Upper Limbs Muscle Co-Contraction Changes Correlate With The Physical Motor Impairments in CMT.

Background: Subjects with Charcot-Marie-Tooth (CMT) disease show hands impairment which is a relevant problem affecting the quality of life. This symptom is related to muscle weakness and reduced motor coordination of the upper limb. However, most studies focus on lower limb impairment, therefore the investigation of upper limb disability is necessary to identify biomarkers able to monitor disease-specific features and to tailor rehabilitation. Objective: This study aimed at characterizing upper limb muscle co-contraction using the co-contraction index (CCI) in CMT population. Methods: Upper limb kinematic and electromyography (EMG) data were collected from fourteen CMT subjects (6-CMT1A and 8-CMT1X) during motor tasks typical of daily living activities. Rudolph's CCI was used to quantify muscle co-contraction of four muscle pairs acting on shoulder, elbow and wrist. All CMT subjects underwent clinical examination. Thirteen healthy subjects served as the normative reference (HC). Results: CMT1X and CMT1A showed a significant reduction in CCI for distal and proximal muscle pairs compared to HC. Furthermore, CMT1A showed greater values of CCI compared to CMT1X mainly for the axial and axial-to-proximal muscle pairs. Movement speed and smoothness were not altered compared to HC. In addition, EMG metrics showed moderate-to-strong significant correlations with clinical outcomes. Conclusions: CCI was able to quantify disease-specific deficits with respect to the normative reference, highlighting motor control alterations even before motor output impairment. CCI was also sensitive in detecting CMT subtypes-based differences and adopted compensatory strategies. Our findings suggest that CCI can be an outcome measure for CMT disease monitoring and interventional studies.

Successful Treatment of Post COVID-19 Neurogenic Dysphagia with Botulinum Toxin.

Introduction: Dysphagia in post COVID-19 patients could be caused by several factors, including reduced pharyngolaryngeal coordination due to SARS-CoV-2 tropism to the central and/or peripheral nervous system. To our knowledge, this is the first reported case of COVID-19-related dysphagia successfully treated with botulinum toxin type A injection. Case description: We report the case of a patient with severe oropharyngeal dysphagia due to COVID-19 confirmed by fibre endoscopy. As a result, the patient required an enteral feeding tube. After two months of traditional swallowing therapies, there was only limited improvement. An electrophysiologic evaluation of the cricopharyngeal muscle was performed and showed a normal inhibition of the cricopharyngeal muscle, followed by a hypertonic rebound. Based on this result, we decided to perform a unilateral laryngeal injection of botulinum toxin type A. After the injection, the patient's swallowing function improved significantly, allowing him to return to oral feeding. Discussion: Newly diagnosed oropharyngeal dysphagia was found in 35.3% of hospitalised patients with COVID-19. There are several possible causes of COVID-19-associated dysphagia, including stroke, encephalitis, critical illness neuropathy, Guillain-Barré syndrome and skeletal muscle injury. In our case, since stroke was excluded by brain MRI, cranial nerve injury was a possible explanation for the difficult recovery of swallowing despite daily swallowing therapy. Conclusion: We suggest that electrophysiology is a valid tool for the diagnosis and follow-up of patients with oropharyngeal dysphagia. LEARNING POINTS: SARS-CoV-2 tropism to the central and/or peripheral nervous system can cause dysphagia in post COVID-19 patients.An electrophysiologic approach is useful for the diagnosis and follow-up of patients with oropharyngeal dysphagia.A single botulinum toxin type A injection is a valid treatment option to improve the swallowing function in patients with post COVID-19 dysphagia.

Effectiveness of a Preventative Program for Groin Pain Syndrome in Elite Youth Soccer Players: A Prospective, Randomized, Controlled, Single-Blind Study.

Groin pain syndrome (GPS) is a prevalent issue in soccer. This study assessed the effectiveness of a new preventive protocol on GPS for youth soccer players. The protocol included targeted stretching and strengthening exercises for the adductor and core muscles from preseason to midseason. A questionnaire and two pain provocation tests were used for the evaluation. Mild GPS required positive results in at least two evaluations, while severe GPS was associated with pain incompatible with engagement in any activity confirmed by diagnostic ultrasound. Forty-two elite male athletes (aged 16.9 ± 0.7 years) participated in the study, with half of them assigned to the usual training (control group) and the remaining athletes undergoing the preventive protocol (treatment group) for 24 weeks. GPS rates were 14.3% (three diagnoses: two mild, one severe) in the treatment group and 28.6% (six diagnoses: three mild, three severe) in the control group. Toward the end of the season, three players, one from the treatment group and two from the control group had to stop playing due to severe GPS problems. In addition, one player in the control group stopped midseason. Even though the reduction in the risk of developing GPS was not significant (relative risk of 0.50 ([95%CI 0.14 to 1.74], p = 0.2759), the halved incidence of severe GPS and the increased muscle strength related to the treatment (p = 0.0277) are encouraging data for future studies.

Useful outcome measures in INPH patients evaluation.

Introduction: Idiopathic normal pressure hydrocephalus (INPH) is a neurological disorder that is potentially reversible and clinically characterized by a specific triad of symptoms, including gait disturbance, cognitive disorders, and urinary incontinence. In INPH assessment, the most commonly used test is the Timed Up and Go test (TUG), but a more comprehensive assessment would be necessary. The first aim of the present study is to verify the sensitivity of a protocol with both clinical and instrumental outcome measures for gait and balance in recognizing INPH patients. The second aim is to verify the most important spatio-temporal parameters in INPH assessment and their possible correlations with clinical outcome measures. Methods: Between January 2019 and June 2022, we evaluated 70 INPH subjects. We assessed balance performances with the Berg Balance Scale (BBS), Short Physical Performance Battery (SPPB), and TUG, both single (ST) and dual task (DT). We also performed an instrumental gait assessment with the GAITRite electronic walkway system, asking the patients to walk on the carpet for one minute at normal speed, fast speed, and while performing a dual task. We compared the results with those of 20 age-matched healthy subjects (HS). Results: INPH patients obtained statistically significant lower scores at the BBS, SPPB, and TUG DT but not at the TUG ST, likely because the DT involves cognitive factors altered in these subjects. Concerning instrumental gait evaluation, we found significant differences between HS and INPH patients in almost all spatio-temporal parameters except cadence, which is considered a relevant factor in INPH guidelines. We also found significant correlations between balance outcome measures and gait parameters. Discussion: Our results confirm the usefulness of BBS and suggest improving the assessment with SPPB. Although the TUG ST is the most commonly used test in the literature to evaluate INPH performances, it does not identify INPH; the TUG DT, instead, might be more useful. The GAITRite system is recognized as a quick and reliable tool to assess walking abilities and spatio-temporal parameters in INPH patients, and the most useful parameters are stride length, stride width, speed, and the percentage of double support. Both clinical and instrumental evaluation may be useful in recognizing subjects at risk for falls.

Increasing the Passive Range of Joint Motion in Stroke Patients Using Botulinum Toxin: The Role of Pain Relief.

By blocking the release of neurotransmitters, botulinum toxin A (BoNT-A) is an effective treatment for muscle over-activity and pain in stroke patients. BoNT-A has also been reported to increase passive range of motion (p-ROM), the decrease of which is mainly due to muscle shortening (i.e., muscle contracture). Although the mechanism of action of BoNT-A on p-ROM is far from understood, pain relief may be hypothesized to play a role. To test this hypothesis, a retrospective investigation of p-ROM and pain was conducted in post-stroke patients treated with BoNT-A for upper limb hypertonia. Among 70 stroke patients enrolled in the study, muscle tone (Modified Ashworth Scale), pathological postures, p-ROM, and pain during p-ROM assessment (Numeric Rating Scale, NRS) were investigated in elbow flexors (48 patients) and in finger flexors (64 patients), just before and 3-6 weeks after BoNT-A treatment. Before BoNT-A treatment, pathological postures of elbow flexion were found in all patients but one. A decreased elbow p-ROM was found in 18 patients (38%). Patients with decreased p-ROM had higher pain-NRS scores (5.08 ± 1.96, with a pain score ≥8 in 11% of cases) than patients with normal p-ROM (0.57 ± 1.36) (p < 0.001). Similarly, pathological postures of finger flexion were found in all patients but two. A decreased finger p-ROM was found in 14 patients (22%). Pain was more intense in the 14 patients with decreased p-ROM (8.43 ± 1.74, with a pain score ≥ 8 in 86% of cases) than in the 50 patients with normal p-ROM (0.98 ± 1.89) (p < 0.001). After BoNT-A treatment, muscle tone, pathological postures, and pain decreased in both elbow and finger flexors. In contrast, p-ROM increased only in finger flexors. The study discusses that pain plays a pivotal role in the increase in p-ROM observed after BoNT-A treatment.

Flexion-extension strength of the index-thumb system in Italian population. A cross-sectional study to gather normative data.

STUDY DESIGN: Cross-sectional study. INTRODUCTION: Flexion (Palmar Pinch, PP-MVC and Tip Pinch, TP-MVC) and extension (E-MVC) maximal voluntary contraction (MVC) of the index-thumb system offers a quick way to estimate the level of hands' impairment in several musculoskeletal and neurologic conditions. PURPOSE OF THE STUDY: This study established normative data of PP-MVC, TP-MVC, E-MVC in the Italian population and evaluated their correlation with hand dominance, anthropometric factors, dexterity and workload level. METHODS: In our study, 303 healthy people (150F, 153M) were recruited. Participants performed PP-MVC, TP-MVC and E-MVC tests per hand, conducted by using a pinch-gauge. T-test was used to analyze MVC means between sexes and between hands. One-way ANOVA was conducted to compare MVC means in male and female samples stratified by age (18-29, 30-44, 45-59, 60-74, +75). Spearman's correlation analysis was performed to determine anthropometric variables, dexterity and workload level effects on MVCs. RESULTS: Medium-to-large effect sizes of age were shown in the majority of tasks. The 30 to 44 years and then +75 years age groups showed the highest and the lowest values, respectively, for both sex and both hands. Men were meanly 50% stronger, and the dominant hand showed higher values (6-10%). MVC-tests correlated moderately with weight and height weakly with dexterity and workload level. CONCLUSIONS: After 30 to 44 years, hand strength declines in line with the normal process of aging that also entails muscle fibers and the reduction of daily activities in older adults. In relative terms, E-MVC showed the highest strength loss in the over 75 seconds. The difference between sexes was higher in E-MVC than in flexion MVCs. E-MVC seems to depend more on musculoskeletal architecture that differs from women to men, according to the highest correlation between E-MVC and anthropometric variables. Only high workload levels impacted hand strength. In heaviest occupations, no PP-MVCs differences were observed between hands.

The Effect of Verbal Encouragement on Performance and Muscle Fatigue in Swimming.

Background and Objectives: Verbal encouragement (VE) can be used to enhance performance in several sports, even though no studies have been conducted among swimmers and only a few effects have been reported in elite athletes. Besides influencing motor performance, VE is also known to enhance the physical load, thus potentially increasing the probability of developing fatigue. With this in mind, this study aimed to explore the effects of VE in swimmers in order to fill in the knowledge gap concerning the aquatic environment. Materials and Methods: Each athlete swam a maximal 200 m freestyle trial under two different conditions: one trial with VE and the other without VE. The two main outcome measures were: (1) performance velocity (m/s); and (2) muscle fatigue, investigated by means of surface electromyography. Sixty swimmers were recruited, aged 18.63 ± 3.46 years (median 18 years), 28 men (47%), and 32 women (53%), with 7.03 ± 3.9 years of experience. Results: With VE, performance significantly improved in the swim trial (p < 0.001, effect size (ES) −0.95, large). When breaking the results down into the first half (first (0−100 m) vs. the second half (100−200 m)), the ES was large in the first part (−1.11), indicating an improvement in performance. This worsened, however, in the second part of the trial (ES 0.63). In the multivariate analysis, years of experience were found to be a significant predictor of the change in overall performance (p = 0.011). There was a significant increase in muscle fatigue induced by VE, overall, and during the second half, but not during the first half of the trial. Conclusions: The present study indicates that VE during a middle-distance event (200 m) increases performance most in swimmers with little experience. However, it has a negative impact on fatigue.

A soft supernumerary hand for rehabilitation in sub-acute stroke: a pilot study.

In patients with subacute stroke, task specific training (TST) has been shown to accelerate functional recovery of the upper limb. However, many patients do not have sufficient active extension of the fingers to perform this treatment. In these patients, here we propose a new rehabilitation technique in which TST is performed through a soft robotic hand (SoftHand-X). In short, the extension of the robotic fingers is controlled by the patient through his residual, albeit minimal, active extension of the fingers or wrist, while the patient was required to relax the muscles to achieve full flexion of the robotic fingers. TST with SoftHand-X was attempted in 27 subacute stroke patients unable to perform TST due to insufficient active extension of the fingers. Four patients (14.8%) were able to perform the proposed treatment (10 daily sessions of 60 min each). They reported an excellent level of participation. After the treatment, both clinical score of spasticity and its electromyographic correlate (stretch reflex) decreased. In subacute stroke patients, TST using SoftHand-X is a well-accepted treatment, resulting in a decrease of spasticity. At present, it can be applied only in a small proportion of the patients who cannot perform conventional TST, though extensions are possible.

A tale of two stories: COVID-19 and disability. A critical scoping review of the literature on the effects of the pandemic among athletes with disabilities and para-athletes.

The still ongoing COVID-19 pandemic has dramatically impacted athletes, and, in particular, para-athletes and athletes with disabilities. However, there is no scholarly appraisal on this topic. Therefore, a critical scoping review of the literature was conducted. We were able to retrieve sixteen relevant studies. The sample size ranged from 4 to 183. Most studies were observational, cross-sectional, and questionnaire-based surveys, two studies were interventional, and two were longitudinal. One study was a technical feasibility study. Almost all studies were conducted as single-country studies, with the exception of one multi-country investigation. Five major topics/themes could be identified: namely, 1) impact of COVID-19-induced confinement on training and lifestyles in athletes with disabilities/para-athletes; 2) impact of COVID-19-induced confinement on mental health in athletes with disabilities/para-athletes; 3) impact of COVID-19-induced confinement on performance outcomes in athletes with disabilities/para-athletes; 4) risk of contracting COVID-19 among athletes with disabilities/para-athletes; and, finally, 5) impact of COVID-19 infection on athletes with disabilities/para-athletes. The scholarly literature assessed was highly heterogeneous, with contrasting findings, and various methodological limitations. Based on our considerations, we recommend that standardized, reliable tools should be utilized and new, specific questionnaires should be created, tested for reliability, and validated. High-quality, multi-center, cross-countries, longitudinal surveys should be conducted to overcome current shortcomings. Involving all relevant actors and stakeholders, including various national and international Paralympic Committees, as a few studies have done, is fundamental: community-led, participatory research can help identify gaps in the current knowledge about sports-related practices among the population of athletes with disabilities during an unprecedented period of measures undertaken that have significantly affected everyday life. Moreover, this could advance the field, by capturing the needs of para-athletes and athletes with disabilities and enabling the design of a truly "disability-inclusive response" to COVID-19 and similar future conditions/situations. Furthermore, follow-up studies on COVID-19-infected para-athletes and athletes with disabilities should be conducted. Evidence of long-term effects of COVID-19 is available only for able-bodied athletes, for whom cardiorespiratory residual alterations and mental health issues a long time after COVID-19 have been described.

A Bibliometrics-Enhanced, PAGER-Compliant Scoping Review of the Literature on Paralympic Powerlifting: Insights for Practices and Future Research.

Paralympic powerlifting (PP), formerly known as "International Paralympic Committee" (IPC) powerlifting, is the format of powerlifting adapted for athletes with disabilities, and it differs from the version for able-bodied athletes in that it consists of bench press only. According to the mandate of the IPC, PP athletes should be enabled to achieve sporting excellence. As such, rigorous evidence is needed. However, to the best of our knowledge, there exists no systematic assessment of the body of scholarly evidence in the field of PP. Therefore, the present study was conducted to fill in this gap of knowledge, by conducting a scoping review of the literature enhanced by a bibliometrics analysis and by mining two major scholarly databases (MEDLINE via PubMed and Scopus). The aim was to provide a review/summary of the findings to date to help practitioners and athletes. Thirty-seven studies were retained in the present study. These covered the following thematic areas: (i) warm-up strategies (n = 2); (ii) aspects of training (n = 2); (iii) physiological aspects and responses (n = 2); (iv) psychological aspects and responses (n = 2); (v) biomechanics of bench press (n = 8); (vi) recovery strategy (n = 5); (vii) impact of the disability and type of disability (n = 4); (viii) epidemiology of PP (n = 6); and (ix) new analytical/statistical approaches for kinematics assessments, internal load monitoring, and predictions of mechanical outputs in strength exercises and in PP (n = 6). Bibliometrics analysis of the PP-related scientific output revealed that, despite having already become a paralympic sports discipline in 1984, only in the last few years, PP has been attracting a lot of interest from the community of researchers, with the first scholarly contribution dating back to 2012, and with more than one-third of the scientific output being published this year (2022). As such, this scholarly discipline is quite recent and young. Moreover, the community dealing with this topic is poorly interconnected, with most authors contributing to just one article, and with one single author being a hub node of the author network. Distributions of the number of articles and the authors/co-authors were found to be highly asymmetrical, indicating that this research is still in its infancy and has great room as well as great potential to grow. Reflecting this, many research topics are also overlooked and underdeveloped, with the currently available evidence being based on a few studies.

Nabiximols effect on blood pressure and heart rate in post-stroke patients of a randomized controlled study.

Background: Cannabinoids may be useful to treat pain, epilepsy and spasticity, although they may bear an increased risk of cardiovascular events. This study aims to evaluate the cardiovascular safety of nabiximols, a cannabis-based drug, in patients with spasticity following stroke, thus presenting an increased cardiovascular risk. Methods: This is an ancillary study stemming from the SativexStroke trial: a randomized double-blind, placebo-controlled, crossover study aimed at assessing the effect of nabiximols on post-stroke spasticity. Patients were treated with nabiximols oromucosal spray or placebo and assessed before and after two phases of 1-month duration each. Only the phase with the active treatment was considered for each patient who completed the study. The average values of blood pressure (diastolic, systolic, differential) and heart rate from the first 5 days of the phase (lowest nabiximols dosage) were compared to the average values recorded during the last 5 days at the end of the phase (highest nabiximols dosage). Baseline comparisons between gender, stroke type and affected side and correlation between age and blood pressure and heart rate were performed. The study was registered with the EudraCT number 2016-001034-10. Results: Thirty-four patients completed the study and were included in the analysis. Thirty-one were taking antihypertensive drugs and, among these, 12 were taking beta-blockers. During the study, no arrhythmic events were recorded, blood pressure and heart rate did not show pathological fluctuations, and no cardiovascular or cerebrovascular events occurred. At baseline blood pressure and heart rate were comparable concerning gender, stroke type and affected side. A significant direct correlation emerged between differential blood pressure and age and an inverse correlation between diastolic blood pressure and age. No correlation emerged between systolic blood pressure or heart rate and age. Blood pressure and heart rate did not change during nabiximols treatment compared to the baseline condition. Conclusion: This ancillary study adds evidence that, in patients who already underwent a cerebrovascular accident, nabiximols does not determine significant blood pressure and heart rate variation or cardiovascular complications. These data support the cardiovascular safety of nabiximols, encouraging more extensive studies involving cannabinoids characterized by slow absorption rates.

Quality of life and upper limb disability in Charcot-Marie-Tooth disease: A pilot study.

Charcot-Marie-Tooth (CMT) patients present mainly lower limbs disability, with slowly progressive distal muscle weakness and atrophy, but hands impairment is a relevant problem affecting the quality of life (QoL). The evaluation of the upper limb is of primary importance. Often these patients present subclinical disorders or report difficulties in manipulating objects, with little evidence in the most used outcome measures. We aim to investigate the impact of hand impairment in the perceived QoL of CMT persons and secondly whether the Disability of Arm, Shoulder and Hand (DASH) scale can be useful in assessing upper limb abilities in CMT. We recruited 23 patients with confirmed genetic diagnosis of CMT. We performed a clinical evaluation with Sollerman Hand Function Test (SHFT), Thumb Opposition Test (TOT) and CMT examination score (CMTES). We completed the clinical assessment with DASH scale and the Short form 36 (SF36) questionnaire for a subjective evaluation of upper limb disability and quality of life. All patients also underwent an instrumental evaluation with a hand-held dynamometer measuring hand grip and tripod pinch and a sensor-engineered glove test (SEGT) to evaluate finger opposition movements in a quantitative spatial-temporal way. As expected, we found significant differences between CMT and control group performances in both clinical and instrumental assessment. Concerning QoL, we found that total score of SF36 and the SF36 Physical Composite Score (PCS) correlate with all clinical and instrumental Outcome Measures (OMs), particularly with Tripod pinch strength and TOT, which are considered major determinants of manual dexterity in CMT. DASH scale correlates with most clinical and instrumental OMs. Not surprisingly, we also found a correlation with DASH work, because CMT affects young patients engaged in work activities. However, we found a low correlation with the TOT and the dynamometer suggesting that DASH may not be the best scale for remote monitoring of upper limb disorders in CMT patients. Nevertheless, the results of our study confirm the usefulness of SF36 in recognizing the impact of upper limb disability in these subjects suggesting its use even in the remote monitoring of physical functioning.

Shear wave elastography combined with electromyography to assess the effect of botulinum toxin on spastic dystonia following stroke: A pilot study.

Background: Shear wave elastography (SWE) is a method for carrying out a quantitative assessment of the mechanical properties of soft tissues in terms of stiffness. In stroke survivors, the paretic muscles may develop hypertonia due to both neural-mediated mechanisms and structural alterations with consequent muscular fibrous-fatty remodeling. Methods: Fourteen adult patients with spastic dystonia following stroke were recruited. Muscle hypertonia was assessed using the modified Ashworth scale (MAS). Muscle activation was measured by surface electromyography (sEMG) with the selected muscle in shortened (spastic dystonia) and stretched (dynamic stretch reflex) positions. SWE was performed on a selected paretic muscle and on the contralateral non-paretic one to calculate shear wave velocities (SWV) along and across muscular fibers. The modified Heckmatt scale (MHS) pattern was also determined. All evaluations were performed shortly before BoNT-A injections (T0) and one month later (T1). Results: All SWV on paretic muscles were higher than contralateral non-paretic ones (p < 0.01). After BoNT-A injection, a significant reduction in MAS (p = 0.0018), spastic dystonia (p = 0.0043), and longitudinal SWE measurements, both in shortened (p = 0.001) and in stretched muscular conditions (p = 0.0029), was observed. No significant changes in SWV on non-paretic muscles were observed. Higher SWV resulted along the direction of muscular fibers vs. across them (p = 0.001). No changes resulted from the MHS evaluations after BoNT-A. There was a positive correlation between MHS scores and SWV values while the muscle was in the shortened position, but not with spastic dystonia recorded by sEMG. Conclusions: This is the first study evaluating the effect of BoNT-A on muscle hypertonia following stroke, assessed by both SWE and sEMG. These findings support SWE as a useful method to disclose intrinsic muscular remodeling, independently of the effect of spastic dystonia, in particular, while muscles were assessed in a neutral position. SWE measurements of muscle stiffness cannot tell apart neural-mediated and intrinsic muscle hypertonia. Interestingly, when sEMG activity is very limited, as in spastic muscles kept in a shortened position, SWE can provide a measurement of stiffness due almost completely to intrinsic muscle changes. Alongside sEMG, SWE could aid clinicians in the assessment of responses to treatments.

Swimming and the human microbiome at the intersection of sports, clinical, and environmental sciences: A scoping review of the literature.

The human microbiota is comprised of more than 10-100 trillion microbial taxa and symbiotic cells. Two major human sites that are host to microbial communities are the gut and the skin. Physical exercise has favorable effects on the structure of human microbiota and metabolite production in sedentary subjects. Recently, the concept of "athletic microbiome" has been introduced. To the best of our knowledge, there exists no review specifically addressing the potential role of microbiomics for swimmers, since each sports discipline requires a specific set of techniques, training protocols, and interactions with the athletic infrastructure/facility. Therefore, to fill in this gap, the present scoping review was undertaken. Four studies were included, three focusing on the gut microbiome, and one addressing the skin microbiome. It was found that several exercise-related variables, such as training volume/intensity, impact the athlete's microbiome, and specifically the non-core/peripheral microbiome, in terms of its architecture/composition, richness, and diversity. Swimming-related power-/sprint- and endurance-oriented activities, acute bouts and chronic exercise, anaerobic/aerobic energy systems have a differential impact on the athlete's microbiome. Therefore, their microbiome can be utilized for different purposes, including talent identification, monitoring the effects of training methodologies, and devising ad hoc conditioning protocols, including dietary supplementation. Microbiomics can be exploited also for clinical purposes, assessing the effects of exposure to swimming pools and developing potential pharmacological strategies to counteract the insurgence of skin infections/inflammation, including acne. In conclusion, microbiomics appears to be a promising tool, even though current research is still limited, warranting, as such, further studies.

Cannabinoid Effect and Safety in Spasticity Following Stroke: A Double-Blind Randomized Placebo-Controlled Study.

Background: Nabiximols is a cannabis-based drug to treat spasticity-associated symptoms currently approved for patients with multiple sclerosis only. Cannabinoids are useful in an increasing number of medical conditions but may bear an increased risk for cardiovascular events. SativexStroke is a double-blind randomized placebo-controlled crossover monocentric clinical trial investigating the efficacy and safety of nabiximols in patients with spasticity following stroke. Methods: Patients were treated with nabiximols oromucosal spray or placebo and assessed before and after two phases of 1-month duration each. Cardiovascular safety was assessed before and during the trial. Primary endpoints were changes in spasticity numeric rating scale scores and electromyographic recording of the stretch reflex in affected wrist flexors. Secondary outcome measures were numeric rating scale scores for pain, sleep and bladder function, the number of daily spasms and clinical assessment of spasticity with the modified Ashworth scale. The study was registered with the EudraCT number 2016-001034-10. Results: Between May 2, 2018, and February 20, 2020, 41 patients entered the study. Seven patients did not complete the study, so 34 were included in the analysis. Two serious adverse events occurred, but none related to cardiovascular function. Primary and secondary efficacy outcome measures did not change from baseline during nabiximols treatment relative to placebo. Conclusion: This study suggests that nabiximols use is probably safe in stroke patients, therefore cannabinoid usefulness may be further investigated. The lack of nabiximols effect could be related to low pain levels in recruited patients or different spasticity mechanisms between post-stroke and multiple sclerosis patients. Similarly, a beneficial effect of nabiximols could have emerged if more patients with a higher level of spasticity at baseline were recruited. Clinical Trial Registration: https://www.clinicaltrialsregister.eu/ctr-search/trial/2016-001034-10/IT.

Not all Forms of Muscle Hypertonia Worsen With Fatigue: A Pilot Study in Para Swimmers.

In hypertonic muscles of patients with upper motor neuron syndrome (UMNS), investigation with surface electromyography (EMG) with the muscle in a shortened position and during passive muscle stretch allows to identify two patterns underlying hypertonia: spasticity and spastic dystonia. We recently observed in Para swimmers that the effect of fatigue on hypertonia can be different from subject to subject. Our goal was, therefore, to understand whether this divergent behavior may depend on the specific EMG pattern underlying hypertonia. We investigated eight UMNS Para swimmers (five men, mean age 23.25 ± 3.28 years), affected by cerebral palsy, who presented muscle hypertonia of knee flexors and extensors. Muscle tone was rated using the Modified Ashworth Scale (MAS). EMG patterns were investigated in rectus femoris (RF) and biceps femoris (BF) before and after two fatiguing motor tasks of increasing intensity. Before the fatiguing tasks, two subjects (#2 and 7) had spasticity and one subject (#5) had spastic dystonia in both RF and BF. Two subjects (#3 and 4) showed spasticity in RF and spastic dystonia in BF, whereas one subject (#1) had spasticity in RF and no EMG activity in BF. The remaining two subjects (#6 and 8) had spastic dystonia in RF and no EMG activity in BF. In all the 16 examined muscles, these EMG patterns persisted after the fatiguing tasks. Spastic dystonia increased (p < 0.05), while spasticity did not change (p > 0.05). MAS scores increased only in the muscles affected by spastic dystonia. Among the phenomena possibly underlying hypertonia, only spastic dystonia is fatigue-dependent. Technical staff and medical classifiers should be aware of this specificity, because, in athletes with spastic dystonia, intense and prolonged motor activity could negatively affect competitive performance, creating a situation of unfairness among Para athletes belonging to the same sports class.

Electromyographic Patterns of Paratonia in Normal Subjects and in Patients with Mild Cognitive Impairment or Alzheimer's Disease.

BACKGROUND: Information on prevalence, pathophysiology, and clinical assessment of paratonia are scarce. In a previous study, we suggested that surface electromyography (EMG) can be used to assess paratonia. OBJECTIVE: To assess clinical and EMG features of paratonia in both patients with cognitive impairment and healthy subjects. METHODS: We examined 18 patients with Alzheimer's disease (AD), 21 patients with mild cognitive impairment (MCI), 30 healthy seniors (seniors), and 30 healthy juniors (juniors). Paratonia was assessed using the "Paratonia Scale". EMG bursts were recorded from biceps and triceps during manually applied passive movements of elbow joint. Continuous (sinusoidal) and discontinuous (linear) movements were applied at 2 different velocities (fast and slow). RESULTS: In comparison to juniors, seniors had higher clinical scores. In comparison to seniors, AD had higher oppositional scores, while MCI had higher facilitatory scores. EMG activity during passive movements correlated with paratonia clinical scores, was velocity-dependent and increased with movement repetition, most effectively for sinusoidal movements. Similar EMG activity was detected in not paratonic muscles. CONCLUSION: Paratonia increases with normal aging and cognitive decline progression. While facilitatory paratonia is due to involuntary contraction of the shortening muscle, oppositional paratonia is due, at least partially, to involuntary contraction of the lengthening muscle. Most characteristic feature of this muscle contraction is the progressive increase with movement repetition, that helps distinguish oppositional paratonia from spasticity and rigidity. A similar EMG activity is detected in not paratonic muscles, showing that, during tone assessment, the descending motor system is incompletely inactivated also in normotonic muscles.

Muscle Fatigue and Swimming Efficiency in Behind and Lateral Drafting.

Drafting in swimming is a tactic in which an athlete (drafter) swims in the wave of another athlete (leader). Our aim was to compare the effects of this tactic on the drafter, as far as muscle fatigue, muscle activity, and swimming efficiency are concerned. Fifteen drafters performed three 200 m front crawl trials at a controlled submaximal pace in three configurations: Behind Drafting (BD), Lateral Drafting (LD), and Free Swimming (FS). Muscle fatigue, muscle activity, and swimming efficiency were obtained by surface electromyography (EMG) and video analysis from flexor carpi radialis, triceps brachii, latissimus dorsi, and rectus femoris muscles. The outcome measures were: time slope of Mean Frequency (MNF), for muscle fatigue; time slope of Root Mean Square (RMS), for muscle activity; and Stroke Index (SI) for swimming efficiency. Negative variations of MNF were 5.1 ± 1.7%, 6.6 ± 4.1%, and 11.1 ± 2.7% in BD, LD, and FS, respectively. Statistical significance was found for all cases except for the rectus femoris. Positive variations of RMS were 3.4 ± 1.2%, 4.7 ± 2.7%, and 7.8 ± 4.6% in BD, LD, and FS, respectively. Statistical significance was found only for the slopes of latissimus dorsi in FS and LD. The largest mean in SI was measured in the BD (2.01 m2/s), while the smallest was measured in the FS (1.86 m2/s). BD was found to be the best swimming configuration, in terms of lower muscle fatigue and higher swimming efficiency. Also, LD resulted to be advantageous with respect to FS.

Genetic Workup for Charcot-Marie-Tooth Neuropathy: A Retrospective Single-Site Experience Covering 15 Years.

Charcot-Marie-Tooth (CMT) disease is the most commonly inherited neurological disorder. This study includes patients affected by CMT during regular follow-ups at the CMT clinic in Genova, a neuromuscular university center in the northwest of Italy, with the aim of describing the genetic distribution of CMT subtypes in our cohort and reporting a peculiar phenotype. Since 2004, 585 patients (447 index cases) have been evaluated at our center, 64.9% of whom have a demyelinating neuropathy and 35.1% of whom have an axonal neuropathy. A genetic diagnosis was achieved in 66% of all patients, with the following distribution: CMT1A (48%), HNPP (14%), CMT1X (13%), CMT2A (5%), and P0-related neuropathies (7%), accounting all together for 87% of all the molecularly defined neuropathies. Interestingly, we observe a peculiar phenotype with initial exclusive lower limb involvement as well as lower limb involvement that is maintained over time, which we have defined as a "strictly length-dependent" phenotype. Most patients with this clinical presentation shared variants in either HSPB1 or MPZ genes. The identification of distinctive phenotypes such as this one may help to address genetic diagnosis. In conclusion, we describe our diagnostic experiences as a multidisciplinary outpatient clinic, combining a gene-by-gene approach or targeted gene panels based on clinical presentation.