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Maccora S, Torrente A, Di Stefano V, Lupica A, Iacono S, Pilati L, Pignolo A, Brighina F. Non-pharmacological treatment of hereditary spastic paraplegia: a systematic review. Neurol Sci 2024; 45:963-976. [PMID: 37968432 PMCID: PMC10858081 DOI: 10.1007/s10072-023-07200-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/08/2023] [Indexed: 11/17/2023]
Affiliation(s)
- Simona Maccora
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Via del Vespro 143, 90127, Palermo, Italy.
- Neurology Unit, ARNAS Civico di Cristina and Benfratelli Hospitals, 90127, Palermo, Italy.
| | - Angelo Torrente
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Via del Vespro 143, 90127, Palermo, Italy
| | - Vincenzo Di Stefano
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Via del Vespro 143, 90127, Palermo, Italy
| | - Antonino Lupica
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Via del Vespro 143, 90127, Palermo, Italy
| | - Salvatore Iacono
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Via del Vespro 143, 90127, Palermo, Italy
| | - Laura Pilati
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Via del Vespro 143, 90127, Palermo, Italy
| | - Antonia Pignolo
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Via del Vespro 143, 90127, Palermo, Italy
- Department of Neuroscience, "S. Giovanni di Dio" Hospital, 88900, Crotone, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neurosciences and Advanced Diagnostics (Bi.N.D.), University of Palermo, Via del Vespro 143, 90127, Palermo, Italy
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Faccioli S, Cavalagli A, Falocci N, Mangano G, Sanfilippo I, Sassi S. Gait analysis patterns and rehabilitative interventions to improve gait in persons with hereditary spastic paraplegia: a systematic review and meta-analysis. Front Neurol 2023; 14:1256392. [PMID: 37799279 PMCID: PMC10548139 DOI: 10.3389/fneur.2023.1256392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 08/29/2023] [Indexed: 10/07/2023] Open
Abstract
Background Hereditary spastic paraplegias (HSPs) are a group of inheritance diseases resulting in gait abnormalities, which may be detected using instrumented gait analysis. The aim of this systematic review was 2-fold: to identify specific gait analysis patterns and interventions improving gait in HSP subjects. Methods A systematic review was conducted in PubMed, Cochrane Library, REHABDATA, and PEDro databases, in accordance with reporting guidelines of PRISMA statement and Cochrane's recommendation. The review protocol was recorded on the PROSPERO register. Patients with pure and complicated HSP of any age were included. All types of studies were included. Risk of bias, quality assessment, and meta-analysis were performed. Results Forty-two studies were included: 19 were related to gait analysis patterns, and 24 were intervention studies. The latter ones were limited to adults. HSP gait patterns were similar to cerebral palsy in younger subjects and stroke in adults. Knee hyperextension, reduced range of motion at knee, ankle, and hip, reduced foot lift, and increased rapid trunk and arm movements were reported. Botulinum injections reduced spasticity but uncovered weakness and improved gait velocity at follow-up. Weak evidence supported intrathecal baclofen, active intensive physical therapy (i.e., robot-assisted gait training, functional exercises, and hydrotherapy), and functional electrical stimulation. Some improvements but adverse events were reported after transcranial magnetic stimulation, transcutaneous spinal direct current stimulation, and spinal cord stimulation implant. Conclusion Knee hyperextension, non-sagittal pelvic movements, and reduced ROM at the knee, ankle, and hip represent the most peculiar patterns in HSP, compared to diplegic cerebral palsy and stroke. Botulinum improved comfortable gait velocity after 2 months. Nonetheless, interventions reducing spasticity might result in ineffective functional outcomes unveiling weakness. Intensive active physical therapy and FES might improve gait velocity in the very short term.
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Affiliation(s)
- Silvia Faccioli
- Children Rehabilitation Unit, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Clinical and Experimental Medicine, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Angela Cavalagli
- Children Rehabilitation Unit, IRCCS Fondazione Don Carlo Gnocchi, Milano, Italy
| | - Nicola Falocci
- Office of Policy Evaluation and Statistical Studies, Umbria Legislative Assembly, Perugia, Italy
| | - Giulia Mangano
- Department of Physical Medicine and Rehabilitation, Azienda Sanitaria Provinciale 3 (ASP 3), Acireale Hospital, Catania, Italy
| | | | - Silvia Sassi
- Children Rehabilitation Unit, Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Lallemant-Dudek P, Parodi L, Coarelli G, Heinzmann A, Charles P, Ewenczyk C, Fenu S, Monin ML, Corcia P, Depienne C, Mochel F, Benard J, Tezenas du Montcel S, Durr A. Individual perception of environmental factors that influence lower limbs spasticity in inherited spastic paraparesis. Ann Phys Rehabil Med 2023; 66:101732. [PMID: 37028193 DOI: 10.1016/j.rehab.2023.101732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/26/2022] [Accepted: 10/28/2022] [Indexed: 04/08/2023]
Abstract
BACKGROUND Phenotypic variability is a consistent finding in neurogenetics and therefore applicable to hereditary spastic paraparesis. Identifying reasons for this variability is a challenge. We hypothesized that, in addition to genetic modifiers, extrinsic factors influence variability. OBJECTIVES Our aim was to describe the clinical variability in hereditary spastic paraparesis from the person's perspective. Our goals were to identify individual and environmental factors that influence muscle tone disorders and derive interventions which could improve spasticity. METHODS This study was based on self-assessments with questions on nominal and ordinal scales completed by participants with hereditary spastic paraparesis. A questionnaire was completed either in-person in the clinic or electronically via lay organization websites. RESULTS Among the 325 responders, most had SPG4/SPAST (n = 182, 56%) with a mean age at onset of 31.7 (SD 16.7) years and a mean disease duration of 23 (SD 13.6) years at the time of participation. The 2 factors identified as improving spasticity for > 50% of the responders were physiotherapy (193/325, 59%), and superficial warming (172/308, 55%). Half of the responders (n = 164, 50%) performed physical activity at least once a month and up to once a week. Participants who reported physiotherapy as effective were significantly more satisfied with ≥ 3 sessions per week. Psychologically stressful situations (246/319, 77%) and cold temperatures (202/319, 63%) exacerbated spasticity for most participants. CONCLUSION Participants perceived that physiotherapy reduced spasticity and that the impact of physiotherapy on spasticity was much greater than other medical interventions. Therefore, people should be encouraged to practice physical activity at least 3 times per week. This study reported participants' opinions: in hereditary spastic paraparesis only functional treatments exist, therefore the participant's expertise is of particular importance.
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Affiliation(s)
- Pauline Lallemant-Dudek
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France; Sorbonne Université, Pediatric Physical Medicine and Rehabilitation Department, Hospital Armand Trousseau, Paris, France.
| | - Livia Parodi
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France
| | - Giulia Coarelli
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France; Sorbonne Université, Genetic Department, University Hospital Pitié-Salpêtrière, Paris, France
| | - Anna Heinzmann
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France; Sorbonne Université, Genetic Department, University Hospital Pitié-Salpêtrière, Paris, France
| | - Perrine Charles
- Sorbonne Université, Genetic Department, University Hospital Pitié-Salpêtrière, Paris, France
| | - Claire Ewenczyk
- Sorbonne Université, Genetic Department, University Hospital Pitié-Salpêtrière, Paris, France
| | - Silvia Fenu
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France
| | - Marie-Lorraine Monin
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France
| | - Philippe Corcia
- Centre SLA, University Hospital Bretonneau, Tours, France; Inserm Unit UMR U1253, iBrain, France
| | - Christel Depienne
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France; Institute of Human Genetics, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Fanny Mochel
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France
| | | | - Sophie Tezenas du Montcel
- Sorbonne Université, Biostatistics and Medical Informatics Unit and Clinical Research Unit, University Hospital Pitié-Salpêtrière, UMR S1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Alexandra Durr
- Sorbonne Université, Paris Brain Institute (ICM Institut du Cerveau), INSERM, CNRS, Assistance Publique-Hôpitaux de Paris (APHP), University Hospital Pitié-Salpêtrière, Paris, France; Sorbonne Université, Genetic Department, University Hospital Pitié-Salpêtrière, Paris, France
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Brief Skin Cooling Prior to Intramuscular Botulinum Toxin Injections. Can J Neurol Sci 2022; 49:598-599. [DOI: 10.1017/cjn.2021.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mornas A, Racinais S, Brocherie F, Alhammoud M, Hager R, Desmedt Y, Guilhem G. Faster early rate of force development in a warmer muscle: an in vivo exploration of fascicle dynamics and muscle-tendon mechanical properties. Am J Physiol Regul Integr Comp Physiol 2022; 323:R123-R132. [PMID: 35579335 DOI: 10.1152/ajpregu.00280.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
While heat exposure has been shown to increase the rate of force development (RFD), the underlying processes remain unknown. This study investigated the effect of heat on gastrocnemius medialis (GM) muscle-tendon properties and interactions. Sixteen participants performed electrically-evoked and voluntary contractions combined with ultrafast ultrasound under thermoneutral (CON: 26°C, core temperature 37.0±0.3°C, muscle temperature 34.0±1.1°C) and passive heat exposure (HOT: 47°C, core temperature 38.4±0.3°C, muscle temperature 37.0±0.8°C) conditions. Maximal voluntary force was unchanged while voluntary activation decreased (-4.6±8.7%, P=0.038) in HOT. Heat exposure increased RFD before 100 ms from contraction onset (+48.2±62.7%; P=0.013), without further changes after 100 ms. GM fascicle dynamics during electrically-evoked and voluntary contractions remained unchanged between conditions. Joint velocity at a given force was higher in HOT (+7.1±6.6%; P=0.004), while the fascicle force-velocity relationship was unchanged. Passive muscle stiffness and active tendon stiffness were lower in HOT than CON (P≤0.030). This study showed that heat-induced increases in early RFD may not be attributed to changes in contractile properties. Late RFD was unaltered, probably explained by decreased soft tissues' stiffness in heat. Investigations are required to explore the possible influence of neural drive and motor unit recruitment in the enhancement of explosive strength elicited by heat exposure.
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Affiliation(s)
- Adèle Mornas
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance (EA 7370), Paris, France.,University of Paris, Paris, France
| | - Sebastien Racinais
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance (EA 7370), Paris, France.,Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar
| | - Franck Brocherie
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance (EA 7370), Paris, France
| | | | - Robin Hager
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance (EA 7370), Paris, France
| | - Yanis Desmedt
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance (EA 7370), Paris, France
| | - Gaël Guilhem
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance (EA 7370), Paris, France
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Mornas A, Racinais S, Brocherie F, Alhammoud M, Hager R, Desmedt Y, Guilhem G. Hyperthermia reduces electromechanical delay via accelerated electrochemical processes. J Appl Physiol (1985) 2021; 130:290-297. [PMID: 33180642 DOI: 10.1152/japplphysiol.00538.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The present study aimed to determine the effect of hyperthermia on both electrochemical and mechanical components of the electromechanical delay (EMD), using very-high-frame-rate ultrasound. Electrically evoked peak twitch force, EMD, electrochemical (Dm; i.e., delay between stimulation and muscle fascicle motion), and mechanical (Tm; i.e., delay between fascicle motion and force production onset) components of EMD were assessed in 16 participants. Assessments were conducted in a control ambient environment (CON; 26°C, 34% relative humidity) and in a hot ambient environment (HOT; 46-50°C, 18% relative humidity, after ∼127 min of heat exposure). Following heat exposure, gastrocnemius medialis temperature was 37.0 ± 0.6°C in HOT vs. 34.0 ± 0.8°C in CON (P < 0.001). EMD was shorter (9.4 ± 0.8 ms) in HOT than in CON (10.8 ± 0.6 ms, P < 0.001). Electrochemical processes were shorter in HOT than in CON (4.0 ± 0.8 ms vs. 5.5 ± 0.9 ms, respectively, P < 0.001), whereas mechanical processes were unchanged (P = 0.622). These results demonstrate that hyperthermia reduces electromechanical delay via accelerated electrochemical processes, whereas force transmission along the active and passive parts of the series elastic component is not affected following heat exposure. The present study demonstrates that heat exposure accelerates muscle contraction thanks to faster electrochemical processes. Further investigations during voluntary contractions would contribute to better understand how these findings translate into motor performance.NEW & NOTEWORTHY Hyperthermia (targeted core temperature: 38.5°C) reduces the time between gastrocnemius medialis stimulation and the onset of plantar flexor force production in vivo. This reduction in electromechanical delay is concomitant to an earlier motion of muscle fascicle compared with thermoneutral environment. However, hyperthermia has no impact on the duration of force transmission along aponeurosis and tendon, thereby reflecting different effects of heat exposure on contractile and elastic properties of the muscle-tendon unit.
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Affiliation(s)
- Adèle Mornas
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance, Paris, France.,Université de Paris, Paris, France
| | - Sébastien Racinais
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance, Paris, France.,Aspetar Orthopaedic and Sports Medicine Hospital, Athlete Health and Performance Research Centre, Doha, Qatar
| | - Franck Brocherie
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance, Paris, France
| | - Marine Alhammoud
- Aspetar Orthopaedic and Sports Medicine Hospital, Athlete Health and Performance Research Centre, Doha, Qatar
| | - Robin Hager
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance, Paris, France
| | - Yanis Desmedt
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance, Paris, France
| | - Gaël Guilhem
- French Institute of Sport (INSEP), Laboratory Sport, Expertise and Performance, Paris, France
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Siow SF, Cameron Smail R, Ng K, Kumar KR, Sue CM. Motor Evoked Potentials in Hereditary Spastic Paraplegia-A Systematic Review. Front Neurol 2019; 10:967. [PMID: 31620065 PMCID: PMC6759520 DOI: 10.3389/fneur.2019.00967] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 08/23/2019] [Indexed: 12/11/2022] Open
Abstract
Background: Hereditary Spastic Paraplegia (HSP) is a slowly progressive neurodegenerative disorder with no disease modifying treatment. Potential therapeutic approaches are emerging and large-scale clinical drug trials for patients with HSP are imminent. A sensitive biomarker to measure the drug efficacy in these trials is required. Motor evoked potentials (MEPs) are a potential biomarker for HSP as they assess the central motor pathways and can be standardized with set protocols and guidelines. Objectives: We performed a systematic review to investigate the utility of MEPs as a diagnostic and disease severity biomarker for HSP. Search Methods: Systematic searches of PubMed, Embase, Medline, and Scopus were performed. Selection Criteria: Studies reporting on central motor conduction time measured with MEPs in adult and pediatric patients with HSP were included. We excluded studies in non-HSP patient cohorts, not in English, not original research, and unpublished journal articles. Data Collection and analysis: Search results were de-duplicated and screened according to the inclusion and exclusion criteria. The included papers were reviewed independently by two reviewers and data was collected on patient cohorts, test methods, results, and study quality. Results were analyzed using descriptive methods. Results: Of the 882 search results, 32 studies were included in the review. The most common finding was absent or prolonged lower limb (LL) central motor conduction time (CMCT) in patients with HSP (78% of patients studied). Quality assessment revealed variability in study methodology and reporting of results. Variations included patient cohorts of various genotypes as well as variations in equipment and techniques used. Aside from CMCT, none of the MEP parameter measures correlated with disease severity and many did not show significant difference between HSP patients and controls. Conclusion: Systematic review of MEP studies in HSP patient cohorts demonstrated mixed findings. Lower limb CMCT was the most promising parameter in terms of differentiating HSP patients from controls, with one study demonstrating a weak correlation with clinical disease severity. It is possible that the lack of consistency in study methodologies and small patient cohorts have contributed to the variable findings. A longitudinal study of MEPs in a large cohort of HSP patients with the same genotype will help clarify the utility of MEPs as a biomarker for disease severity and use in clinical trials.
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Affiliation(s)
- Sue-Faye Siow
- Department of Neurogenetics, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,Department of Neurology and Neurophysiology, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Ruaridh Cameron Smail
- Department of Neurology and Neurophysiology, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Karl Ng
- Department of Neurology and Neurophysiology, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Kishore R Kumar
- Department of Neurogenetics, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia.,Department of Neurology, Concord Hospital, Sydney, NSW, Australia.,Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,Molecular Medicine Laboratory, Concord Hospital, Sydney, NSW, Australia
| | - Carolyn M Sue
- Department of Neurogenetics, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,Department of Neurology and Neurophysiology, Royal North Shore Hospital, St Leonards, NSW, Australia.,Northern Clinical School, Kolling Institute, Royal North Shore Hospital, St Leonards, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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Effects of superficial heating and insulation on walking speed in people with hereditary and spontaneous spastic paraparesis: A randomised crossover study. Ann Phys Rehabil Med 2017; 61:72-77. [PMID: 29241713 DOI: 10.1016/j.rehab.2017.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 12/01/2017] [Accepted: 12/03/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Cooling of the lower limb in people with Hereditary and Spontaneous Spastic Paraparesis (pwHSSP) has been shown to affect walking speed and neuromuscular impairments. The investigation of practical strategies, which may help to alleviate these problems is important. The potential of superficial heat to improve walking speed has not been explored in pwHSSP. Primary objective was to explore whether the application of superficial heat (hot packs) to lower limbs in pwHSSP improves walking speed. Secondary objective was to explore whether wearing insulation after heating would prolong any benefits. METHODS A randomised crossover study design with 21 pwHSSP. On two separate occasions two hot packs and an insulating wrap (Neo-G™) were applied for 30minutes to the lower limbs of pwHSSP. On one occasion the insulating wrap was maintained for a further 30minutes and on the other occasion it was removed. Measures of temperature (skin, room and core), walking speed (10 metre timed walk) and co-ordination (foot tap time) were taken at baseline (T1), after 30 mins (T2) and at one hour (T3). RESULTS All 21 pwHSSP reported increased lower limb stiffness and decreased walking ability when their legs were cold. After thirty minutes of heating, improvements were seen in walking speed (12.2%, P<0.0001, effect size 0.18) and foot tap time (21.5%, P<0.0001, effect size 0.59). Continuing to wear insulation for a further 30minutes gave no additional benefit; with significant improvements in walking speed maintained at one hour (9.9%, P>0.001) in both conditions. CONCLUSIONS Application of 30minutes superficial heating moderately improved walking speed in pwHSSP with effects maintained at 1hour. The use of hot packs applied to lower limbs should be the focus of further research for the clinical management of pwHSSP who report increased stiffness of limbs in cold weather and do not have sensory deficits.
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