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Shoja O, Shojaei M, Hassanlouei H, Towhidkhah F, Zhang L. Quantifying Human Gait Symmetry During Blindfolded Treadmill Walking. Motor Control 2024; 28:225-240. [PMID: 38402881 DOI: 10.1123/mc.2023-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 12/20/2023] [Accepted: 01/05/2024] [Indexed: 02/27/2024]
Abstract
Bilateral gait symmetry is an essential requirement for normal walking since asymmetric gait patterns increase the risk of falls and injuries. While human gait control heavily relies on the contribution of sensory inputs, the role of sensory systems in producing symmetric gait has remained unclear. This study evaluated the influence of vision as a dominant sensory system on symmetric gait production. Ten healthy adults performed treadmill walking with and without vision. Twenty-two gait parameters including ground reaction forces, joint range of motion, and other spatial-temporal gait variables were evaluated to quantify gait symmetry and compared between both visual conditions. Visual block caused increased asymmetry in most parameters of ground reaction force, however mainly in the vertical direction. When vision was blocked, symmetry of the ankle and knee joint range of motion decreased, but this change did not occur in the hip joint. Stance and swing time symmetry decreased during no-vision walking while no significant difference was found for step length symmetry between the two conditions. This study provides a comprehensive analysis to reveal how the visual system influences bilateral gait symmetry and highlights the important role of vision in gait control. This approach could be applied to investigate how vision alters gait symmetry in patients with disorders to help better understand the role of vision in pathological gaits.
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Affiliation(s)
- Otella Shoja
- Faculty of Sport Sciences, Department of Motor Behavior, Alzahra University, Tehran, Iran
- Center for Interdisciplinary Research in Rehabilitation of Greater Montreal (CRIR), Montreal, QC, Canada
- Department of Neuroscience, Institute of Biomedical Engineering, University of Montreal, Montreal, QC, Canada
| | - Masoumeh Shojaei
- Faculty of Sport Sciences, Department of Motor Behavior, Alzahra University, Tehran, Iran
| | - Hamidollah Hassanlouei
- Faculty of Sport Science and Health, Department of Motor Behavior, Shahid Beheshti University, Tehran, Iran
| | - Farzad Towhidkhah
- Department of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
| | - Lei Zhang
- Institute for Neural Computation, Ruhr University Bochum, Bochum, Germany
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Tramontano M, Ferri N, Turolla A, Orejel Bustos AS, Casagrande Conti L, Sorge C, Pillastrini P, Manzari L. Video head impulse test in subacute and chronic stroke survivors: new perspectives for implementation of assessment in rehabilitation. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08721-x. [PMID: 38758244 DOI: 10.1007/s00405-024-08721-x] [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: 01/12/2024] [Accepted: 05/03/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION The Video Head Impulse Test (vHIT) is a safe and reliable assessment of peripheral vestibular function. Many studies tested its accuracy in clinical settings for differential diagnosis and quantification of the vestibulo-oculomotor reflex (VOR) in various disorders. However, the results of its application after lesions of the CNS are discordant and have never been studied in rehabilitation. This study aims to assess the VOR performance in a sample of stroke survivors. METHODS This is a cross-sectional study on 36 subacute and chronic stroke survivors; only persons with first-ever stroke and able to walk independently, even with supervision, were included. We performed VOR assessments for each semicircular canal by vHIT and balance assessments by the Berg Balance Scale and the MiniBESTest scale. RESULTS Two hundred and sixteen semicircular canals were assessed using the Head Impulse paradigm (in both the vertical and horizontal planes), while 72 semicircular canals were assessed using the Suppressed Head Impulse paradigm (horizontal plane). There was a high prevalence of participants with dysfunctional canals, particularly for the left anterior and right posterior canals, which were each prevalent in more than one-third of our sample. Furthermore, 16 persons showed an isolated canal dysfunction. The mean VOR gain for the vertical canals had confidence intervals out of the normal values (0.74-0.91 right anterior; 0.74-0.82 right posterior; 0.73-0.87 left anterior). CONCLUSION Our findings suggest that peripheral vestibular function may be impaired in people with stroke; a systematic assessment in a rehabilitation setting could allow a more personalized and patient-centred approach.
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Affiliation(s)
- Marco Tramontano
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Unit of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
| | - Nicola Ferri
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Andrea Turolla
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Unit of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
| | - Amaranta Soledad Orejel Bustos
- Santa Lucia Foundation, Scientific Institute for Research and Health Care, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Rome, Italy
| | | | - Chiara Sorge
- Santa Lucia Foundation, Scientific Institute for Research and Health Care, Rome, Italy
| | - Paolo Pillastrini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Unit of Occupational Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138, Bologna, Italy
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Tramontano M, Manzari L, Bustos ASO, De Angelis S, Montemurro R, Belluscio V, Bergamini E, Vannozzi G. Instrumental assessment of dynamic postural stability in patients with unilateral vestibular hypofunction during straight, curved, and blindfolded gait. Eur Arch Otorhinolaryngol 2024; 281:83-94. [PMID: 37382626 DOI: 10.1007/s00405-023-08082-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/15/2023] [Indexed: 06/30/2023]
Abstract
PURPOSE To characterise dynamic postural stability of gait in patients with vestibular hypofunction (PwVH) using a sensor-based assessment while performing dynamic tasks and to correlate the results of this evaluation with clinical scales. METHODS This cross-sectional study involved 22 adults between 18 and 70 years old from a healthcare hospital centre. Eleven patients suffering from chronic vestibular hypofunction (PwVH) and eleven healthy controls (HC) were evaluated through a combined inertial sensor-based and clinical scale assessment. Participants were equipped with five synchronised inertial measurement units (IMUs) (128 Hz, Opal, APDM, Portland, OR, USA): three IMUs were located on the occipital cranium bone, near the lambdoid suture of the head, at the centre of the sternum, and at L4/L5 level, just above the pelvis, and were used to quantify gait quality parameters, while the other two were located slightly above lateral malleoli and used to perform stride and step segmentation. Three different motor tasks were performed in a randomized order: the 10-m Walk Test (10mWT), the Figure of Eight Walk Test (Fo8WT) and the Fukuda Stepping Test (FST). A set of gait quality parameters related to stability, symmetry and smoothness of gait were extracted from IMU data and correlated with the clinical scale scores. PwVH and HC results were compared to test for significant between-group differences. RESULTS Significant differences were found for the three motor tasks (10mWT, Fo8WT and FST) when comparing PwVH and HC groups. For the 10mWT and the Fo8WT, significant differences between the PwVH and HC groups were found for the stability indexes. Considering the FST, significant differences between the PwVH and HC groups were also found in the stability and symmetry of gait. A significant correlation was found between the Dizziness Handicap Inventory and gait indices during the Fo8WT. CONCLUSIONS In this study, we characterized the dynamic postural stability alterations during linear, curved, and blindfolded walking/stepping in PwVH combining an instrumental IMU-based with traditional clinical scales approach. Combining instrumental and clinical evaluation for dynamic stability of gait alterations in PwVH is useful in thoroughly evaluating the effects of unilateral vestibular hypofunction.
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Affiliation(s)
- M Tramontano
- Fondazione Santa Lucia IRCCS, 00179, Rome, Italy
| | | | - A S Orejel Bustos
- Fondazione Santa Lucia IRCCS, 00179, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", 00135, Rome, Italy
| | - S De Angelis
- Fondazione Santa Lucia IRCCS, 00179, Rome, Italy
| | - R Montemurro
- Fondazione Santa Lucia IRCCS, 00179, Rome, Italy
| | - V Belluscio
- Fondazione Santa Lucia IRCCS, 00179, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", 00135, Rome, Italy
| | - E Bergamini
- Fondazione Santa Lucia IRCCS, 00179, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", 00135, Rome, Italy
| | - G Vannozzi
- Fondazione Santa Lucia IRCCS, 00179, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", 00135, Rome, Italy
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Tramontano M, Belluscio V, Bergamini E, Allevi G, De Angelis S, Verdecchia G, Formisano R, Vannozzi G, Buzzi MG. Vestibular Rehabilitation Improves Gait Quality and Activities of Daily Living in People with Severe Traumatic Brain Injury: A Randomized Clinical Trial. SENSORS (BASEL, SWITZERLAND) 2022; 22:8553. [PMID: 36366250 PMCID: PMC9657265 DOI: 10.3390/s22218553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/03/2022] [Accepted: 11/03/2022] [Indexed: 06/16/2023]
Abstract
Neurorehabilitation research in patients with traumatic brain injury (TBI) showed how vestibular rehabilitation (VR) treatments positively affect concussion-related symptoms, but no studies have been carried out in patients with severe TBI (sTBI) during post-acute intensive neurorehabilitation. We aimed at testing this effect by combining sensor-based gait analysis and clinical scales assessment. We hypothesized that integrating VR in post-acute neurorehabilitation training might improve gait quality and activity of daily living (ADL) in sTBI patients. A two-arm, single-blind randomized controlled trial with 8 weeks of follow-up was performed including thirty sTBI inpatients that underwent an 8-week rehabilitation program including either a VR or a conventional program. Gait quality parameters were obtained using body-mounted magneto-inertial sensors during instrumented linear and curvilinear walking tests. A 4X2 mixed model ANOVA was used to investigate session−group interactions and main effects. Patients undergoing VR exhibited improvements in ADL, showing early improvements in clinical scores. Sensor-based assessment of curvilinear pathways highlighted significant VR-related improvements in gait smoothness over time (p < 0.05), whereas both treatments exhibited distinct improvements in gait quality. Integrating VR in conventional neurorehabilitation is a suitable strategy to improve gait smoothness and ADL in sTBI patients. Instrumented protocols are further promoted as an additional measure to quantify the efficacy of neurorehabilitation treatments.
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Affiliation(s)
- Marco Tramontano
- IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Roma, Italy
| | - Valeria Belluscio
- IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Roma, Italy
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis 15, 00135 Roma, Italy
| | - Elena Bergamini
- IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Roma, Italy
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis 15, 00135 Roma, Italy
| | - Giulia Allevi
- IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Roma, Italy
| | - Sara De Angelis
- IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Roma, Italy
| | | | - Rita Formisano
- IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Roma, Italy
| | - Giuseppe Vannozzi
- IRCCS Santa Lucia Foundation, Via Ardeatina 306, 00179 Roma, Italy
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Piazza Lauro de Bosis 15, 00135 Roma, Italy
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Manzari L, Perez-Fernandez N, Tramontano M. Editorial: Gaze and postural stability rehabilitation. Front Neurol 2022; 13:1034012. [PMID: 36341124 PMCID: PMC9635923 DOI: 10.3389/fneur.2022.1034012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 09/26/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Leonardo Manzari
- MSA ENT Academy Center, Cassino, Italy
- *Correspondence: Leonardo Manzari
| | | | - Marco Tramontano
- Fondazione Santa Lucia IRCCS, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, Rome, Italy
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Ren M, Lin T, Chien JH. Different Types of Visual Perturbation Induced Different Demands and Patterns in Active Control: Implication for Future Sensorimotor Training. Front Physiol 2022; 13:919816. [PMID: 35910572 PMCID: PMC9325964 DOI: 10.3389/fphys.2022.919816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Sensorimotor training using visual perturbations has been widely applied to astronauts for rapidly handling and adapting to unpredictable environments. However, these visual perturbations might not be strong enough to trigger long-term effects. Therefore, this study aimed to develop a novel sensorimotor training paradigm using pseudo-random visual perturbations and to determine the demands and patterns of active control under different types of visual perturbations. Method: Thirty healthy young adults participated in this study. Four walking conditions were randomly assigned to these participants: 1) walking without optic flow (NoOptic), 2) walking with the optic flow (Optic), 3) walking under reduced visual capability (Vre), and 4) walking under perturbed optic flow (Vpe). The dependent variables were the step length variability, the step width variability, the 95% confidence interval ellipse area, the long axis of the ellipse, and the short axis of the ellipse. Results: The results indicated that 1) the step length variability and the ellipse area were greater in Vre compared to Optic (p < 0.001, p < 0.001). Moreover, the step width variability and ellipse area were greater in Vpe than Optic (p < 0.001, p = 0.002). Conclusion: The abovementioned results demonstrated that 1) walking in both Vre and Vpe conditions required greater demands and different patterns in active controls compared to the Optic condition, suggesting both Vre and Vpe conditions could be applied for sensorimotor training; 2) the Vre condition would be the first choice if there were no concerns in potential trips on the treadmill.
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Affiliation(s)
- Muchen Ren
- Department of Health and Rehabilitation Science, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, United States
| | - Tangdi Lin
- Department of Health and Rehabilitation Science, College of Allied Health Professions, University of Nebraska Medical Center, Omaha, NE, United States
| | - Jung Hung Chien
- Independent Researcher, Omaha, NE, United States
- *Correspondence: Jung Hung Chien,
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Dal Farra F, Arippa F, Arru M, Cocco M, Porcu E, Tramontano M, Monticone M. Effects of exercise on balance in patients with non-specific low back pain: a systematic review and meta-analysis. Eur J Phys Rehabil Med 2022; 58:423-434. [PMID: 34636528 PMCID: PMC9980551 DOI: 10.23736/s1973-9087.21.07293-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Non-specific low back pain (NS-LBP) is one of the most common musculoskeletal conditions related to medical expenses and disability. Evidence suggests that changes in motion patterns could induce trunk instability and impaired postural control. Therefore, this systematic review investigated the effects of exercise on balance in patients with NS-LBP. EVIDENCE ACQUISITION A systematic review and meta-analysis were conducted. Findings were reported following the 2020 PRISMA statement and the main databases were searched for RCTs. Studies were independently screened through a standardized form and their internal validity assessed by using the Cochrane risk of bias (RoB) tool. Pooled effects were calculated at post-treatment and quality of evidence was assessed through the GRADE framework. EVIDENCE SYNTHESIS Twelve articles were included in the review, eight in the meta-analysis. None of the studies were judged at low RoB. There is very low-quality evidence that exercise is effective in reducing Centre of Pressure (CoP) displacement (-16.99 [-27.29, -6.68]; P=0.001) and in improving single-leg stance test performance (-28.7 [-48.84, -8.67]; P=0.005) and dynamic balance (-4.74 [-8.02, -1.46]; P=0.005). Conversely, no significant results were observed in "ellipse area" and in "limits of stability" indexes. Other results were summarized in a qualitative synthesis. CONCLUSIONS Exercise could be effective in improving both static and dynamic balance in patients with NS-LBP over a short-term period. However, quality of evidence was estimated as very low, hence further double-blinded, high-quality RCTs are needed to address clinical practice and research.
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Affiliation(s)
- Fulvio Dal Farra
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Federico Arippa
- Unit of Neurorehabilitation, Department of Neuroscience and Rehabilitation, ARNAS G. Brotzu, Cagliari, Italy -
| | - Mauro Arru
- Unit of Physical and Rehabilitation Medicine, Department of Clinical Sciences and Translational Medicine, Tor Vergata University, Rome, Italy
| | - Martina Cocco
- Unit of Physical and Rehabilitation Medicine, Department of Clinical Sciences and Translational Medicine, Tor Vergata University, Rome, Italy
| | - Elisa Porcu
- Unit of Physical and Rehabilitation Medicine, Department of Clinical Sciences and Translational Medicine, Tor Vergata University, Rome, Italy
| | - Marco Tramontano
- IRCCS Santa Lucia Foundation, Rome, Italy.,Department of Movement, Human and Health Sciences, Interuniversity Center of Bioengineering of the Human Neuromusculoskeletal System, Foro Italico University of Rome, Rome, Italy
| | - Marco Monticone
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,Unit of Neurorehabilitation, Department of Neuroscience and Rehabilitation, ARNAS G. Brotzu, Cagliari, Italy
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Tramontano M, De Angelis S, Galeoto G, Cucinotta MC, Lisi D, Botta RM, D’ippolito M, Morone G, Buzzi MG. Physical Therapy Exercises for Sleep Disorders in a Rehabilitation Setting for Neurological Patients: A Systematic Review and Meta-Analysis. Brain Sci 2021; 11:brainsci11091176. [PMID: 34573197 PMCID: PMC8467393 DOI: 10.3390/brainsci11091176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Sleep occupies one-third of human life and is essential for health and for emotional, physical, and cognitive well-being. Poor or insufficient sleep is associated with a wide range of dysfunctions that involve different body systems, such as the endocrine, metabolic, and immune systems, thus compromising the higher cortical functions, cognitive performance, mood, and post-physical activity recovery. The present systematic review and meta-analysis aimed to explore the effectiveness of physical therapy exercises on sleep disorders in patients with neurological disorders. Our systematic review identified 10 articles that investigated the effects of physical therapy on sleep disorders in patients with neurological disorders, 6 of which were included in the meta-analysis. Results suggest that physical therapy exercises are a safe and useful strategy for managing sleep disorders in neurorehabilitation.
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Affiliation(s)
- Marco Tramontano
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (M.C.C.); (M.D.); (G.M.); (M.G.B.)
- Correspondence: ; Tel.: +39-0651501420
| | - Sara De Angelis
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (M.C.C.); (M.D.); (G.M.); (M.G.B.)
| | - Giovanni Galeoto
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy;
- IRCCCS Neuromed, 86077 Pozzilli, IS, Italy
| | - Maria Carmela Cucinotta
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (M.C.C.); (M.D.); (G.M.); (M.G.B.)
| | - Danilo Lisi
- Azienda Ospedaliera Rilievo Nazionale Sant’Anna e San Sebastiano, UOC Risk Management, 81100 Caserta, Italy;
| | | | - Mariagrazia D’ippolito
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (M.C.C.); (M.D.); (G.M.); (M.G.B.)
| | - Giovanni Morone
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (M.C.C.); (M.D.); (G.M.); (M.G.B.)
| | - Maria Gabriella Buzzi
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (M.C.C.); (M.D.); (G.M.); (M.G.B.)
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Sangarapillai K, Norman BM, Almeida QJ. Boxing vs Sensory Exercise for Parkinson's Disease: A Double-Blinded Randomized Controlled Trial. Neurorehabil Neural Repair 2021; 35:769-777. [PMID: 34121511 PMCID: PMC8414806 DOI: 10.1177/15459683211023197] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background. Exercise is increasingly becoming recognized as an important adjunct to medications in the clinical management of Parkinson's disease (PD). Boxing and sensory exercise have shown immediate benefits, but whether they continue beyond program completion is unknown. This study aimed to investigate the effects of boxing and sensory training on motor symptoms of PD, and whether these benefits remain upon completion of the intervention. Methods. In this 20-week double-blinded randomized controlled trial, 40 participants with idiopathic PD were randomized into 2 treatment groups, (n = 20) boxing or (n = 20) sensory exercise. Participants completed 10 weeks of intervention. Motor symptoms were assessed at (week 0, 10, and 20) using the Unified Parkinson's Disease Rating Scale (UPDRS-III). Data were analyzed using SPSS, and repeated-measures ANOVA was conducted. Results. A significant interaction effect between groups and time were observed F(1, 39) = 4.566, P = .036, where the sensory group improved in comparison to the boxing group. Post hoc analysis revealed that in comparison to boxing, the effects of exercise did not wear off at washout (week 20) P < .006. Conclusion. Future rehabilitation research should incorporate similar measures to explore whether effects of exercise wear off post intervention.
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Affiliation(s)
- Kishoree Sangarapillai
- Movement Disorders Research and
Rehabilitation Centre, Wilfrid Laurier University, Waterloo, ON, Canada
| | - Benjamin M. Norman
- Movement Disorders Research and
Rehabilitation Centre, Wilfrid Laurier University, Waterloo, ON, Canada
| | - Quincy J. Almeida
- Movement Disorders Research and
Rehabilitation Centre, Wilfrid Laurier University, Waterloo, ON, Canada
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Cerebellar Intermittent Theta-Burst Stimulation Combined with Vestibular Rehabilitation Improves Gait and Balance in Patients with Multiple Sclerosis: a Preliminary Double-Blind Randomized Controlled Trial. THE CEREBELLUM 2021; 19:897-901. [PMID: 32681455 DOI: 10.1007/s12311-020-01166-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Difficulties in gait and balance disorders are among the most common mobility limitations in multiple sclerosis (MS), mainly due to a damage of cerebellar circuits. Moreover, the cerebellum plays a critical role in promoting new motor tasks, which is an essential function for neurorehabilitation. In this study, we investigated the effects of cerebellar intermittent theta burst stimulation (c-iTBS), a high-frequency rTMS protocol able to increase cerebellar activity, on gait and balance in a sample of 20 hospitalized participants with MS, undergoing vestibular rehabilitation (VR), an exercise-based program primarily designed to reduce vertigo and dizziness, gaze instability, and/or imbalance and falls in MS. Patients were assigned to receive either c-iTBS or sham iTBS before being treated with VR during 2 weeks. VR consisted of two types of training: gaze stability and postural stability exercises. The primary outcome measure was the change from baseline in the Tinetti Balance and Gait scale (TBG). The secondary outcome measures were changes from baseline in Berg Balance Scale (BBS), Fatigue Severity Scale (FSS), Two Minute Walking Test (2MWT), and Timed 25-ft walk test (T25FW) scales. MS patients treated with c-iTBS-VR showed a significant improvement in the TBG as compared to patients treated with sham iTBS-VR. Moreover, MS patients in the c-iTBS groups showed better performances in the vestibular-ocular reflex exercises. Combined c-iTBS and VR improves gait and balance abilities more than standard VR treatment in MS patients with a high level of disability.
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De Angelis S, Princi AA, Dal Farra F, Morone G, Caltagirone C, Tramontano M. Vibrotactile-Based Rehabilitation on Balance and Gait in Patients with Neurological Diseases: A Systematic Review and Metanalysis. Brain Sci 2021; 11:brainsci11040518. [PMID: 33921655 PMCID: PMC8072538 DOI: 10.3390/brainsci11040518] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 04/10/2021] [Accepted: 04/14/2021] [Indexed: 01/06/2023] Open
Abstract
Postural instability and fear of falling represent two major causes of decreased mobility and quality of life in cerebrovascular and neurologic diseases. In recent years, rehabilitation strategies were carried out considering a combined sensorimotor intervention and an active involvement of the patients during the rehabilitation sessions. Accordingly, new technological devices and paradigms have been developed to increase the effectiveness of rehabilitation by integrating multisensory information and augmented feedback promoting the involvement of the cognitive paradigm in neurorehabilitation. In this context, the vibrotactile feedback (VF) could represent a peripheral therapeutic input, in order to provide spatial proprioceptive information to guide the patient during task-oriented exercises. The present systematic review and metanalysis aimed to explore the effectiveness of the VF on balance and gait rehabilitation in patients with neurological and cerebrovascular diseases. A total of 18 studies met the inclusion criteria and were included. Due to the lack of high-quality studies and heterogeneity of treatments protocols, clinical practice recommendations on the efficacy of VF cannot be made. Results show that VF-based intervention could be a safe complementary sensory-motor approach for balance and gait rehabilitation in patients with neurological and cerebrovascular diseases. More high-quality randomized controlled trials are needed.
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Affiliation(s)
- Sara De Angelis
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (A.A.P.); (G.M.); (C.C.)
| | | | | | - Giovanni Morone
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (A.A.P.); (G.M.); (C.C.)
| | - Carlo Caltagirone
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (A.A.P.); (G.M.); (C.C.)
| | - Marco Tramontano
- Fondazione Santa Lucia IRCCS, 00179 Rome, Italy; (S.D.A.); (A.A.P.); (G.M.); (C.C.)
- Department of Movement, Human and Health Sciences, University of Rome “Foro Italico”, 00185 Rome, Italy
- Correspondence: ; Tel.: +39-06-5150-1420
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Efficacy of Vestibular Rehabilitation in Patients With Neurologic Disorders: A Systematic Review. Arch Phys Med Rehabil 2020; 102:1379-1389. [PMID: 33383031 DOI: 10.1016/j.apmr.2020.11.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 11/10/2020] [Accepted: 11/30/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this systematic review is to critically assess the effectiveness of vestibular rehabilitation (VR) administered either alone or in combination with other neurorehabilitation strategies in patients with neurologic disorders. DATA SOURCES An electronic search was conducted by 2 independent reviewers in the following databases: MEDLINE (PubMed), the Physiotherapy Evidence Database, and the Cochrane Database of Systematic Reviews. STUDY SELECTION All clinical studies carried out on adult patients with a diagnosis of neurologic disorders who performed VR provided alone or in combination with other therapies were included. DATA EXTRACTION Screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using a modified version of the Newcastle-Ottawa Scale. DATA SYNTHESIS The summary of results was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Twelve studies were included in the review. All the included studies, with 1 exception, report that improvements provided by customized VR in subject affected by a central nervous system diseases are greater than traditional rehabilitation programs alone. CONCLUSIONS Because of the lack of high-quality studies and heterogeneity of treatments protocols, clinical practice recommendations on the efficacy of VR cannot be made. Results show that VR programs are safe and could easily be implemented with standard neurorehabilitation protocols in patients affected by neurologic disorders. Hence, more high-quality randomized controlled trials of VR in patients with neurologic disorders are needed.
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Tramontano M, Consorti G, Morone G, Lunghi C. Vertigo and Balance Disorders - The Role of Osteopathic Manipulative Treatment: A Systematic Review. Complement Med Res 2020; 28:368-377. [PMID: 33361695 DOI: 10.1159/000512673] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 10/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Balance disorders are among the most frequent reasons for consultation and referral to specialist care. Osteopathic Manipulative Treatment (OMT) can influence the proprioceptive system by inducing alterations in the proprioceptive stimuli, hence affecting postural control. OBJECTIVE The present systematic review aimed to explore the effects of OMT in managing patients with vertigo and balance disorders. METHODS MEDLINE (PubMed), ScienceDirect, and Google Scholar were searched. Clinical trials and prospective observational studies were considered. Only studies that considered OMT as the main intervention, provided alone or combined with other interventions, were included. The methodological quality of the evidence was assessed with a modified version of the Newcastle-Ottawa Scale. RESULTS Five studies that enrolled a total of 114 subjects met our inclusion criteria. Overall, it has been observed that there is a positive effect on balance disorders through different outcomes in all of the included studies. Only two studies (9 subjects) mentioned low to moderate adverse events after OMT. CONCLUSIONS OMT showed weak positive effects on balance function, encouraging the connection of conventional medicine and evidence-based complementary medicine for integrative clinical practice and interprofessional work. However, full-sized adequately powered randomized trials are required to determine the effectiveness of OMT for vertigo and balance disorders.
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Affiliation(s)
| | - Giacomo Consorti
- Clinical-Based Human Research Department, Centre for Osteopathic Medicine Collaboration, Pescara, Italy.,Educational Department of Osteopathy, Istituto Superiore Osteopatia, Milan, Italy
| | | | - Christian Lunghi
- Clinical-Based Human Research Department, Centre for Osteopathic Medicine Collaboration, Pescara, Italy
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Curcio A, Temperoni G, Tramontano M, De Angelis S, Iosa M, Mommo F, Cochi G, Formisano R. The effects of aquatic therapy during post-acute neurorehabilitation in patients with severe traumatic brain injury: a preliminary randomized controlled trial. Brain Inj 2020; 34:1630-1635. [PMID: 32991207 DOI: 10.1080/02699052.2020.1825809] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The primary aim is to verify the effectiveness of an aquatic training (AT) in inpatients with severe Traumatic Brain Injury (sTBI) on balance. The secondary aims are to explore the effects on gait, activities of daily living, and quality of life, comparing to a land-based conventional protocol. METHODS Two-arm, randomized controlled trial. Twenty inpatients with sTBI, Glasgow Coma Scale score ≤8, and Level of Cognitive Functioning ≥7 were recruited and randomly assigned to the aquatic therapy group (ATG) or to the Conventional Training Group (CTG). Patients underwent 12 individual rehabilitation sessions (3 days/week, 4 weeks), in a rehabilitation pool during the post-acute intensive neurorehabilitation. The primary outcome measure was the Berg Balance Scale (BBS). Secondary outcome measures were the Modified Barthel Index (MBI), Disability Rating Scale (DRS), Tinetti Gait Balance Scale (TBG) and Quality of Life After Brain Injury (QOLIBRI). All the evaluations were performed at the baseline and after 4 weeks of training. RESULTS The within-subjects analysis showed a significant improvement both in ATG and CTG in MBI, BBS, TBG, and QOLIBRI. CONCLUSION Our results may support the use of AT during post-acute phase to improve motor functions and quality of life in patients with sTBI.
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Affiliation(s)
- A Curcio
- Fondazione Santa Lucia IRCCS , Rome, Italy
| | | | - Marco Tramontano
- Fondazione Santa Lucia IRCCS , Rome, Italy.,Department of Movement, Human and Health Sciences, University of Rome "Foro Italico," Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System , Rome, Italy
| | | | - M Iosa
- Fondazione Santa Lucia IRCCS , Rome, Italy
| | - F Mommo
- Fondazione Santa Lucia IRCCS , Rome, Italy
| | - G Cochi
- Fondazione Santa Lucia IRCCS , Rome, Italy
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Effects of Vestibular Rehabilitation on Fatigue and Activities of Daily Living in People with Parkinson's Disease: A Pilot Randomized Controlled Trial Study. PARKINSONS DISEASE 2020; 2020:8624986. [PMID: 32963754 PMCID: PMC7501553 DOI: 10.1155/2020/8624986] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/05/2020] [Accepted: 09/02/2020] [Indexed: 12/03/2022]
Abstract
One of the most disabling nonmotor symptoms in persons with Parkinson's disease is fatigue, which can decrease the quality of life by restricting the function and activities of daily living (ADL). Nonetheless, sufficient evidence for treating fatigue, including drug or nondrug treatment, is not available. In this study, we evaluated the probable effects of vestibular rehabilitation on fatigue and ADL in patients with Parkinson's disease. Methods. This was a single-blind clinical trial study in which patients with Parkinson's disease voluntarily participated based on the inclusion and exclusion criteria. The patients were randomly assigned to the case and control groups. The case group received 24 sessions of vestibular rehabilitation protocol, and conventional rehabilitation was performed in the control group (i.e., 3 sessions each week, each lasted about 60 minutes). Both groups were also given fatigue management advice. Fatigue was measured by the Parkinson Fatigue Scale (PFS) and the Modified Fatigue Impact Scale (MFIS). ADL was measured by the Functional Independence Measure (FIM). All changes were measured from the baseline at the completion of the intervention. Results. Both fatigue (P ≤ 0.001) and ADL (P ≤ 0.001) improved significantly more in the vestibular intervention group than in the control one. Conclusion. Vestibular rehabilitation may improve fatigue and ADL and therefore can be used as an effective intervention for patients with Parkinson's disease, which was also found to be well tolerated.
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Temperoni G, Curcio A, Iosa M, Mangiarotti MA, Morelli D, De Angelis S, Vergano S, Tramontano M. A Water-Based Sequential Preparatory Approach vs. Conventional Aquatic Training in Stroke Patients: A Randomized Controlled Trial With a 1-Month Follow-Up. Front Neurol 2020; 11:466. [PMID: 32655473 PMCID: PMC7326023 DOI: 10.3389/fneur.2020.00466] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/29/2020] [Indexed: 12/26/2022] Open
Abstract
Background: Many studies hypothesize that people who have suffered stroke could benefit from water-based exercises to improve their strength and ability to perform the activities of daily living. Objective: The study aim was to compare the effects of a water-based sequential preparatory approach (SPA) and conventional aquatic therapy in improving motor functions and quality of life in patients with chronic stroke. Methods: Thirty-three chronic stroke outpatients diagnosed with hemiplegia were recruited and randomly assigned to the experimental or control group. Subjects in the experimental group underwent a trial water-based SPA balance training, and patients in the control group were given traditional water balance training. Both groups of participants underwent 45 min of therapy twice a week for 4 weeks. All patients were evaluated before treatment (T0), after 4 weeks of training (T1), and 4 weeks after the end of training (T2) using the Berg balance scale (BBS), the modified Barthel index (MBI), the Tinetti balance and gait scale (TBG), the Stroke Specific Quality Of Life Scale (SS-QOL), and the modified Ashworth scale (MAS). Results: After the training, statistically significant differences (p < 0.05) were found between the groups in their score averages on the BBS (p = 0.01) and the SS-QOL scale (p = 0.03). Furthermore, the SPAg showed a significantly greater percentage of improvement on the BBS (p = 0.02) and the SS-QOL (p = 0.03). Both groups obtained a significantly improved MAS score (p < 0.01). Conclusion: Results indicate that water training based on an SPA is more effective than traditional aquatic training for balance rehabilitation of chronic poststroke patients.
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Affiliation(s)
| | | | - Marco Iosa
- Fondazione Santa Lucia IRCCS, Rome, Italy
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Tramontano M, Morone G, De Angelis S, Casagrande Conti L, Galeoto G, Grasso MG. Sensor-based technology for upper limb rehabilitation in patients with multiple sclerosis: A randomized controlled trial. Restor Neurol Neurosci 2020; 38:333-341. [PMID: 32925119 DOI: 10.3233/rnn-201033] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Sensor-based technological therapy devices may be good candidates for neuromotor rehabilitation of people with Multiple Sclerosis (MS), especially for treating upper extremities function limitations. The sensor-based device rehabilitation is characterized by interactive therapy games with audio-visual feedback that allows training the movement of shoulders, elbows, and wrist, measuring the strength and the active range of motion of upper limb, registering data in an electronic database to quantitatively monitoring measures and therapy progress. OBJECTIVE This study aimed to investigate the effects of sensor-based motor rehabilitation in add-on to the conventional neurorehabilitation, on increasing the upper limb functions of patients with MS. METHODS Thirty patients were enrolled in the study and randomly assigned to the experimental group and the control group. The training consisting of twelve sessions of upper limb training was compared with twelve sessions of upper limb sensory-motor training, without robotic support. Both rehabilitation programs were performed for 40 minutes three times a week, for 4 weeks, in addition to conventional therapy. All patients were evaluated at the baseline (T0) and after 4 weeks of training (T1). RESULTS The within-subject analysis showed a statistically significant improvement in both groups, in the Modified Barthel Index and in the Rivermead Mobility Index scores and a significant improvement in Multiple Sclerosis Quality of Life-54 in the experimental. The analysis of effectiveness revealed that, compared with baseline (T0), the improvement percentage in all clinical scale scores was greater in the experimental group than the control group. CONCLUSIONS Proposed training provides an intensive and functional-oriented rehabilitation that objectively evaluates achieved progress through exercises. Therefore, it can represent a good complementary strategy for hand rehabilitation in MS patients.
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Affiliation(s)
- Marco Tramontano
- Santa Lucia Foundation, IRCCS, Rome, Italy
- Department of Movement, Human and Health Sciences, University of Rome "Foro Italico", Interuniversity Centre of Bioengineering of the Human Neuromusculoskeletal System, Rome, Italy
| | | | | | | | - Giovanni Galeoto
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, Rome 00185, Italy
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Peppe A, Paravati S, Baldassarre MG, Bakdounes L, Spolaor F, Guiotto A, Pavan D, Sawacha Z, Bottino S, Clerici D, Cau N, Mauro A, Albani G, Avenali M, Sandrini G, Tassorelli C, Volpe D. Proprioceptive Focal Stimulation (Equistasi®) May Improve the Quality of Gait in Middle-Moderate Parkinson's Disease Patients. Double-Blind, Double-Dummy, Randomized, Crossover, Italian Multicentric Study. Front Neurol 2019; 10:998. [PMID: 31620071 PMCID: PMC6760030 DOI: 10.3389/fneur.2019.00998] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 09/02/2019] [Indexed: 01/17/2023] Open
Abstract
Objective: The object of the study was to evaluate the efficacy of Proprioceptive Focal Stimulation on Gait in middle—advanced Parkinson (PD) patients by a crossover, randomized, double Blind double dummy study using Equistasi®, a nano-technological device of the dimension of a plaster which generates High Frequency Vibration (FV). Background: The efficacy of Gait Analysis (GA) on evaluating gait modification on Parkinson's disease (PD) Patients is already well-known. Therefore, GA was recorded in a group of PD patients using Equistasi® device and its placebo. Methods: Forty PD patients on optimal therapy were enrolled in the study. Patients were randomly assigned to receive active or sham stimulation for 8 weeks and, following a wash-out period, switched to an additional 8-week period with the reverse intervention. GA was performed at baseline and at the end of both 8-weeks treatment periods Clinical state was monitored by MDUPDRS part III. Results: Active stimulation induced a significant improvement in Mean Velocity (Velocity), Stride Length (SL), Stance (STA), and Double Support (DST) percentage, both in left and right stride. The ANOVA analysis using H&Y stage as a factor, showed that DST and MDUPDRS III scores improved significantly more in the more severely affected subjects. Conclusions: The findings obtained in this randomized controlled study show the efficacy of mechanical focal vibration, as stimulation of the proprioceptive system, in PD and encourage further investigation. The effect of the device on more severe patients may open a new possibility to identify the most appropriate candidate for the management of gait disturbances and postural instability with FV delivered with Equistasi®.
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Affiliation(s)
| | | | - Maria Giulia Baldassarre
- Parkinson Excellence Center of the Fresco Institute for Italy, Villa Margherita Clinic of Vicenza, Vicenza, Italy
| | - Leila Bakdounes
- Parkinson Excellence Center of the Fresco Institute for Italy, Villa Margherita Clinic of Vicenza, Vicenza, Italy
| | - Fabiola Spolaor
- Department of Information Engineering, University of Padova, Padua, Italy
| | - Annamaria Guiotto
- Department of Information Engineering, University of Padova, Padua, Italy
| | - Davide Pavan
- Department of Information Engineering, University of Padova, Padua, Italy
| | - Zimi Sawacha
- Department of Information Engineering, University of Padova, Padua, Italy
| | | | - Daniela Clerici
- Department of Neurology, Italian Auxological Institute, IRCCS, Verbania, Italy
| | - Nicola Cau
- Department of Neurology, Italian Auxological Institute, IRCCS, Verbania, Italy.,Politecnico of Milano, Milan, Italy
| | - Alessandro Mauro
- Department of Neurology, Italian Auxological Institute, IRCCS, Verbania, Italy.,University of Torino, Turin, Italy
| | - Giovanni Albani
- Department of Neurology, Italian Auxological Institute, IRCCS, Verbania, Italy
| | - Micol Avenali
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Department of Neurology and Neurorehabilitation, Mondino Foundation, Pavia, Italy
| | - Giorgio Sandrini
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Department of Neurology and Neurorehabilitation, Mondino Foundation, Pavia, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy.,Department of Neurology and Neurorehabilitation, Mondino Foundation, Pavia, Italy
| | - Daniele Volpe
- Parkinson Excellence Center of the Fresco Institute for Italy, Villa Margherita Clinic of Vicenza, Vicenza, Italy
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Tramontano M, Piermaria J, Morone G, Reali A, Vergara M, Tamburella F. Postural Changes During Exteroceptive Thin Plantar Stimulation: The Effect of Prolonged Use and Different Plantar Localizations. Front Syst Neurosci 2019; 13:49. [PMID: 31572134 PMCID: PMC6753192 DOI: 10.3389/fnsys.2019.00049] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 08/30/2019] [Indexed: 01/01/2023] Open
Abstract
Somatosensory information arising from the foot has an important role in posture as well as visual and vestibular cues. Our hypothesis is that the effects of prolonged stimulation are greater than those of short stimulation and that varying the plantar location can affect postural control. Forty healthy participants were recruited and randomly assigned to four different plantar location groups: Lateral Insert (LI), Medial Insert (MI), Disharmonious Insert (DI), and Central Insert (CI). An instrumental assessment was performed before the plantar stimulation (T0), immediately after the positioning of the inserts (T1), and after 7 days of daily stimulation (T7). A follow-up was performed 15 days after (T15). The following stabilometric parameters were considered for both open eyes (OE) and closed eyes (CE) conditions: length of the sway (L) of the Center of Pressure (CoP); CoP maximum movements in the medio-lateral (X), and antero-posterior directions (Y). Comparing the effects of different plantar insert locations, the MI and CI groups were significantly different in the follow-up measures at T15, specifically for closed eyes measures. When we compared measures across time within each location group, CI group increased measures of X and Y data at T7 compared to other assessment times (T0, T1, and T15). In both MI and LI groups, L was significantly reduced, and X significantly increased at the T7 assessment compared to the T0, T1, and T15 assessments. The prolonged use of exteroceptive plantar stimulation and the location of plantar inserts may have a role to reshape postural control.
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