Efficacy of intensive multidisciplinary rehabilitation in Parkinson's disease: a randomised controlled study.

OBJECTIVE: To evaluate whether a 4-week multidisciplinary, aerobic, motor-cognitive and intensive rehabilitation treatment (MIRT) improves the quality of life (QoL) of patients with Parkinson's disease (PD), in the short-term and long-term period. METHODS: This is a prospective, parallel-group, single-centre, single-blind, randomised clinical trial (ClinicalTrials.gov NCT02756676). 186 patients with PD, assigned to experimental group, underwent MIRT; conversely, 48 patients, assigned to control group, did not receive rehabilitation. Parkinson's Disease Questionnaire-39 was assessed 2 (T0), 10 (T1) and 18 (T2, only experimental group) weeks after the enrolment. We compared T1 versus T0 scores within subjects and delta scores (T1-T0) between subjects. To investigate the long-term effects, we compared T2 and T0 scores in the experimental group. RESULTS: At T0, no between-group differences in the Global Index Score (GBI) were observed (experimental group: 43.6±21.4, controls: 41.6±22.9, P=0.50). At T1, we did not find significant changes in controls (delta score: 1.2±9.9, P=0.23), and we found an improvement in GBI in the experimental group (delta score: -8.3±18.0, P<0.0001), significant also between subjects (P<0.0001). Comparing T2 versus T0 in the experimental group, the GBI maintained a significant improvement (delta score: -4.8±17.5, P<0.0001). CONCLUSIONS: A rehabilitation treatment such as MIRT could improve QoL in patients with PD in the short-term and long-term period. Even though the single-blind design and the possible role of the placebo effect on the conclusive results must be considered as limitations of this study, the improvement in outcome measure, also maintained after a 3-month follow-up period, suggests the effectiveness of MIRT on the QoL. CLINICAL TRIAL REGISTRATION: NCT02756676: Pre-results.

Effectiveness of aquatic versus land physiotherapy in the treatment of peripheral neuropathies: a randomized controlled trial.

OBJECTIVE: To compare the effects on gait and balance of aquatic physiotherapy versus on-land training, in the context of an inpatient rehabilitation treatment tailored for peripheral neuropathies. DESIGN: Parallel-group, single-center, single-blind randomized controlled trial. SUBJECTS AND SETTING: Consecutive patients affected by peripheral neuropathy admitted in our Neuro-Rehabilitation Unit. INTERVENTIONS: Patients received a four-week rehabilitation program composed by daily sessions of conventional physiotherapy and three sessions/week of specific treatment (aquatic vs. on-land). MAIN MEASURES: Primary outcome measures were Berg Balance Scale and Dynamic Gait Index. Secondary outcome measures were Neuropathic Pain Scale, Overall Neuropathy Limitations Scale, Functional Independence Measure, Functional Ambulation Classification, Conley Scale and Medical Research Council Scale score for the strength of hip and ankle flexor and extensor muscles. For each scale, we calculated the difference between the scores at discharge and admission and compared it between the two groups. RESULTS: Forty patients were enrolled: 21 in the water-based rehabilitation group and 19 in the land-based one. Patients were similar between groups. When comparing the groups, we found that "in-water" patients had a significant better improvement in the Dynamic Gait Index score (6.00 (4.00, 7.25) vs. 4.00 (1.25, 6.00), P = 0.0433). On the opposite, the "on-land" group showed a better improvement of the Functional Ambulation Classification score (1.0 (0.75, 1.0) vs. 1.0 (1.0, 2.0), P = 0.0386). CONCLUSION: Aquatic physiotherapy showed an effect comparable to the land-based rehabilitation on gait and balance dysfunctions of neuropathic patients.

Land Plus Aquatic Therapy Versus Land-Based Rehabilitation Alone for the Treatment of Balance Dysfunction in Parkinson Disease: A Randomized Controlled Study With 6-Month Follow-Up.

OBJECTIVES: To assess whether a specific land-based physical intervention with the inclusion of aquatic therapy is more effective than land-based rehabilitation alone for the treatment of balance dysfunction in patients with Parkinson disease (PD), immediately after therapy and at 6 months' follow-up. DESIGN: Randomized controlled study with 6-month follow-up. SETTING: A PD and brain injury rehabilitation department in a general hospital. PARTICIPANTS: Patients (N=34) with moderate-stage PD. INTERVENTION: Seventeen patients underwent a land-based rehabilitation protocol called multidisciplinary intensive rehabilitation treatment (MIRT), and 17 underwent MIRT plus aquatic therapy (MIRT-AT). MAIN OUTCOME MEASURES: The primary outcome measure was the Berg Balance Scale (BBS); secondary outcome measures were the Unified Parkinson Disease Rating Scale parts II and III (UPDRS II/III) and the Timed Up and Go (TUG) test. These measures were assessed in both groups at admission, at discharge, and after 6 months. RESULTS: BBS improved after treatment in both groups. Even though no statistically significant difference between groups was observed at each observation time, BBS scores at follow-up were significantly higher than at baseline in MIRT-AT patients. Both groups also showed an improvement in UPDRS II/III and TUG at the end of treatment compared with baseline, but these findings were lost at the 6-month follow-up. CONCLUSIONS: Aquatic therapy added to land-based rehabilitation could provide a contribution to the treatment of balance dysfunction in patients with moderate-stage PD.

Early Rehabilitation Reduces Time to Decannulation in Patients With Severe Acquired Brain Injury: A Retrospective Study.

Purpose: Early decannulation is considered a main rehabilitative goal in tracheostomized patients. Our aim is to evaluate whether a very early rehabilitation protocol helps to reduce the tracheostomy duration in patients affected by an Acquired Brain Injury (ABI). Methods: Data about consecutive tracheostomized patients admitted in our Neuro-Rehabilitation Unit (NRU) were retrospectively collected. We defined two groups: Early Rehabilitation Group patients came from our ICU, where they started the rehabilitative treatment; Delayed Rehabilitation Group patients arrived from external ICUs and started rehabilitation in our NRU. Primary outcome was the time from tracheostomy to decannulation. Secondary outcomes were: ICU length of stay, time from NRU admission to decannulation, Glasgow Coma Scale, Coma Recovery Scale revised and Levels of Cognitive Functioning scores at NRU discharge and the re-cannulation rate. Results: We enrolled 66 patients, 40 in the Early Rehabilitation Group and 26 in the Delayed Rehabilitation Group. 70% of patients for each group could be decannulated (p = 0.73) and were analyzed. Only one patient was re-cannulated. Early Rehabilitation Group showed a shorter tracheostomy duration (61.0 vs. 94.5 days, p = 0.013), a higher probability of occurrence of decannulation (p = 0.008) and a lower ICU length of stay (30.0 vs. 52.0 days, p = 0.001). The time to decannulation in NRU was similar between groups (30.0 vs. 45.50 days, p = 0.14). All the scale scores had a significant improvement in both groups (p < 0.0001 all). Conclusions: The present study shows that an early neuro-rehabilitation protocol helps to reduce the time to decannulation in tracheostomized patients affected by ABI.

Rehabilitation in progressive supranuclear palsy: Effectiveness of two multidisciplinary treatments.

BACKGROUND: to date, there are no medical or surgical treatments for progressive supranuclear palsy (PSP). It is possible to speculate that patients with PSP could benefit from rehabilitative treatments designed for Parkinson's disease, including the use of robot-assisted walking training. OBJECTIVE: to evaluate whether the use of the robotic device Lokomat® is superior in PSP patients to the use of treadmill with visual cues and auditory feedbacks (treadmill-plus) in the context of an aerobic, multidisciplinary, intensive, motor-cognitive and goal-based rehabilitation treatment (MIRT) conceived for Parkinsonian patients. METHODS: we enrolled twenty-four PSP patients. Twelve subjects underwent a 4-week MIRT exploiting the use of the treadmill-plus (MIRT group). Twelve subjects underwent the same treatment, but replacing the treadmill-plus with Lokomat® (MIRT-Lokomat group). Subjects were evaluated with clinical and functional scales at admission and discharge. The primary outcomes were the total PSP Rating Scale (PSPRS) score and its "limb" and "gait" sub-scores. Secondary outcomes were Berg Balance Scale (BBS), Six Minutes Walking test (6MWT) and the number of falls. RESULTS: total PSPRS, PSPRS-gait sub-score, BBS, 6MWT and number of falls improved significantly in both groups (p ≤ 0.003 all, except 6MWT, p = 0.032 and p = 0.018 in MIRT-Lokomat and MIRT group respectively). The PSPRS-limb sub-score improved significantly only in the MIRT group (p = 0.002). A significant difference between groups was observed only for total PSPRS, indicating a slightly better improvement for patients in the MIRT group (p = 0.047). No differences between groups were revealed for the other outcomes, indicating that the effect of rehabilitation was similar in both groups. CONCLUSIONS: Lokomat® training, in comparison with treadmill-plus training, does not provide further benefits in PSP patients undergoing MIRT. Our findings suggest the usefulness of an aerobic, multidisciplinary, intensive, motor-cognitive and goal-based approach for the rehabilitation of patients suffering from such a complex disease as PSP. TRIAL REGISTRATION: This trial was registered on ClinicalTrials.gov, NCT02109393.

Treadmill Training with Cues and Feedback Improves Gait in People with More Advanced Parkinson's Disease.

BACKGROUND: Gait disturbances in Parkinson's disease (PD) are highly disabling and poorly responsive to drugs, especially in advanced stages. While the efficacy of a treadmill training based on external feedback and cues (treadmill-plus) on gait disturbances in early PD stages is demonstrated, no definitive evidence exists about advanced stages. OBJECTIVE: We aimed to evaluate the feasibility and the effects of a treadmill-plus training on gait disturbances in advanced PD. METHODS: Two hundred and six PD patients from medium to more advanced Hoehn & Yahr stage (stage 2, n = 79, stage 3 n = 74, and stage 4 = 53) who underwent a 4-week treadmill-plus training, were retrospectively identified. All patients were able to walk on a treadmill for one minute at 1.5 km/h, without support. Feasibility was evaluated by measuring safety, adverse events, and attrition rate. The effects of treatment were evaluated by assessing, both at enrolment and at the end of treatment, the on-land, self-paced 6-minute Walking Test (6MWT) and the gait parameters obtained from the treadmill during a 1.5 km/h trial. RESULTS: All patients completed the treadmill-plus training and no adverse events were recorded, even among more disabled patients. After training, we observed a significant improvement in the 6MWT, an increase in step length and a reduction of cadence and step variability in the whole sample. After stratifying patients according to disease stage, we found that patients in more advanced stages experienced the same improvements in all gait parameters as patients in less advanced stages. CONCLUSIONS: Treadmill-plus training is well tolerated and may have a positive impact on many aspects of gait in more advanced PD stages.

Blink-associated contralateral eccentric saccades as a rare sign of unilateral brain injury.

OBJECTIVE: To describe a rare sign of unilateral brain injury as a form of unwanted blink-associated contralateral eccentric saccades. METHODS: A 62-year-old patient who underwent an ischemic stroke affecting the entire right middle cerebral artery territory came to our attention 1 year after stroke, manifesting with transient contralateral conjugate gaze deviations associated with spontaneous blinking. We complemented the regular neurologic evaluation with brain MRI, study of evoked potentials, electroneurography of the facial nerve, and infrared video-oculoscopy. RESULTS: The patient had left-sided hemiparesis, hypoesthesia, hemianopia, and hemispatial neglect. He also showed the occurrence of a rapid leftward conjugate deviation of the eyes, followed by a corrective movement to the primary ocular position. MRI showed a wide malacic area spanning the right frontal, temporal, and parietal cortical and subcortical regions, with signs of wallerian degeneration of the descending right corticospinal tract. Motor and somatosensory evoked potentials were centrally altered on the right side. Electroneurography of the facial nerves was normal. Infrared video-oculoscopy indicated persistence of the same blink-related saccades even in darkness. CONCLUSIONS: It is known that unilateral cerebral lesions may manifest with a contralateral conjugate gaze deviation evoked by closure of the lids. This sign, known as spasticity of conjugate gaze, may be due to the suppression of the fixation reflex. In our case, the persistence of this sign in the darkness allowed us to exclude this diagnosis. We hypothesized that the blink-related neural pathways may improperly activate the oculomotor circuitry at both the cortical and subcortical levels.

Effectiveness of a Very Early Stepping Verticalization Protocol in Severe Acquired Brain Injured Patients: A Randomized Pilot Study in ICU.

BACKGROUND AND OBJECTIVE: Verticalization was reported to improve the level of arousal and awareness in patients with severe acquired brain injury (ABI) and to be safe in ICU. We evaluated the effectiveness of a very early stepping verticalization protocol on their functional and neurological outcome. METHODS: Consecutive patients with Vegetative State or Minimally Conscious State were enrolled in ICU on the third day after an ABI. They were randomized to undergo conventional physiotherapy alone or associated to fifteen 30-minute sessions of verticalization, using a tilt table with robotic stepping device. Once stabilized, patients were transferred to our Neurorehabilitation unit for an individualized treatment. Outcome measures (Glasgow Coma Scale, Coma Recovery Scale revised -CRSr-, Disability Rating Scale-DRS- and Levels of Cognitive Functioning) were assessed on the third day from the injury (T0), at ICU discharge (T1) and at Rehab discharge (T2). Between- and within-group comparisons were performed by the Mann-Whitney U test and Wilcoxon signed-rank test, respectively. RESULTS: Of the 40 patients enrolled, 31 completed the study without adverse events (15 in the verticalization group and 16 in the conventional physiotherapy). Early verticalization started 12.4±7.3 (mean±SD) days after ABI. The length of stay in ICU was longer for the verticalization group (38.8 ± 15.7 vs 25.1 ± 11.2 days, p = 0.01), while the total length of stay (ICU+Neurorehabilitation) was not significantly different (153.2 ± 59.6 vs 134.0 ± 61.0 days, p = 0.41). All outcome measures significantly improved in both groups after the overall period (T2 vs T0, p<0.001 all), as well as after ICU stay (T1 vs T0, p<0.004 all) and after Neurorehabilitation (T2 vs T1, p<0.004 all). The improvement was significantly better in the experimental group for CRSr (T2-T0 p = 0.033, T1-T0 p = 0.006) and (borderline) for DRS (T2-T0 p = 0.040, T1-T0 p = 0.058). CONCLUSIONS: A stepping verticalization protocol, started since the acute stages, improves the short-term and long-term functional and neurological outcome of ABI patients. TRIAL REGISTRATION: clinicaltrials.gov NCT02828371.

Efficacy and tolerability of pregabalin versus topiramate in the prophylaxis of chronic daily headache with analgesic overuse: an open-label prospective study.

OBJECTIVES: Medication-overuse headache is one of the most disabling headaches. Antiepileptic drugs have been considered a promising strategy as prophylactic treatment in these patients, even if their use often has been limited by low tolerability or safety. The objective of this study was to evaluate the efficacy and safety of pregabalin compared with topiramate for the prophylaxis of chronic daily headache with medication overuse using an open-label prospective study. METHODS: After a 2-month baseline period (T0), 100 consecutive patients with medication overuse headache were assigned to receive 150 mg/d pregabalin or 100 mg/d topiramate. After a titration period of 4 weeks, a follow-up visit was scheduled every 2 months (T1 and T2) to evaluate headache frequency, the amount of rescue medication intake, and disability. RESULTS: Of the 46 pregabalin-treated patients, the mean monthly headache frequency significantly decreased from 21.8 ± 4.8 (T0) to 5.1 ± 3.8 (T2), and the monthly number of days with medication intake decreased from 15.1 ± 4.8 (T0) to 2.9 ± 1.9 (T2). Similarly, of the 42 topiramate-treated patients, the mean monthly headache frequency decreased from 21.8 ± 4.9 (T0) to 5.3 ± 3.5 (T2), and the mean monthly number of days with medication intake decreased from 15.1 ± 3.7 (T0) to 2.6 ± 1.5 (T2). A significant improvement of disability score was reported in both groups. CONCLUSIONS: Similar to topiramate, pregabalin seems to be an effective and well-tolerated preventive therapy in chronic headache and a new option in the management of withdrawal from abused drugs in patients with analgesic overuse, a difficult-to-treat population.