Consensus paper on postural dysfunction: recommendations for prevention, diagnosis and therapy

Good fundamentals of posture and balance are essential for the efficient performance of both simple daily tasks and more complex movement patterns. In particular, postural balance is the ability to keep the body in equilibrium and to regain balance after the shift of body segments: postural control mechanisms of integration of the visual, vestibular and foot afferential channels contribute to this. This document provides recommendations based on scientific evidence, clinical practice, and consensus between experts concerning the prevention, diagnosis, and treatment of postural dysfunction at the three stages of life as the developmental age, adult age, and old age > 65 years and follows the "National Guidelines on Classification and Measuring of Posture and its Dysfunctions" per the Italian Ministry of Health (December 2017). The paper answers four main questions: i) "Which measures can be adopted to prevent postural dysfunctions?" ii) "What can we do in order to make a correct diagnosis of postural dysfunction?" iii) "What are the correct treatment programs for postural dysfunctions?" iv) Which professional competencies and experiences are useful for preventing, diagnosing and treating postural dysfunctions? By the Consensus of the Experts and the scientific evidence, emerge that the approach to postural dysfunctions requires a multidisciplinary and interdisciplinary team. Furthermore, rehabilitation treatment interventions must be specific to the age groups that have been indicated, to consider the integration of the main systems and subsystems of postural control that change with age.

A novel microgravity postural rehabilitation protocol in Beckwith Wiedemann syndrome: a case report

BACKGROUND

Beckwith-Wiedemann syndrome (BWS) is a genetic overgrowth syndrome. The excess growth can manifest as whole-body or regional overgrowth in approximately 25% of patients.

PURPOSE

The aim of this case report is to show an original rehabilitation protocol in BWS for improving the recovery of postural control in asymmetric body growth of the body.

CASE DESCRIPTION

An 11-year-old male with BWS performed a rehabilitation program for 12 months, once a week (every session lasted 45 minutes), composed of postural exercises under microgravity conditions using the Dynamic-Antigravity-Postural-System (SPAD) and proprioceptive insoles.

CONCLUSIONS

The results showed that: SPAD improved the asymmetry of the morphology and body dynamics and could prevent further postural alterations; the proprioceptive insoles increased the postural stability of the patient with improved walking. Future research will be needed to expand these results.

Idiopathic facial palsy: umbrella review of systematic reviews and meta-analyses

Idiopathic facial palsy is the most common disease of the VII cranial nerve. There are many treatments to facilitate recovery from this condition: pharmacological, surgical, rehabilitative, but the effectiveness of some of these treatments, especially the latter, is still under discussion. The purpose of this umbrella review of systematic reviews is to analyse the literature in order to investigate the different rehabilitation interventions in patients suffering from idiopathic facial palsy. A scientific literature search was carried out from January 2009 until August 2019, using Mesh the terms "facial palsy", "Bell's Palsy", "idiopathic facial nerve palsy", combined with "rehabilitation" and "therapy". Initially all the systematic reviews and meta-analyses of the last 10 years concerning rehabilitation treatments for the recovery of injured functions in facial palsy were included. Given the heterogeneity of the studies in the literature, which do not differentiate the different causes of facial palsy, all the causes of idiopathic facial palsy were included in the review. The research resulted in 94 published systematic reviews but only 6 were considered in respect to the inclusion criteria. All studies agree on the lack of high-quality scientific work to be able to say that Bell's physiotherapy treatments for facial palsy are effective, in particular with regard to recovery times during the rehabilitation process. Future studies are needed, in order to highlight the therapeutic implications of the different rehabilitation methods, with standardized protocols, in patients suffering from facial palsy of different aetiology.

Effects of capacitive and resistive electric transfer therapy in patients with painful shoulder impingement syndrome: a comparative study

Objective

Capacitive and resistive electric transfer therapy (CARE) reduces pain and improves quality of life for many orthopaedic degenerative and inflammatory disorders. The research aim was to determine the effects of CARE on painful shoulder. The outcomes were pain reduction and recovery of shoulder function.

Methods

A retrospective, observational case-control study was conducted. Participants were 46 patients (22 in the CARE group and 24 in the SHAM group). Clinical data, pain (visual analogic scale, VAS) and functional scale scores (Disabilities of the Arm, Shoulder and Hand scale, and Constant–Murley Scale) were measured at baseline T0 (before treatment), T1 (after treatment) and follow-up T2 (2 months after the end of the treatment).

Results

VAS scores in the CARE group improved from 7.23 ± 1.11 at baseline to 2.68 ± 0.99 at follow-up. The SHAM group did not experience any improvement. Similarly, functional scale scores improved in the CARE group compared with the SHAM group.

Conclusion

Considering the small number of sessions needed, low cost and long-term benefits, CARE could be a useful therapeutic option for the conservative management of shoulder pain to restore pain-free and powerful movement to the shoulder joint.

Mesotherapy in the treatment of musculoskeletal pain in rehabilitation: the state of the art

Background

Mesotherapy can be included as an ancillary treatment in the management of localized pain in rehabilitation, but there are no definitive treatment protocols for this approach.

Objectives

The purpose of this review was to examine new indications for more standard protocols of mesotherapy in rehabilitation.

Materials and methods

This systematic review was performed using the following resources: PubMed, Cochrane, PEDro, Scopus, and Google Scholar. The following algorithm was developed, based on the PICO acronym, to evaluate the effects of mesotherapy, with pain as the primary outcome (MESH terms): [mesotherapy AND pain], [mesotherapy AND musculoskeletal], [mesotherapy AND musculoskeletal disorder], [intradermal therapy AND pain], and [intradermal therapy AND musculoskeletal disorder].

Results

Seven articles (N=7) satisfied the inclusion criteria and were considered in the review: two of them treated osteoarthritis of the knee (3 sessions) and pes anserine (9 sessions) emphasizing a good efficacy of mesotherapy. Five studies analyzed spine diseases (specifically, two was about chronic and nonspecific neck pain, two about acute low back pain and one about chronic spinal pain): the results of mesotherapy treatment are encouraging both for the resolution of acute and chronic musculoskeletal vertebral pain from one to five sessions.

Conclusion

Mesotherapy showed a good effect to reduce acute and chronic musculoskeletal pain and, also, it is a well-tolerated treatment. Nonetheless future randomized controlled trials should be desirable for more uniform treatment protocols.

Extracorporeal shockwaves as regenerative therapy in orthopedic traumatology: a narrative review from basic research to clinical practice

Extracorporeal Shock Wave Therapy (ESWT), after its first medical application in the urological field for lithotripsy, nowadays represents a valid therapeutical tool also for many musculoskeletal diseases, as well as for regenerative medicine applications. This is possible thanks to its mechanisms of action, which in the non-urological field are not related to mechanical disruption (as for renal stones), but rather to the capacity, by mechanotransduction, to induce neoangiogenesis, osteogenesis and to improve local tissue trophism, regeneration and remodeling, through stem cell stimulation. On the basis of these biological assumptions, it becomes clear that ESWT can represent a valid therapeutic tool also for all those pathological conditions that derive from musculoskeletal trauma, and are characterized by tissue loss and/or delayed healing and regeneration (mainly bone and skin, but not only). As a safe, repeatable and non–invasive therapy, in many cases it can represent a first–line therapeutic option, as an alternative to surgery (for example, in bone and skin healing disorders), or in combination with some other treatment options. It is hoped that with its use in daily practice also the muscle–skeletal field will grow, not only for standard indications, but also in post–traumatic sequelae, in order to improve recovery and shorten healing time, with undoubted advantages for the patients and lower health service expenses.

Clinical application of shock wave therapy in musculoskeletal disorders: part II related to myofascial and nerve apparatus

Shock waves have been widely recognized in literature as a biological regulator; accordingly we carried out a review on the effect of shock waves on the mesenchymal cells in their various expressions: bone, muscle, ligament and tendon tissue. To date, the application of Shock Wave Therapy (SWT) in musculoskeletal disorders has been primarily used in the treatment of tendinopathies (proximal plantar fasciopathy, lateral elbow tendinopathy, calcific tendinopathy of the shoulder, and patellar tendinopathy, etc.) and bone defects (delayed and non-union of bone fractures, avascular necrosis of femoral head, etc.). Although the mechanism of their therapeutic effects is still unknown, the majority of published papers have shown the positive and beneficial effects of using SWT as a treatment for musculoskeletal disorders, with a success rate ranging from 65% to 91%, while the complications are low or negligible. The purpose of this paper is to present the published data on the clinical application of SWT in the treatment of myofascial and nerve disorders. With the help of the relevant literature, in this paper we outline the indications and success rates of SWT, as well as the adequate SWT parameters (e.g., rate of impulses, energy flux density) defined according to the present state of knowledge.

Role of TNF in mast cell neuroinflammation and pain

Inflammatory mediators, such as cytokines, chemokines and arachidonic acid compounds, lead to vascular permeability and dilation and increase sensitization and pain receptors. Proinflammatory cytokines, including tumor necrosis factor, are involved in the etiology of clinical neurological disorders. These cytokines activate nuclear factor-κB (NF-κB) which leads to the activation of different inflammatory genes. TNF implicated in neurological disorders has an important role in the activation of microglia and astrocytes. The inhibition of TNF may lead to the decrease of microglia activation and can be useful for therapeutic intervention. TNF, at the site of nerve injury may activate mast cells (MCs) which mediate pathologic events such as headache and pain. TNF is the only cytokine stored in mast cells and can be rapidly released along with biogenic amines after MC stimulation. Activation of MCs leads to NF-κB and AP1 generation with release of many cytokines including TNF, IL-33 and IL-1. In this paper we discuss the role of TNF in MC activation, mediating pain and neurological disorders.

IMMUNOMODULATORY EFFECTS OF VITAMIN D ON SKIN INFLAMMATION

Vitamin D has a major role in calcium absorption and maintenance of healthy bones. Vitamin D is also involved in cancer, cardiovascular system, allergic diseases, immune regulation and immune disor¬ders. Irradiation of food as well as animals produces vitamin D and more than 90% of previtamin D3 synthesis in the skin occurs in the epidermis. Vitamin D receptor has been found in many cells including T and B lymphocytes, macrophages, mast cells, NK cells and Tregs, and it selectively binds with high affinity to its ligand. Vitamin D binds its receptor VDR, resulting in transcription of a number of genes playing a role in inhibition of MAPK. Its effect may be also mediated by the direct activation of PKC. Vitamin D has the ability to suppress inflammatory cytokines such as TNF, IL-1, IFN-gamma and IL-2; while it increases the generation of anti-inflammatory cytokines IL-4 and IL-10. In B cells, vitamin D3 have also been shown to suppress IgE antibody class switch partly through the inhibition of NF-kB. Here we discuss the relationship between vitamin D, immunity and skin disorders.

CLINICAL APPLICATION OF SHOCK WAVE THERAPY IN MUSCULOSKELETAL DISORDERS: PART I

The shock wave has been widely recognized in literature as a biological regulator; therefore we carried out a review on the activity performed by shock waves on the bone-myofascial tissue system. To date, the application of Shock Wave Therapy (SWT) in musculoskeletal disorders has been primarily used in the treatment of tendinopathies (proximal plantar fasciopathy, lateral elbow tendinopathy, calcific tendinopathy of the shoulder, and patellar tendinopathy, etc.) and bone defects (delayed- and non-union of bone fractures, avascular necrosis of femoral head, etc.). Although the mechanism of their therapeutic effects is still unknown, the majority of published papers have shown positive and beneficial effects of using SWT as a treatment for musculoskeletal disorders, with a success rate ranging from 65 to 91%, while the complications are low or negligible. The purpose of this paper is to inform the reader about the published data on the clinical application of SWT in the treatment of musculoskeletal disorders. In this paper, with the help of a literature review, indications and success rates for SWT in the treatment of musculoskeletal disorders are outlined, while adequate SWT parameters (e.g., rate of impulses, energy flux density, etc.) are defined according to the present state of knowledge. Given the abundance of the argument, it seems appropriate to subdivide the review into two parts, the first concerning the evidence of Extracorporeal Shock Wave Therapy (ESWT) on bone disorders, the second concerning findings on tendon and muscle treatment.

CROSSTALK BETWEEN VITAMIN B AND IMMUNITY

Vitamin B1 (thiamin) is considered to be the oldest vitamin and in 1936 R.R. Williams and colleagues determined its chemical structure and were able to synthesize this vitamin. Vitamin B1 influences pro-apoptotic proteins, mitochondrial membrane potential, cytochrome C release, protein kinases, p38-MAPK, suppresses oxidative stress-induced NF-kappaB and has anti-inflammatory properties. Deficiency of vitamin B1 may cause beriberi, dysfunction of the nervous system, neuroinflammation, T cell infiltration, chemokine CCL2 activation, over expression of proinflammatory cytokines, such as IL-1, TNF, IL-6, and arachidonic acid products, and induces expression of CD40 by the microglia and CD40L by astrocytes which provoke the death of neurons. Here we report the relationship between vitamin B complex and immunity.

Role of mast cells in atherosclerosis: a classical inflammatory disease

Atherosclerosis is an inflammatory disease and hyperlipidaemia is one of the main risk factors for aging, hypertension and diabetes. Variance in plasma LDL cholesterol concentration may be associated with differences in cardiovascular disease risk and high levels of lipids are associated with increased risk of developing atherosclerosis. Macrophages, which generate pro-inflammatory cytokines, mainly interleukin-1 (IL-1) and tumor necrosis factor-α (TNF-alpha), are deeply involved in atherosclerosis, as well as mast cells which generate several cytokines, including IL-6 and IFN-gamma, and chemokines such as eotaxin, MCP-1 and RANTES involved in monocyte recruitment and differentiation in the arterial wall. In addition, mast cells participate in lipid retention and vascular cell remodeling, and are mediators of innate and adaptive immunity during atherosclerosis. Mast cells which accumulate in the human arterial intima and adventitia during atherosclerotic plaque progression, release vasoactive and angiogenic compounds, and pro-inflammatory mediators, such as arachidonic acid metabolites, histamine, cytokines/chemokines, platelet activating factor (PAF) and proteolytic enzymes. Mast cells can be activated by pro-inflammatory stimuli, including cytokines, hypercholesterolemia, and hyperglycemia, and trigger the endothelial expression of adhesion molecules such as P-selection, vascular cell adhesion molecule-1 (VCAM-1) and chemokines which mediate the recruitment and adhesion of leukocytes. The participation of mast cells in atherosclerosis is still an enigma and it may be of therapeutic interest to clarify this process.

Italian survey on the use of anti-inflammatory drugs in osteoarthritis

Osteoarthritis (OA) is the most common painful arthritic disease in adults, causes severe disability and worsens the quality of life of the patients. The aim of this survey, carried out on 147 Italian orthopedic doctors who attended an ISIAT (International Symposium Intra Articular Treatment) educational course in Barcelona, was to investigate some aspects of daily clinical practice in the management of OA: the most used pharmacological treatments, compliance to the most important Guidelines, the advantages of COXIBs in this setting and pharmacoeconomic aspects. The main results of this survey are: a) inflammation has become the main target in OA; b) Guidelines are a useful and valid tool for daily clinical practice; c) acetaminophen is no longer a valid therapeutical option for OA patients; d) anti-inflammatory drugs (NSAIDs and COXIBs) have a primary role in the management of OA, due to their dual activity (anti-inflammatory and analgesic); e) selectivity of COXIBs for COX-2 is very important; f) within the COXIB class, the therapeutic value of etoricoxib has been widely recognized, especially in terms of safety and cost/benefit ratio.

Can vitamin a mediate immunity and inflammation?

Vitamins are natural components of foods and are organic compounds distinct from fat, carbohydrates and proteins. Vitamin A is the generic descriptor for compounds with the qualitative biological activity of retinol. Unlike beta-carotene, vitamin A is not an antioxidant and its benefit is related to possible boosting of immune reactions. The effect of vitamin A on immune function is wide-reaching and its deficiency appears to affect immunity in several ways. Innate and adaptive immune responses are affected in some way by lack of vitamin A. Retinoids seem to act on differentiation of lymphocytes, antibody production, phagocytosis of macrophages, NK, Treg, and T helper cell activity. In addition, in humans, signs of a vitamin A deficiency also include the dysregulation of cytokine/chemokine generation and release. However, excess of vitamin A has been demonstrated to have toxic effects in most species studied. Here we summarize some important effects of vitamin A in immunity and inflammation.

Impact of mast cells on multiple sclerosis: inhibitory effect of natalizumab

Mast cells (MCs) derive from a distinct precursor in the bone marrow and are predominantly found in tissues at the interface between the host and the external environment where they can secrete mediators without overt degranulation. Mast cells mature under local tissue microenvironmental factors and are necessary for the development of allergic reactions, through crosslinking of their surface receptors for IgE (FcεRI), leading to degranulation and the release of vasoactive, pro-inflammatory and nociceptive mediators that include histamine, pro-inflammatory and anti-inflammatory cytokines and proteolytic enzymes. Multiple sclerosis (MS) is an autoimmune disease characterized by inflammatory demylination within the central nervous system. MCs are involved in the pathogenesis of MS by generating various vasoactive mediators and cytokines and participate in the destruction of the myelin sheath and the neuronal cells. The process of the development of demyelinating plaques in MS is probably linked with the rupture of the blood-brain barrier by MC products. The effects of natalizumab, which is a very effective drug in reducing the annualized relapse rate and other relapse-based endpoints, are discussed. Here, we report the relationship between MCs and MS.

Obesity, Inflammation and Neurological Alterations

Inflammation, neurodegeneration, imbalance of neurotransmitter systems, oxidative stress and depression are all risk factors for obesity. There is evidence regarding the cross-talk between adipose tissue and the immune system and obese patients may show an alteration of immune functions with major depression, including immune suppression with reduced T-cell and macrophage activity. Obesity is mediated by inflammatory cells such as lymphocytes, macrophages and mast cells which release pro-inflammatory cytokines and chemokines. Obesity-induced leukocyte infiltrations in adipose tissue cause cytokine/chemokine release and inflammation. Here, we report the relationship between obesity, neurological alterations and inflammation.

Corticotropin-releasing hormone, microglia and mental disorders

Microglia derive from mononuclear myeloid progenitors and are a major glial complement of the central nervous system. When microglia are activated they secrete inflammatory cytokines and toxic mediators which amplify the inflammatory response. In addition, the microglia inflammatory products are implicated in the neuronal destruction usually observed in various neurodegenerative diseases. Microglia cells express corticotropin releasing hormone (CRH) receptors, and activation of microglia by CRH releases bioactive molecules which have a biological effect in the brain and regulate several neurological diseases. CRH plays a pivotal role in stress responses and is a key mediator of the hypothalamic-pituitary-adrenocortical system. CRH is expressed in human mast cells, leading to autocrine effects and participates in inflammatory response together with neuropeptides, and stimulates mast cells. IL-33-activated mast cells release vascular endothelial growth factor in response to CRH and act synergistically to increase vascular permeability. CRH also up-regulates IL-18 expression by increasing intracellular reactive oxygen in microglia cells. Here we report the relationship between CRH, microglia and mental disorders.

Relationship between serotonin and mast cells: inhibitory effect of anti-serotonin

Serotonin (5-HT) is an important neurotransmitter that acts in both central and peripheral nervous system, and has an impact on cell proliferation, migration and apoptosis. 5HT exerts its effects via several receptors. Treatment with anti-5-HT receptors diminish the severity of contact allergy in experimental animals, an effect mediated by mast cells; while an agonist reduces the stress level and relieves pruritus in patients with atopic dermatitis. Mast cells are important for both innate and adaptive immunity and they are activated by cross-linking of FceRI molecules, which are involved in the binding of multivalent antigens to the attached IgE molecules, resulting in a variety of responses including the immediate release of potent inflammatory mediators. Serotonin is present in murine mucosal mast cells and some authors reported that human mast cells may also contain serotonin, especially in subjects with mastocytosis. Here we report the interrelationship between mast cells, serotonin and its receptor inhibitor.

Nerve growth factor interactions with mast cells

Neuropeptides are involved in neurogenic inflammation where there is vasodilation and plasma protein extravasion in response to this stimulus. Nerve growth factor (NGF), identified by Rita Levi Montalcini, is a neurotrophin family compound which is important for survival of nociceptive neurons during their development. Therefore, NGF is an important neuropeptide which mediates the development and functions of the central and peripheral nervous system. It also exerts its proinflammatory action, not only on mast cells but also in B and T cells, neutrophils and eosinophils. Human mast cells can be activated by neuropeptides to release potent mediators of inflammation, and they are found throughout the body, especially near blood vessels, epithelial tissue and nerves. Mast cells generate and release NGF after degranulation and they are involved in iperalgesia, neuroimmune interactions and tissue inflammation. NGF is also a potent degranulation factor for mast cells in vitro and in vivo, promoting differentiation and maturation of these cells and their precursor, acting as a co-factor with interleukin-3. In conclusion, these studies are focused on cross-talk between neuropeptide NGF and inflammatory mast cells.

Asthma and Mast Cell Biology

Asthma is a chronic inflammatory disease of the lung and its pathophysiology is initiated by mast cell activation in response to the antigen binding to IgE receptor as well as by TH2 cell activation. Mast cells are well established effector cells in asthma where they exacerbate the inflammatory response, playing a key role in early phase, degranulating and increasing histamine. Human mast cells possess high affinity IgE receptors and are ubiquitous but predominantly localized in mucosal and connective tissue and are distributed along blood vessels. There are two types of mast cells: connective tissue mast cells (TC) and mucosal mast cells (T mast cells). TC mast cells contain more heparin, whereas T mast cells contain more chondroitin sulfate. In asthma, mast cell activation can trigger degranulation, releasing secretory granule complex and preformed mediators, such as histamine and proteases, along with the synthesis of leukotrines and prostaglandins, and induction of cytokines and chemokines. Leukotrine inhibitors and omalizumab, which inhibits IgE, both relieve the asthma exacerbation when administered to humans and permit to reduce the use of other drugs. The release of cytokines by mast cells, such as TNF-alpha, IL-1, IL-6 and IL-33, participate in the pathogenesis of asthma. Stress worsens asthma, and this effect is also mediated by mast cell activation through the release of cytokines. Administration of IL-33 in experimental animals provokes pathological effects in the mucosal tissues and augments antibody IgE and IgA in blood vessels. Here, we report the impact of mast cell biology in asthma pathogenesis.

Neuropeptide NGF mediates neuro-immune response and inflammation through mast cell activation

Human mast cells (first described in 1879 by Paul Ehrlich) develop from committed precursors in the bone marrow expressing the differentiation marker CD34+ and distinct from the three other myeloid cells. Mast cells are present in various tissues especially near blood vessels, epithelia and nerves and they are activated by cross-linking of FcεRI, but also by a number of neuropeptides. NGF mediates a number of inflammatory and autoimmune states in conjunction with an increased accumulation of mast cells which appear to be involved in neuroimmune interactions and tissue inflammation. Here we report some relationships between mast cells and nerve growth factor (NGF).

IgE Generation and Mast Cell Activation

IgE is an important marker for allergy and plays a central role in the induction of allergic diseases through its binding of the high affinity receptor on mast cells. Mast cells can influence B cell survival, proliferation and differentiation into CD138+cells. Among TH2 cytokines, interleukin (IL)-4 and IL-13 are responsible for class-switching in B cells which resolves in production of allergen-specific IgE antibodies that bind to specific receptor on mast cells. IgE synthesis by B cells is regulated by CD40 ligand, IL-4 and interferon-gamma, therefore inhibition of B cell antigen-specific IgE may prevent the cleavage of CD23 from B cells, having a therapeutic impact which also includes the removal of circulating free IgE, omalizumab, corticosteroids, mast cell stabilizers, leukotriene receptor antagonist, and others. B cell differentiation into IgE-producing cells requires two signals provided by TH2 cells and IL-4, however IL-4, IL-1 and IL-10 as well as several hormones are critical for the development of TH2 cells, while cytokines, such as interferon (IFN)-alpha, IFN-gamma, IL-12 and transforming growth factor (TGF)-beta play a negative role. However, the exact mechanism of this process has not yet been defined.

Interrelationship between IL-3 and mast cells

It is well established that mast cells, which are found in the tissues in the proximity of small blood vessels and post-capillary venules, play a key role in the early phase of IgE-mediated allergic reactions. A greatly expanded understanding of the biology of IL-3 has emerged since the early 1980s. IL-3 is a specific factor that stimulates the growth of hematopoietic stem and progenitor cells of a variety of lineages and can promote the proliferation of certain classes of lymphocytes distinct from those that are dependent on IL-2. IL-3 has been identified among the most important cytokines for regulation of mast cell growth and differentiation, migration and effector function activities of many hematopoietic cells. IL-3 termed multi colony-stimulating-factor (multi-CSF) or mast cell growth factor (MCGF) is a haematopoietic growth factor which stimulates the formation of colonies for erythroid, megakaryocytic, granulocytic and monocytic lineages. It is predominantly produced by activated T cells, natural killer (NK) cells and mast cells and supports the growth-promoting effects of SCF on mast cell precursors. IL-3 causes severe hypersensivity reactions and plays a pivotal role in exacerbating the inflammatory response in vivo. Here we report the interrelationship between IL-3 and mast cells.

Vascular endothelial growth factor (VEGF), mast cells and inflammation

Vascular endothelial growth factor (VEGF) is one of the most important inducers of angiogenesis, therefore blocking angiogenesis has led to great promise in the treatment of various cancers and inflammatory diseases. VEGF, expressed in response to soluble mediators such as cytokines and growth factors, is important in the physiological development of blood vessels as well as development of vessels in tumors. In cancer patients VEGF levels are increased, and the expression of VEGF is associated with poor prognosis in diseases. VEGF is a mediator of angiogenesis and inflammation which are closely integrated processes in a number of physiological and pathological conditions including obesity, psoriasis, autoimmune diseases and tumor. Mast cells can be activated by anti-IgE to release potent mediators of inflammation and can also respond to bacterial or viral antigens, cytokines, growth factors and hormones, leading to differential release of distinct mediators without degranulation. Substance P strongly induces VEGF in mast cells, and IL-33 contributes to the stimulation and release of VEGF in human mast cells in a dose-dependent manner and acts synergistically in combination with Substance P. Here we report a strong link between VEGF and mast cells and we depict their role in inflammation and immunity.

Impact of Mast Cells on the Skin

When through the skin a foreign antigen enters it provokes an immune response and inflammatory reaction. Mast cells are located around small vessels that are involved in vasaldilation. They mature under the influence of local tissue to various cytokines. Human skin mast cells play an essential role in diverse physiological and pathological processes and mediate immediate hypersensitive reaction and allergic diseases. Injection of anti-IgE in the skin or other agents that directly activate mast cells may cause the decrease in vascular tone, leakage of plasma and may lead to a fall in blood pressure with fatal anaphylactic shock. Skin mast cells are also implicated as effector cells in response to multiple parasites such as Leishmania which is primarily characterized by its tissue cutaneous tropism. Activated macrophages by IFNγ, cytotoxic T cells, activated mast cells and several cytokines are involved in the elimination of the parasites and immunoprotection. IL-33 is one of the latest cytokines involved in IgE-induced anaphylaxis and in the pathogenesis of allergic skin disorders. IL-33 has been shown in epidermis of patients with psoriasis and its skin expression causes atopic dermatitis and it is crucial for the development of this disease. Here we review the impact of mast cells on the skin.

Luteolin inhibits mast cell-mediated allergic inflammation

Mast cells are ubiquitous in the body and multifunctional immune cells; they are known to be primary responders in allergic reactions, orchestrating strong responses to minute amounts of allergens. Mature mast cells perform important beneficial roles in host defense, both in IgE-dependent immune responses to certain parasites and in natural immunity to bacterial infection. In IgE-associated biological responses, the crosslinking of FcεRI-bound IgE with multivalent antigens initiate the activation of mast cells by promoting aggregation of FceRI. This cross-linking receptor-bound IgE by multivalent Ag initiates a cascade of intracellular reactions leading to mediator release such as proinflammatory mediators, chemokines and cytokines. Luteolin belongs to a flavone group of compounds called flavonoids, it has anti-oxidant properties, inhibits some cancer cell proliferation and exerts a regulatory effect on mast cell-mediated inflammatory diseases and allergy. Here we report the impact of luteolin on mast cell activation.

Task-Oriented Physical Exercise Using Postural Re-Alignment with Body Weight Support in Chronic Stroke

The recovery of functional gait is the main target for subjects who have suffered a stroke. The methods designed to improve balance and gait appear to be essential for skills and autonomy and to reduce the costs of assistance. The aim of our study was to evaluate the improvement of stroke victims in the chronic phase through the rehabilitation of gait, balance and posture using postural re-alignment with specific body weight support. The study includes 20 subjects with residual hemiparetic gait after stroke. Evaluation with international rating scales, gait analysis and stabilometric test was carried out at the beginning and after the 1st and the 3rd month of therapy; a follow-up control was made 3 months after the end of the rehabilitation program. All subjects underwent the rehabilitation protocol with Dynamic Antigravity Postural System 2 times a week for 3 months and were also treated with high efficiency focused acoustic waves (ViSS) to increase strength and muscular endurance (300Hz) or to reduce spastic hypertonia (200–120 Hz). The study shows a significant improvement in gait and balance with the persistence of results at the follow-up 3 months after the end of treatment. The subjects showed an increase in walking speed, greater stability and a consequent reduction of sedentary lifestyle with less risk of complications or recurrence. In conclusion this rehabilitation program is efficient for posture and walking quality.

Impact of Mast Cells in Rejection of Allografts

Mast cells in the tissue are located close to nerves in and around the small vessels where they orchestrate important immune response after antigen recognition through Toll-like receptors. Mast cells can activate T and B lymphocytes and dendritic cells and have been postulated to act directly within tissue allografts and/or to induce indirect effects via inflammatory mediator release, therefore they have been shown to play an indispensable role in allograft tolerance. Major limitation in the success of transplantation is the immune response of the recipient to the donor tissue. The failure of tissue grafting is caused by an inflammatory reaction called rejection. Mast cells play a role during immune response and are elicited with transplanted allograft and also may exhibit their immune-regulatory effects directly through secretion of modulatory cytokines and activation of metabolic pathways. However, the role of mast cells in transplantation is poorly understood. The most severe rejection episodes have been found in patients with an increased number of mast cells. Mast cell mediators which can activate latent forms of TGF-β or increase angiotensin II levels are capable of inducing fibrosis through various mechanisms, activating fibroblasts and inducing collagen synthesis. Mast cells are also implicated in regulatory T-cell functions and are required to sustain peripheral tolerance via Treg, therefore there is an interaction between mast cells and Treg cells. Treg create IL-9 in enhancing mast cell growth and Chemotaxis, suggesting that Treg and mast cells form a functional unit that mediates graft tolerance. In this study we concentrate our attention on the role of mast cells in rejection of allografts and try to understand the role of mast cell-related immune mechanisms in organ transplantation.

Mast cell involvement in rheumatoid arthritis

Autoimmunity is a failure of self-tolerance resulting in immune reactions against autologous antigen. Rheumatoid arthritis is characterized by inflammation of synovium associated with destruction of the join cartilage and bone. A role of mast cell-mediated inflammation and antibodies are involved in this disease. Numerous cytokines such as IL-1, TNF, IL-8, IL-33 and IFN gamma have been implicated in rheumatoid arthritis and in particular in the synovial joint fluid. Since TNF is believed to activates resident synovial cells to produce collagenase that mediate destruction of cartilage, antagonists against the inflammatory cytokine TNF have a beneficial effects in this disease. Here we review the interrelationship between rheumatoid arthritis and mast cell activation.

Flexible flatfoot treatment in children with mechanical sound vibration therapy

The flat foot can be defined as a syndrome with multiple etiopathogenesis, characterized by an altered structure of the longitudinal arch of the plantar vault with its reduction in height. The plantar arch collapse can be counteracted by strengthening the muscles involved; for many years, specific physical exercises have been proposed with this purpose in physical and rehabilitation medicine. The aim of our work was to improve the plantar arch muscles' tone using high focal vibration therapy (300Hz)

METHODS

10 children with a 4th degree flat foot (age: 8,7±2,2; height: 132±15cm; weight: 35,2±12,3Kg) underwent 10 sessions, 2 days/wk, of 30 min of focused high vibratory therapy at a frequency of 300 Hz (Vissman, Italy). Before and after treatment stabilometry (StT), static and dynamic baropodometry tests were performed.

RESULTS

Evaluation of StT showed an improvement of stability, a decrease of sway area and ellipse area. Baropodometry tests showed a decrease in foot surface. Also dynamic tests showed a decrease in both foot surfaces.

DISCUSSION

The results lead us to consider this method as a method of first choice to a conservative approach in the rehabilitation of flat foot syndrome also for the 4th grade in children.

Visual sensory disability: rehabilitative treatment in an aquatic environment

The outcome of this study is based on the concept of the enormous potentiality that is expressed, after the elimination of myofascial and articular compensation, from the body system. 10 low vision and blind subjects aged between 35 and 50 years. The subjects performed 10 sessions (2/week) for 5 weeks. Each session consisted of a training in the gym (30 minutes) and hydrokinetic therapy (45 minutes) All the subjects at the beginning (T0) and at the end (T1) of the rehabilitation program were tested by static baropodometry and the stabilometric (Milletrix, Diagnostic support, Rome, Italy). Our results shows an increase of the total area of support surface (p0.05). The stabilometry results shows an improvement of the orthostatic balance, sway area and the ellipse area decrease respectively 15% (236,9vs201 p≤0.05) and 41% b(p≤0.05). Thus, the energy expenditure of the patient in maintaining the orthostatic position without visual afferences is lower. Rehabilitative treatment in an aquatic environment resulted effective in improving posture and balance in all patients with increased precision in the execution of the step, which implies less effort during walk, less energy consumption and better quality of life.

Biomechanical modification and sense motor control of body posture after plastic surgery

Plastic surgery offers a quite unique window on abrupt and permanent modifications of a human's body schema. Its impact is comparable to amputations or other severe injuries, with the evident advantage from the experimenter's (and patient's) point of view that it is planned, allowing longitudinal studies and quantification of the weight and distribution of modified bodily masses (e.g., weight of the prosthesis). One potential drawback is that modifications due to (aesthetic) plastic surgery are often too little to be revealed by motor control tasks, making it difficult to measure the time course of body schema readaptation. The aim of our study is measuring the capability of the body scheme to re-adapt to significant and abrupt changes, such as the distribution of mass centers, and in particular to assess what is the time course of such re-adaptation. For this reason, we have carried out a longitudinal study on postural modifications on a population of female patients (N = 30) who were subjected to additive or reductive plastic surgery. Posture and stabilometry evaluations were performed before surgery (T0), and after 1 months (T1), 4 months (T2), and 1 year (T3). Posture was reconstructed from spatial tracking system (FastrackTM Polhemus) recordings. Stabilometry analysis was performed by force platform (Globus Italia). The results document a modification in posture and a significant increase in the sway area after body mass alterations. Posture and stabilometry data return to equilibrium after 1 year. Our data suggest that posture control relies on, at least in part, feedforward than only on feedback strategies.

Inhibitor Effect of Antioxidant Flavonoids Quercitin, and Capsaicin in Mast Cell Inflammation

Mast cells are essential not only for allergies but also for innate and acquired immunity, autoimmunity and inflammation, and they are recognized as a new type of immunoregulatory cells capable of producing different cytokines. Natural compounds have long been recognized to possess anti-inflammatory, antioxidant and anticancergenic activity. Quercitin is an inhibitor for mast cells and is a potent antioxidant, cytoprotective and anti-inflammatory compound and has a negative effect on intracellular regulator signal events initiated by FceRI receptor cross-linking and other activating receptors on mast cells. These observations candidate quercitin as a therapeutic compound in association with other therapeutic molecules. Capsaicin is a compound derived from peppers, especially capsicum, and is involved in stimulating circulation aiding digestion and relieving pain. Capsaicin receptor sub type I (VRI) is expressing in neurons and is present in a number of brain nuclei and in non-neuronal tissues, mediating inflammatory response. Capsaicin is involved in migraine, allergic symptoms, arthritis pain and gastric secretion. In this paper we review the biological effects of quercitin and capsaicin.

Intrarticular treatment of osteoartropaty knee with polynucleotides: a pilot study with medium-term follow-up

Knee osteoarthritis is a major cause of disability in the elderly. Many therapies are nowadays available, ranging from non-pharmacologic to pharmacological approaches like visco-supplementation, oral supplements or topical treatments, but a flawless treatment is still to be found. Visco-supplementation represents a valid treatment option for reducing pain associated with knee osteoarthritis and improving function in the affected joint. Many literature data report on the efficacy and safety profiles of hyaluronic acid in knee osteoarthritis, however the efficacy of intra-articular hyaluronic acid remains controversial, in fact while several clinical trials claimed a disease-modifying effect for hyaluronic acid, subsequent meta-analyses have cast doubts on this fact. The ideal intra-articular treatment for osteoarthritis should not only provide a mechanical protection of the cartilage surface, but also restore condrocytes’ homeostasis by restoring the physiological articular micro-environment and supplying nutrients. In this perspective an innovative medical product made up of polynucleotides (Condrotide) has been developed. The aim of this study is to test the 2-months efficacy in pain relief and improving function of intra-articular injections of Condrotide in patients with knee osteoarthritis or with grade III or IV chondropathy. Ninety-five subjects (33 men, 62 women), aged between 53 and 80, were included between May 2011 to July 2012. All subjects received intra-articular injections of Condrotide and were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS), the NRS scale for pain assessment, the measurement of the range of motion (R.O.M.). In all subjects a significant improvement was found in KOOS score after 60 days. The mean global NRS pain decreased in both groups and there was also a R.O.M. improvement. These results show that the intra-articular administration of nucleotides in subjects with both severe knee arthritis and chondropathy can be recommended since is able to reverse in the short and medium term symptoms and function with a significant improvement in quality of life.

Role of vitamins D, E and C in immunity and inflammation

Inflammatory responses are operationally characterized by pain, redness, heat and swelling at the site of infection and trauma. Mast cells reside near small blood vessels and, when activated, release potent mediators involved in allergy and inflammation. Vitamin D modulates contraction, inflammation and remodeling tissue. Vitamin D deficiency has been linked to multiple diseases and several data have demonstrated a strong relationship between serum vitamin D levels and tissue function. Therapy targeting vitamin D3 signaling may provide new approaches for infectious and inflammatory skin diseases by affecting both innate and adaptive immune functions. Mast cells are activated by oxidized lipoproteins, resulting in increased expression of inflammatory cytokines and suggesting that the reduction of oxidation of low density lipoprotein by vitamin E may also reduce mast cell activation. Vitamin C is also an anti-oxidant well-known as an anti-scurvy agent in humans. Vitamin C inhibits peroxidation of membrane phospholipids and acts as a scavenger of free radicals and is also required for the synthesis of several hormones and neurotransmitters. In humans, vitamin C reduces the duration of common cold symptoms, even if its effect is not clear. Supplementation of vitamin C improves the function of the human immune system, such as antimicrobial and natural killer cell activities, lymphocyte proliferation, chemotaxis and delayed-type hypersensitivity. Vitamin C depletion has been correlated with histaminemia which has been shown to damage endothelial-dependent vasodilation. However, the impact of these vitamins on allergy and inflammation is still not well understood.

Muscle Strength and Balance Training in Sarcopenic Elderly: A Pilot Study with Randomized Controlled Trial

In aging, there is a gradual decrease in muscle mass (sarcopenia) and muscle strength which contributes to a decline in physical functions, increased disability, frailty, and loss of independence. Physical activity can reduce functional decline due to aging. Randomized controlled trials (RCT) are needed to determine the effectiveness of different exercise stimuli on muscle strength and balance in the sarcopenic elderly. Forty male volunteers diagnosed with sarcopenia (CDCP) (70.9±5.2yrs) were enrolled in this study. A randomized, controlled trial, with blind assessment, was designed to study the effect of global sensorimotor, high intensity focused vibrational (intensity: 300Hz) and resistance training (intensity: 60–80% of maximum theoretical force, 10–12 repetitions for 3 sets) stimuli on muscle strength and balance confidence. The subjects were randomly assigned to three different training programs or a control group which was encouraged to maintain their habitual activity level. The training was performed for 12 weeks in all groups: 2 sessions/week in Gsm and Ret groups; 1 session/week for the first 8 weeks and 3 sessions/week for the last 4 weeks in Vam group. The main outcome was maximal force contraction of the lower limbs, and secondary outcomes were static and dynamic balance confidence. All the training regimens increased isometric strength. Both the sensorimotor and the vibrational training increased stability with a reduction of sway area and of ellipse surface (p<0.01). Gait analysis showed a significant increase in the length of the half-step in all three groups (respectively 108%, p <0.01; 92% p< 0.01; 65% p <0.05). AH the training programs implemented in the present investigation increase muscle strength. In addition, sensorimotor and vibrational training intervention aims to transfer these peripheral gains to the functional and more complex task of balance, in order to reduce the risk of falls.

A study of postural changes after abdominal rectus plication abdominoplasty

PURPOSE

Factors such as body masses and humour are known to influence human posture. Abdominoplasty, which causes a sudden change in body masses, significantly improves body image and self-esteem. The aim of this study was to assess postural changes after abdominoplasty by studding the position and orientation through space of the body and the centre of pressure.

METHODS

Patients affected by excess abdominal skin and/or significant abdominal muscular anterior wall laxity due to undergo an abdominoplasty were enrolled. Posture was evaluated both before and for 1 year after surgery by quantifying the centres of mass, using the Fastrak™ system, and the centre of pressure, using stabilometry. The Wilcoxon signed-rank sum test was used to compare changes.

RESULTS

Forty-six patients were enrolled. A retro-positioning of the pelvis with a compensatory advancement of the head and shoulders, confirmed by the baropodometric analysis, was evident in the early post-operative period. The biomechanical system subsequently stabilized, achieving a state of equilibrium 1 year after surgery.

CONCLUSIONS

We believe that the change in posture following abdominoplasty is a consequence of both surgery (changes in body masses) and psychological factors that influence posture. Indeed, redundant abdominal skin and abdominal muscular anterior wall weakness are often associated with kyphosis since patients try to hide what they consider to be a source of embarrassment. The discovery of a new body image eliminates dissatisfaction, reduces anxiety and increases self-esteem, which provide psychological and physical benefits that improve the quality of life.

Long-Term Results of Rehabilitative Management with Extracorporeal Shockwave Therapy in Rotator Cuff Disease with Partial Tears

The purpose of this study is to evaluate the effects of rehabilitative approach using MJS and dynamic antigravity postural system (SPAD) with extracorporeal Shockwave therapy (ESWT) on rotator cuff syndrome associated tendon supraspinatus and infraspinatus medium tear (1–3 cm) of the tendons. In the last few years, ESWT has been proposed as an elective treatment in somatic diseases with encouraging short-term results. For this study the authors enrolled 108 patients who underwent 3 treatments with ESWT associated with 24 rehabilitation sessions over 3 weeks. Outcome measures were the VAS for pain and the Constant Murley Scale. The outcomes were measured pre-training, post-training and at 2, 4, 6 month follow-ups. Additional follow-up evaluation sessions were performed every year for 5 years by a telephone interview to evaluate changes in pain and function and the efficacy of treatment. Our study shows that the therapeutic efficacy of rehabilitative approach with ESWT in the rotator cuff syndrome with medium tears persists over time and significantly improves the patient's quality of life. The results obtained are certainly to be attributed to the biological mechanisms that ESWT are able to engage in tissues of the rotator cuff. The results seen at the conclusion of the treatment were maintained over the following years, thanks to the use of MJS and SPAD. In our opinion a conservative treatment with extracorporeal shock-wave (ESW), dynamic antigravity postural system (SPAD) and multi joint system (MJS) should be considered as an alternative and effective treatment for rotator cuff syndromes with medium tears.

Long-Term Effectiveness of Combined Mechanotransduction Treatment in Jumper's Knee

The aim of the study was to show that the addition of extracorporeal shockwave therapy (ESWT) may significantly improve beneficial effects of eccentric training together with high efficiency focused acoustic waves for jumper's knee. We speculate that such an effect may be due to increased mechanotransduction effects on affected tissues. We assessed changes in pain and function in 42 male football players (aged 1834 years) after a treatment protocol consisting of I session with focused ESWT per week combined with 3 physiotherapy sessions per week, for 3 consecutive weeks. While treatment protocol was administered, ordinary activities, but not playing football were permitted. Their condition was evaluated before treatment, at the end of the rehabilitation period (3 weeks) and at 2 months, 4 months and 6 months after the end of treatment by clinical examination, instrumental analysis and VAS for pain assessment. Functional ability related to symptoms was assessed with VISA score. At the end of 2005,2006,2007,2008 and 2009 we carried out a telephone interview to investigate changes in pain and function and the efficacy of the treatment over time. Follow-up controls showed a reduction of average VAS score; after 6 months, tendons showed a structure closer to normal at ultrasonographic investigation. At the last telephone interview in 2009 many patients reported to consider ESWT as an effective treatment and described a significant improvement in their functional abilities, a significant reduction in drug consumption and 88% of subjects continued to play agonistic football. In conclusion, our results showed that, through the addition of ESWT, the effects of the classic vibration and eccentric training combination were improved compared to those found in our experience without ESWT. Although a control group was not included in the study (vibration and eccentric training without ESWT), results show a promising improvement and justify future prospective studies with a control group and more case series.