A wearable system for visual cueing gait rehabilitation in Parkinson's disease: a randomized non-inferiority trial.

BACKGROUND: Gait disturbances represent one of the most disabling features of Parkinson's disease (PD). AIM: The aim of this study was to evaluate the non-inferiority of a new wearable visual cueing system (Q-Walk) for gait rehabilitation in PD subjects, compared to traditional visual cues (stripes on the floor). DESIGN: Open-label, monocentric, randomized controlled non-inferiority trial. SETTING: Outpatients. POPULATION: Patients affected by idiopathic PD without cognitive impairment, Hoehn and Yahr stage II-IV, Unified Parkinson's Disease Rating Scale motor section III ≥2, stable drug usage since at least 3 weeks. METHODS: At the enrollment (T0), all subjects underwent a clinical/functional evaluation and the instrumental gait and postural analysis; then they were randomly assigned to the Study Group (SG) or Control Group (CG). Rehabilitation program consisted in 10 consecutive individual sessions (5 sessions/week for 2 consecutive weeks). Each session included 60 minutes of conventional physiotherapy plus 30 minutes of gait training by Q-Walk (SG) or by traditional visual cues (CG). Follow-up visits were scheduled at the end of the treatment (T1) and after 3 months (T2). RESULTS: Fifty-two subjects were enrolled in the study, 26 in each group. The within-groups analysis showed a significant improvement in clinical scales and instrumental data at T1 and at T2, compared to baseline, in both groups. According to the between-group analysis, Q-Walk cueing system was not-inferior to the traditional cues for gait rehabilitation. The satisfaction questionnaire revealed that most subjects described the Q-Walk cueing system as simple, motivating and easily usable, possibly suitable for home use. CONCLUSIONS: Data showed that motor rehabilitation of PD subjects performed by means of the new wearable Q-Walk cueing system was feasible and as effective as traditional cues in improving gait parameters and balance. CLINICAL REHABILITATION IMPACT: Wearable devices can act as an additional rehabilitation strategy for long-term and continuous care, allowing patients to train intensively and extensively in household settings, favoring a tailor-made and personalized approach as well as remote monitoring.

Assessing the Impact of Electrosuit Therapy on Cerebral Palsy: A Study on the Users' Satisfaction and Potential Efficacy.

The aim of this study is to evaluate the effectiveness of electrosuit therapy in the clinical treatment of children with Cerebral Palsy, focusing on the effect of the therapy on spasticity and trunk control. Moreover, the compliance of caregivers with respect to the use of the tool was investigated. During the period ranging from 2019 to 2022, a total of 26 children (18 M and 8 F), clinically stable and affected by CP and attending the Neurorehabilitation Unit of the "Padre Pio Foundation and Rehabilitation Centers", were enrolled in this study. A subset of 12 patients bought or rented the device; thus, they received the administration of the EMS-based therapy for one month, whereas the others received only one-hour training to evaluate the feasibility (by the caregivers) and short-term effects. The Gross Motor Function Classification System was utilized to evaluate gross motor functions and to classify the study sample, while the MAS and the LSS were employed to assess the outcomes of the EMS-based therapy. Moreover, between 80% and 90% of the study sample were satisfied with the safety, ease of use, comfort, adjustment, and after-sales service. Following a single session of electrical stimulation with EMS, patients exhibited a statistically significant enhancement in trunk control. For those who continued this study, the subscale of the QUEST with the best score was adaptability (0.74 ± 0.85), followed by competence (0.67 ± 0.70) and self-esteem (0.59 ± 0.60). This study investigates the impact of the employment of the EMS on CP children's ability to maintain trunk control. Specifically, after undergoing a single EMS session, LSS showed a discernible improvement in children's trunk control. In addition, the QUEST and the PIADS questionnaires demonstrated a good acceptability and satisfaction of the garment by the patients and the caregivers.

Neurorehabilitation in brain tumours: evidences and suggestions for spreading of knowledge and research implementation.

PURPOSE OF REVIEW: The last few decades have seen an increase in life expectancy in brain tumour patients; however, many patients report sensory-motor and cognitive disabilities due to the tumour itself, but also to the effect of anticancer treatments (surgery, radiotherapy, chemotherapy), supportive treatments, as well as individual patient factors. This review outlines the principles on which to base neurorehabilitation treatments, with the aim of stimulating an early rehabilitative management, in order to reduce disability and functional limitation and improve the quality of life of the persons affected by brain tumour. RECENT FINDINGS: Although not definitive, evidences suggest that an early neurorehabilitative evaluation, performed with a multidisciplinary approach, may identify the different functional impairments that can affect people with brain tumour. Furthermore, identifying and classifying the person's level of functioning is useful for designing achievable recovery goals, through the implementation of tailored multidisciplinary rehabilitation programs. The involvement of different professional figures allows to treat all the components (physical, cognitive, psychological and participation) of the person, and to redesign one's life project, lastly improving the quality of life. SUMMARY: Overall, the evidences suggest a critical need for the development of this clinical area by spreading the concept of rehabilitation among neuro-oncologists and producing high quality research.

Botulinum Toxin-A High-Dosage Effect on Functional Outcome and Spasticity-Related Pain in Subjects with Stroke.

Stroke patients can develop spasticity and spasticity-related pain (SRP). These disorders are frequent and can contribute to functional limitations and disabling conditions. Many reports have suggested that higher doses than initially recommended of BTX-A can be used effectively and safely, especially in the case of severe spasticity; however, whether the treatment produces any benefit on the functional outcome and SRP is unclear. Studies published between January 1989 and December 2022 were retrieved from MEDLINE/PubMed, Embase, and Cochrane Central Register. Only obabotulinumtoxinA (obaBTX-A), onabotulinumtoxinA, (onaBTX-A), and incobotulinumtoxinA (incoBTX-A) were considered. The term "high dosage" indicates ≥600 U. Nine studies met the inclusion criteria. Globally, 460 subjects were treated with BTX-A high dose, and 301 suffered from stroke. Studies had variable method designs, sample sizes, and aims. Only five (55.5%) reported data about the functional outcome after BTX-A injection. Functional measures were also variable, and the improvement was observed predominantly in the disability assessment scale (DAS). SRP pain was quantified by visual analog scale (VAS) and only three studies reported the BTX-A effect. There is no scientific evidence that this therapeutic strategy unequivocally improves the functionality of the limbs. Although no clear-cut evidence emerges, certain patients with spasticity might obtain goal-oriented improvement from high-dose BTX-A. Likewise, data are insufficient to recommend high BTX dosage in SRP.

Case Report: Functional Outcome of COVID-19 Subjects With Myasthenia Gravis and Critical Illness Polyneuropathy.

Background: The COVID-19 disease can affect subjects suffering from myasthenia gravis (MG) and worsen its clinical course, leading to intensive care unit (ICU) admission. Critically ill subjects can develop a neuromuscular complication called ICU-acquired weakness (ICUAW). This disorder has also been detected in ICU subjects with COVID-19, but the association between MG and ICUAW has never been described in critically ill patients. We describe the case and functional outcome of a COVID-19 patient suffering from MG who developed critical illness polyneuropathy (CIP). Case Presentation: A 66-year-old man with a history of hypertension and ocular MG had COVID-19 and required ICU admission. The patient underwent mechanical ventilation and tracheotomy and was treated with remdesivir and corticosteroids. Fifteen days after admission, he complained of tetraparesis without the ocular involvement that remained unchanged despite the increase in anticholinesterase therapy. The length of stay (LOS) in ICU was 35 days. On day 2 of admission, the patient underwent a frontal muscle jitter study that confirmed the MG, and electroneurography (ENG) and electromyography (EMG) that showed overlapping ICUAW with electrophysiological signs characteristic of CIP. The cerebrospinal fluid (CSF) showed normal pressure, cell count, and protein levels (<45 mg/dl) without albumin-cytologic disassociation. The CSF/serum glucose ratio was normal. The CSF culture for possible organisms, laboratory tests for autoimmune disorders, the panel of antiganglioside antibodies, and the paraneoplastic syndrome were negative. Strength and functional outcomes were tested with the MRC scale, the DRS, Barthel scale, and the Functional Independence Measure (FIM) at admission, discharge, and follow-up. Muscular strength improved progressively, and the MRC scale sum-score was 50 at discharge. Anticholinesterase therapy with pyridostigmine at a dosage of 30 mg 3 times daily, which the patient was taking before COVID-19, was resumed. His motor abilities recovered, and functional evaluations showed full recovery at follow-up. Conclusion: In the described subject, the coexistence of both neuromuscular disorders did not affect the clinical course and recovery, but the question remains about generalization to all patients with MG. The rehabilitation interventions might have facilitated the outcome.

Impact of healthcare-associated infections on functional outcome of severe acquired brain injury during inpatient rehabilitation.

To describe healthcare-associated infections in inpatient neuro-rehabilitation and their impact on functional outcome, a multicenter observational study with severe acquired brain injury (sABI) patients was performed. Patients were divided into infected (INF-group) or not infected (noINF-group) and assessed at admission and discharge, by means of the Glasgow Coma Scale (GCS), the Rancho Los Amigos Levels of Cognitive Functioning Scale (LCF), the Disability Rating Scale (DRS), and the modified Barthel Index (mBI). One hundred-nineteen patients were included in the INF-group, and 109 in the noINF-group. Culture specimens were found positive for bloodstream (43.8%), respiratory tract (25.7%), urinary tract (16.2%), gastro-intestinal system (8.6%) and skin (2.4%) infections. Multiple microorganisms were the most frequent (58.1%) and 55.5% of patients needed functional isolation due to multidrug resistant germs. The functional status of both groups improved after rehabilitation, but multivariable analyses showed that the INF-group showed a significantly lower gain to GCS (p = 0.008), DRS (p = 0.020) and mBI (p = 0.021) compared to the noINF-group. Length of stay (LOS) and number of skipped rehabilitative sessions were not statistically different between the groups; mortality rate was significantly higher in the INF-group (p = 0.04). Infected sABI patients showed longer LOS, significant increased mortality, and a lower functional outcome than not infected patients.

Recovery and long term functional outcome in people with critical illness polyneuropathy and myopathy: a scoping review.

BACKGROUND: Intensive care unit acquired weakness (ICUAW), embraces an array of disorders labeled "critical illness polyneuropathy" (CIP), "critical illness myopathy" (CIM) or "critical illness polyneuromyopathy" (CIPNM). Several studies have addressed the various characteristics of ICUAW, but the recovery is still unclear. OBJECTIVE: The present review investigated the recovery and the long-term functional outcome of subjects with ICUAW, whether the types of ICUAW have different outcomes and whether there is any supporting evidence. METHODS: Literature search was performed from MEDLINE/PubMed, CINAHL, EMBASE, PeDro, Web of Science and Scopus. Inclusion criteria were: i) sample size including five or more subjects; ii) subjects who suffered from ICUAW and/or CIP, CIM and CIP/CIM; iii) ICUAW ascertained by EMG. Follow-ups longer than one year were defined as long-term. RESULTS: Twenty-nine studies met the inclusion criteria. In total, 788 subjects with ICUAW were enrolled: 159 (20.1%) died and 588 (74.6%) were followed. Of all the included patients, 613 (77.7%) had CIP, 82 (10.4%) CIM and 56 (7.1%) CIP/CIM. Overall, 70.3% of the subjects with ICUAW fully recovered. Seven (24.1%) studies had a follow-up longer than 1 year (range 2-8) with 173 (21.9%) subjects enrolled globally and 108 followed. Of these subjects, 88.8% gained full recovery. Most of the studies did not use proper functional scales and only 4 and 3 studies employed the Barthel scale and the Functional Independence Measure (FIM) scale. Differentiation between the types of ICUAW was performed in 7 studies, but only 3 studies reported that subjects with CIM had a better prognosis and earlier recovery than subjects with CIP/CIM. CONCLUSIONS: Subjects with ICUAW could achieve good recovery and could improve at follow-up. However, the quality of the published studies due to short follow-ups and the paucity of defined outcome measures require confirms.

Critical Illness Polyneuropathy and Functional Outcome in Subjects with Covid-19: Report on Four Patients and a Scoping Review of the Literature.

Patients with COVID-19 may develop a range of neurological disorders. We report here 4 COVID-19 subjects with intensive care unit-acquired weakness and their functional outcome. In addition, a scoping review of COVID-19 literature was performed to investigate this issue. Of the post-COVID-19 patients admitted to our Neuro-Rehabilitation Unit, 4 (3 males, 1 female; mean age 59.2 ± 8.62 years) had intensive care unit-acquired weakness, diagnosed with electromyography. Muscle strength and functional evaluation were performed on all patients with Medical Research Council, Disability Rating Scale and Functional Independence Measure, respectively, at admission, discharge and 6-month follow-up after discharge. Electromyography revealed that 3 subjects had critical illness polyneuropathy and 1 had critical illness polyneuropathy/critical illness myopathy. At follow-up, the 3 subjects with critical illness polyneuropathy reached full recovery. The patient with critical illness polyneuropathy/critical illness myopathy showed moderate disability requiring bilateral ankle foot-orthosis and support for ambulation. The scoping review retrieved 11 studies of COVID-19 patients with intensive care unit-acquired weakness, concerning a total of 80 patients: 23 with critical illness myopathy (7 probable), 21 with critical illness polyneuropathy (8 possible), 15 with critical illness polyneuropathy and myopathy (CIPNM) and 21 with intensive care unit-acquired weakness. Of 35 patients who survived, only 3 (8.5%) reached full recovery. All 3 had critical illness myopathy, but 2 of these had a diagnosis of probable critical illness myopathy. Intensive care unit-acquired weakness commonly occurred in subjects with COVID-19. Recovery was variable and a low percentage reached full recovery. However, the heterogeneity of studies did not allow definitive conclusions to be drawn.

Ultrasonographic Evaluation of Three Approaches for Botulinum Toxin Injection into Tibialis Posterior Muscle in Chronic Stroke Patients with Equinovarus Foot: An Observational Study.

Spastic equinovarus (SEV) foot deformity is commonly observed in patients with post-stroke spasticity. Tibialis posterior (TP) is a common target for botulinum toxin type-A (BoNT-A) injection, as a first-line treatment in non-fixed SEV deformity. For this deep muscle, ultrasonographic guidance is crucial to achieving maximum accuracy for the BoNT-A injection. In current clinical practice, there are three approaches to target the TP: an anterior, a posteromedial, and a posterior. To date, previous studies have failed to identify the best approach for needle insertion into TP. To explore the ultrasonographic characteristics of these approaches, we investigated affected and unaffected legs of 25 stroke patients with SEV treated with BoNT-A. We evaluated the qualitative (echo intensity) and quantitative (muscle depth, muscle thickness, overlying muscle, subcutaneous tissue, cross-sectional area) ultrasound characteristics of the three approaches for TP injection. In our sample, we observed significant differences among almost all the parameters of the three approaches, except for the safety window. Moreover, our analysis showed significant differences in cross-sectional area between treated and untreated. Advantages and disadvantages of each approach were investigated. Our findings can thus provide a suitable reference for clinical settings, especially for novice operators.

User-centered practices in the eyes of informal caregivers of in-patients with severe acquired brain injury: needs, caring experience, and satisfaction.

OBJECTIVE: This study examines the perceived needs, experience, and satisfaction of informal caregivers (ICGs) in in-hospital settings, related to their involvement in the design and delivery of services together with hospital staff, namely co-production. DESIGN: To obtain a picture of current ICG-staff relationship, a multicenter observational study was carried out. Participants were 75 ICGs recruited in five dedicated in-patient neurorehabilitation wards. Participants answered a self-report questionnaire tapping perceived information/communication needs, emotional/social needs, and their satisfaction; family-centered practices implemented by the staff (namely involving practices and cooperative communication); and ICGs' satisfaction with the service. RESULTS: Need satisfaction related positively to staff practices aimed at involving IGCs in treatment and training, but not in decision-making. Involving practices concerning treatment also related positively to ICGs' information/communication needs. In addition, the more the staff involved ICGs in decision-making and promoted cooperative communication regarding treatment, the more ICGs felt that their collaboration in the healthcare process was valuable. Finally, all involvement practices and cooperative communication were positively related to ICGs' overall satisfaction with the service. CONCLUSION: The results of the study help to identify gaps in meeting ICGs' needs and to promote strategies to implement family participation toward co-production in in-hospital settings.

The Effect of Robotic Assisted Gait Training With Lokomat® on Balance Control After Stroke: Systematic Review and Meta-Analysis.

Introduction: Disturbances of balance control are common after stroke, affecting the quality of gait and increasing the risk of falls. Because balance and gait disorders may persist also in the chronic stage, reducing individual independence and participation, they represent primary goals of neurorehabilitation programs. For this purpose, in recent years, numerous technological devices have been developed, among which one of the most widespread is the Lokomat®, an actuated exoskeleton that guide the patient's limbs, simulating a symmetrical bilateral gait. Preliminary evidence suggests that beyond gait parameters, robotic assisted gait training may also improve balance. Therefore, the aim of this systematic review was to summarize evidence about the effectiveness of Lokomat® in improving balance in stroke patients. Methods: Randomized controlled trials published between January 1989 and August 2020, comparing Lokomat® training to conventional therapy for stroke patients, were retrieved from seven electronic databases. Balance, assessed by means of validated clinical scales, was considered as outcome measure. The Physiotherapy Evidence Database (PEDro) scale was used to evaluate the methodological quality of the studies. The study protocol was registered on PROSPERO (no. CRD42020197531). Results: After the removal of the duplicates, according to the inclusion criteria, 13 studies were selected, involving 445 subacute or chronic stroke patients. Eleven papers contributed to three meta-analyses. Favorable results for recovery of balance in stroke survivors treated with Lokomat® were shown using Timed Up and Go (pooled mean difference = -3.40, 95% CI -4.35 to -2.44; p < 0.00001) and Rivermead Mobility Index as outcome measures (pooled mean difference = 0.40, 95% CI 0.26-0.55; p < 0.00001). Inconclusive results were found when balance was measured by means of the Berg Balance Scale (pooled mean difference = 0.17, 95% CI -0.26 to 0.60; p = 0.44). Conclusions: Overall, most studies have shown beneficial effects of Lokomat® on balance recovery for stroke survivors, at least comparable to conventional physical therapy. However, due to the limited number of studies and their high heterogeneity, further research is needed to draw more solid and definitive conclusions.

Localized muscle vibration in the treatment of motor impairment and spasticity in post-stroke patients: a systematic review.

INTRODUCTION: During the last decades, many studies have been carried out to understand the possible positive effects of vibration therapy in post-stroke rehabilitation. In particular, the use of localized muscle vibration (LMV) seems to have promising results. The aim of this systematic review was to describe the use of LMV in post-stroke patients to improve motor recovery, reducing spasticity and disability in both upper and lower limb. EVIDENCE ACQUISITION: A search was conducted on PubMed, Scopus, Pedro and REHABDATA electronic database. Only randomized controlled trials have been included, excluding no-localized vibratory treatments and other pathological conditions. Fourteen studies met the inclusion criteria and were included in this review. EVIDENCE SYNTHESIS: Collectively, the studies involved 425 stroke patients. Most studies included chronic stroke patients (ten) and treated only the upper limb (eleven). There is evidence that LMV therapy is effective in reducing spasticity and improving motor recovery, especially when associated with conventional physical therapy. CONCLUSIONS: LMV may be a feasible and safe tool to be integrated into traditional and conventional neurorehabilitation programs for post-stroke patients to reduce spasticity. Analysis of the available clinical trials do not allow us to indicate vibration therapy as effective in functional motor recovery, despite some studies showed encouraging results. Further studies, with larger size of homogeneous patients and with a shared methodology are needed to produce more reliable data, especially on the lower limb.

Healthcare-Associated Infections in Subjects With Severe Acquired Brain Injury: The Effect of Microbial Colonization on the Functional Outcome. Data From a Multicenter Observational Study.

Background: Hospital-acquired infections (HAIs) and microbial colonization are a worldwide serious threat for human health. Neurological patients with infections who undergo rehabilitation have a significantly poor recovery. The effect of microbial colonization on the functional outcome in severe acquired brain injury (sABI) subjects is still unclear. Aim: The aim of this multicenter observational study was to describe the clinical impact of HAIs and colonization on the functional outcome of sABI subjects admitted to inpatient neurorehabilitation. Methods: Patients were assigned to three groups: infected (INF), not infected (noINF), and colonized (COL). The Glasgow Coma Scale (GCS), the Rancho Los Amigos Levels of Cognitive Functioning Scale, Disability Rating Scale, and modified Barthel Index (mBI) assessments were performed both at admission and discharge. Results: Two hundred sixty-five (92 female/173 male) patients were enrolled: 134 were assigned to INF, 63 to COL, and 68 to noINF. In the INF group, 231 culture specimens were found positive for bloodstream (44.2%), respiratory tract (25.5%), urinary tract (18.6%), gastrointestinal tract (8.3%), skin (3%), and cerebrospinal fluid (0.4%) infections. After rehabilitation, all groups showed a significant improvement in all assessment tests, except for the noINF group that did not show any improvement in GCS. Both noINF and COL groups showed a significantly higher gain in mBI than the INF group (p = 0.000). The COL group showed a significantly higher gain than the noINF group in GCS (p = 0.001). A significantly lower improvement was detected in the INF group than the COL and noINF groups. The rate of patients who needed functional isolation was higher in the INF group than the COL group. Length of stay (LOS) (in days) was 56 ± 50.7, 88.3 ± 55, and 101.3 ± 73.6 for noINF, INF, and COL groups, respectively. The number of deaths in the INF group was significantly higher (24.6%) than the noINF group (7.4%) (p = 0.005) and comparable to the COL group (19%). Conclusion: Colonized sABI patients obtained a similar functional outcome to that of subjects who had no infections, even if they needed a significantly higher LOS.

Caregivers' engagement during in-hospital care of sABI's patients: Evaluation of informal co-production from the health providers' perspective.

One of the challenges of providing healthcare services is to enhance its value (for patients, staff and the service) by integrating the informal caregivers into the care process, both concretely managing their patient's health conditions and treatment (co-executing) and participating in the whole healthcare process (co-planning). This study aims at exploring the co-production contribution to the healthcare process, analysing whether and how it is related to higher caregivers' satisfaction with service care and reduced staff burnout, in the eyes of the staff. It also investigated two possible factors supporting caregivers in their role of co-producers, namely relationship among staff and informal caregivers related to knowledge sharing (i.e. an ability determinant supporting co-production) and related to role social conflict (i.e. a willingness determinant reducing co-production). Results of a structural equation model on a sample of 119 healthcare providers employed by neurorehabilitation centers in Italy with severe acquired brain injury confirmed that knowledge sharing positively related with caregivers' co-executing and co-planning. Also, social role conflict was negatively related with co-executing but positively with co-planning. Furthermore, co-planning resulted in being unrelated to both outcomes, whereas co-executing was associated with caregivers' satisfaction, as measured by staff perceptions. Overall, our data provided initial empirical evidence supporting the ability of the determinant's contribution in allowing informal caregivers to assume an active role in both co-production domains. Furthermore, as expected, the role of conflict willingness determinant was found to be a hindering factor for co-executing but, conversely, a trigger for co-planning. This result should be considered more carefully in future studies.

Urgent Measures for the Containment of the Coronavirus (Covid-19) Epidemic in the Neurorehabilitation/Rehabilitation Departments in the Phase of Maximum Expansion of the Epidemic.

COVID-19 has rapidly become a pandemic emergency, distressing health systems in each affected country. COVID-19 determines the need for healthcare in a large number of people in an extremely short time and, like a tsunami wave, overruns emergency, infectious diseases, and pneumology departments as well as intensive care units, choking healthcare services. Rehabilitation services are also affected by this epidemic which forces radical changes both in the organization and in the operating methods. In the absence of reference literature on this issue, this report aims to provide a background documentation to support physicians and healthcare personnel involved in neurorehabilitation and rehabilitation care.

High Dosage of Botulinum Toxin Type A in Adult Subjects with Spasticity Following Acquired Central Nervous System Damage: Where Are We at?

Spasticity is a common disabling disorder in adult subjects suffering from stroke, brain injury, multiple sclerosis (MS) and spinal cord injury (SCI). Spasticity may be a disabling symptom in people during rehabilitation and botulinum toxin type A (BTX-A) has become the first-line therapy for the local form. High BTX-A doses are often used in clinical practice. Advantages and limitations are debated and the evidence is unclear. Therefore, we analysed the efficacy, safety and evidence for BTX-A high doses. Studies published from January 1989 to February 2020 were retrieved from MEDLINE/PubMed, Embase, Cochrane Central Register. Only obabotulinumtoxinA (obaBTX-A), onabotulinumtoxinA (onaBTX-A), and incobotulinumtoxinA (incoBTX-A) were considered. The term "high dosage" indicated ≥ 600 U. Thirteen studies met the inclusion criteria. Studies had variable method designs, sample sizes and aims, with only two randomised controlled trials. IncoBTX-A and onaBTX-A were injected in three and eight studies, respectively. BTX-A high doses were used predominantly in treating post-stroke spasticity. No studies were retrieved regarding treating spasticity in MS and SCI. Dosage of BTX-A up to 840 U resulted efficacious and safety without no serious adverse events (AEs). Evidence is insufficient to recommend high BTX-A use in clinical practice, but in selected patients, the benefits of high dose BTX-A may be clinically acceptable.

Vitamin D serum level in subjects with critical illness polyneuropathy and myopathy.

BACKGROUND: Critical illness polyneuropathy and myopathy (CIPNM) is a disabling neuropathy that occurs in intensive care unit (ICU) subjects. It was hypothesized that a low serum level or deficiency of 25(OH)D might be associated with CIPNM. The aim of the present study was to ascertain the 25(OH)D serum level in subjects with CIPNM. METHOD: Consecutive ICU patients admitted to neuro-rehabilitation were prospectively enrolled. At admission, vitamin D serum levels were measured and EMG examination was performed to ascertain those with CIPNM. 25(OH)D was stratified as sufficient (≥30 ng/mL) insufficient (20-29.9 ng/mL), and deficient (<20 ng/mL). RESULTS: Eighty-four patients (31 F, 53 M; mean age 51.7±12.6) were identified and 63 (21 F, 42 M) enrolled. CIPNM was detected in 38 (9 F, 29 M) patients. A deficient mean serum level of vitamin D was observed in the whole population: 18.1 ± 9.2 ng/mL. No difference of vitamin D serum levels was detected in subjects with and without CIPNM: 17.5 ± 8.4 and 19.0 ± 10.5 ng/mL (p=0.58), respectively. CONCLUSION: Almost all subjects showed Vitamin D deficiency. No difference was detected between those with and without CIPNM. The condition might represent a secondary phenomenon resulting from the inflammatory process as well as from conditions that could interfere with vitamin D metabolism.

Botulinum Toxin Type A for the Treatment of Lower Limb Spasticity after Stroke.

Post-stroke lower limb spasticity impairs balance and gait leading to reduced walking speed, often increasing wheelchair use and caregiver burden. Several studies have shown that appropriate treatments for lower limb spasticity after stroke include injections of botulinum toxin type A (BoNT-A), phenol or alcohol, surgical correction and a rehabilitation program. In the present article, we review the safety and effectiveness of BoNT-A for the treatment of lower limb spasticity after stroke, with a focus on higher doses of BoNT-A. The cumulative body of evidence coming from the randomized clinical trials and open-label studies selected in the article suggest BoNT-A to be safe and efficacious in reducing lower limb spasticity after stroke. Studies of high doses of BoNT-A also showed a greater reduction of severe post-stroke spasticity. In stroke survivors with spasticity of the ankle plantar-flexor muscles, a combined approach between surgery and BoNT-A can be indicated. However, controversy remains about improvement in motor function relative to post-stroke spasticity reduction after BoNT-A treatment.

Rehabilitation in oldest-old stroke patients: a comparison within over 65 population.

BACKGROUND: Considering the demographic trend, characterized by a marked aging due to the increase in life expectancy and the improvement in medical care, in the next future elderly patients will represent the majority of stroke victims with a strong impact on rehabilitative services. AIM: To investigate and characterize differences in functional outcome in elderly patients after stroke. DESIGN: Observational study. SETTING: Post-acute inpatient rehabilitation. POPULATION: Subjects aged ≥65 years with acute (i.e. within 30 days from onset) ischemic or hemorrhagic stroke. METHODS: At admission, all patients underwent neurological and clinical examination, functional evaluation and laboratory assessment. Comorbidities and clinical complications during hospital stay were recorded. Functional status was evaluated by means of the Functional Independence Measure (FIM) administered at admission and discharge. All patients underwent neuromotor rehabilitation, and speech therapy in case of aphasia, once a day, six days per week. RESULTS: The study enrolled 402 patients, who were stratified in three groups according to age: 145 patients in Group 1, the young-old (65-74.9 years, G1), 206 in Group 2, the middle-old (75-84.9 years, G2) and 51 in Group 3, the oldest-old (≥85 years, G3). At discharge, FIM total scores increased significantly for all the groups (P<0.001); however FIM gains, as well as the efficiency parameters derived from FIM were significantly lower in G3 when compared with G1 and G2. G3 showed a significantly higher rate of comorbidities and a higher presence of pressure sores; infections occurred mainly in G2 and G3. Hospitalization was significantly longer for G1 and G2 with respect to G3, while mortality rates were significantly higher in G2 and G3 with respect to G1. The variables that predicted functional outcome were age, previous stroke, stroke severity and functional status at admission. CONCLUSIONS: Despite advancing age seems to be associated with a reduced effectiveness of the rehabilitation process and a greater number of complications, intensive rehabilitation can produce significant functional gains for all stroke survivors, regardless of age. CLINICAL REHABILITATION IMPACT: Understanding the specificity of this population will offer older subjects targeted interventions and, for health systems, better allocation of resources and the development of more effective approaches.

The Role of Rehabilitation in Patients With Progressive Supranuclear Palsy: A Narrative Review.

Progressive supranuclear palsy (PSP) is a progressive neurodegenerative disorder caused by the deposition of abnormal proteins in neurons of the basal ganglia that limit motor ability, resulting in disability and reduced quality of life. So far, no pharmacologic therapy has been developed, and the treatment remains symptomatic. The aim of the present study is to perform a systematic investigation of the literature, and to determine the types and effects of rehabilitative interventions used for PSP. A search of all studies was conducted in MEDLINE/PubMed, the Cochrane Central Register of Controlled Trials, CINAHL, and EMBASE. Twelve studies were identified, including 6 case reports, 3 case series, one case-control study, one quasi-randomized trial (i.e. not truly random) with crossover design, and one randomized controlled trial, with 88 patients investigated overall. Rehabilitative interventions varied in type, number, frequency, and duration of sessions. The most commonly used clinical measures were the Progressive Supranuclear Palsy Rating Scale (PSPRS) and Unified Parkinson's Disease Rating Scale (UPDRS). Physical exercises were the main rehabilitative strategy but were associated with other interventions and rehabilitative devices, in particular treadmill and robot-assisted gait training. All studies showed an improvement in balance and gait impairment with a reduction of falls after rehabilitation treatment. Because of poor methodological quality and the variety of rehabilitative approaches including different and variable strategies, there was insufficient evidence of the effectiveness of any specific rehabilitation intervention in PSP. Despite this finding, rehabilitation might improve balance and gait, thereby reducing falls in PSP patients. LEVEL OF EVIDENCE: IV.