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Grishin NK, De Souza AM, Fairbairn J, Sheel AW, Puterman E, Blydt-Hansen T, Potts JE, Armstrong KR. An 8-Week Virtual Exercise Training Program for Pediatric Solid Organ Transplant Recipients. Pediatr Exerc Sci 2023:1-11. [PMID: 38096811 DOI: 10.1123/pes.2023-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 09/07/2023] [Accepted: 09/18/2023] [Indexed: 01/25/2024]
Abstract
PURPOSE Musculoskeletal strength can be impaired in pediatric solid organ transplant recipients. Exercise training programs can be beneficial but in-person delivery can be challenging; virtual exercise programs can alleviate some of these challenges. This feasibility study aimed to deliver an 8-week virtual exercise program in pediatric solid organ transplant recipients. METHOD Program delivery occurred 3 times per week for 30 minutes. An exercise stress test was completed prior to program start. The Bruininks-Oseretsky Test of Motor Proficiency strength subtest and self-report surveys were used to assess musculoskeletal strength, quality of life, fatigue, and physical activity. Contact was maintained through a text messaging platform. Z scores were calculated using standardized normative data. Medians (interquartile range) are reported for all other data. RESULTS Eleven participants completed the program (2 liver, 5 kidney, 4 heart; 58% females; median age = 11.5 [10.3-13.8] y). Six participants attended ≥60% of classes, 5 participants attended <50% of classes. After 8 weeks, strength scores improved (Z score, Pre: -1.0 [-1.65 to -0.60] to Post: -0.2 [-1.30 to 0.40]; P = .007) with no change in other outcome measures. CONCLUSION The virtual exercise program was delivered without technical issues and received positive participant feedback. Engagement and costs need to be considered.
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Affiliation(s)
- Nikol K Grishin
- School of Kinesiology, The University of British Columbia, Vancouver, BC,Canada
| | - Astrid M De Souza
- Children's Heart Center, Division of Cardiology, Department of Pediatrics, British Columbia Children's Hospital, The University of British Columbia Vancouver, Vancouver, BC,Canada
| | - Julie Fairbairn
- Multi-Organ Transplant Program, British Columbia Children's Hospital, Vancouver, BC,Canada
| | - A William Sheel
- School of Kinesiology, The University of British Columbia, Vancouver, BC,Canada
| | - E Puterman
- School of Kinesiology, The University of British Columbia, Vancouver, BC,Canada
| | - Tom Blydt-Hansen
- Multi-Organ Transplant Program, British Columbia Children's Hospital, Vancouver, BC,Canada
- Division of Nephrology, Department of Pediatrics, British Columbia Children's Hospital, The University of British Columbia Vancouver, Vancouver, BC,Canada
| | - James E Potts
- Children's Heart Center, Division of Cardiology, Department of Pediatrics, British Columbia Children's Hospital, The University of British Columbia Vancouver, Vancouver, BC,Canada
| | - Kathryn R Armstrong
- Children's Heart Center, Division of Cardiology, Department of Pediatrics, British Columbia Children's Hospital, The University of British Columbia Vancouver, Vancouver, BC,Canada
- Division of Nephrology, Department of Pediatrics, British Columbia Children's Hospital, The University of British Columbia Vancouver, Vancouver, BC,Canada
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Baker LA, March DS, Wilkinson TJ, Billany RE, Bishop NC, Castle EM, Chilcot J, Davies MD, Graham-Brown MPM, Greenwood SA, Junglee NA, Kanavaki AM, Lightfoot CJ, Macdonald JH, Rossetti GMK, Smith AC, Burton JO. Clinical practice guideline exercise and lifestyle in chronic kidney disease. BMC Nephrol 2022; 23:75. [PMID: 35193515 PMCID: PMC8862368 DOI: 10.1186/s12882-021-02618-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 11/22/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | - Mark D. Davies
- Betsi Cadwaladr University Health Board and Bangor University, Bangor, UK
| | | | | | | | | | | | - Jamie H. Macdonald
- School of Sport, Health and Exercise Sciences, Bangor University, Bangor, UK
| | | | | | - James O. Burton
- University of Leicester and Leicester Hospitals NHS Trust, Leicester, UK
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Pesce de Souza F, Massierer D, Anand Raje U, Tansey CM, Boruff J, Janaudis-Ferreira T. Exercise interventions in solid organ transplant candidates: A systematic review. Clin Transplant 2020; 34:e13900. [PMID: 32391965 DOI: 10.1111/ctr.13900] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Exercise training may be recommended to solid organ transplant (SOT) candidates to improve fitness and tolerance before surgery. We aimed to determine the acceptance, safety, and effectiveness of exercise interventions in SOT candidates. METHODS Online databases were searched. Studies of any design were included. Outcomes of interest were acceptance, safety, exercise capacity, and health-related quality of life. RESULTS Twenty-three articles were included. Acceptance ranged from 16% to 100%. In the fifteen studies that assessed adverse events, none mentioned any adverse events occurring during the study. Five out of seven studies reported an increase in maximal exercise capacity post-exercise in the intervention group (range of mean change: 0.45 to 2.9 mL/kg). Eight out of fourteen studies reported an increase in 6-minute walking distance in the intervention group after the training period (range of mean change: 40-105 m). Two articles showed an improvement in the mental composite scores as well as in the physical composite scores post-exercise in the intervention group. CONCLUSION There was a lack of significant findings among most randomized controlled trials. Exercise training is acceptable and safe for selective SOT candidates. The effects of exercise training on exercise capacity and quality of life in SOT candidates are unclear.
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Affiliation(s)
| | - Daniela Massierer
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada.,Centre for Health Outcomes Research (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
| | - Uma Anand Raje
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Catherine M Tansey
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada
| | - Jill Boruff
- Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal, QC, Canada
| | - Tania Janaudis-Ferreira
- School of Physical and Occupational Therapy, McGill University, Montreal, QC, Canada.,Centre for Health Outcomes Research (CORE), Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada.,Respiratory Epidemiology and Clinical Research Unit, Research Institute, McGill University Health Center Montreal, QC, Canada
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Neuberger J, Armstrong MJ, Fisher J, Mark P, Schmidtke K, Sharif A, Vlaev I. Sport and Exercise in Improving Outcomes After Solid Organ Transplantation: Overview From a UK Meeting. Transplantation. 2019;103:S1-S11. [PMID: 31259878 DOI: 10.1097/tp.0000000000002710] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Outcomes after solid organ transplantation continue to improve, but premature loss of life remains a major concern, with death from cerebrovascular disease and cardiovascular disease accounting for around 20% late deaths. There are multiple contributory factors including preexisting, and the posttransplant development of, cardiometabolic conditions (such as hypertension, diabetes mellitus, hyperlipidemia, and obesity). There is accumulating evidence that the regular engagement in exercise is an important factor affecting outcomes before, during, and after transplantation; yet most waitlist candidates and recipients have reduced levels of physical activity. The mechanisms whereby physical activity is associated with better outcomes and a reduction in risk factors for cardiovascular disease are incompletely understood. Attempts to increase physical activity in the transplant population, as in the general population, have had limited success. Use of concepts from Nudge theory provides an evidence-based approach that may help increase physical activity and so reduce premature mortality. Both National and International Transplant Games provide a vehicle for increasing physical activity in this population and may also help to reduce premature death by providing a forum for mutual support for recipients and their families as well as an excellent forum for highlighting the success and impact of organ donation.
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de Melo Marinho PÉ, da Rocha LG, de Araújo Filho JC, Sañudo B, Seixas A, de Andrade AD. Is whole body vibration an alternative physical training method for renal transplant recipients? Physiother Res Int 2020; 25:e1838. [PMID: 32124538 DOI: 10.1002/pri.1838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 12/23/2019] [Accepted: 02/08/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate the effect of a 12-week whole-body vibration (WBV) training program on quadriceps muscle strength, quadriceps thickness, the 6-min walk test (6MWT), respiratory muscle strength and quality of life in adults with a kidney transplant. METHOD Five renal transplant recipients (age: 43-52 years; body mass: 67.1 kg; height: 1.60 m) were examined individually before and after a 12-week WBV program (two weekly sessions, 35 Hz frequency, 2-4 mm amplitude) using quadriceps strength, quadriceps thickness, 6-min walking test, inspiratory muscle strength and quality of life. RESULTS There were no complications during WBV protocol, and the program was considered safe. Two of the participants changed quadriceps muscle strength, and one increased muscle thickness. Inspiratory muscle strength improved in one participant. The distance covered on 6MWT increased for two participants. Most of the subjects (P3, P4 and P5) reported improved quality of life, mainly regarding pain and social aspects. CONCLUSION The protocol improved the physical function and quality of life in some of the patients. However, WBV training prescription should be adjusted according to individual needs. Thus, studying the use of WBV in this patient group is necessary to understand and apply the benefits for this population.
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Affiliation(s)
| | - Lívia Gomes da Rocha
- Post Graduate Program in Physical Therapy, Universidade Federal de Pernambuco, Recife, Brazil
| | | | - Borja Sañudo
- Department of Physical Education and Sport, University of Seville, Seville, Spain
| | - Adérito Seixas
- Escola Superior de Saúde, Universidade Fernando Pessoa, Porto, Portugal
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Leddington Wright S, Bloxham A, Hames T, Price M. Therapeutic perceptions in management of transplant athletes at transplant games. Phys Ther Sport 2019; 39:114-9. [PMID: 31344534 DOI: 10.1016/j.ptsp.2019.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/10/2019] [Accepted: 07/14/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To investigate manual therapist's knowledge and beliefs of working with Transplantee Athletes (TxA) at Transplant Games. DESIGN On-line questionnaire. PARTICIPANTS Thirty present and previous members of Transplant Sport 'therapy team' (age; 35 ± 14 years, 24 female). MAIN OUTCOME MEASURES Questions concerned demographics and general information on the background of the therapists. Closed questions with rating statements concerning beliefs when treating TxA and open questions asking for advice the participants would give to colleagues and further information they would like to have available to them. RESULTS TxA were thought to be a vulnerable group of athletes requiring special precautions and considerations. Two areas of information evolved: "general advice for TxA management" and "specific advice for therapists". General advice was to understand TxAs and be vigilant with hygiene. Specific therapy advice was to avoid grade V manipulations and care with taping and massage, because of complications resulting from side effects of long-term medication. CONCLUSION There appears to be a lack of research-based evidence to guide practitioners in their management of TxAs. Generic, good advice is now available from experienced practitioners however there is a paucity of research evidence to support this. Thus, there is a potential danger of being overcautious in approaches to treatment which ultimately may impact on athletic performance. .
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Maia TO, Paiva DN, Filho DCS, Cavalcanti FCB, Rocha LG, Macedo Júnior ARA, de Melo Marinho PÉ. Effects of whole body vibration on cardiac autonomic function and exercise capacity in renal transplant recipients. International Journal of Therapy and Rehabilitation 2019. [DOI: 10.12968/ijtr.2018.0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Background/Aims Whole body vibration is an exercise alternative that can be used in the rehabilitation of renal transplant recipients with the aim of reducing cardiovascular risk. The aim of this study was to evaluate the effects of whole body vibration training on heart rate variability, cardiorespiratory parameters and functional capacity on five renal transplant recipients. Methods Renal transplant recipients underwent whole body vibration exercise twice a week for a total of 12 weeks. All participants were monitored using the 24-hour Holter to evaluate the heart rate variability domains. An exercise test to evaluate maximal oxygen consumption and the distance walked in the Six-Minute Walk Test to evaluate functional capacity were also recorded. Results Overall, two of the five transplant recipients improved sympathovagal balance at the end of the study. Maximal oxygen consumption improved in three transplanted patients, and the distance walked improved for two patients. The results showed that whole body vibration training improved heart rate variability and maximal and submaximal test performance in some transplanted recipients. Conclusion The 12-week training protocol with twice weekly whole body vibration sessions was sufficient to improve heart rate variability and the performance of maximal and submaximal tests in some renal transplant recipients, although the responses were heterogeneous for the considered variables. Whole body vibration may be an alternative to conventional means of physical exercise because it causes minimal cardiovascular stress, which could be especially indicated for this population given the risk presence of arrhythmias and sudden death; therefore studies with better designs need to be developed in order to verify the effectiveness of this intervention.
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Affiliation(s)
- Tuíra O Maia
- Physiotherapist, Post-Graduate Programme in Health Sciences, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Dulciane N Paiva
- Professor, Post-Graduate Programme in Health Promotion, Universidade de Santa Cruz do Sul, Santa Cruz do Sul, Rio Grande do Sul, Brazil
| | - Dário C Sobral Filho
- Professor, Coronary Care Unit of Pernambuco Cardiac Emergency Hospital, Universidade de Pernambuco, Recife, Pernambuco, Brazil
| | - Frederico CB Cavalcanti
- Professor, Real Portuguese Hospital of Beneficence of Pernambuco, Recife, Pernambuco, Brazil
| | - Livia G Rocha
- Physiotherapist, Post-Graduate Programme in Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Aluísio RA Macedo Júnior
- Cardiologist, Clinics Hospital of Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
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Smith BK, Carter N, Arteaga A, Dinh AC, Martin AD. Acute and 6-Month Outcomes in Recipients of Lung Transplantation Following Lower Extremity Strength Training: Pilot Study. Journal of Acute Care Physical Therapy 2018; 9:145-154. [DOI: 10.1097/jat.0000000000000081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Pang A, Lingham S, Zhao W, Leduc S, Räkel A, Sapir-Pichhadze R, Mathur S, Janaudis-Ferreira T. Physician Practice Patterns and Barriers to Counselling on Physical Activity in Solid Organ Transplant Recipients. Ann Transplant 2018; 23:345-359. [PMID: 29784902 PMCID: PMC6248028 DOI: 10.12659/aot.908629] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Many solid organ transplant (SOT) recipients fail to meet the recommended physical activity (PA) levels. “Physician recommendation” has previously been reported by SOT recipients as a key facilitator to being more physically active. The purpose of this study was to determine the proportion of Canadian SOT physicians providing PA counselling and identify barriers to including such counselling as part of the SOT recipients’ routine care. Material/Methods We conducted a cross-sectional web-based survey study to evaluate physicians’ PA counselling practices, including the prevalence and barriers to such practice. A survey link was sent to a convenience sample of transplant physicians who are members of the Canadian Society of Transplantation. Results Thirty-four physicians (13.6%) participated in the survey. While 97% (n=33) of the participants reported providing PA counselling to their transplant patients, only 18% (n=6) responded they were very confident in PA counselling. Lack of time (n=19; 56%) and a lack of exercise guidelines (n=18; 53%) were identified as the main barriers to PA counselling. Conclusions Incorporating sufficient PA knowledge into physicians’ educational curricula system, developing specific PA guidelines as well as establishing an easier referral system to exercise specialists might improve the frequency and quality of PA counselling post-transplant.
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Affiliation(s)
- Amy Pang
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Sarangan Lingham
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Weina Zhao
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Stephanie Leduc
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada
| | - Agnès Räkel
- Division of Endocrinology, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Ruth Sapir-Pichhadze
- Division of Nephrology and Multi-Organ Transplant Program, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada.,Metabolic Disorders and Complications, Centre for Outcomes Research and Evaluation, Research Institute of McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Sunita Mathur
- Department of Physical Therapy, University of Toronto, Toronto, Ontario, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, Canada
| | - Tania Janaudis-Ferreira
- School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada.,Canadian National Transplant Research Program, Edmonton, Alberta, Canada.,Translational Research in Respiratory Diseases Program, Research Institute of The McGill University Health Centre, Montreal, Quebec, Canada
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Roi GS, Mosconi G, Totti V, Angelini ML, Brugin E, Sarto P, Merlo L, Sgarzi S, Stancari M, Todeschini P, La Manna G, Ermolao A, Tripi F, Andreoli L, Sella G, Anedda A, Stefani L, Galanti G, Di Michele R, Merni F, Trerotola M, Storani D, Nanni Costa A. Renal function and physical fitness after 12-mo supervised training in kidney transplant recipients. World J Transplant 2018; 8:13-22. [PMID: 29507858 PMCID: PMC5829451 DOI: 10.5500/wjt.v8.i1.13] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/06/2017] [Accepted: 12/28/2017] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate the effect of a 12-mo supervised aerobic and resistance training, on renal function and exercise capacity compared to usual care recommendations.
METHODS Ninety-nine kidney transplant recipients (KTRs) were assigned to interventional exercise (Group A; n = 52) and a usual care cohort (Group B; n = 47). Blood and urine chemistry, exercise capacity, muscular strength, anthropometric measures and health-related quality of life (HRQoL) were assessed at baseline, and after 6 and 12 mo. Group A underwent a supervised training three times per week for 12 mo. Group B received only general recommendations about home-based physical activities.
RESULTS Eighty-five KTRs completed the study (Group A, n = 44; Group B, n = 41). After 12 mo, renal function remained stable in both groups. Group A significantly increased maximum workload (+13 W, P = 0.0003), V’O2 peak (+3.1 mL/kg per minute, P = 0.0099), muscular strength in plantar flexor (+12 kg, P = 0.0368), height in the countermovement jump (+1.9 cm, P = 0.0293) and decreased in Body Mass Index (-0.5 kg/m2, P = 0.0013). HRQoL significantly improved in physical function (P = 0.0019), physical-role limitations (P = 0.0321) and social functioning scales (P = 0.0346). No improvements were found in Group B.
CONCLUSION Twelve-month of supervised aerobic and resistance training improves the physiological variables related to physical fitness and cardiovascular risks without consequences on renal function. Recommendations alone are not sufficient to induce changes in exercise capacity of KTRs. Our study is an example of collaborative working between transplant centres, sports medicine and exercise facilities.
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Affiliation(s)
- Giulio Sergio Roi
- Department of Education and Research, Isokinetic Medical Group, Bologna 40123, Italy
| | - Giovanni Mosconi
- Department of Nephrology and Dialysis, Morgagni-Pierantoni Hospital, Forlì 47121, Italy
| | - Valentina Totti
- Department of Biomedical & Neuromotor Sciences, University of Bologna, Bologna 40121, Italy
- Associazione Nazionale Emodializzati, Dialisi e Trapianto, Milano 20121, Italy
| | - Maria Laura Angelini
- Department of Nephrology and Dialysis, Morgagni-Pierantoni Hospital, Forlì 47121, Italy
| | - Erica Brugin
- Department of Cardiovascular, Sports Medicine, Noale 30033, Italy
| | | | - Laura Merlo
- Sports Medicine, ULSS Company 9, Treviso 31100, Italy
| | - Sergio Sgarzi
- Sports Medicine, Regional Hospital of Bologna, Bologna 40121, Italy
| | - Michele Stancari
- Sports Medicine, Regional Hospital of Bologna, Bologna 40121, Italy
| | - Paola Todeschini
- Department of Nephrology and Dialysis, S. Orsola Hospital, Bologna 40121, Italy
| | - Gaetano La Manna
- Department of Nephrology and Dialysis, S. Orsola Hospital, Bologna 40121, Italy
| | - Andrea Ermolao
- Sports Medicine Unit DIMED, Department of Medicine, University of Padua, Padua 35100, Italy
| | - Ferdinando Tripi
- Sports Medicine, Regional Hospital of Modena, Modena 41100, Italy
| | - Lucia Andreoli
- Sports Medicine, Regional Hospital of Modena, Modena 41100, Italy
| | - Gianluigi Sella
- Sports Medicine, Regional Hospital of Ravenna, Ravenna 48121, Italy
| | - Alberto Anedda
- Sports Medicine, Regional Hospital of Parma, Parma 43121, Italy
| | - Laura Stefani
- Department of Experimental and Clinical Medicine, School of Sports Medicine, University of Florence, Sports Medicine Centre, Florence 50100, Italy
| | - Giorgio Galanti
- Department of Experimental and Clinical Medicine, School of Sports Medicine, University of Florence, Sports Medicine Centre, Florence 50100, Italy
| | - Rocco Di Michele
- Department of Biomedical & Neuromotor Sciences, University of Bologna, Bologna 40121, Italy
| | - Franco Merni
- Department of Biomedical & Neuromotor Sciences, University of Bologna, Bologna 40121, Italy
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