Comparison of virtual reality rehabilitation and conventional rehabilitation in Parkinson's disease: a randomised controlled trial

OBJECTIVE

To compare a 6-week virtual reality (VR) rehabilitation programme with a conventional rehabilitation programme in patients with Parkinson's disease.

DESIGN

Prospective, single-blinded, randomised controlled trial.

SETTING

Outpatients.

PARTICIPANTS

Fifty-one patients with Parkinson's disease were assigned at random to a VR rehabilitation programme or a conventional rehabilitation programme.

INTERVENTIONS

Both programmes ran for 6 consecutive weeks, with a 40-minute session three times per week.

MAIN OUTCOME MEASURES

The Balance Berg Scale (BBS) was used to measure balance. Secondary outcome measures were: Dynamic Gait Index (DGI) to evaluate ability to adapt gait to complex walking tasks; Disabilities of the Arm, Shoulder and Hand (DASH) scale to measure performance of the upper limb; and Short Form 36 (SF-36) to evaluate quality of life.

RESULTS

The VR rehabilitation programme led to an increase in BBS score {45.6 [standard deviation (SD) 7.9] vs 49.2 (SD 8.1), mean difference 3.6, 95% confidence interval (CI) 1.3 to 5.9; P=0.003}, DGI score [18.7 (SD 4.7) vs 20.2 (SD 4.2), mean difference 1.6, 95% CI 0.6 to 2.5; P=0.003] and SF-36 mental composite score [37.7 (SD 11.4) vs 43.5 (SD 9.2), mean difference 5.8, 95% CI 0.4 to 11.3; P=0.037], and a decrease in DASH scale score [29.6 (SD 17.5) vs 21.6 (SD 15.1), mean difference -7.9, 95% CI -13.7 to -2.2; P=0.009]. In contrast, the conventional rehabilitation programme only led to a decrease in DASH scale score [30.3 (SD 18.1) vs 25.1 (SD 15.8), mean difference -5.2, 95% CI -8.8 to -1.5; P=0.007].

CONCLUSION

These findings suggest that rehabilitation is useful in Parkinson's disease, and the VR rehabilitation programme was more effective in determining overall improvement than the conventional rehabilitation programme.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02807740.

Cognitive reserve as a useful variable to address robotic or conventional upper limb rehabilitation treatment after stroke: a multicentre study of the Fondazione Don Carlo Gnocchi

BACKGROUND AND PURPOSE

Rehabilitation plays a central role in stroke recovery. Besides conventional therapy, technological treatments have become available. The effectiveness and appropriateness of technological rehabilitation are not yet well defined; hence, research focused on different variables impacting recovery is needed. Results from the literature identified cognitive reserve (CR) as a variable impacting on the cognitive outcome. In this paper, the aim was to evaluate whether CR influences the motor outcome in patients after stroke treated with conventional or robotic therapy and whether it may influence one treatment rather than another.

METHODS

Seventy-five stroke patients were enrolled in five Italian neurological rehabilitation centres. Patients were assigned either to a robotic group, rehabilitation by means of robotic devices, or to a conventional group, where a traditional approach was used. Patients were evaluated at baseline and after rehabilitation treatment of 6 weeks through the Action Research Arm Test (ARAT), the Motricity Index (MI) and the Barthel Index (BI). CR was assessed at baseline using the Cognitive Reserve Index (CRI) questionnaire.

RESULTS

Considering all patients, a weak correlation was found between the CRI related to leisure time and MI evolution (r = 0.276; P = 0.02). Amongst the patients who performed a robotic rehabilitation, a moderate correlation emerged between the CRI related to working activities and MI evolution (r = 0.422; P = 0.02).

CONCLUSIONS

Our results suggest that CR may influence the motor outcome. For each patient, CR and its subcategories should be considered in the choice between conventional and robotic treatment.

Treadmill training in patients affected by Charcot-Marie-Tooth neuropathy: results of a multicenter, prospective, randomized, single-blind, controlled study

Background and purpose

Muscle‐strengthening, stretching or proprioceptive treatments may slow symptom progression in Charcot—Marie–Tooth (CMT) neuropathy. The aim of the study was to evaluate safety and efficacy of treadmill training in CMT1A.

Methods

We planned a multicenter, prospective, randomized, single‐blind, controlled study. We recruited 53 outpatients affected by CMT1A and randomized them into two treatment groups: one underwent stretching and proprioceptive exercise, whereas the other was additionally treated with treadmill training (TreSPE). Primary outcome measures (OMs) were the walking evaluations and secondary OM was the balance assessment. All participants were assessed at baseline and after 3 and 6 months of treatment.

Results

Most patients showed an improvement in at least one OM after 3 months [42/47 (89.4%)] and 6 months [38/40 (95%)] of treatment. No adverse events were reported in either group.

Conclusions

The most important finding was that both stretching and proprioceptive exercise and treadmill training had an objective benefit on patients affected by CMT disease, without causing overwork weakness. We had a low rate of drop out and did not find deterioration in motor performance. Our results also confirm that applying evidence‐based medicine methods to rehabilitative research is the correct way to test the efficacy of a treatment.

Malignant Melanoma of the Glans Penis in a Chronic Myeloid Leukemia Patient after Busulfan Therapy

There are many case reports of secondary neoplasms occurring after treatment with alkylating agents. A case of malignant melanoma of the glans penis in a chronic myeloid leukemia (CML) Ph'-positive patient after 13 years on busulfan treatment is described. Since neither impairment of immune status nor increased incidence of secondary neoplasm have hitherto been reported in CML, the suggestion that busulfan has a carcinogenetic effect is discussed.

Novel outcome measures for Charcot-Marie-Tooth disease: validation and reliability of the 6-min walk test and StepWatch(™) Activity Monitor and identification of the walking features related to higher quality of life

BACKGROUND AND PURPOSE

Charcot-Marie-Tooth (CMT) disease is the most common inherited neuropathy, but therapeutic options have been limited to symptom management. Past pharmacological trials have failed, possibly due to insensitive outcome measures (OMs). The aim of the current study was to evaluate the validity and reliability of the 6-min walk test (6MWT) and StepWatch(™) Activity Monitoring (SAM) with other previously validated OMs in CMT disease.

METHODS

A prospective multicenter study was performed, consecutively enrolling 168 CMT patients (104 with CMT1A, 27 with CMT1B, 37 with X-linked CMT) from Italian centers specializing in CMT care.

RESULTS

Statistical analysis showed that the 6MWT was highly related with all previously used OMs. Some, but not all, SAM parameters were related to commonly used OMs but may provide more information about quality of life.

CONCLUSIONS

The current study demonstrated the validity and reliability of the 6MWT and SAM as OMs for CMT. Moreover, SAM provides data that correlate better with quality of life measures, making it useful in future rehabilitation trials.

Pain in stroke patients: characteristics and impact on the rehabilitation treatment. A multicenter cross-sectional study

BACKGROUND

Post-stroke pain (PSP) is a common and disabling complication, difficult to treat, that often decreases patients' quality of life (QoL). The hypothesis is that PSP may negatively affect rehabilitation treatment.

AIM

The aim of this paper was to quantify and characterize pain in a sample of post-stroke patients undergoing rehabilitation and to investigate the impact of pain in slowing down or discontinuing the rehabilitation program.

DESIGN

Multicenter cross-sectional study.

SETTING

Inpatients and outpatients of rehabilitation department.

POPULATION

One hundred and six subacute and chronic stroke patients.

METHODS

Pain intensity was measured with the NRS or the PAINAD (if cognitive/language impairment was present); pain characteristics were assessed with the DN4, and NPSI questionnaire. Qol was measured with the SF-36. A clinical assessment and a semi-structured questionnaire on pain occurrence, impact, and management was administered by the physiotherapist in charge of the patients and by the physician.

RESULTS

Nearly 1/3 of the patients (32.9%) with normal cognitive functions and language reported pain occurrence after stroke; 81.8% of them had NRS≥3 and 31.8% DN4≥4 (meaning neuropathic origin of pain). In about 20% of the patients the PAINAD was used to measure pain; 17.4% of them presented a score ≥3. In 24.5% of our sample, pain influenced rehabilitation treatment. In 16% of the whole sample, pain influenced patients' attention during rehabilitation session. Patients with hypoesthesia presented significantly higher neuropathic pain scores than patients with normal sensory function. Regarding QoL, we found that patients with higher neuropathic pain showed more severe deterioration of mental aspects of QoL, where patients with higher nociceptive pain presented more severe deterioration of physical aspects of QoL.

CONCLUSION

The results from this multicenter study showed that in about ¼ of the patients, pain negatively influenced the rehabilitation program delaying the recovery and likely increasing the cost of rehabilitation.

CLINICAL REHABILITATION IMPACT

Clinicians should pay more attention to pain, especially neuropathic pain, in post-stroke patients. Tailored pharmacological therapy, to treat and prevent pain, might improve patients' compliance during the rehabilitation process.

Rehabilitation for Charcot Marie tooth: a survey study of patients and familiar/caregiver perspective and perception of efficacy and needs

BACKGROUND

Charcot Marie Tooth (CMT) disease is the most common inherited polyneuropathy. At the moment there is no pharmacological therapy for this pathology and the conservative treatment is mostly based on rehabilitation program. Moreover there is no medical consensus on it and the perception of its efficacy is mostly clinician-oriented.

AIM

To evaluate, through ad hoc self-administered questionnaires, the patient and family/caregiver perspective on rehabilitation access and perceived benefit from it.

DESIGN

Observational survey study.

SETTING

Clinical and genetic records of in and out-patients of third level hospitals and a patients association (ACMT-Rete) and familiar/caregiver.

POPULATION

Patients affected by CMT and familiar/caregiver.

RESULTS

Questionnaires showed that patients perceive physical and mental benefit from rehabilitation, but also perceived that do not perform the best rehabilitation program for their pathology. Familiar and caregiver, are not sure that rehabilitation is effective for their kin, probably because the benefits are too small to be seen by someone other than the patient.

CONCLUSION

The study shows as the lack of a consensus on rehabilitation tailored on CMT patients need is perceived by patients and familiar/caregiver.

CLINICAL REHABILITATION IMPACT

The knowledge of patients perception is very important in order to obtain the best rehabilitation program for CMT disease.

Reliability of SFEMG in diagnosing myasthenia gravis: sensitivity and specificity calculated on 100 prospective cases

OBJECTIVE

The study aimed to determine the utility of single-fibre electromyography (SFEMG) in the diagnosis of myasthenia gravis (MG) in subjects with a clinical suspicion of the disease.

METHODS

We performed a prospective, single-blinded study on 100 consecutive patients. SFEMG was not considered a criterion in making the MG diagnosis. For all cases, a different physician than the one performing SFEMG made the diagnosis of MG. All subjects underwent standard SFEMG of a single muscle, the orbicularis oculi.

RESULTS

SFEMG was abnormal in 67 of 100 patients. A final diagnosis of definite MG was made in 54 patients (30 men/24 women). SFEMG was positive in 53 of 54 patients diagnosed with MG. The sensitivity of SFEMG in diagnosing MG was 98% (95% CI: 0.94-1.02), while the specificity was 70% (95% CI: 0.54-0.86), with a positive predictive value of 79% (95% CI: 0.74-0.79) and a negative predictive value of 97% (95% CI: 0.94-0.99).

CONCLUSIONS

In this cohort of patients, normal SFEMG findings were unlikely to occur in patients with MG.

SIGNIFICANCE

SFEMG is not a confirmatory test for the diagnosis of MG, but it has a high negative predictive value in identifying patients without MG.

Pregnancy-induced analgesia: a combined psychophysical and neurophysiological study

BACKGROUND

To investigate changes in heat pain threshold and modifications in heat pain processing during pregnancy and labour, seventy-six nulliparous pregnant women were enrolled in two studies.

METHODS

In the first study (psychophysical), 60 pregnant women underwent a quantitative sensory testing (QST) investigating heat perception in two body areas (right forearm and T10 dermatome) according to these groups: 32-33 gestational weeks (GW), 39-40 GW, early stage of active labour and 24 h after the delivery. In the other study (neurophysiological), contact heat-evoked potentials (CHEPs) were recorded in other 16 women at the 32nd GW and in 11 of these also at the 40th GW.

RESULTS

The psychophysical study showed that heat pain threshold was significantly increased at the forearm at 32-33 GW (median ± IQR: 39.6 ± 0.7 °C), at 39-40 GW (40.6 ± 1.1 °C) and at early stage of active labour (40.8 ± 1.5 °C) as compared to 20 non-pregnant controls (p < 0.001). Heat pain threshold tested at T10 level was significantly increased at 32-33 GW (41.0 ± 1.6 °C), at 39-40 GW (42.1 ± 1.8 °C), and at early stage of active labour (42.3 ± 1.3 °C) as compared to the non-pregnant women (p < 0.001). The N2-P2 CHEP amplitude (main negative N2 and positive P2 components of the vertex biphasic potential) recorded from the pregnant women was significantly lower at the 40th than at the 32nd GW, after stimulation of both the forearm (p < 0.001) and the abdomen (p < 0.001).

CONCLUSIONS

In pregnant women, there is a progressive increase of heat pain threshold and a reduction of the CHEP amplitude, suggesting that a general inhibitory mechanism may be involved.

Occurrence and characterization of Pain in immune-mediated neuropathies: a multicentre prospective study

BACKGROUND

pain is a common symptom of peripheral neuropathies that may severely affect patients' Quality of Life. Pain questionnaires, based on verbal descriptors, are a useful way to investigate it.

METHODS

we performed a multicentre study through validated measures to characterize pain in a sample of consecutive patients affected by immune-mediated neuropathies.

RESULTS

ninety-three patients were enrolled in 16 Italian centres. Based on the numeric rating scale, almost half of the patients complained of moderate pain and one-third of the patients severe pain. Overall, up to 50% of our patients with immune-mediated neuropathies complained of neuropathic pain. The most common neuropathic symptoms were paraesthesia/dysesthesia and superficial spontaneous pain. Surprisingly, also patients with neuropathies commonly thought to be painless (such as multifocal motor neuropathy) reported discomfort and painful symptoms.

CONCLUSIONS

pain questionnaires should be considered in the clinical evaluation of immune-mediated neuropathies, also when evaluating therapy efficacy, because they may provide clinicians with useful information on painful symptoms and patients' quality of life.

Contribution of ultrasound in the assessment of nerve diseases

BACKGROUND AND PURPOSE

Recently, ultrasound (US) has been used to assess the peripheral nervous system; however, there is no real study about its possible significant role in routine practice. Our study aims to assess the contribution of US as a routine tool in a neurophysiological laboratory.

METHODS

The study assesses 130 patients who presented clinical suspicion of peripheral nerve diseases, excluding motor neuron disease, radiculopathy, hereditary and acquired polyneuropathy. All patients were clinically, neurophysiologically and sonographically assessed in the same session by the same neurologist/neurophysiologist. To avoid interpretation bias, two independent and blinded clinicians, different than the examiners performing electrodiagnosis and US, reviewed clinical, neurophysiological and US findings (also data about follow-up, when available) and classified the contribution of US as follows: Contributive (US had influence on the diagnostic and therapeutic strategies), Confirming (US confirmed the clinical and neurophysiological diagnosis), Non-Confirming (US findings were normal) and Incorrect (US findings led to incorrect diagnosis).

RESULTS

US impacted, namely modified the diagnostic and therapeutic path in 42.3% of cases (55 patients); US had a confirmatory role in 40% (52 patients); US did not confirm clinical and neurophysiological diagnosis in 17.7% (23 cases); no incorrect US findings were observed.

CONCLUSION

US complements neurophysiological assessment even in routine practice, and this confirms the increasing interest in US for a multidimensional evaluation of peripheral nerve system diseases.

Long term follow-up of carpal tunnel syndrome during pregnancy: a cohort study and review of the literature

INTRODUCTION

Carpal tunnel syndrome (CTS) occurring during pregnancy is considered to have a short and benign course and very few cases required surgery, however there is no information in literature on long term follow-up. The aim of this study was a systematic review of the literature and to report 3-year follow-up after delivery in a sample of pregnant women with CTS.

PATIENTS AND METHODS

We enrolled 45 consecutive pregnant women with CTS (mean age 32 years). Diagnosis was based on clinical and neurographic findings. Clinical and electrophysiological severity of CTS were scored according to an ordinal scale and the self-administered Boston questionnaires on symptoms (BQ-SYMPT) and functional status (BQ-FUNCT) of the hand during pregnancy and one-year after delivery. Symptoms were evaluated again by BQ over the telephone three years after delivery.

RESULTS

At one-year follow-up BQ-SYMPT and BQ-FUNCT scores improved in 40% of women, did not change in 46.7% and 55.6% and worsened in 13.3% and 4.4%, respectively. Clinical severity was stage 0 (i. e. without symptoms) in 26.7% of women, improved in 6.7%, unchanged in 60% and worse in 6.7%. Electrophysiological severity was stage 0 (i.e. no delay in median nerve conduction) in 17.8%, improved in 20%, unchanged in 57.8% and worse in 4.4%. Only one woman underwent surgery (5 months after delivery), three were treated with local steroid injection before delivery and 18 used a splint, 8 of whom continued to do so periodically after one year. At 3-year follow-up 51% were symptom-free and 49% had anomalous ( > 1) BQ scores, but mean BQ scores improved with respect to those at baseline and one-year follow-up.

CONCLUSION

A Pubmed search identified 20 papers in which therapy and follow-up could be deduced. Almost all reported a short follow-up with disappearance of symptoms. Our study confirms that pregnancy-related CTS has a benign course: improvement of symptoms was evident at one- and 3-year follow-up, but about half the women still complained of symptoms 3 years after delivery. Only one woman underwent surgery and 11% still sometimes wore a splint at night. Despite improvement of symptoms, distal sensory conduction velocity of the median nerve improved but remained delayed in 84% of women one year after delivery.

Multidimensional study on quality of life in children with type 1 diabetes

AIM

To study the Health Related Quality of Life (HRQoL) and metabolic assessment in 33 children affected with type 1 diabetes (18 males, 15 females; mean age 10.3 years).

METHODS AND RESULTS

We used the Child Health Questionnaire-Parental Form 50 items (CHQ-PF50), measurements of metabolic control and we related them to patient management and family status. Quality of life (QoL) in diabetic children was worse than in the healthy sample. Interestingly, mean and last glycosylated hemoglobin (mean HbAlc r: -.4410 p < .01 and last HbAlc r: -.4012 p < .01), age of patients (r: -.4428; p < .009) and number of glycaemia controls (r: -.37, p < .03) were the most important parameters related to HRQoL parameters.

CONCLUSION

This multidimensional study stressed that HRQoL is influenced by the metabolic assessment. Moreover, the report examined the parental perception of QoL in children with chronic diseases. Higher number of glycaemia controls/day, better metabolic control, lower age of children and earlier onset of diabetes produced better physical and psychological aspects of QoL. In comparison with adolescent patients, in children with diabetes, factors as number of insulin injections and daily snacks, and the level of education of the mother were not so important to influence QoL. Unexpectedly, in this sample, life habits, family features, and anthropometric parameters did not correlate with specific domains of QoL.

Misdiagnosis of lumbar-sacral radiculopathy: usefulness of combination of EMG and ultrasound

In the presence of sensitive symptoms along the lumbar-sacral dermatomeric region, it is easy to suspect a lumbar-sacral radiculopathy, it being a very common disease. Clinical evaluation, neurophysiology and magnetic resonance imaging are common tools in diagnosing lumbosacral radiculopathy. Nevertheless, sometimes tumour may mimic radiculopathy. With the improvement of ultrasound, most peripheral nerves may be virtually identified. We describe two patients where tumour of sural nerve and tibial nerve mimicked S1 radiculopathy. We diagnosed the tumours only through a comprehensive nerve assessment combining clinical evaluation, US and neurophysiology. The association of neurophysiological and imaging US assessments, possibly in the same session, may avoid misdiagnosis.

Contribution of ultrasound in a neurophysiological lab in diagnosing nerve impairment: A one-year systematic assessment

OBJECTIVE

To evaluate the usefulness of a combination of electromyography (EMG) and ultrasound (US) assessments in diagnosing nerve trunk involvement. We hypothesised that in some cases, when the clinical or neurophysiological picture is unclear, the simultaneous study of the peripheral nervous system through both US and EMG may provide pathologic information not obtainable through EMG alone, and this may influence therapeutic decisions.

METHODS

In 2005, we performed a prospective study in 77 consecutive patients with involvement of a single nerve trunk, using a combination of EMG and US in the same session. We divided the diagnostic contribution of US into four categories: diagnostic, confirming, inconclusive and misdiagnostic.

RESULTS

In about a quarter of the patients, US provided results confirming the clinical neurophysiological diagnosis. In another quarter of the cases, US was very helpful in modifying diagnosis and therapy. In most of these cases, the contribution of US was important for the detection of tumors or cysts, thus showing the cause of nerve involvement. In half of the cases the US results were inconclusive, and in one case US was misdiagnostic.

CONCLUSIONS

The combination of EMG and US performed in the same session (or in collaboration with an ultrasound examiner) may be useful for diagnosis and determination of appropriate therapy.

SIGNIFICANCE

Diagnosis of mononeuropathies is improved through a combined functional and morphological evaluation of the nerve by using EMG and US.

Quality of life of patients operated on for lumbar stenosis: a long-term follow-up

BACKGROUND

We evaluated a sample of 28 patients surgically treated for lumbar stenosis (LS) four years after the first evaluation (length of the first follow-up mean 44.6 months, range 15-88) in order to evaluate the long-term follow-up of Quality of Life (QoL) after surgical treatment as LS may greatly impair the patients' QoL. We previously assessed QoL in 30 patients operated on for LS four years before, by performing a retrospective follow-up through the Short-Form 36 Health Survey (SF-36).

METHODS

In this current study we performed a phone call evaluation administering the SF-36 and the official Italian version of the North American Spine Society (NASS) lumbar spine outcome assessment instrument.

FINDINGS

With regard to the SF-36 results at long term follow-up we observed a significant improvement of Physical Function, Bodily Pain, Mental Health and the Physical Composite Score with respect to the first follow-up. Conversely, Vitality worsened. Regarding the results of NASS an improvement of neurological symptoms was observed. Comparison of SF-36 mean scores in the current LS sample vs. the Italian normal population at the same age, showed similar QoL pattern.

CONCLUSIONS

The long-term follow-up showed that patients operated on for LS continue to improve their QoL pattern even between the 4th and the 8th year after surgery.