Influence of rTMS over the left primary motor cortex on initiation and performance of a simple movement executed with the contralateral arm in healthy volunteers.

Repetitive transcranial magnetic stimulation (rTMS) affects cortical excitability according to the frequency of stimulation. Few data are available on the influence of rTMS applied over the primary motor cortex (M1) on motor performances in healthy volunteers. The aim of this study was to determine, through kinematic analysis, whether rTMS over the left M1 changes initiation and performance of movement executed with the contralateral arm. Nine healthy males completed a set of motor tasks, consisting of a single-joint rapid movement between two objects performed under three different behavioral conditions (self-initiated; externally triggered known, during which the subject could see where the target was positioned in advance; externally triggered unknown, during which the subject could not see where the target was positioned until he reached it). The tasks were performed in a randomized order in three different sessions, with a seven-day interval between each session: (1) without stimulation (baseline); (2) immediately after 1-Hz rTMS; (3) immediately after 10-Hz rTMS. We measured reaction time, movement time, calculated as the sum of the time taken to reach the target from movement onset (T1) and that taken to reach the target to movement termination (T2), acceleration and deceleration time on the velocity profile, as well as the ratio between them, and maximum speed and maximum acceleration. Reaction time, movement time, and T2 significantly increased after 1-Hz rTMS and decreased after 10-Hz rTMS, while the other parameters remained unchanged. Our results suggest that rTMS may modify both initiation and performance of a voluntary movement.

Does giving segmental muscle vibration alter the response to botulinum toxin injections in the treatment of spasticity in people with multiple sclerosis? A single-blind randomized controlled trial.

OBJECTIVE: To determine if segmental muscle vibration and botulinum toxin-A injection, either alone or in combination, reduces spasticity in a sample of patients with multiple sclerosis. DESIGN: Single-blind, randomized controlled trial. SETTING: Physical medicine and rehabilitation outpatients service. SUBJECTS: Forty-two patients affected by the secondary progressive form of multiple sclerosis randomized to group A (30 minutes of 120 Hz segmental muscle vibration over the rectus femoris and gastrocnemius medial and lateral, three per week, over a period of four weeks), group B (botulinum toxin in the rectus femoris, gastrocnemius medial and lateral and soleus, and segmental muscle vibration) and group C (botulinum toxin). MAIN MEASURES: Modified Ashworth Scale at knee and ankle, and Fatigue Severity Scale. All the measurements were performed at baseline (T0), 10 weeks (T1) and 22 weeks (T2) postallocation. RESULTS: Modified Ashworth Scale at knee and ankle significantly decreased over time (p < 0.001) in all groups. Patients in group C displayed a significant increase of knee and ankle spasticity at T2 when compared with T1 (p < 0.05). Fatigue Severity Scale values in groups A and C were significantly higher at T0 [A: 53.6 (2.31); C: 48.5 (2.77)] than at either T1 [A: 48.6 (2.21); p = 0.03; C: 43.5 (3.22); p = 0.03] or T2 [A: 46.7 (2.75); p = 0.02; 42.5 (2.17); p = 0.02], while no differences were detected in group B [T0: 43.4 (3.10); T1: 37.3 (3.15); T2: 39.7 (2.97)]. CONCLUSION: Segmental muscle vibration and botulinum toxin-A reduces spasticity and improves fatigue in the medium-term follow-up in patients with multiple sclerosis.

Robotic-assisted locomotor treadmill therapy does not change gait pattern in children with cerebral palsy.

Although robotic-assisted locomotor treadmill therapy is utilized on children with cerebral palsy (CP), its impact on the gait pattern in childhood is not fully described. We investigated the outcome of robotized gait training focusing on the gait pattern modifications and mobility in individuals with CP. An additional intention is to compare our results with the previous literature advancing future solutions. Twenty-four children with diplegic CP (average age 6.4 years old with Gross Motor Functional Classification System range I-IV) received robotized gait training five times per week for 4 weeks. Gait analysis and Gross Motor Function Measurement (GMFM) assessments were performed before and at the end of the treatment. Gait analysis showed inconsistent modifications of the gait pattern. GMFM showed a mild improvement of the dimension D in all subjects, while dimension E changed only in the younger and more severely affected patients. In this study, a detailed investigation comprehensive of electromyography patterns, where previous literature reported only sparse data without giving information on the whole gait pattern, were conducted. We carried on the analysis considering the age of the participants and the severity of the gait function. The findings differentiate the concept of specific pattern recovery (no gait pattern changes) from the concept of physical training (mild GMFM changes).

Coordination between pelvis and shoulder girdle during walking in bilateral cerebral palsy.

BACKGROUND: Studies revealed that pelvis and shoulder girdle kinematics is impaired in children with the diplegic form of bilateral cerebral palsy while walking. The features of 3D coordination between these segments, however, have never been evaluated. METHODS: The gait analyses of 27 children with bilateral cerebral palsy (18 males; mean age 124 months) have been retrospectively reviewed from the database of a Movement Analysis Laboratory. The spatial-temporal parameters and the range-of-motions of the pelvis and of the shoulder girdle on the three planes of motion have been calculated. Continuous relative phase has been calculated for the 3D pelvis-shoulder girdle couplings on the transverse, sagittal and frontal planes of motion to determine coordination between these segments. Data from 10 typically developed children have been used for comparison. FINDINGS: Children with bilateral cerebral palsy walk with lower velocity (P=0.01), shorter steps (P<0.0001), larger base of support (P<0.01) and increased duration of the double support phase (P=0.005) when compared to typically developed children. The mean continuous relative phase on the transverse plane has been found lower in the cerebral palsy group throughout the gait cycle (P=0.003), as well as in terminal stance, pre-swing and mid-swing. The age, gait speed and pelvis range-of-motions on the transverse plane have been found correlated to continuous relative phase on the transverse plane. INTERPRETATION: Compared with typically developed children, children with bilateral cerebral palsy show a more in-phase coordination between the pelvis and the shoulder girdle on the transverse plane while walking.

Complete remission of plantar fasciitis with a gluten-free diet: relationship or just coincidence?

We report the case of a 46-year-old woman with no known history for gluten sensitivity who presented severe heel pain, and was successfully managed with a gluten-free diet. Previously she had been unsuccessfully treated with several conservative remedies. The presence of musculoskeletal problems in patients with gluten sensitivity is not rare. To the best of our knowledge, however, this is the first case report mentioning the successful management of plantar fasciitis with a gluten-free diet. The case report highlights the importance of considering gluten sensitivity among other possible differential diagnosis for musculoskeletal pain insensitive to traditional therapies.

Segmental muscle vibration modifies muscle activation during reaching in chronic stroke: A pilot study.

BACKGROUND: Segmental muscle vibration (SMV) improves motor performances in neurological conditions, including stroke. OBJECTIVE: To determine if SMV modifies upper limb muscular activity in chronic stroke patients performing a reaching movement. METHODS: We randomized 22 chronic stroke patients to an experimental group (EG; n = 12), receiving 10 sessions of exercise + 120 Hz SMV over the biceps brachii (BB) and the flexor carpi ulnaris (FCU) muscles, or to a control group (CG; n = 10) receiving exercise only. All subjects performed a reaching movement with the affected side before and 4 weeks after therapy ended. We recorded surface EMG activity of the anterior deltoid (AD), posterior deltoid (PD), BB, triceps brachii (TB), FCU and extensor carpi radialis (ECR) muscles. We calculated muscular onset times, modulation ratio, co-contractions and degree of contraction. RESULTS: After SMV, onset times of the PD (p = 0.03), BB (p = 0.02) and ECR (p = 0.04) in the EG were less anticipated than at baseline; the modulation ratio increased in AD (p = 0.003) and BB (p = 0.01); co-contractions decreased in the pairs BB/TB (p = 0.007), PD/BB (p = 0.004) and AD/BB (p = 0.01); and the degree of contraction decreased in BB (p = 0.01). CONCLUSIONS: The modulation of muscular function induced by SMV may aid to explain its action on smoothness and coordination of movements.

Segmental muscle vibration improves reaching movement in patients with chronic stroke. A randomized controlled trial.

BACKGROUND: Segmental muscle vibration (SMV) has been used to improve gait and to reduce spasticity in stroke patients. No data exist about the possibility to improve upper limb motor function by using SMV. METHODS: Forty-four patients with hemiparesis following chronic stroke were randomized to an experimental (n = 24) and a control group (n = 20). Patients in the experimental group received two weeks of general physical therapy and SMV over the biceps brachii and flexor carpi ulnaris muscles of the paretic side, while those in the control group received two weeks of general physical therapy. Kinematic analysis of reaching movement was performed at baseline and two weeks after treatment ended. RESULTS: Normalized jerk, indicating the smoothness of movement, significantly improved in the experimental group, with significant difference emerging between groups at the post-treatment evaluation. Patients in the experimental group also displayed a significant improvement for mean linear velocity, mean angular velocity at shoulder, distance to target at the end of movement and movement duration. No differences emerged between baseline and post-treatment evaluations in the control group. CONCLUSIONS: when added to general physical therapy, SMV is effective in improving, in a short-term period, upper limb motor performances of reaching movement in chronic stroke patients.

Extracorporeal shock-wave therapy compared with surgery for hypertrophic long-bone nonunions.

BACKGROUND: The authors of several studies have recommended extracorporeal shock-wave therapy as an alternative to surgical treatment for long-bone nonunions. This study was performed to compare the results of extracorporeal shock-wave therapy produced by two different devices with those of surgical treatment in the management of long-bone nonunions. METHODS: One hundred and twenty-six patients with a long-bone nonunion were randomly assigned to receive either extracorporeal shock-wave therapy (Groups 1 and 2) or surgical treatment (Group 3). The patients in the shock-wave groups received four treatments with 4000 impulses of shock waves with an energy flux density of 0.40 mJ/mm(2) (Group 1) or 0.70 mJ/mm(2) (Group 2). The patients in the three groups had similar demographic characteristics, durations of nonunion, and durations of follow-up. Radiographic results (the primary outcome) and clinical results (the secondary outcomes) were determined before and three, six, twelve, and twenty-four months after treatment. RESULTS: The radiographic findings did not differ among the three groups of patients. At six months, 70% of the nonunions in Group 1, 71% of the nonunions in Group 2, and 73% of the nonunions in Group 3 had healed. Three and six months after treatment, the clinical outcomes in the two shock-wave groups were significantly better than those in the surgical group (p < 0.001). However, at both twelve and twenty-four months after treatment, there were no differences among the three groups, with the exception of the DASH score, which differed significantly between Groups 1 and 3 (p = 0.038) and between Groups 2 and 3 (p = 0.021) at twelve months. CONCLUSIONS: Extracorporeal shock-wave therapy is as effective as surgery in stimulating union of long-bone hypertrophic nonunions and yields better short-term clinical outcomes.