Secondary neurodegeneration following Stroke: what can blood biomarkers tell us?

Stroke is one of the leading causes of death and the primary source of disability in adults, resulting in neuronal necrosis of ischemic areas, and in possible secondary degeneration of regions surrounding or distant to the initial damaged area. Secondary neurodegeneration (SNDG) following stroke has been shown to have different pathogenetic origins including inflammation, neurovascular response and cytotoxicity, but can be associated also to regenerative processes. Aside from focal neuronal loss, ipsilateral and contralateral effects distal to the lesion site, disruptions of global functional connectivity and a transcallosal diaschisis have been reported in the chronic stages after stroke. Furthermore, SNDG can be observed in different areas not directly connected to the primary lesion, such as thalamus, hippocampus, amygdala, substantia nigra, corpus callosum, bilateral inferior fronto-occipital fasciculus and superior longitudinal fasciculus, which can be highlighted by neuroimaging techniques. Although the clinical relevance of SNDG following stroke has not been well understood, the identification of specific biomarkers that reflect the brain response to the damage, is of paramount importance to investigate in vivo the different phases of stroke. Actually, brain-derived markers, particularly neurofilament light chain, tau protein, S100b, in post-stroke patients have yielded promising results. This review focuses on cerebral morphological modifications occurring after a stroke, on associated cellular and molecular changes and on state-of-the-art of biomarkers in acute and chronic phase. Finally, we discuss new perspectives regarding the implementation of blood-based biomarkers in clinical practice to improve the rehabilitation approaches and post stroke recovery.

Is mirror therapy associated with progressive muscle relaxation more effective than mirror therapy alone in reducing phantom limb pain in patients with lower limb amputation?

Mirror therapy is a widely used treatment for phantom limb pain (PLP) relief in patients with limb loss. Less common is progressive muscle relaxation (PMR), used mostly in other medical conditions (psychological, terminal cancer pain, etc). The purpose of this study is to evaluate the efficacy of a mirror therapy preceded by PMR intervention compared to mirror therapy preceded by unguided generic relaxation-mirror therapy in patients with lower limb amputation suffering from PLP. This pilot study was a single-blind, controlled, randomized trial. Thirty lower limb amputees suffering from PLP were recruited and randomly assigned to three groups respectively undergoing a PMR-mirror therapy rehabilitative intervention, generic relaxation-mirror therapy, and conventional physiotherapy (ConvPT). Selected items from Prosthesis Evaluation Questionnaire (PEQ) and the Brief Pain Inventory (BPI) were used to test the pain features at the beginning and 1 week after 3 weeks of intervention. A decrease of about 65% was found in the rate and duration of PLP at the PEQ in PMR-mirror therapy with respect to generic relaxation-mirror therapy (about 30%) and ConvPT (about 6%). A decrease of about 90% in intensity (worst and average) of PLP in PMR-mirror therapy when compared to generic relaxation-mirror therapy (about 45%) and ConvPT (about 20%) was found at the BPI. We preliminary concluded, albeit with limitations due to the small sample of patients, that mirror therapy can improve PLP when associated with PMR. Further studies are required to confirm that PMR could be an effective technique for more successful PLP management.

Effect of Early Radial Shock Wave Treatment on Spasticity in Subacute Stroke Patients: A Pilot Study.

Background: Spasticity is a complication that can start immediately after stroke. Radial extracorporeal shock wave therapy (rESWT) is a physical therapy tool used to manage chronic spasticity. However, the effect of rESWT's early use to treat spasticity after stroke is still not clearly investigated. The aim of this study is to evaluate the efficacy of rESWT in improving poststroke spasticity of the upper limb in patients with a recent onset of spasticity compared to conventional physiotherapy alone. Methods: 40 stroke patients were randomly assigned to experimental (EG) or control group (CG). Both groups underwent two daily sessions of conventional rehabilitation therapy (CRT) 5 days per week; the EG underwent one rESWT session a week for 4 weeks. The modified Ashworth scale (MAS) tested at the shoulder, elbow, and wrist was used as outcome measure. MAS was evaluated at baseline, after 2 and 4 rESWT session, and one month after the last session (follow-up). Results: No significant differences between groups were found at baseline in terms of age, days from onset of spasticity after stroke, and MAS at each body segment. The sample lost eight drop-out patients. Except for the shoulder MAS values, the EG showed statistically significant lower MAS values already after the second rESWT session compared to CG. This significant difference was maintained until the follow-up. The CG showed a significant increase of wrist spasticity after the second evaluation, while the EG maintained constant MAS values throughout the observational period. The elbow spasticity was significantly higher in the CG at the follow-up evaluation. Conclusion: The rESWT combined with CRT seems to be effective in avoiding the increasing progression of spasticity after stroke.

Do chronic pain syndromes in lower limb amputees have an effect on the use of prostheses?

BACKGROUND: The use of a prosthesis is critical to regain the ability to walk in lower limb amputees but the relationship between the use of a prosthesis and chronic pain syndromes (PLS, PLP, RLP), common in amputees patients, is still poorly understood. OBJECTIVE: This long-term follow-up study investigates the possible correlation between prosthesis use and the presence of PLP, PLS and RLP in lower limb amputees. METHODS: Patients undergoing transtibial, transfemoral or hemipelvectomy amputation of any aetiology at the Rizzoli Orthopaedic Institute from 2008 to 2018 were included. The Houghton scale was used to assess functional use of the prosthesis. The PEQ was used for pain assessment. RESULTS: The results show that, in lower limb amputees, prosthesis use is greater in individuals with below-the-knee amputation and in those who were younger at the time of amputation. No significant correlation between the presence of pain syndromes (PLS, PLP, RLP) and the various items on the Houghton scale was found. CONCLUSIONS: The study found no significant correlation indicating that phantom limb pain syndromes affect amputee use of a prosthesis in the long term follow up.

Clonazepam: An Old "New" Therapy for the Treatment of Phantom Limb Pain-A Brief Report of a Retrospective Study.

The purpose of this study is to describe the results of clonazepam use in the treatment of phantom limb pain (PLP). Although the efficacy of clonazepam on PLP has been reported in 1996, there are no subsequent known studies that confirmed this report. A consecutive sample of 32 patients who suffered from PLP after recent lower limb amputation was studied based on clinical charts. Wilcoxon's signed rank test was used to compare Numeric Rating Scale (NRS) values before and after the treatment with clonazepam. Twenty-three amputees were treated only with clonazepam, without adding other drugs or targeted rehabilitation treatments. The median NRS before the treatment with clonazepam was 7 (2), the median NRS after 31 ± 5 days of treatment was 3 (3.5) (p < 0.0001). The average dosage of clonazepam used was 1.5 ± 1 mg per day. The results suggest that clonazepam has to be considered as an alternative drug for PLP treatment.

Chronic pain in lower limb amputees: Is there a correlation with the use of perioperative epidural or perineural analgesia?

BACKGROUND: Chronic pain is common in patients who undergo lower limb amputation. The use of epidural or perineural catheters seems to reduce acute pain after surgery but their effects in a longer follow up are unknown. OBJECTIVE: To evaluate the long-term prevalence of phantom limb sensation (PLS), phantom limb pain (PLP), and residual limb pain (RLP) and their correlation with perioperative use of epidural or perineural catheters. METHODS: Postal survey. Patients with trans-femoral, trans-tibial or hemi-pelvectomy amputation were asked to partake in the study. The Prosthetic Evaluation Questionnaire was used for the presence of chronic post-surgical pain. Use of catheters was retrieved from medical notes. RESULTS: 57 patients at a mean of 4.4 years follow up were included. PLS was reported in 68.4%, PLP in 63.2 % and RLP in 54.4% of amputees. No correlation was identified between pain syndromes and the presence of individual catheters and the duration of their permanence. The simultaneous use of 2 catheters was related to a lesser presence of PLP. CONCLUSIONS: Data on prevalence of PLP, PLS and RLP are consistent with the literature. Favourable effects in PLP reduction in the long term follow up was related to the simultaneous use of two catheters.

Early balance training with a computerized stabilometric platform in persons with mild hemiparesis in subacute stroke phase: A randomized controlled pilot study.

BACKGROUND: Along with conventional therapy, novel tools are being developed in balance training for the rehabilitation of persons with stroke sequelae. The efficacy of Computerized Balance Training thus far been the object of studies only in persons with chronic stroke. OBJECTIVE: To investigate the effects of an early Computerized Balance Training on balance, walking endurance and independence in activities of daily living, in persons with mild hemiparesis in subacute phase. METHODS: Thirty-two persons with a recent hemiparesis (within 4 weeks from stroke onset), able to maintain a standing position for at least 30 seconds, were randomly assigned to an experimental or control group. The control group (CG) were administered conventional physiotherapy of 40 minutes twice a day, 5 times a week for 4 weeks, while the experimental group (EG) underwent conventional physiotherapy 40 minutes once a day and Computerized Balance Training once a day, 5 times a week for 4 weeks. Outcomes were evaluated by means of Berg Balance Scale (BBS), Tinetti Balance Scale (TBS), Two Minutes Walk Test (2MWT), Barthel Index (BI) and stabilometric tests. RESULTS: Twelve participants for each group completed the training. Each group experienced 8 dropouts. The mean age (years) was 58.1±20.4 for EG and 59.7±14,7 for CG; the days from stroke were respectively 27.9±15.5 and 20±11.7. The difference between the two groups was statistically significant in experimental group for BBS (p = 0.003), for TBS (p = 0.028), for Sensory Integration and Balance tests performed with closed eyes on steady (p = 0.009) or instable surface (p = 0.023). and for 2MWT (p = 0.008). CONCLUSIONS: Computerized Balance Training is an effective therapeutic tool for balance and gait endurance improvement in persons with stroke in subacute phase.

Radial extracorporeal shock wave therapy: a novel approach for the treatment of Dupuytren's contractures: A case report.

INTRODUCTION: While the efficacy of focused Extracorporeal Shock Wave Therapy (ESWT) in the treatment of Dupuytren's disease (DD) is supported by one positive trial, the effects of radial ESWT is unclear. PATIENT CONCERNS: A 79-year-old man with a 4-year history of impairment of left-hand function and pain due to DD with weakness and flexion deformities of middle and ring fingers. He has not been treated before for this impairment. DIAGNOSIS: The diagnosis of DD was based on clinical features and ultrasound images. INTERVENTIONS: Four weekly sessions of radial ESWT with 1400 impulses 3 bar each, 12 Hz. OUTCOMES: The limitations in activities of daily living were analyzed through the Disabilities of Arm Shoulder and Hand Questionnaire (DASH) and Michigan Hand Outcome Questionnaire (MHQ) at baseline, after four sessions of radial ESWT and at 4-months follow-up. Data analysis showed a significant reduction of hand deformities and an improvement of daily living performance. The effects continued at the 4-months follow-up. CONCLUSION: This case report demonstrates the feasibility of radial ESWT. Radial ESWT sessions may be carried out by a physiotherapist in outpatient clinics with cost reduction compared with surgical treatment and focused ESWT. Radial ESWT is a non-invasive, well tolerated therapy, so it should be considered in the DD treatment.

Neural modifications in lower limb amputation: an fMRI study on action and non-action oriented body representations.

The loss of sensorimotor and visual information that follows limb amputation is known to affect both the action-oriented (body schema, BS) and non-action oriented (NA) body representations. However, the neural underpinnings of these effects have not yet been fully understood. We investigated the neural correlates of body representations in a group of 9 healthy right-handed individuals with left lower limb amputation (LLA) and 11 healthy age-matched controls (HC) by using event-related functional magnetic resonance imaging. Participants were scanned while performing mental rotation of body parts (i.e. hand, foot and eye) and objects (i.e. a rear-view mirror). Although the performance of LLA were similar to that of HC, they showed a different activation profile in relation to both BS and to NA within a wide range of brain areas. The bilateral intraparietal sulcus was less activated in LLA than HC, whereas the bilateral anterior insula as well as the fusiform body area, the precentral gyrus, the supplementary motor area in the left hemisphere and the inferior occipital gyrus in the right hemisphere were more activated during the mental rotation of left stimuli in the LLA. Also, the left EBA showed higher activation during the mental rotation of the foot than that of the eye in the LLA but not in the HC. Our results are consistent with the hypothesis that left LLA yields to a modification in the body representation network even when it does not lead to clear behavioral deficits.

Early body weight-supported overground walking training in patients with stroke in subacute phase compared to conventional physiotherapy: a randomized controlled pilot study.

Among the new rehabilitation strategies aimed at improving independent walking after stroke, the body weight-support training allows an early and controlled ambulatory training. To date, most available studies are based on treadmill body weight-support (BWS) training and involve patients with chronic stroke sequelae. In contrast, the effects of a BWS training performed on the ground in patients with subacute hemiparesis (stroke within 4 weeks), with significant gait deficiencies, is unknown. The primary aim of this study was to evaluate the efficacy of a rehabilitative program that combines conventional approach with an early overground body weight-support training, in terms of recovery of independent walking focussing on patients with subacute stroke. The secondary aim was to evaluate the impact of body weight-support also on functional mobility, overall disability, and gait endurance. A total of 37 participants were enrolled and randomized to experimental group or control group for the baseline evaluations. In the experimental group, body weight-supported overground walking was added to conventional physiotherapy for 4 weeks. The outcome measurements used were: Functional Ambulation Classification (FAC), Rivermead Mobility Index, Barthel Index, and the 6-minute Walk Test. At the evaluation 1 week after the end of the intervention period, experimental group reached a statistically significant increase of independent walking as detected by FAC (experimental group: 3 vs. control group: 2, P < 0.01). No differences were observed by the other evaluation outcome measures. We conclude that BWS training may be more effective than conventional therapy alone in improving walking autonomy in persons with subacute stroke.

Sensitivity to change and minimal clinically important difference of the Locomotor Capabilities Index-5 in people with lower limb amputation undergoing prosthetic training.

OBJECTIVE: To determine the sensitivity to change and minimal clinically important difference (MCID) for the self-administered Locomotor Capabilities Index-5 (LCI-5) in people with lower limb amputation undergoing prosthetic training. DESIGN: Prospective single-group observational study. METHODS: The LCI-5 was administered to 110 patients (69 males [63%]; median [interquartile range] age, 60 [48-69] years) before and after prosthetic training. The external anchor administered after the program was a 7-point Global Rating of Change Scale (GRCS) designed to quantify the effect (improvement or deterioration) of the intervention. RESULTS: Test-retest reliability of the LCI-5 (n=30) was high (intraclass correlation coefficient [ICC2,1]=0.92). The minimum detectable change at the 95% confidence level was 5.66 points. After triangulating these results with those of the mean-change approach and receiver operating characteristic (ROC) curve analysis (area under the ROC curve≥0.90), based on a different GRCS score splitting, we identified 2 cutoffs for the LCI-5: a change of 7 points, indicating the MCID, and 12 points, indicating "large improvement" in locomotor capabilities (12.5% and 21.4% of the maximum possible score, respectively). CONCLUSIONS: The LCI-5 showed a high ability to detect change over time (responsiveness). The 2 proposed values (MCID of 7 points and large improvement of 12 points), based on a mix of distribution- and anchor-based approaches, represent cutoffs that can accurately identify 2 different levels of true change (as perceived by the patient) in locomotor capability after prosthetic training.

Upper body accelerations during level walking in transtibial amputees.

BACKGROUND:: The observation of upper body movement is gaining interest in the gait analysis community. Recent studies involved the use of body-worn motion sensors, allowing translation of laboratory measurements to real-life settings in the context of patient monitoring and fall prevention. OBJECTIVES:: It was shown that amputee persons demonstrate altered acceleration patterns due to the presence of prosthetic components, while no information is available on how accelerations propagate upwards to the head during level walking. This descriptive study aims to fill this gap. STUDY DESIGN:: Original research report. METHODS:: Twenty definitive prosthesis users with transtibial amputation and 20 age-matched able-bodied individuals participated in the study. Three magneto-inertial measurement units were placed at head, sternum and pelvis level to assess acceleration root mean square. Three repetitions of the 10-m walking test were performed at a self-selected speed. RESULTS:: Acceleration root mean square was significantly larger at pelvis and head level in individuals with amputation than in able-bodied participants, mainly in the transverse plane ( p < 0.05). Differences were also observed in how accelerations propagate upwards, highlighting that a different motor strategy is adopted in amputee persons gait to compensate for increased instability. CONCLUSION:: The obtained parameters allow an objective mobility assessment of amputee persons that can integrate with the traditional clinical approach. CLINICAL RELEVANCE: Transtibial amputees exhibit asymmetries due to the sound limb's support prevalence during gait: this is evidenced by amplified accelerations on the transverse plane and by related differences in upper body movement control. Assessing these accelerations and their attenuations upwards may be helpful to understand amputee's motor strategies and to improve prosthetic training.

Action and Non-Action Oriented Body Representations: Insight from Behavioural and Grey Matter Modifications in Individuals with Lower Limb Amputation.

OBJECTIVE: Following current model of body representations, we aimed to systematically investigate the association between brain modifications, in terms of grey matter loss, and body representation deficits, in terms of alterations of the body schema (BS) and of non-action oriented body representations (NA), in individuals with lower limb amputation (LLA). METHOD: BS and NA (both semantic and visuospatial NA) were evaluated in 11 healthy controls and in 14 LLA, considering the impact of clinical variables such as prosthesis use. The association between BS and NA deficits and grey matter loss was also explored in LLA by using Voxel Based Morphometry analysis. RESULTS: LLA's performance was fine in terms of semantic NA, while it showed behavioural impairments both in BS and visuospatial NA as compared to healthy controls. Interestingly the visuospatial NA performance was related to the amount of prosthesis use. NA deficits in terms of visuospatial body map processing were associated with grey matter reduction in left (lobule VIII) and right (crus II) cerebellum, while BS deficits were associated with grey matter reduction in right anterior cingulate cortex and the bilateral cuneus. No significant association was detected for semantic NA. CONCLUSION: The study of BS and NA representations after limb loss has informed our understanding of the different dynamics (i.e., adjustments to body change) of such representations, supporting current cognitive models of body representation. The clinical relevance of present findings is also discussed.

Cerebellar grey matter modifications in lower limb amputees not using prosthesis.

Plastic brain changes following peripheral deafferentation, in particular those following limb amputations, are well-documented, with significant reduction of grey matter (GM) in the sensory-motor cerebral areas representing the amputated limb. However, few studies have investigated the role played by the use of a prosthesis in these structural brain modifications. Here we hypothesized that using a functional prosthesis that allows individuals to perform actions may reduce grey matter reduction. We investigated the brain structural reorganization following lower limb amputation by using a Voxel Based Morphometry (VBM) analysis of structural magnetic resonance imaging (MRI) in 8 right-handed individuals with lower limb amputation (LLA) fitted with prostheses (LLAwp), compared to 6 LLA who had never used a prosthesis (LLAnp). 14 age-matched healthy controls were also enrolled (HC). We did not find any significant effect when comparing LLAwp and HC. However we found a decreased GM volume in the bilateral cerebellum in LLAnp compared with HC. These results suggest that prosthesis use prevents GM decrease in the cerebellum after lower limb amputation.

Diagnosis and treatment of pain in plexopathy, radiculopathy, peripheral neuropathy and phantom limb pain. Evidence and recommendations from the Italian Consensus Conference on Pain on Neurorehabilitation.

Pain may affect all aspects of social life and reduce the quality of life. Neuropathic pain (NP) is common in patients affected by plexopathy, radiculopathy, mononeuropathy, peripheral neuropathy. Phantom limb pain (PLP) is a painful sensation that is common after amputation, and its pathophysiological mechanisms involve changes in the peripheral and central nervous system. Given the lack of conclusive evidence and specific guidelines on these topics, the aim of the Italian Consensus Conference on Pain on Neurorehabilitation (ICCPN) was to collect evidence and offer recommendations to answer currently open questions on the assessment and treatment of NP associated with the above conditions and PLP. When no evidence was available, recommendations were based on consensus between expert opinions. Current guidelines on the assessment and pharmacological treatment of NP can be applied to plexopathy, radiculopathy, mononeuropathy, peripheral neuropathy, while evidence for invasive treatments and physical therapy is generally poor because of the low quality of studies. Treatment of PLP is still unsatisfactory. Data on the functional outcome and impact of pain on neurorehabilitation outcome in these conditions are lacking. In most cases, a multidisciplinary approach is recommended to offer a better outcome and reduce side effects. High quality studies are requested to address the unmet needs in this field.

Comparison between SACH foot and a new multiaxial prosthetic foot during walking in hypomobile transtibial amputees: physiological responses and functional assessment.

BACKGROUND: The most prescribed prosthetic foot for hypomobile transtibial amputees (TTAs) is the solid ankle cushion heel (SACH). Recently, the new 1M10 Adjust (Ottobock, Duderstadt, Germany) has been designed for hypomobile TTAs. No studies are available about the physiological responses to walking with 1M10 Adjust or about the related energy cost of walking (ECW). The aim of this study was to assess physiological responses to walking with 1M10 Adjust and with SACH in low-mobility TTAs and their ECW, and to compare 1M10 Adjust and SACH for physiological responses, ECW, relative perceived effort and satisfaction (SATPRO) using the prosthesis. DESIGN: Observational study. SETTING: The study was conducted in the outpatient rehabilitation unit of a rehabilitation center. POPULATION: Twenty hypomobile unilateral TTAs were enrolled. Amputees who ranged K-levels 1 or 2 were defined. METHODS: TTAs performed two over ground walking tests in two separate days, with an interval time in between of 30 days. TTAs performed the first walking test wearing their habitual SACH foot; the second walking test fitting the 1M10 Adjust, after 30 days of its use. During walking tests, TTAs walked back and forth for 6 minutes at self-selected walking speed (SSWS) and physiological data were collected. At the end of each walking test, the relative perceived effort was assessed by Borg scale. Finally, SATPRO questionnaire was administered. RESULTS: Twenty TTAs (17 males) were enrolled (mean age, body mass and height were 66.6±6.7 years, 78.5±13.2 kg, and 168.5±7.5 cm, respectively): 19 had a K-level 2 and one had a K-level 1. Physiological responses using SACH or 1M10 Adjust foot did not show statistical differences. ECW, SSWS and relative perceived effort significantly improved using the 1M10 Adjust. Satisfaction with 1M10 Adjust was significantly greater than with SACH. CONCLUSIONS: TTAs showed a significant improvement in ECW, relative perceived effort and SATPRO with 1M10 Adjust than with SACH. This suggests that 1M10 Adjust foot could be a good choice for hypomobile TTAs. CLINICAL REHABILITATION IMPACT: The better prosthetic performance provided by 1M10 Adjust foot during gait could improve mobility in TTAs with low mobility contributing to prevent comorbidity deriving from sedentary lifestyle. With its long-term benefits, 1M10 Adjust could contribute to a better quality of life.

Functional Outcome After Lower Limb Amputation: Is Hyperhomocysteinemia a Predictive Factor?: An Observational Study.

Lower limb amputation (LLA) is the drastic stage of peripheral arterial disease (PAD) where the hyperhomocysteinemia (H-HCY) seems to be a risk factor. Surprisingly, in literature the levels and the role of homocysteinemia (HCY) in persons with LLA are understudied. This study aims to investigate the level of HCY and its correlation with the functional outcomes after LLA.A case-control study to analyze HCY levels in amputees admitted in a rehabilitation hospital during an investigation period of 1.5 years. Barthel Index was used to assess the functional outcome.We enrolled 91 dysvascular amputees and 44 amputees for other reasons than PAD (controls). The mean level of HCY was found higher in dysvascular amputees (15.2 ±â€Š7.5) compared to controls (11.0 ±â€Š5.0, P < 0.0001) with a risk related ratio of 4.78. Normal Gaussian distribution of HCY was observed in controls, whereas in dysvascular amputees the data follow a double Gaussian distribution. Finally, a significant negative correlation was found between HCY and the effectiveness of rehabilitation (R = -0.37, P = 0.001) only in dysvascular amputees.Dysvascular amputees had a level of HCY significantly higher than amputees without PAD. H-HCY seems to influence the functional outcomes of the rehabilitative treatment only in LLA due to PAD.

The Conventional Non-Articulated SACH or a Multiaxial Prosthetic Foot for Hypomobile Transtibial Amputees? A Clinical Comparison on Mobility, Balance, and Quality of Life.

The effects of a non-articulated SACH and a multiaxial foot-ankle mechanism on the performance of low-activity users are of great interest for practitioners in amputee rehabilitation. The aim of this study is to compare these two prosthetic feet and assess possible improvements introduced by the increased degrees of freedom provided by the multiaxial foot. For this purpose, a group of 20 hypomobile transtibial amputees (TTAs) had their usual SACH replaced with a multiaxial foot. Participants' functional mobility, involving ambulatory skills in overground level walking, ramps, and stairs, was evaluated by performing Six-Minute Walking Test (6 MWT), Locomotor Capability Index-5 (LCI-5), Hill Assessment Index (HAI), and Stair Assessment Index (SAI). Balance performances were assessed using Berg Balance Scale (BBS) and analysing upper body accelerations during gait. Moreover, the Prosthesis Evaluation Questionnaire (PEQ) was performed to indicate the prosthesis-related quality of life. Results showed that participants walked faster using the multiaxial foot (p < 0.05) maintaining the same upright gait stability. Significant improvements with the multiaxial foot were also observed in BBS, LCI-5, and SAI times and 4 of 9 subscales of the PEQ. Our findings demonstrate that a multiaxial foot represents a considerable alternative solution with respect to the conventional SACH in the prosthetic prescription for hypomobile TTAs.

Efficacy of progressive muscle relaxation, mental imagery, and phantom exercise training on phantom limb: a randomized controlled trial.

OBJECTIVE: To evaluate the reduction in phantom pain and sensation with combined training of progressive muscle relaxation, mental imagery, and phantom exercises. DESIGN: Randomized controlled prospective trial with 2 parallel groups. SETTING: Amputee unit of a rehabilitation hospital. PARTICIPANTS: Subjects with unilateral lower limb amputation (N=51) with phantom limb pain (PLP) and/or phantom limb sensation (PLS). INTERVENTIONS: The experimental group performed combined training of progressive muscle relaxation, mental imagery, and phantom exercises 2 times/wk for 4 weeks, whereas the control group had the same amount of physical therapy dedicated to the residual limb. No pharmacological intervention was initiated during the trial period. MAIN OUTCOME MEASURES: The Prosthesis Evaluation Questionnaire and the Brief Pain Inventory were used to evaluate changes over time in different aspects (intensity, rate, duration, and bother) of PLS and PLP. Blind evaluations were performed before and after treatment and after 1-month follow-up. RESULTS: The experimental group showed a significant decrease over time in all the Prosthesis Evaluation Questionnaire domains (in terms of both PLS and PLP; P<.04 for both) and the Brief Pain Inventory (P<.03). No statistically significant changes were observed in the control group. Between-group analyses showed a significant reduction in intensity (average and worst pain) and bother of PLP and rate and bother of PLS at follow-up evaluation, 1 month after the end of the treatment. CONCLUSIONS: Combined training of progressive muscle relaxation, mental imagery, and modified phantom exercises should be taken into account as a valuable technique to reduce phantom limb pain and sensation.

Assessment of gait stability, harmony, and symmetry in subjects with lower-limb amputation evaluated by trunk accelerations.

Analysis of upper-body accelerations is a promising and simple technique for quantitatively assessing some general features of gait such as stability, harmony, and symmetry. Despite the growing literature on elderly healthy populations and neurological patients, few studies have used accelerometry to investigate these features in subjects with lower-limb amputation. We enrolled four groups of subjects: subjects with transfemoral amputation who walked with a locked knee prosthesis, subjects with transfemoral amputation who walked with an unlocked knee prosthesis, subjects with transtibial amputation, and age-matched nondisabled subjects. We found statistically significant differences for stability (p < 0.001), harmony (p < 0.001), and symmetry (p < 0.001) of walking, with general trends following the noted order of subjects, but with the lowest laterolateral harmony in subjects with transtibial amputation. This study is the first to investigate upper-body acceleration of subjects with unilateral lower-limb amputation during walking who were evaluated upon dismissal from a rehabilitation hospital; it is also the first study to differentiate the sample in terms of level of amputation and type of prosthesis used.