterity, strength or fatigue. Finally, usability of this technology was overall judged moderate, with lower scores assigned to items representing user-friendliness.

Assessing balance in non-disabled subjects with multiple sclerosis: Validation of the Fullerton Advanced Balance Scale.

OBJECTIVE: To validate the Fullerton Advanced Balance (FAB) scale for high-functioning non-disabled people with multiple sclerosis (PwMS). DESIGN: Cross-sectional study. PARTICIPANTS: A convenience sample of early-diagnosed PwMS (N = 82; Expanded Disability Status Scale score ≤ 2.5) with disease duration ≤ 5 years and a control group of healthy volunteers (N = 45). MAIN OUTCOME MEASURES: FAB scale, Timed Up and Go test (TUG), 6 Min Walk Test (6MWT) and 25 Foot Walk Test (25FWT). RESULTS: Six of the ten original FAB scale items were selected to represent a unidimensional construct. Only one factor with eigenvalues > 1.0 (1.90) was found. The new version of the scale reported a Cronbach alpha value of 0.65, and it was also statistically significantly correlated with TUG (r = -0.48). The new six-item scale, dubbed the FAB-short scale (FAB-s), discriminated between healthy volunteers and PwMS; moreover, both the FAB-s and the TUG test discriminated between the two PwMS subgroups: EDSS=0-1.5 (no disability) and EDSS=2-2.5 (minimal disability). CONCLUSIONS: FAB-s is a unidimensional clinical tool for assessing balance. The scale is a promising instrument for detecting subtle changes in balance performance in high-functioning PwMS.