Effects of robot assisted gait training in progressive supranuclear palsy (PSP): a preliminary report

Gait Performance and Brain Activity Are Improved by Gait Automatization during Robot-Assisted Gait Training in Patients with Burns: A Prospective, Randomized, Single-Blinded Study

Background: Patients with lower extremity burn injuries have decreased gait function. Gait dysfunctions are compensated by activation of executive areas such as the prefrontal cortex (PFC). Although robot-assisted gait training (RAGT) can improve gait function, the training mechanisms of RAGT are unknown. We aimed to determine the clinical effects of RAGT in patients with burns and investigate their underlying mechanisms. Methods: This single-blind, randomized controlled trial involved 54 patients with lower extremity burns. The RAGT group underwent RAGT using SUBAR® and conventional training. The control (CON) group underwent only conventional training. The primary outcome was cortical activity measured using a functional near-infrared spectroscopy device before and after 8 weeks of training to confirm the compensatory effect of gait dysfunction. The secondary outcomes were the functional ambulation category (FAC) to evaluate gait performance, 6-min walking test (6 MWT) distance to measure gait speed, isometric force and range of motion (ROM) of lower extremities to evaluate physical function, and the visual analog scale (VAS) score to evaluate subjective pain during gait. Results: PFC activation during the gait phase in the RAGT group decreased significantly compared with that of the CON. The VAS score decreased and FAC score improved after 8 weeks of training in both groups. The 6 MWT scores, isometric strengths (the left knee flexor and bilateral ankle plantar flexors), and the ROMs (the extensions of bilateral hip and bilateral knee) of the RAGT group were significantly improved compared with those of the CON. RAGT improved gait speed, lower extremity ROMs, and lower extremity muscles strengths in patients with burns. Conclusions: The improvement in gait speed and cerebral blood flow evaluation results suggests that the automatization of gait is related to the treatment mechanism during RAGT.

Pharmacotherapies for the Treatment of Progressive Supranuclear Palsy: A Narrative Review

Progressive supranuclear palsy (PSP) is a neurodegenerative disorder resulting from the deposition of misfolded and neurotoxic forms of tau protein in specific areas of the midbrain, basal ganglia, and cortex. It is one of the most representative forms of tauopathy. PSP presents in several different phenotypic variations and is often accompanied by the development of concurrent neurodegenerative disorders. PSP is universally fatal, and effective disease-modifying therapies for PSP have not yet been identified. Several tau-targeting treatment modalities, including vaccines, monoclonal antibodies, and microtubule-stabilizing agents, have been investigated and have had no efficacy. The need to treat PSP and other tauopathies is critical, and many clinical trials investigating tau-targeted treatments are underway. In this review, the PubMed database was queried to collect information about preclinical and clinical research on PSP treatment. Additionally, the US National Library of Medicine's ClinicalTrials.gov website was queried to identify past and ongoing clinical trials relevant to PSP treatment. This narrative review summarizes our findings regarding these reports, which include potential disease-modifying drug trials, modifiable risk factor management, and symptom treatments.

Effects of physiotherapy and home-based training in parkinsonian syndromes: protocol for a randomised controlled trial (MobilityAPP)

INTRODUCTION

Gait and mobility impairment are pivotal signs of parkinsonism, and they are particularly severe in atypical parkinsonian disorders including multiple system atrophy (MSA) and progressive supranuclear palsy (PSP). A pilot study demonstrated a significant improvement of gait in patients with MSA of parkinsonian type (MSA-P) after physiotherapy and matching home-based exercise, as reflected by sensor-based gait parameters. In this study, we aim to investigate whether a gait-focused physiotherapy (GPT) and matching home-based exercise lead to a greater improvement of gait performance compared with a standard physiotherapy/home-based exercise programme (standard physiotherapy, SPT).

METHODS AND ANALYSIS

This protocol was deployed to evaluate the effects of a GPT versus an active control undergoing SPT and matching home-based exercise with regard to laboratory gait parameters, physical activity measures and clinical scales in patients with Parkinson's disease (PD), MSA-P and PSP. The primary outcomes of the trial are sensor-based laboratory gait parameters, while the secondary outcome measures comprise real-world derived parameters, clinical rating scales and patient questionnaires. We aim to enrol 48 patients per disease group into this double-blind, randomised-controlled trial. The study starts with a 1 week wearable sensor-based monitoring of physical activity. After randomisation, patients undergo a 2 week daily inpatient physiotherapy, followed by 5 week matching unsupervised home-based training. A 1 week physical activity monitoring is repeated during the last week of intervention.

ETHICS AND DISSEMINATION

This study, registered as 'Mobility in Atypical Parkinsonism: a Trial of Physiotherapy (Mobility_APP)' at clinicaltrials.gov (NCT04608604), received ethics approval by local committees of the involved centres. The patient's recruitment takes place at the Movement Disorders Units of Innsbruck (Austria), Erlangen (Germany), Lausanne (Switzerland), Luxembourg (Luxembourg) and Bolzano (Italy). The data resulting from this project will be submitted to peer-reviewed journals, presented at international congresses and made publicly available at the end of the trial.

TRIAL REGISTRATION NUMBER

NCT04608604.

Balance and gait in progressive supranuclear palsy: a narrative review of objective metrics and exercise interventions

Background

The use of objective gait and balance metrics is rapidly expanding for evaluation of atypical parkinsonism, and these measures add to clinical observations. Evidence for rehabilitation interventions to improve objective measures of balance and gait in atypical parkinsonism is needed.

Aim

Our aim is to review, with a narrative approach, current evidence on objective metrics for gait and balance and exercise interventions in progressive supranuclear palsy (PSP).

Methods

Literature searches were conducted in four computerized databases from the earliest record up to April 2023: PubMed, ISI's Web of Knowledge, Cochrane's Library, and Embase. Data were extracted for study type (cross-sectional, longitudinal, and rehabilitation interventions), study design (e.g., experimental design and case series), sample characteristics, and gait and balance measurements.

Results

Eighteen gait and balance (16 cross-sectional and 4 longitudinal) and 14 rehabilitation intervention studies were included. Cross-sectional studies showed that people with PSP have impairments in gait initiation and steady-state gait using wearable sensors, and in static and dynamic balance assessed by posturography when compared to Parkinson's disease (PD) and healthy controls. Two longitudinal studies observed that wearable sensors can serve as objective measures of PSP progression, using relevant variables of change in turn velocity, stride length variability, toe off angle, cadence, and cycle duration. Rehabilitation studies investigated the effect of different interventions (e.g., balance training, body-weight supported treadmill gait, sensorimotor training, and cerebellar transcranial magnetic stimulation) on gait, clinical balance, and static and dynamic balance assessed by posturography measurements. No rehabilitation study in PSP used wearable sensors to evaluate gait and balance impairments. Although clinical balance was assessed in 6 rehabilitation studies, 3 of these studies used a quasi-experimental design, 2 used a case series, only 1 study used an experimental design, and sample sizes were relatively small.

Conclusion

Wearable sensors to quantify balance and gait impairments are emerging as a means of documenting progression of PSP. Robust evidence for improving balance and gait in PSP was not found for rehabilitation studies. Future powered, prospective and robust clinical trials are needed to investigate the effects of rehabilitation interventions on objective gait and balance outcomes in people with PSP.

Effect of therapeutic exercise on the balance of patients with progressive supranuclear palsy: A pilot study

Background

Progressive supranuclear palsy (PSP) is a parkinsonian-like progressive neurodegenerative syndrome. Key clinical features include ocular motor dysfunction, postural instability, and cognitive dysfunction. Maintaining and improving balance function and gait function are very important for patients with PSP with severe postural dysfunction and repeated falls. In addition, patients with PSP have a poor response to pharmacological treatment; hence, rehabilitation is a key approach in dealing with this syndrome. However, no conclusion on the beneficial effects of rehabilitation for patients with PSP have been established in the literature.

Objectives

The effectiveness of multiple therapeutic exercise program with probable or possible PSP according to the Movement Disorder Society criteria for the clinical diagnosis of PSP was validated.

Methods

Participants underwent multiple therapeutic exercise program customized for each participant, including resistance training, balance training, and walking exercises that were performed for 60–80 minutes a day, 5 days a week for 4 weeks. The outcomes measured were as follows: pull test, Berg Balance Scale (BBS), timed up and go test (TUG), and gait speed test.

Results

A total of 117 patients with PSP were enrolled and the analysis was performed on 20 patients with probable PSP. Four-week rehabilitation significantly improved pull test (p = 0.034) and BBS scores (p = 0.001). There were no significant differences both TUG (p = 0.502) and gait speed (p = 0.813).

Conclusion

The multiple therapeutic exercise program had beneficial effects on balance performance in patients with PSP in 4 weeks and could be an essential element in their rehabilitation. Although this pilot study was conducted without a control group, it provided valuable information for future prospective randomized controlled trials.

Rehabilitation in movement disorders: From basic mechanisms to clinical strategies

Movement disorders encompass a variety of conditions affecting the nervous system at multiple levels. The pathologic processes underlying movement disorders alter the normal neural functions and could lead to aberrant neuroplastic changes and to clinical phenomenology that is not expressed only through mere motor symptoms. Given this complexity, the responsiveness to pharmacologic and surgical therapies is often disappointing. Growing evidence supports the efficacy of neurorehabilitation for the treatment of movement disorders. Specific form of training involving both goal-based practice and aerobic training could drive and modulate neuroplasticity in order to restore the circuitries dysfunctions and to achieve behavioral gains. This chapter provides an overview of the alterations expressed in some movement disorders in terms of clinical signs and symptoms and plasticity, and suggests which ones and why tailored rehabilitation strategies should be adopted for the management of the different movement disorders.

An innovative training based on robotics for older people with subacute stroke: study protocol for a randomized controlled trial

BACKGROUND

Stroke is a leading cause of disability, injury, and death in elderly people and represents a major public health problem with substantial medical and economic consequences. The incidence of stroke rapidly increases with age, doubling for each decade after age 55 years. Gait impairment is one of the most important problems after stroke, and improving walking function is often a key component of any rehabilitation program. To achieve this goal, a robotic gait trainer seems to be promising. In fact, some studies underline the efficacy of robotic gait training based on end-effector technology, for different diseases, in particular in stroke patients. In this randomized controlled trial, we verify the efficacy of the robotic treatment in terms of improving the gait and reducing the risk of falling and its long-term effects.

METHODS

In this single-blind randomized controlled trial, we will include 152 elderly subacute stroke patients divided in two groups to receive a traditional rehabilitation program or a robotic rehabilitation using G-EO system, an end-effector device for the gait rehabilitation, in addition to the traditional therapy. Twenty treatment sessions will be conducted, divided into 3 training sessions per week, for 7 weeks. The control group will perform traditional therapy sessions lasting 50 min. The technological intervention group, using the G-EO system, will carry out 30 min of traditional therapy and 20 min of treatment with a robotic system. The primary outcome of the study is the evaluation of the falling risk. Secondary outcomes are the assessment of the gait improvements and the fear of falling. Further evaluations, such as length and asymmetry of the step, walking and functional status, and acceptance of the technology, will be carried.

DISCUSSION

The final goal of the present study is to propose a new approach and an innovative therapeutic plan in the post-stroke rehabilitation, focused on the use of a robotic device, in order to obtain the beneficial effects of this treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04087083 . Registered on September 12, 2019.

Effects of Robot-Assisted Gait Training in Patients with Burn Injury on Lower Extremity: A Single-Blind, Randomized Controlled Trial

This study investigated the effects of robot-assisted gait training (RAGT) on gait function in burn patients. Briefly, 40 burn patients were randomly divided into an RAGT group or a conventional training (CON) group. SUBAR^® (Cretem, Korea) is a wearable robot with a footplate that simulates normal gait cycles. The RAGT group underwent 30 min of robot-assisted training using SUBAR^® with 30 min of conventional physiotherapy once a day, 5 days a week for 12 weeks. Patients in the CON group received 30 min of overground gait training and range-of-motion (ROM) exercises twice a day for 5 days a week for 12 weeks. The RAGT group and the CON group underwent 60 min of training per day. The intervention frequency and duration did not differ between the RAGT group and the CON group. The main outcomes were functional ambulatory category (FAC); 6-min walking test (6MWT); visual analogue scale (VAS) during gait movement; ROM; and isometric forces of bilateral hip, knee, and ankle muscles before and after 12 weeks of training. The results of the VAS, FAC, and 6MWT (8.06 ± 0.66, 1.76 ± 0.56, and 204.41 ± 85.60) before training in the RAGT group improved significantly (4.41 ± 1.18, 4.18 ± 0.39, and 298.53 ± 47.75) after training (p < 0.001, p < 0.001, and p < 0.001). The results of the VAS, FAC, and 6MWT (8.00 ± 1.21, 1.75 ± 0.58, and 220.94 ± 116.88) before training in the CON group improved significantly (5.00 ± 1.03, 3.81 ± 1.05, and 272.19 ± 110.14) after training (p < 0.001, p < 0.001, and p = 0.05). There were differences in the improvement of results of the VAS, FAC, and 6MWT between groups after training, but they were not statistically significant (p = 0.23, p = 0.14, and p = 0.05). The isometric strengths of the right hip extensor (p = 0.02), bilateral knee flexor (p = 0.04 in the right, and p = 0.001 in the left), bilateral knee extensor (p = 0.003 in the right, and p = 0.002 in the left), bilateral ankle dorsiflexor (p = 0.04 in the right, and p = 0.02 in the left), and bilateral ankle plantarflexor (p = 0.001 in the right, and p = 0.008 in the left) after training were significantly improved compared with those before training in the RAGT group. The ROMs of the right knee extension (p = 0.03) and bilateral ankle plantarflexion (p = 0.008 in the right, and p = 0.03 in the left) were significantly improved compared with measurements before training in the RAGT. There were no significant differences of the isometric strengths and ROMs of the bilateral hip, knee, and ankle muscles after training in the CON group. There were significant improvements in the isometric strengths of the left knee flexor (p = 0.01), left ankle dorsiflexor (p = 0.01), and left ankle plantarflexor (p = 0.003) between the two groups. The results suggested that RAGT is effective to facilitate early recovery of muscles strength after a burn injury. This is the first study to evaluate the effectiveness of RAGT in patients with burns compared with those receiving conventional training. The absence of complications in burn patients provides an opportunity to enlarge the application area of RAGT.

Exercise and Progressive Supranuclear Palsy: the need for explicit exercise reporting

BACKGROUND

Progressive Supranuclear Palsy (PSP) is the most frequent form of atypical Parkinsonism. Although there is preliminary evidence for the benefits of gait rehabilitation, balance training and oculomotor exercises in PSP, the quality of reporting of exercise therapies appears mixed. The current investigation aims to evaluate the comprehensiveness of reporting of exercise and physical activity interventions in the PSP literature.

METHODS

Two independent reviewers used the Consensus on Exercise Reporting Template (CERT) to extract all exercise intervention data from 11 studies included in a systematic review. CERT items covered: 'what' (materials), 'who' (instructor qualifications), 'how' (delivery), 'where' (location), 'when', 'how much' (dosage), 'tailoring' (what, how), and 'how well' (fidelity) exercise delivery complied with the protocol. Each exercise item was scored '1' (adequately reported) or '0' (not adequately reported or unclear). The CERT score was calculated, as well as the percentage of studies that reported each CERT item.

RESULTS

The CERT scores ranged from 3 to 12 out of 19. No PSP studies adequately described exercise elements that would allow exact replication of the interventions. Well-described items included exercise equipment, exercise settings, exercise therapy scheduling, frequency and duration. Poorly described items included decision rules for exercise progression, instructor qualifications, exercise adherence, motivation strategies, safety and adverse events associated with exercise therapies.

DISCUSSION

The results revealed variability in the reporting of physical therapies for people living with PSP. Future exercise trials need to more comprehensively describe equipment, instructor qualifications, exercise and physical activity type, dosage, setting, individual tailoring of exercises, supervision, adherence, motivation strategies, progression decisions, safety and adverse events.

CONCLUSION

Although beneficial for people living with PSP, exercise and physical therapy interventions have been inadequately reported. It is recommended that evidence-based reporting templates be utilised to comprehensively document therapeutic exercise design, delivery and evaluation.

Exercise and physical activity for people with Progressive Supranuclear Palsy: a systematic review

Objective:

To conduct a systematic review to evaluate exercise and structured physical activity for people living with Progressive Supranuclear Palsy.

Data sources:

AMED, CINAHL, Cochrane, EMBASE, Informit, MEDLINE, PEDro, PsycINFO, PubMed and SportDiscus were searched until 18 August 2019. Reference lists of included studies were hand-searched.

Methods:

Cochrane guidelines informed review methods. English language peer-reviewed studies of any design, in any setting, were included. Method quality was appraised with the Physiotherapy Evidence Database scale and Joanna Briggs Institute instruments. Data were extracted for study design, sample characteristics and therapy content. Effectiveness was calculated where possible.

Results:

Eleven studies were included. Method appraisal showed moderate to high risk of bias. Research designs included three randomized controlled trials, two quasi-experimental studies, one cohort study, four case studies and one case series. Sample sizes ranged from 1 to 24. Exercise interventions included supported and robot-assisted gait training, gaze training, balance re-education and auditory-cued motor training. Dosage ranged from two to five sessions per week over four to eight weeks. End-of-intervention effect sizes were small (6-minute walk test: –0.07; 95% confidence interval (CI): –0.87, 0.73) to moderate (balance: –0.61; 95% CI: –1.40, 0.23; Timed Up and Go: 0.42; 95% CI: –0.49, 1.33) and statistically non-significant. Function, quality of life and adverse events were inconsistently reported.

Conclusions:

For people with Progressive Supranuclear Palsy, robust evidence was not found for therapeutic exercises. Reported improvements in walking were derived from two clinical trials. The effects of structured physical activity for people with advanced Progressive Supranuclear Palsy are not known.

Sensor-based gait analysis in atypical parkinsonian disorders

BACKGROUND AND OBJECTIVES

Gait impairment and reduced mobility are typical features of idiopathic Parkinson's disease (iPD) and atypical parkinsonian disorders (APD). Quantitative gait assessment may have value in the diagnostic workup of parkinsonian patients and as endpoint in clinical trials. The study aimed to identify quantitative gait parameter differences in iPD and APD patients using sensor-based gait analysis and to correlate gait parameters with clinical rating scales.

SUBJECTS AND METHODS

Patients with iPD and APD including Parkinson variant multiple system atrophy and progressive supranuclear palsy matched for age, gender, and Hoehn and Yahr (≤3) were recruited at two Movement Disorder Units and assessed using standardized clinical rating scales (MDS-UPDRS-3, UMSARS, PSP-RS). Gait analysis consisted of inertial sensor units laterally attached to shoes, generating as objective targets spatiotemporal gait parameters from 4 × 10 m walk tests.

RESULTS

Objective sensor-based gait analysis showed that gait speed and stride length were markedly reduced in APD compared to iPD patients. Moreover, clinical ratings significantly correlated with gait speed and stride length in APD patients.

CONCLUSION

Our findings suggest that patients with APD had more severely impaired gait parameters than iPD patients despite similar disease severity. Instrumented gait analysis provides complementary rater independent, quantitative parameters that can be exploited for clinical trials and care.

Effectiveness of allied health therapy in the symptomatic management of progressive supranuclear palsy: a systematic review

BACKGROUND

Progressive supranuclear palsy (PSP) is an adult onset neurodegenerative condition associated with mobility, balance, speech, swallowing, vision and cognitive changes. The condition is diagnosed using the National Institute for Neurological Disorders and Stroke (NINDS) and the Society of Progressive Supranuclear Palsy (SPSP) criteria. Therapeutic interventions for PSP are important, and a healthcare team should include a physiotherapist, occupational therapist and speech therapist. Mobility, speech and swallowing problems are commonly experienced, and aspiration pneumonia is the leading cause of death. A preliminary search of the literature has indicated that beyond small case series, there is very little evidence to guide specific allied health therapies in PSP. Many strategies for optimizing independence and function for PSP predominately rely on data extrapolated from the study of Parkinson's disease.

OBJECTIVES

The objective of this review was to examine the effectiveness of physical, occupational and speech therapy interventions in the symptomatic management of PSP.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

This review included participants with PSP as per the NINDS and the SPSP criteria, aged over 40 years of age from all community and clinical settings.

TYPES OF INTERVENTIONS

This review included studies evaluating any allied health therapy that addressed mobility, vision, swallowing, communication or cognitive/neuropsychiatric difficulties experienced by patients with PSP. Studies examining interventions within the current scope of practice, and emerging interventions (non-invasive brain stimulation therapy) were eligible for inclusion.

TYPES OF COMPARATOR

The effectiveness of interventions of interest was compared with usual care and/or baseline measurements.

OUTCOMES

Outcomes of interest included the degree of change, or no change, in the symptoms experienced by patients with PSP relevant to allied health. These included difficulties with mobility, vision, swallowing, communication and cognition.

TYPES OF STUDIES

All types of quantitative study designs published in English from the time of development of the NINDS and the SPSP criteria in 1996-2014 were considered for inclusion.

SEARCH STRATEGY

A broad range of synonyms for PSP and a three-step search strategy was utilized to identify possible published and unpublished studies from 11 different databases. An initial limited search via MEDLINE (PubMed), CINAHL, Health Informit, PsycINFO, PEDRO, OTSeeker and SpeechBite was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Third, hand-searching was conducted and the reference list of all identified reports and articles was searched for additional studies.

METHODOLOGICAL QUALITY

Critical appraisal was conducted by two independent reviewers using standardized instruments.

DATA EXTRACTION

Quantitative data were extracted from articles included in the review using standardized data extraction tools.

DATA SYNTHESIS

As the quantitative articles examined different interventions, pooling of data was not appropriate. Instead, the findings were presented in narrative summary and tabular form.

RESULTS

Following methodological appraisal, six studies were included in the review. Aside from one small quasi-randomized control study, most studies were small case series and one was a case report. Five of the six studies examined the effectiveness of a range of different physiotherapy rehabilitation programs targeting gait, balance and physical capability, with one study also targeting gaze control. The sixth study examined non-invasive brain stimulation in improving gait and midline symptoms in PSP. No studies examined the effectiveness of occupational therapy or speech therapy interventions in PSP.

CONCLUSIONS

Research into the effectiveness of allied health therapeutic interventions for PSP symptoms is in its infancy. This review found preliminary evidence to support the use of various physiotherapy rehabilitation programs to improve balance, gait and gaze control in people affected by PSP. Further research is urgently required to identify effective interventions to manage mobility, vision, swallowing, communication and cognitive/neuropsychiatric symptoms associated with this devastating condition.

Training for mobility with exoskeleton robot in spinal cord injury patients: a pilot study

BACKGROUND

Wearable robots are people-oriented robots designed to be worn all day, thus helping in the daily activities. They can assist in walking, running, jumping higher or even lifting objects too heavy in normal conditions.

AIM

The aim of this report was to investigate the changes in gait pattern through 3D gait analysis of subjects with spinal cord injury (SCI) undergoing an adaptive training with a wearable exoskeletal device (ESD). The change in the quality of life was also investigate together with the possibility to wear these devices all day, to improve the mobility.

DESIGN

Prospective quasi-experimental study, pre- and post-design.

SETTING

Outpatient SCI patients.

POPULATION

On a voluntary basis, eight SCI patients who had never used any ESD device were recruited.

METHODS

Subjects underwent a three-dimensional gait analysis (3D GA) while wearing the ESD at baseline (inclusion) (T0) and after 20 sessions of training over an expected average of 5/6 weeks (T1). The secondary outcome measures were: Participant Satisfaction Questionnaire, 6-Minute Walking Test (6MWT), Borg Scale (the test was administered in indoor and outdoor conditions) and Timed Up-and-Go test (TUG). Spatiotemporal and kinematic parameters were assessed and their change from the beginning to the end of the training was the secondary outcome.

RESULTS

No dropouts were recorded during the training and all subjects were able to terminate the protocol (compliant subjects: N.=8). After the training, all person showed some significant improvements for TUG, 6MWT and 10 MWT (Z=-2.521; P=0.008) and for the spatiotemporal and kinematics parameters.

CONCLUSIONS

This paper confirms that the adaptive training with ESD is safe and feasible in a heterogeneous sample of persons with SCI, especially in ameliorating the interaction between the patients and the device with an improvement of spatiotemporal and kinematics parameters.

CLINICAL REHABILITATION IMPACT

Since the training has been proven safe and the hypothesis that the subjects with spinal cord injury improving their performance over time and being able to adapt at the use of device in full autonomy at home during all the activities of the daily living has strengthened.

The Role of Rehabilitation in Patients With Progressive Supranuclear Palsy: A Narrative Review

Progressive supranuclear palsy (PSP) is a progressive neurodegenerative disorder caused by the deposition of abnormal proteins in neurons of the basal ganglia that limit motor ability, resulting in disability and reduced quality of life. So far, no pharmacologic therapy has been developed, and the treatment remains symptomatic. The aim of the present study is to perform a systematic investigation of the literature, and to determine the types and effects of rehabilitative interventions used for PSP. A search of all studies was conducted in MEDLINE/PubMed, the Cochrane Central Register of Controlled Trials, CINAHL, and EMBASE. Twelve studies were identified, including 6 case reports, 3 case series, one case-control study, one quasi-randomized trial (i.e. not truly random) with crossover design, and one randomized controlled trial, with 88 patients investigated overall. Rehabilitative interventions varied in type, number, frequency, and duration of sessions. The most commonly used clinical measures were the Progressive Supranuclear Palsy Rating Scale (PSPRS) and Unified Parkinson's Disease Rating Scale (UPDRS). Physical exercises were the main rehabilitative strategy but were associated with other interventions and rehabilitative devices, in particular treadmill and robot-assisted gait training. All studies showed an improvement in balance and gait impairment with a reduction of falls after rehabilitation treatment. Because of poor methodological quality and the variety of rehabilitative approaches including different and variable strategies, there was insufficient evidence of the effectiveness of any specific rehabilitation intervention in PSP. Despite this finding, rehabilitation might improve balance and gait, thereby reducing falls in PSP patients.

LEVEL OF EVIDENCE

IV.

Rehabilitation in progressive supranuclear palsy: Effectiveness of two multidisciplinary treatments

BACKGROUND

to date, there are no medical or surgical treatments for progressive supranuclear palsy (PSP). It is possible to speculate that patients with PSP could benefit from rehabilitative treatments designed for Parkinson's disease, including the use of robot-assisted walking training.

OBJECTIVE

to evaluate whether the use of the robotic device Lokomat® is superior in PSP patients to the use of treadmill with visual cues and auditory feedbacks (treadmill-plus) in the context of an aerobic, multidisciplinary, intensive, motor-cognitive and goal-based rehabilitation treatment (MIRT) conceived for Parkinsonian patients.

METHODS

we enrolled twenty-four PSP patients. Twelve subjects underwent a 4-week MIRT exploiting the use of the treadmill-plus (MIRT group). Twelve subjects underwent the same treatment, but replacing the treadmill-plus with Lokomat® (MIRT-Lokomat group). Subjects were evaluated with clinical and functional scales at admission and discharge. The primary outcomes were the total PSP Rating Scale (PSPRS) score and its "limb" and "gait" sub-scores. Secondary outcomes were Berg Balance Scale (BBS), Six Minutes Walking test (6MWT) and the number of falls.

RESULTS

total PSPRS, PSPRS-gait sub-score, BBS, 6MWT and number of falls improved significantly in both groups (p ≤ 0.003 all, except 6MWT, p = 0.032 and p = 0.018 in MIRT-Lokomat and MIRT group respectively). The PSPRS-limb sub-score improved significantly only in the MIRT group (p = 0.002). A significant difference between groups was observed only for total PSPRS, indicating a slightly better improvement for patients in the MIRT group (p = 0.047). No differences between groups were revealed for the other outcomes, indicating that the effect of rehabilitation was similar in both groups.

CONCLUSIONS

Lokomat® training, in comparison with treadmill-plus training, does not provide further benefits in PSP patients undergoing MIRT. Our findings suggest the usefulness of an aerobic, multidisciplinary, intensive, motor-cognitive and goal-based approach for the rehabilitation of patients suffering from such a complex disease as PSP.

TRIAL REGISTRATION

This trial was registered on ClinicalTrials.gov, NCT02109393.