Rehabilitation and COVID-19: systematic review by Cochrane Rehabilitation

INTRODUCTION

Until the last update in February 2022, the Cochrane Rehabilitation COVID-19 Evidence-based Response (REH-COVER) action identified an increasing volume of evidence for the rehabilitation management of COVID-19. Therefore, our aim was to identify the best available evidence on the effectiveness of interventions for rehabilitation for COVID-19-related limitations of functioning of rehabilitation interest in adults with COVID-19 or post COVID-19 condition (PCC).

EVIDENCE ACQUISITION

We ran the searches on February 17th, 2023, in the following databases: PubMed, EMBASE, CENTRAL, CINHAL, and the Cochrane COVID-19 Study Register, applying a publication date restriction to retrieve only papers published in 2022. To retrieve papers published before 2022, we screened the reference lists of previous publications included in the REH-COVER action, covering papers from early 2020 to the end of 2022. This current review includes only randomised controlled trials and concludes the rapid living systematic reviews of the Cochrane Rehabilitation REH-COVER action. The risk of bias and certainty of evidence were evaluated in all studies using the Cochrane Risk of Bias tool and GRADE, respectively. We conducted a narrative synthesis of the evidence. PROSPERO registration number: CRD42022374244.

EVIDENCE SYNTHESIS

After duplicate removal, we identified 18,950 individual records and 53 RCTs met the inclusion criteria. Our findings suggest that the effect of breathing and strengthening exercise programs on dyspnea and physical exercise capacity compared to no treatment in non-severe COVID-19 patients is uncertain. Multicomponent telerehabilitation may slightly increase physical exercise capacity compared to educational intervention in adults with PCC. There is, however, uncertainty about its effect on lung function and physical exercise capacity when compared to no treatment. Finally, the effect of inspiratory muscle training on maximal inspiratory pressure compared to no treatment in adults with PCC is uncertain.

CONCLUSIONS

Interventions that are part of comprehensive pulmonary rehabilitation approaches may benefit dyspnea and exercise tolerance in adults with COVID-19 and PCC. The available evidence has several methodological limitations that limit the certainty of evidence and the clinical relevance of findings. Therefore, we cannot provide robust suggestions for practice. While high-quality RCTs are being conducted, clinicians should consider using high-quality evidence from other pulmonary conditions to rehabilitate patients with COVID-19 or PCC using context-specific interventions.

Evidence-based position paper on physical and rehabilitation medicine professional practice for persons with COVID-19, including post COVID-19 condition: the European PRM position (UEMS PRM Section)

Although multiple factors still pose challenges to inpatient/outpatient rehabilitation for survivors of COVID-19, rehabilitation plays a key role for this patient population. This study aimed to improve Physical and Rehabilitation Medicine (PRM) physician's professional practice for persons with COVID-19-related functioning limitations, to promote functional recovery and reduce activity limitations and/or participation restrictions. A systematic review of the scientific literature was performed from December 2019 to August 2022, followed by production of recommendations through 5 Delphi rounds, by consensus among the delegates of all European countries represented in the Union of European Medical Specialists PRM Section. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The PRM physician's role for persons with COVID-19-related limitations of functioning is to develop, foster, and monitor the implementation of an individual rehabilitation project tailored to the patient's age, previous medical and functional status, current comorbidities and complications, activity limitations and participation restrictions and personal and environmental factors. This is done by applying the concept of a multi-specialty integrated service model with multi-professional/interdisciplinary teams, providing care at all stages of COVID-19 illness. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section.

The Impact of Reduction Mammaplasty on Breast Sensation: A Systematic Review

Loss of sensation is one of the most feared complications of breast reduction surgery. Although several techniques have been proposed to maximize sensitivity preservation, the scientific literature still reports contradictory findings. This systematic review aimed to assess whether breast reduction mammaplasty is associated with measurable changes in breast sensation. This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed (National Institutes of Health, Bethesda, MD), Scopus (Elsevier, Amsterdam, the Netherlands), and Web of Science (Clarivate, Philadelphia, PA) databases were searched for clinical studies investigating breast sensation after breast reduction mammaplasty. The initial search identified 1523 studies of which 22 articles met our specific inclusion criteria. Most of the included studies are consistent in describing only transient sensation decrease or even sensation improvement after surgery compared to the presurgery condition with any approach, except those investigating outcomes after superior or superolateral pedicle reduction mammaplasty. Nevertheless, the overall quality of evidence is low or very low due to the limited availability of randomized controlled trials or controlled studies and the high risk of bias.

LEVEL OF EVIDENCE: 4

A Robot-Assisted Framework for Rehabilitation Practices: Implementation and Experimental Results

One of the most interesting characteristics of collaborative robots is their ability to be used in close cooperation scenarios. In industry, this facilitates the implementation of human-in-loop workflows. However, this feature can also be exploited in different fields, such as healthcare. In this paper, a rehabilitation framework for the upper limbs of neurological patients is presented, consisting of a collaborative robot that helps users perform three-dimensional trajectories. Such a practice is aimed at improving the coordination of patients by guiding their motions in a preferred direction. We present the mechatronic setup, along with a preliminary experimental set of results from 19 volunteers (patients and control subjects) who provided positive feedback on the training experience (52% of the subjects would return and 44% enjoyed performing the exercise). Patients were able to execute the exercise, with a maximum deviation from the trajectory of 16 mm. The muscular effort required was limited, with average maximum forces recorded at around 50 N.

Robot-assisted gait training in patients with Parkinson's disease: Implications for clinical practice. A systematic review

BACKGROUND

Gait impairments are common disabling symptoms of Parkinson's disease (PD). Among the approaches for gait rehabilitation, interest in robotic devices has grown in recent years. However, the effectiveness compared to other interventions, the optimum amount of training, the type of device, and which patients might benefit most remains unclear.

OBJECTIVE

To conduct a systematic review about the effects on gait of robot-assisted gait training (RAGT) in PD patients and to provide advice for clinical practice.

METHODS

A search was performed on PubMed, Scopus, PEDro, Cochrane library, Web of science, and guideline databases, following PRISMA guidelines. We included English articles if they used a robotic system with details about the intervention, the parameters, and the outcome measures. We evaluated the level and quality of evidence.

RESULTS

We included twenty papers out of 230 results: two systematic reviews, 9 randomized controlled trials, 4 uncontrolled studies, and 5 descriptive reports. Nine studies used an exoskeleton device and the remainders end-effector robots, with large variability in terms of subjects' disease-related disability.

CONCLUSIONS

RAGT showed benefits on gait and no adverse events were recorded. However, it does not seem superior to other interventions, except in patients with more severe symptoms and advanced disease.

Gait robot-assisted rehabilitation in persons with spinal cord injury: A scoping review

BACKGROUND

Many robots are available for gait rehabilitation (BWSTRT and ORET) and their application in persons with SCI allowed an improvement of walking function.

OBJECTIVE

The aim of the study is to compare the effects of different robotic exoskeletons gait training in persons with different SCI level and severity.

METHODS

Sixty-two studies were included in this systematic review; the study quality was assessed according to GRADE and PEDro's scale.

RESULTS

Quality assessment of included studies (n = 62) demonstrated a prevalence of evidence level 2; the quality of the studies was higher for BWSTRT (excellent and good) than for ORET (fair and good). Almost all persons recruited for BWSTRT had an incomplete SCI; both complete and incomplete SCI were recruited for ORET. The SCI lesion level in the persons recruited for BWSTRT are from cervical to sacral; mainly from thoracic to sacral for ORET; a high representation of AIS D lesion resulted both for BWSTRT (30%) and for ORET (45%). The walking performance, tested with 10MWT, 6MWT, TUG and WISCI, improved after exoskeleton training in persons with incomplete SCI lesions, when at least 20 sessions were applied. Persons with complete SCI lesions improved the dexterity in walking with exoskeleton, but did not recover independent walking function; symptoms such as spasticity, pain and cardiovascular endurance improved.

CONCLUSION

Different exoskeletons are available for walking rehabilitation in persons with SCI. The choice about the kind of robotic gait training should be addressed on the basis of the lesion severity and the possible comorbidities.

Evidence-based improvement of gait in post-stroke patients following robot-assisted training: A systematic review

BACKGROUND

The recovery of walking after stroke is a priority goal for recovering autonomy. In the last years robotic systems employed for Robotic Assisted Gait Training (RAGT) were developed. However, literature and clinical practice did not offer standardized RAGT protocol or pattern of evaluation scales.

OBJECTIVE

This systematic review aimed to summarize the available evidence on the use of RAGT in post-stroke, following the CICERONE Consensus indications.

METHODS

The literature search was conducted on PubMed, Cochrane Library and PEDro, including studies with the following criteria: 1) adult post-stroke survivors with gait disability in acute/subacute/chronic phase; 2) RAGT as intervention; 3) any comparators; 4) outcome regarding impairment, activity, and participation; 5) both primary studies and reviews.

RESULTS

Sixty-one articles were selected. Data about characteristics of patients, level of disability, robotic devices used, RAGT protocols, outcome measures, and level of evidence were extracted.

CONCLUSION

It is possible to identify robotic devices that are more suitable for specific phase disease and level of disability, but we identified significant variability in dose and protocols. RAGT as an add-on treatment seemed to be prevalent. Further studies are needed to investigate the outcomes achieved as a function of RAGT doses delivered.

AOPEP variants as a novel cause of recessive dystonia: Generalized dystonia and dystonia-parkinsonism

INTRODUCTION

The genetic basis of autosomal-recessive dystonia remains poorly understood. Our objective was to report identification of additional individuals with variants in AOPEP, a recently described gene for recessively inherited dystonic disorders (OMIM:619565).

METHODS

Ongoing analysis on a high-throughput genetic platform and international case-recruitment efforts were undertaken.

RESULTS

Novel biallelic, likely pathogenic loss-of-function alleles were identified in two pedigrees of different ethnic background. Two members of a consanguineous Iranian family shared a homozygous c.1917-1G>A essential splice-site variant and featured presentations of adolescence-onset generalized dystonia. An individual of Chinese descent, homozygous for the nonsense variant c.1909G>T (p.Glu637*), displayed childhood-onset generalized dystonia combined with later-manifesting parkinsonism. One additional Iranian patient with adolescence-onset generalized dystonia carried an ultrarare, likely protein-damaging homozygous missense variant (c.1201C>T [p.Arg401Trp]).

CONCLUSIONS

These findings support the implication of AOPEP in recessive forms of generalized dystonia and dystonia-parkinsonism. Biallelic AOPEP variants represent a worldwide cause of dystonic movement-disorder phenotypes and should be considered in dystonia molecular testing approaches.

Rehabilitation and COVID-19: rapid living systematic review by Cochrane Rehabilitation Field - third edition. Update as of June 30th, 2021

INTRODUCTION

This paper updates and summarizes the current evidence informing rehabilitation of patients with COVID-19 and/or describing the consequences of the disease and its treatment.

EVIDENCE ACQUISITION

Studies published from May 1st to June 30th, 2021 were selected, excluding descriptive studies and expert opinions. Papers were categorized according to study design, research question, COVID-19 phase, limitations of functioning of rehabilitation interest, and type of rehabilitation service involved. From this edition, we improved the quality assessment using the Joanna Briggs Institute checklists for observational studies and the Cochrane Risk of Bias Tool for randomized-controlled clinical trials (RCTs).

EVIDENCE SYNTHESIS

Twenty-five, out of 3699 papers, were included. They were three RCTs, 13 cross-sectional studies and nine cohort studies. Twenty studies reported data on symptom prevalence (N.=13) or disease natural history (N.=7); and five studies reported intervention effectiveness at the individual level. All study participants were COVID survivors and 48% of studies collected information on participants 6 months or longer after COVID-19 onset. The most frequent risks of bias for RCTs concerned weaknesses in allocation concealment, blinding of therapists, and lack of intention-to-treat analysis. Most analytical studies failed to identify or deal with confounders, describe or deal with dropouts or eventually perform an appropriate statistical analysis.

CONCLUSIONS

Most studies in this updated review targeted the prevalence of limitations of functioning of rehabilitation interest in COVID-19 survivors. This is similar to past review findings; however, data in the new studies was collected at longer follow-up periods (up to one year after symptom onset) and in larger samples of participants. More RCTs and analytical observational studies are available, but the methodological quality of recently published studies is low. There is a need for good quality intervention efficacy and effectiveness studies to complement the rapidly expanding evidence from observational studies.

What does evidence tell us about the use of gait robotic devices in patients with multiple sclerosis? A comprehensive systematic review on functional outcomes and clinical recommendations

INTRODUCTION

There is growing evidence on the efficacy of gait robotic rehabilitation in patients with multiple sclerosis (MS), but most of the studies have focused on gait parameters. Moreover, clear indications on the clinical use of robotics still lack. As part of the CICERONE Italian Consensus on Robotic Rehabilitation, the aim of this systematic review was to investigate the existing evidence concerning the role of lower limb robotic rehabilitation in improving functional recovery in patients with MS.

EVIDENCE ACQUISITION

We searched for and systematically reviewed evidence-based studies on gait robotic rehabilitation in MS, between January 1^st, 2010 and December 31^st, 2020, in the following databases: Cochrane Library, PEDro, PubMed and Google Scholar. The study quality was assessed by the 16-item assessment of multiple systematic reviews 2 (AMSTAR 2) and the 10-item PEDro scale for the other research studies.

EVIDENCE SYNTHESIS

After an accurate screening, only 17 papers were included in the review, and most of them (13 RCT) had a level II evidence. Most of the studies used the Lokomat as a grounded robotic device, two investigated the efficacy of end-effectors and two powered exoskeletons. Generally speaking, robotic treatment has beneficial effects on gait speed, endurance and balance with comparable outcomes to those of conventional treatments. However, in more severe patients (EDSS >6), robotics leads to better functional outcomes. Notably, after gait training with robotics (especially when coupled to virtual reality) MS patients also reach better non-motor outcomes, including spasticity, fatigue, pain, psychological well-being and quality of life. Unfortunately, no clinical indications emerge on the treatment protocols.

CONCLUSIONS

The present comprehensive systematic review highlights the potential beneficial role on functional outcomes of the lower limb robotic devices in people with MS. Future studies are warranted to evaluate the role of robotics not only for walking and balance outcomes, but also for other gait-training-related benefits, to identify appropriate outcome measures related to a specific subgroup of MS subjects' disease severity.

Robotic-assisted gait rehabilitation following stroke: a systematic review of current guidelines and practical clinical recommendations

INTRODUCTION

Stroke is the third leading cause of adult disability worldwide, and lower extremity motor impairment is one of the major determinants of long-term disability. Although robotic therapy is becoming more and more utilized in research protocols for lower limb stroke rehabilitation, the gap between research evidence and its use in clinical practice is still significant. The aim of this study was to determine the scope, quality, and consistency of guidelines for robotic lower limb rehabilitation after stroke, in order to provide clinical recommendations.

EVIDENCE ACQUISITION

We systematically reviewed stroke rehabilitation guideline recommendations between January 1, 2010 and October 31, 2020. We explored electronic databases (N.=4), guideline repositories and professional rehabilitation networks (N.=12). Two independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and brief syntheses were used to evaluate and compare the different recommendations, considering only the most recent version.

EVIDENCE SYNTHESIS

From the 1219 papers screened, ten eligible guidelines were identified from seven different regions/countries. Four of the included guidelines focused on stroke management, the other six on stroke rehabilitation. Robotic rehabilitation is generally recommended to improve lower limb motor function, including gait and strength. Unfortunately, there is still no consensus about the timing, frequency, training session duration and the exact characteristics of subjects who could benefit from robotics.

CONCLUSIONS

Our systematic review shows that the introduction of robotic rehabilitation in standard treatment protocols seems to be the future of stroke rehabilitation. However, robot assisted gait training (RAGT) for stroke needs to be improved with new solutions and in clinical practice guidelines, especially in terms of applicability.

Exploring three levels of interoception in people with functional motor disorders

INTRODUCTION

A three-level model of interoception has recently been defined. We aim to study the interoceptive processing in individuals with functional motor disorder (FMD).

METHODS

Twenty-two patients with FMD were compared to 23 healthy controls. They underwent a protocol measuring different levels of interoception including: accuracy (a heart-beat tracking task), awareness (participant's confidence level) and sensibility (the Body Awareness Questionnaire-BAQ). Depression, anxiety and alexithymia were assessed by means of validated clinical scales.

RESULTS

The FMD group showed a lower cardiac interoceptive accuracy and sensibility than healthy controls but they did not differ in terms of awareness (p = 0.03 and 0.005 respectively). They were aware of their poor performance in the accuracy task. Cardiac interoceptive accuracy positively correlated with the BAQ sub-scales "Predict Body Reaction" (r = 0.49, p = 0.001) and "Sleep-Wake Cycle" (r = 0.52, p < 0.001). A mediation analysis showed a significant indirect effect of group on cardiac interoceptive accuracy through BAQ "Predict Body Reaction" (b = -2.95, 95% BCa CI[-7.2;-0.2]). The direct effect of group on "Predict Body Reaction" was still significant (b = - 6.95, p = 0.02, 95% CI[-13.18;-0.73]).

CONCLUSIONS

People with FMD have impaired cardiac interoceptive accuracy and sensibility but no difference in metacognitive interoception compared to healthy controls.

Rehabilitation and COVID-19: a rapid living systematic review by Cochrane Rehabilitation Field updated as of December 31st, 2020 and synthesis of the scientific literature of 2020

INTRODUCTION

COVID-19 infection significantly increased mortality risk and the burden of disability in most survivors, regardless of symptom severity at onset. The rehabilitation needs of people infected are receiving growing attention, as evidenced by the increasing number of publications, including those addressing the chronic consequences of infection. This rapid living systematic review reports the evidence published in November and December 2020 and summarises the entire body of literature on rehabilitation in COVID-19 patients published in 2020.

EVIDENCE ACQUISITION

This update was performed using the methodology reported by the second edition conducted by Cochrane Rehabilitation REH-COVER Action. We searched PubMed, Embase, CINAHL, Scopus, Web of Science, and Pedro databases. Papers related to COVID-19 and rehabilitation were retrieved and summarised descriptively.

EVIDENCE SYNTHESIS

The search retrieved 4441 studies. After the removal of duplicates and the screening for title and abstract, we retained 105 studies. Of these, we included 54 in the qualitative synthesis of this update. According to OCEBM 2011 levels of evidence table, most studies (64.8%) fall within the category of level 4 evidence. Up to 40.7% of papers included COVID-19 patients in the postacute phase. In 2020, our rapid living systematic review included 230 studies; most of these (73.9%) were level 4 studies, 25.7% were level 3, and only one study was level 2. The evidence level improved over time. While most studies (44.8%) included patients with acute COVID-19, we observed a gradual increase in the number of reports about chronic symptoms and the long-term consequences of the infection.

CONCLUSIONS

The update of the rapid living systematic review by Cochrane Rehabilitation Field demonstrates an increase in the level of evidence of studies addressing the rehabilitation needs associated with COVID-19 infection. Although most studies are still case reports/series, there is a trend towards conducting prospective investigations of the early natural history of the disease (first months post onset). High-quality-level studies on the efficacy of rehabilitation, and long-term monitoring of the disease and its sequelae are yet to emerge.

Rehabilitation and COVID-19: a rapid living systematic review 2020 by Cochrane Rehabilitation Field. Update as of October 31st, 2020

INTRODUCTION

This living systematic review presents the monthly update of the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER Action Steering Committee. The aim of this study was to update the monthly COVID-19 and rehabilitation literature research up to October 31^st, 2020.

EVIDENCE ACQUISITION

Methodology described in the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER action was applied. PubMed, Embase, CINAHL, Scopus, Web of Science, and PEDro databases were searched, and papers related to COVID-19 and rehabilitation were retrieved and summarized descriptively.

EVIDENCE SYNTHESIS

The database search retrieved 2704 publications. Duplicates were removed, and 1185 unique records were screened for inclusion. After screening titles, abstracts and full-texts, 22 papers were included in the present review. According to OCEBM 2011 Levels of Evidence table, 17 studies (77%) fall within the level of evidence 4 category, while the remainder (23%) are categorized as level of evidence 3. Most studies (N.=19; 86%) provided epidemiological data about the disease natural history/determining factor or the clinical presentation of COVID-19 infection, while only two studies focused on health service organization and intervention efficacy.

CONCLUSIONS

The most recent published COVID-19 research relevant to rehabilitation primarily provides data on the clinical course and the clinical presentation of the pathology, rather than on rehabilitation interventions or service delivery. Studies with high levels of evidence regarding the efficacy of interventions, long-term monitoring, or new health service organization models are lacking.

Rehabilitation and COVID-19: a rapid living systematic review 2020 by Cochrane Rehabilitation Field. Update as of September 30th, 2020

INTRODUCTION

The COVID-19 outbreak response requires identifying and understanding the long-term consequences of this new pathology and how to manage these. This living systematic review presents the most current and seminal information coming from the scientific literature. It is the monthly update of the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER Action Steering Committee. The aim of this review was to update the monthly COVID-19 and rehabilitation literature research up to September 30, 2020.

EVIDENCE ACQUISITION

Methodology described in the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER action was applied. The most important medical databases were searched, and papers related to COVID-19 and rehabilitation were retrieved and summarized descriptively.

EVIDENCE SYNTHESIS

The database search retrieved 2526 publications. Duplicates were removed, and 1150 unique records were screened for inclusion. After screening titles, abstracts and full-texts, 37 papers were included in the present review. According to OCEBM 2011 levels of evidence table, most studies (78.4%) fall within the level of evidence 4 category, while the remainder (22.6%) are categorized as level of evidence 3. Most studies described patients in acute (51.4%) or subacute (35.0%) phase, while no studies described the chronic consequences of COVID-19. Just one study dealt with rehabilitation interventions regarding COVID-19, and two discussed reorganization of rehabilitative services.

CONCLUSIONS

The most recently published COVID-19 research focuses more on describing the clinical presentations and the natural history of the pathology, rather than rehabilitation interventions or service delivery. Studies with high levels of evidence regarding the efficacy of interventions, long-term monitoring, or new organization models remain lacking.

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Update as of August 31st, 2020

INTRODUCTION

A monthly systematic review update is carried out to maintain the currency of scientific literature on rehabilitation of patients with COVID-19 and/or describing consequences due to the disease and its treatment, as they relate to limitations in functioning of rehabilitation interest. The aim of this study was to provide an updated summary of the available evidence published in August 2020.

EVIDENCE ACQUISITION

An extensive search on the main medical literature databases from August 1^st, 2020 to August 31^st, 2020 was performed, according to the methodology described in the second edition of the Cochrane Rehabilitation 2020 rapid living systematic review.

EVIDENCE SYNTHESIS

After removing duplicates, 1136 papers were identified, and 51 studies were finally included. According to OCEBM 2011 Levels of Evidence Table, they were Level 4 in most cases (76.5%) and Level 3 in the remaining (23.5%). Randomized controlled trials (RCTs) were not found. Thirty-two studies (62.7%) included COVID-19 patients who were assessed in the acute (20/32) or postacute phases (12/32). The other studies reported data on the impact of COVID-19 infection (7/19) or on the effect of lockdown restrictions (12/19) on subjects with pre-existing health conditions.

CONCLUSIONS

The scientific literature of August 2020 mainly focused on limitations in functioning of nervous system structure and related functions. Albeit the increased availability of data from analytical studies (both cohort and cross-sectional), there is still a lack of well-conducted Level 2 studies, to improve the knowledge on the effects of rehabilitation in COVID-19 patients.

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Update as of July 31st, 2020

INTRODUCTION

This paper is the first update of the second edition of the rapid living systematic review on the latest scientific literature informing rehabilitation of patients with COVID-19 and/or describing consequences of the disease and its treatment, as they relate to limitations in functioning of rehabilitation interest. The aim of this study was to report data of a systematic search performed on papers published in July 2020.

EVIDENCE ACQUISITION

The methodology described in the second edition of the rapid living systematic review was applied to search eligible papers included in the databases between July 1, 2020 and July 31, 2020.

EVIDENCE SYNTHESIS

Eight-hundred-ninety-two papers were identified through database searching (after removal of duplicates); of these, only 23 studies were included. According to OCEBM 2011 Levels of Evidence Table, they were level 3 in 30.5% cases and level 4 in 69.5%. No RCT was found. Nineteen papers studied COVID-19 patients, assessed in the acute (10 studies), post-acute (8 studies) and chronic phase (one study). Four studies reported data on the impact of COVID-19 on subjects with pre-existing health conditions.

CONCLUSIONS

The current literature production still focuses more on describing all the possible aspects and complications of the pathology than on interventions or new organization models to deal with it. Albeit evidence on handling COVID-19 from a rehabilitative point of view is improving each month, further studies are still mandatory to report the role of rehabilitation in this scenario.

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review

INTRODUCTION

This paper improves the methodology of the first edition of the rapid living systematic review started in April 2020, with the aim to gather and present the current evidence informing rehabilitation of patients with COVID-19 and/or describing the consequences due to the disease and its treatment.

EVIDENCE ACQUISITION

The Cochrane methodology for a rapid living systematic review was applied. Primary research papers, published from 1 January to 30 June 2020, reporting patients' data, with no limits of study design were included. Studies were categorized for study design, research question, COVID-19 phase, limitations of functioning (disability) of rehabilitation interest and type of rehabilitation service involved. Methodological quality assessment was based on the Cochrane Risk of Bias tools, and the level of evidence table (OCEBM 2011) for all the other studies.

EVIDENCE SYNTHESIS

Thirty-six, out of 3703 papers, were included. One paper was of level 2 (RCT), 7 were of level 3 (2 cohort studies, 2 cross-sectional studies and 3 case-control studies), and 28 papers of level 4 (descriptive studies); 61% of papers reported epidemiological data on clinical presentations, 5 investigated natural history/determining factors, 1 searched prevalence, 2 studies reported on intervention efficacy (though not on harms), and 5 studies looked at health service organization.

CONCLUSIONS

Main issues emerging from the review: it is advised to test for COVID-19 people with neurological disorders presenting with symptom changes; dysphagia is a frequent complication after oro-tracheal intubation in COVID-19 patients admitted to the ICU; after discharge, COVID-19 survivors may report persistent restrictive ventilatory deficits regardless of disease severity; there is only sparse and low quality evidence concerning the efficacy of any rehabilitation intervention to promote functional recovery; a substantial increase in resource (staff and equipment) is needed for rehabilitation.

Systematic rapid "living" review on rehabilitation needs due to COVID-19: update to March 31st, 2020

INTRODUCTION

The outbreak of COVID-19 epidemics has challenged the provision of health care worldwide, highlighting the main flaws of some national health systems with respect to their capacity to cope with the needs of frail subjects. People experiencing disability due to COVID-19 express specific rehabilitation needs that deserve a systematic evidence-based approach. The aim of this article is to provide the rehabilitation community with updates on the latest scientific literature on rehabilitation needs due to COVID-19. The first rapid "living" review will present the results of a systematic search performed up to March 31st, 2020.

EVIDENCE ACQUISITION

A systematic search in PubMed, Pedro, and Google Scholar was performed using the search terms: "COVID-19," "Coronavirus," "severe acute respiratory syndrome coronavirus 2," "rehabilitation," "physical therapy modalities," "exercise," "occupational therapy," and "late complications." Papers published up to March 31st, 2020, in English, were included.

EVIDENCE SYNTHESIS

Out of the 2758 articles retrieved, nine were included in the present review. Four of them are "calls for action", three provide recommendations about rehabilitation interventions in the acute phase, two address the needs of people quarantined at home or with restricted mobility due to the lockdown, and one provides a Core Outcome Set to be used in clinical trials to test the efficacy of health strategies in managing COVID-19 patients.

CONCLUSIONS

All selected papers were based on previous literature and not on the current COVID-19 pandemic. Main messages included: 1) early rehabilitation should be granted to inpatients with COVID-19; 2) people with restricted mobility due to quarantine or lockdown should receive exercise programs to reduce the risk of frailty, sarcopenia, cognitive decline and depression; 3) telerehabilitation may represent the first option for people at home. Further updates are warranted in order to characterize the emerging disability in COVID-19 survivors and the adverse effects on the health of chronically disabled people.

Does the Degree of Trunk Bending Predict Patient Disability, Motor Impairment, Falls, and Back Pain in Parkinson's Disease?

Background: Postural abnormalities in Parkinson's disease (PD) form a spectrum of functional trunk misalignment, ranging from a "typical" parkinsonian stooped posture to progressively greater degrees of spine deviation. Objective: To analyze the association between degree of postural abnormalities and disability and to determine cut-off values of trunk bending associated with limitations in activities of daily living (ADLs), motor impairment, falls, and back pain. Methods: The study population was 283 PD patients with ≥5° of forward trunk bending (FTB), lateral trunk bending (LTB) or forward neck bending (FNB). The degrees were calculated using a wall goniometer (WG) and software-based measurements (SBM). Logistic regression models were used to identify the degree of bending associated with moderate/severe limitation in ADLs (Movement Disorders Society Unified PD Rating Scale [MDS-UPDRS] part II ≥17), moderate/severe motor impairment (MDS-UPDRS part III ≥33), history of falls (≥1), and moderate/severe back pain intensity (numeric rating scale ≥4). The optimal cut-off was identified using receiver operating characteristic (ROC) curves. Results: We found significant associations between modified Hoehn & Yahr stage, disease duration, sex, and limitation in ADLs, motor impairment, back pain intensity, and history of falls. Degree of trunk bending was associated only with motor impairment in LTB (odds ratio [OR] 1.12; 95% confidence interval [CI], 1.03-1.22). ROC curves showed that patients with LTB of 10.5° (SBM, AUC 0.626) may have moderate/severe motor impairment. Conclusions: The severity of trunk misalignment does not fully explain limitation in ADLs, motor impairment, falls, and back pain. Multiple factors possibly related to an aggressive PD phenotype may account for disability in PD patients with FTB, LTB, and FNB.

Postural Abnormalities in Parkinson's Disease: An Epidemiological and Clinical Multicenter Study

INTRODUCTION

The overall frequency of postural abnormalities (PA) in Parkinson's disease (PD) is unknown. We evaluated the overall prevalence of PA and assessed the association with demographic and clinical variables.

METHODS

For this multicenter, cross-sectional study, consecutive PD outpatients attending 7 tertiary Italian centers were enrolled. Patients were evaluated and compared for the presence of isolated PA such as camptocormia, Pisa syndrome, and anterocollis and for combined forms (ie, camptocormia + Pisa syndrome) together with demographic and clinical variables.

RESULTS

Of the total 811 PD patients enrolled, 174 (21.5%; 95% confidence interval [CI], 18.6%-24.3%) presented PA, 144 of which had isolated PA and 30 had combined PA. The prevalence of camptocormia was 11.2% (95% CI, 9%-13.3%), Pisa syndrome 8% (95% CI, 6.2%-9.9%), and anterocollis 6.5% (95% CI, 4.9%-8.3%). Patients with PA were more often male and older with longer disease duration, more advanced disease stage, more severe PD symptoms, a bradykinetic/rigid phenotype, and poorer quality of life. They were initially treated with levodopa, and more likely to be treated with a combination of levodopa and dopamine agonist, took a higher daily levodopa equivalent daily dose, and had more comorbidities. Falls and back pain were more frequent in PD patients with PA than in those without PA. Multiple logistic regression models confirmed an association between PA and male gender, older age, Hoehn and Yahr stage, and total Unified Parkinson's Disease Rating Scale score.

CONCLUSIONS

PA are frequent and disabling complications in PD, especially in the advanced disease stages.

An Early Tailored Approach Is the Key to Effective Rehabilitation in the Intensive Care Unit

OBJECTIVE

To investigate the effectiveness, feasibility, and safety of an evidence-based rehabilitation care pathway in the intensive care unit (ICU) in different patient populations.

DESIGN

Observational prospective cohort study, with retrospective controls.

SETTING

ICUs of a university hospital.

PARTICIPANTS

Patients admitted between April 1, 2015, and June 30, 2015, were compared to a retrospective cohort admitted to the same ICUs during the same 3-month period in 2014. The number of patients studied (N=285) included 152 in the prospective group and 133 in the retrospective group.

INTERVENTIONS

The prospective cohort benefited of a rehabilitation care pathway based on (1) interdisciplinary teamwork; (2) early customized and goal-oriented rehabilitation; (3) daily functional monitoring and treatment revision; (4) agreed discharge policy; and (5) continuity of care. The retrospective cohort underwent usual care.

MAIN OUTCOME MEASURES

Included the following: (1) proportions of patients undergoing rehabilitation team evaluation; (2) latency between patient admission to ICUs and rehabilitation team assessment; (3) proportions of patients undergoing rehabilitation treatment during ICU stay; (4) latency between the patient admission to ICUs and rehabilitation start; (5) ICU stay and total acute hospital stay; and (5) proportion of ventilator-free days out of ICU stay.

RESULTS

The novel rehabilitation care pathway led to (1) an increased proportion of patients receiving rehabilitative assessment (P<.0001); (2) a decreased latency from ICU admission to both rehabilitation team assessment and rehabilitation start (P<.0001); (3) an increased proportion of patients undergoing rehabilitation (P<.0001); (4) a shorter length of stay in ICUs (P<.0001) and in hospital (P=.047); and (5) a shorter mechanical ventilation duration (P<.02). A direct relationship between rehabilitation start latency and ICU length of stay was observed.

CONCLUSIONS

An early, interdisciplinary team approach, providing a customized dynamic planning of physiotherapy programs, increases ventilator-free time and reduces total hospital stay, especially in patients admitted to the ICU after general surgery. This rehabilitation care pathway can be generalized to different geopolitical scenarios, being feasible, safe and cost effective.

Pain processing in functional and idiopathic dystonia: An exploratory study

BACKGROUND

Pain is often experienced by patients with functional dystonia and idiopathic cervical dystonia and is likely to be determined by different neural mechanisms.

OBJECTIVE

In this exploratory study, we tested the sensory-discriminative and cognitive-emotional component of pain in patients with functional and idiopathic dystonia.

METHODS

Ten patients with idiopathic cervical dystonia, 12 patients with functional dystonia, and 16 age- and sex-matched healthy controls underwent psychophysical testing of tactile and pain thresholds and pain tolerance. We delivered electrical pulses of increasing intensity to the index finger of each hand and the halluces of each foot. Pain threshold and pain tolerance were respectively defined as the (1) intensity at which sensation changed from unpainful to faintly painful and (2) intensity at which painful sensation was intolerable.

RESULTS

No differences were found between the three groups for tactile and pain thresholds assessed in hands and feet. Pain tolerance was significantly increased in all body regions only in functional dystonia. Patients with continuous functional dystonia had higher pain tolerance compared to subjects with paroxysmal functional dystonia and idiopathic cervical dystonia. There was no correlation between pain tolerance and pain scores, depression, anxiety, disease duration, and motor disability in both groups.

CONCLUSIONS

Patients with functional dystonia have a dissociation between the sensory-discriminative and cognitive-emotional components of pain, as revealed by normal pain thresholds and increased pain tolerance. Abnormal connectivity between the motor and limbic systems might account for abnormal pain processing in functional dystonia. © 2018 International Parkinson and Movement Disorder Society.

Features and predictors of activity limitations and participation restriction 2 years after intensive rehabilitation following first-ever stroke

BACKGROUND

Although stroke-related disability has been extensively studied, only few studies have investigated Participation restriction in chronic stroke survivors.

AIM

To identify features and predictors of Activity limitation and Participation restriction in the chronic phase of a first-ever stroke.

DESIGN

Cross-sectional observational study.

SETTING

Comprehensive stroke unit with outpatient rehabilitation facility.

POPULATION

Subjects submitted to intensive rehabilitation after first-ever stroke, from 1st January 2009 to 31st December 2010.

METHODS

Participation was investigated through the Frenchay Activity Index (FAI) and the Functional Status Questionnaire (FSQ) at 2.4±0.5 years after the event. Basic activities of daily living (ADL) and mood were also assessed through the Modified Barthel Index (MBI) and the Beck Depression Inventory (BDI). A retrospective search of the medical records looked for: type/side of brain lesion, stroke clinical syndromes, comorbidities and functional condition at discharge from intensive rehabilitation (upper limb motricity index-ULMI-, Functional Ambulation Category-FAC, MBI, cognitive deficits).

RESULTS

Forty-five subjects (17 female, age 70.1±11.5 years) were enrolled. They showed a striking restriction in their Participation, mainly for FAI-outdoor activities (median FAI score was <50% of the theoretical maximum). A poor gait function (FAC) and an impaired mood (BDI) were the only independent predictors of FAI indoor (F=6.1; p=,005; R^2= 64%) and outdoor activities (F=4.1; P=0.01; R^2=48%), respectively. The univariate analysis showed a strong dependence of all FSQ scores from global disability (MBI), motor function impairment (ULMI and FAC) and cognitive deficits. Depression influenced "psychological function" score, whereas gait capacity was the only factor significantly associated with the "work performance" score. The gait function level, achieved after intensive rehabilitation, was extrapolated by the multivariate analysis, as the most powerful independent predictor of the chronic activity limitations, as measured by MBI (F=33.8, P<0.0001, R2=0.539).

CONCLUSION

Gait dysfunction is the main factor of Activity limitations and Participation restriction in chronic stroke. Participation is restricted by global disability, depression, older age and dementia. More than 50% variance of Participation measures cannot be explained by the quoted factors.

CLINICAL REHABILITATION IMPACT

The study results support the need to integrate the standard rehabilitation approach with vocational rehabilitation in order to reduce Participation restriction.