The Role of Botulinum Toxin Type-A in Spasticity: Research Trends from a Bibliometric Analysis

Botulinum toxin type-A (BoNT-A) has emerged as a key therapeutic agent for the management of spasticity. This paper presents a comprehensive bibliometric and visual analysis of research concerning BoNT-A treatment of spasticity to elucidate current trends and future directions in this research area. A search was conducted in the Web of Science database for articles focused on the use of BoNT-A in spasticity published between 2000 and 2022. We extracted various metrics, including counts of publications and contributions from different countries, institutions, authors, and journals. Analytical methods in CiteSpace were employed for the examination of co-citations, collaborations, and the co-occurrence of keywords. Our search yielded 1489 publications. Analysis revealed a consistent annual increase in research output. The United States, United Kingdom, and Italy were the leading contributors. The top institution in this research was Assistance Publique Hopitaux, Paris. The journal containing the highest number of relevant publications was Toxins. Key frequently occurring keywords were 'stroke', 'cerebral palsy', 'adult spasticity', and 'upper extremity'. This study identified 12 clusters of keywords and 15 clusters of co-cited references, indicating the main focus areas and emerging themes in this field. This study comprehensively analyzed and summarized trends in BoNT-A research in the field of spasticity over the past 22 years.

A new mutation in the CAVIN1/PTRF gene in two siblings with congenital generalized lipodystrophy type 4: case reports and review of the literature

Lipodystrophy syndromes are characterized by a progressive metabolic impairment secondary to adipose tissue dysfunction and may have a genetic background. Congenital generalized lipodystrophy type 4 (CGL4) is an extremely rare subtype, caused by mutations in the polymerase I and transcript release factor (PTRF) gene. It encodes for a cytoplasmatic protein called caveolae-associated protein 1 (Cavin-1), which, together with caveolin 1, is responsible for the biogenesis of caveolae, being a master regulator of adipose tissue expandability. Cavin-1 is expressed in several tissues, including muscles, thus resulting, when dysfunctional, in a clinical phenotype characterized by the absence of adipose tissue and muscular dystrophy. We herein describe the clinical phenotypes of two siblings in their early childhood, with a phenotype characterized by a generalized reduction of subcutaneous fat, muscular hypertrophy, distinct facial features, myopathy, and atlantoaxial instability. One of the siblings developed paroxysmal supraventricular tachycardia leading to cardiac arrest at 3 months of age. Height and BMI were normal. Blood tests showed elevated CK, a mild increase in liver enzymes and triglycerides levels, and undetectable leptin and adiponectin concentrations. Fasting glucose and HbA1c were normal, while Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) was mildly elevated. Both patients were hyperphagic and had cravings for foods rich in fats and sugars. Genetic testing revealed a novel pathogenic mutation of the CAVIN1/PTRF gene (NM_012232 exon1:c T21A:p.Y7X) at the homozygous state. The diagnosis of lipodystrophy can be challenging, often requiring a multidisciplinary approach, given the pleiotropic effect, involving several tissues. The coexistence of generalized lack of fat, myopathy with elevated CK levels, arrhythmias, gastrointestinal dysmotility, and skeletal abnormalities should prompt the suspicion for the diagnosis of CGL4, although phenotypic variability may occur.

Decreased Gas6 and sAxl Plasma Levels Are Associated with Hair Loss in COVID-19 Survivors

Post-acute conditions after coronavirus disease 2019 (COVID-19) are quite common, although the underlying pathogenetic mechanisms leading to these conditions are not yet completely understood. In this prospective observational study, we aimed to test the hypothesis that Growth Arrest-Specific 6 (Gas6) and its soluble receptors, Axl (sAxl) and MerTK (sMer), might be implicated. A total of 263 subjects underwent a structured clinical evaluation one year after their hospital discharge for COVID-19, and they consented to donate a blood sample to measure their circulating Gas6, sAxl, and sMer levels. A total of 98 (37.3%) post-COVID-19 subjects complained of at least one residual physical symptom one year after their hospital discharge. Univariate analysis revealed that sAxl was marginally associated with residual symptoms, but at the level of logistic regression analysis, only the diffusing capacity of the lungs for carbon monoxide (DLCO) (OR 0.98, CI 95%: 0.96–0.99; p = 0.007) and the female sex (OR 2.49, CI 95%: 1.45–4.28; p = 0.001) were independently associated with long-lasting symptoms. A total of 69 (26.2%) subjects had hair loss. At the level of univariate analysis, Gas6, sAxl, DLCO, and the female gender were associated with its development. In a logistic regression analysis model, Gas6 (OR 0.96, CI 95%: 0.92–0.99; p = 0.015) and sAxl (OR 0.98, CI 95%; 0.97–1.0; p = 0.014), along with the female sex (OR 6.58, CI 95%: 3.39–12.78; p = 0.0001), were independent predictors of hair loss. Decreased levels of Gas6 and sAxl were associated with a history of hair loss following COVID-19. This was resolved spontaneously in most patients, although 23.7% complained of persistent hair loss one year after hospital discharge.

Long-Term Spasticity Management in Post-Stroke Patients: Issues and Possible Actions-A Systematic Review with an Italian Expert Opinion

Spasticity is a well-known motor dysfunction occurring after a stroke. A group of Italian physicians' experts in treating post-stroke spasticity (PSS) reviewed the current scientific evidence concerning the state-of-the-art clinical management of PSS management and the appropriate use of botulinum toxin, aiming to identify issues, possible actions, and effective management of the patient affected by spasticity. The participants were clinicians specifically selected to cover the range of multidisciplinary clinical and research expertise needed to diagnose and manage PSS. When evidence was not available, the panel discussed and agreed on the best way to manage and treat PSS. To address the barriers identified, the panel provides a series of consensus recommendations. This systematic review provides a focused guide in the evaluation and management of patients with PSS and its complications. The recommendations reached by this panel of experts should be used by less-experienced doctors in real life and should be used as a guide on how to best use botulinum toxin injection in treating spasticity after a stroke.

Sensor based assessment of turning during instrumented Timed Up and Go Test for quantifying mobility in chronic stroke patients

BACKGROUND

Turning may be particularly challenging for stroke patients leading to decreased mobility and increased functional restriction. Timed up and go instrumentation using a simple technology in the clinical context could allow for the collection of both traditional and potentially more discriminatory variables in turning ability.

AIM

Determine whether the speed turning metrics obtained by a single inertial sensor are suitable for differentiating between stroke patients with varying levels of mobility and disability.

DESIGN

Cross-sectional study.

SETTING

Outpatients setting.

POPULATION

Chronic stroke patients.

METHODS

A total of 48 chronic stroke patients and 23 healthy controls were included. Stroke patients were divided in two groups based on the total iTUG score: an impaired mobility (> 20 seconds) and an available mobility (<20 seconds) group. All subjects performed an instrumented Timed Up and Go (iTUG) wearing a single IMU sensor on the lower back. Time of subcomponents of the timed up and go test and kinematic parameters of turning were quantified. Other clinical outcomes were: 10 meters walk test, Functional Ambulation Categories Scale (FAC), the Rivermead Mobility Index (RMI), Modified Rankin Scale and the Saltin-Grimby Physical Activity Level Scale (SGPALS).

RESULTS

There were significant differences (P<0.01) in iTUG phases and turning speeds among groups. Low to strong significant correlations were found between measures derived from the turning speeds and clinical measures. The area under the curve (AUC) of Receiver Operating Characteristic (ROC) turning speeds was demonstrated to be able to discriminate (AUC: 0.742-0.912) from available to impaired stroke patients.

CONCLUSIONS

This study provides evidence that turning speeds during timed up and go test are accurate measures of mobility and capable of discriminating stroke patients with impaired mobility from those with normal mobility.

CLINICAL REHABILITATION IMPACT

The turning metrics are related to impairment and mobility in chronic stroke patients; hence they are important to include during clinical evaluation and may assist in creating a customized strategy, assess potential treatments, and effectively organize recovery.

Tolerability, Safety and Efficacy of a Specific Rehabilitation Treatment Protocol for Axillary Web Syndrome: An Observational Retrospective Study

Axillary web syndrome (AWS) is a highly prevalent surgical complication affecting BC survivors. It presents as a subcutaneous cording that limits the upper limb range of motion (ROM) and causes pain. Its etiology is still debated, and its treatment is not well defined. Therefore, we aimed to investigate the safety, tolerability and efficacy of our specific AWS rehabilitative treatment protocol. We conducted an observational retrospective study on a cohort of 92 AWS patients referred to the oncological outpatient service of a university hospital. We collected data from medical records before (T0) and after (T1) the treatment. The studied protocol was composed of 60-min sessions, carried out 3 times/week by specialized physiotherapists, until the clinical resolution of AWS. We found that a mean of 8.74 ± 2.12 rehabilitative sessions were needed, and only one patient stopped early. At T1, shoulder ROM was complete in both abduction and flexion in 98% of patients; AWS was no longer detectable in 64% of them, and pain significantly decreased compared to T0. In conclusion, our protocol proved to be safe, well-tolerated and seemed to be effective in treating AWS.

Balance Rehabilitation through Robot-Assisted Gait Training in Post-Stroke Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Balance impairment is a common disability in post-stroke survivors, leading to reduced mobility and increased fall risk. Robotic gait training (RAGT) is largely used, along with traditional training. There is, however, no strong evidence about RAGT superiority, especially on balance. This study aims to determine RAGT efficacy on balance of post-stroke survivors.

METHODS

PubMed, Cochrane Library, and PeDRO databases were investigated. Randomized clinical trials evaluating RAGT efficacy on post-stroke survivor balance with Berg Balance Scale (BBS) or Timed Up and Go test (TUG) were searched. Meta-regression analyses were performed, considering weekly sessions, single-session duration, and robotic device used.

RESULTS

A total of 18 trials have been included. BBS pre-post treatment mean difference is higher in RAGT-treated patients, with a pMD of 2.17 (95% CI 0.79; 3.55). TUG pre-post mean difference is in favor of RAGT, but not statistically, with a pMD of -0.62 (95%CI - 3.66; 2.43). Meta-regression analyses showed no relevant association, except for TUG and treatment duration (β = -1.019, 95% CI - 1.827; -0.210, p-value = 0.0135).

CONCLUSIONS

RAGT efficacy is equal to traditional therapy, while the combination of the two seems to lead to better outcomes than each individually performed. Robot-assisted balance training should be the focus of experimentation in the following years, given the great results in the first available trials. Given the massive heterogeneity of included patients, trials with more strict inclusion criteria (especially time from stroke) must be performed to finally define if and when RAGT is superior to traditional therapy.

Clinical efficacy of botulinum toxin type A in patients with traumatic brain injury, spinal cord injury, or multiple sclerosis: An observational longitudinal study

Botulinum toxin type A (BoNT-A) is the treatment of choice for focal spasticity, with a concomitant effect on pain reduction and improvement of quality of life (QoL). Current evidence of its efficacy is based mainly on post stroke spasticity. This study aims to clarify the role of BoNT-A in the context of non-stroke spasticity (NSS). We enrolled 86 patients affected by multiple sclerosis, spinal cord injury, and traumatic brain injury with clinical indication to perform BoNT-A treatment. Subjects were evaluated before injection and after 1, 3, and 6 months. At every visit, spasticity severity using the modified Ashworth scale, pain using the numeric rating scale, QoL using the Euro Qol Group EQ-5D-5L, and the perceived treatment effect using the Global Assessment of Efficacy scale were recorded. In our population BoNT-A demonstrated to have a significant effect in improving all the outcome variables, with different effect persistence over time in relation to the diagnosis and the number of treated sites. Our results support BoNT-A as a modifier of the disability condition and suggest its implementation in the treatment of NSS, delivering a possible starting point to generate diagnosis-specific follow-up programs.

Clinical trial identifier

NCT04673240.

Ageing, functioning patterns and their environmental determinants in the spinal cord injury (SCI) population: A comparative analysis across eleven European countries implementing the International Spinal Cord Injury Community Survey

BACKGROUND

As the European population with Spinal Cord Injury (SCI) is expected to become older, a better understanding of ageing with SCI using functioning, the health indicator used to model healthy ageing trajectories, is needed. We aimed to describe patterns of functioning in SCI by chronological age, age at injury and time since injury across eleven European countries using a common functioning metric, and to identify country-specific environmental determinants of functioning.

METHODS

Data from 6'635 participants of the International Spinal Cord Injury Community Survey was used. The hierarchical version of Generalized Partial Credit Model, casted in a Bayesian framework, was used to create a common functioning metric and overall scores. For each country, linear regression was used to investigate associations between functioning, chronological age, age at SCI or time since injury for persons with para- and tetraplegia. Multiple linear regression and the proportional marginal variance decomposition technique were used to identify environmental determinants.

RESULTS

In countries with representative samples older chronological age was consistently associated with a decline in functioning for paraplegia but not for tetraplegia. Age at injury and functioning level were associated, but patterns differed across countries. An association between time since injury and functioning was not observed in most countries, neither for paraplegia nor for tetraplegia. Problems with the accessibility of homes of friends and relatives, access to public places and long-distance transportation were consistently key determinants of functioning.

CONCLUSIONS

Functioning is a key health indicator and the fundament of ageing research. Enhancing methods traditionally used to develop metrics with Bayesian approach, we were able to create a common metric of functioning with cardinal properties and to estimate overall scores comparable across countries. Focusing on functioning, our study complements epidemiological evidence on SCI-specific mortality and morbidity in Europe and identify initial targets for evidence-informed policy-making.

Determinants of long COVID among adults hospitalized for SARS-CoV-2 infection: A prospective cohort study

Rationale

Factors associated with long-term sequelae emerging after the acute phase of COVID-19 (so called "long COVID") are unclear. Here, we aimed to identify risk factors for the development of COVID-19 sequelae in a prospective cohort of subjects hospitalized for SARS-CoV-2 infection and followed up one year after discharge.

Methods

A total of 324 subjects underwent a comprehensive and multidisciplinary evaluation one year after hospital discharge for COVID-19. A subgroup of 247/324 who consented to donate a blood sample were tested for a panel of circulating cytokines.

Results

In 122 patients (37.8%) there was evidence of at least one persisting physical symptom. After correcting for comorbidities and COVID-19 severity, the risk of developing long COVID was lower in the 109 subjects admitted to the hospital in the third wave of the pandemic than in the 215 admitted during the first wave, (OR 0.69, 95%CI 0.51-0.93, p=0.01). Univariable analysis revealed female sex, diffusing capacity of the lungs for carbon monoxide (DLCO) value, body mass index, anxiety and depressive symptoms to be positively associated with COVID-19 sequelae at 1 year. Following logistic regression analysis, DLCO was the only independent predictor of residual symptoms (OR 0.98 CI 95% (0.96-0.99), p=0.01). In the subgroup of subjects with normal DLCO (> 80%), for whom residual lung damage was an unlikely explanation for long COVID, the presence of anxiety and depressive symptoms was significantly associated to persistent symptoms, together with increased levels of a set of pro-inflammatory cytokines: interferon-gamma, tumor necrosis factor-alpha, interleukin (IL)-2, IL-12, IL-1β, IL-17. In logistic regression analysis, depressive symptoms (p=0.02, OR 4.57 [1.21-17.21]) and IL-12 levels (p=0.03, OR 1.06 [1.00-1.11]) 1-year after hospital discharge were independently associated with persistence of symptoms.

Conclusions

Long COVID appears mainly related to respiratory sequelae, prevalently observed during the first pandemic wave. Among patients with little or no residual lung damage, a cytokine pattern consistent with systemic inflammation is in place.

Reasons and Determinants of BoNT-A Treatment Discontinuation in Patients Living with Spasticity: A 10-Year Retrospective Analysis

BACKGROUND

The present study aimed to evaluate the reasons and determinants of BoNT-A discontinuation in patients with stroke, multiple sclerosis, spinal cord injury, and traumatic brain injury.

METHODS

It is a retrospective study of 56 discontinuer patients treated with botulinum toxin between January 2011 and December 2021. Discontinuation rates and their predictors were estimated using Kaplan-Meier, Log rank test, and Cox's regression method of analyses.

RESULTS

The mean age was 56.54 years, 53.57% were affected by post-stroke spasticity, 17.86% by spinal cord injury, 12.5% and 16.07% by traumatic brain injury and multiple sclerosis, respectively. The median discontinuation time was 5 months. The main reason for discontinuation were logistic problems (37%) and orthopedic surgeries or intrathecal baclofen (27%). Discontinuers were more likely to have severe spasticity (R = 1.785), have no pain (HR = 1.320), no access to rehabilitation services (HR = 1.402), and have cognitive impairment (HR = 1.403).

CONCLUSIONS

The main reasons for discontinuation are related to logistic issues (due to distance or the absence of an adequate caregiver) and surgical interventions for spasticity, including intrathecal baclofen. It is crucial to identify possible predictors of discontinuation to improve the effectiveness of a multidisciplinary management. The study confirms the crucial role of rehabilitation and caregivers in achieving better long-term outcomes.

Anxiety, Stress and Depression in COVID-19 Survivors From an Italian Cohort of Hospitalized Patients: Results From a 1-Year Follow-Up

Background

Mental health-related symptoms can persist over time beyond the most common respiratory clinical features of COVID-19. A recent meta-analysis underlined that mental health sequalae may be relevant for COVID-19 survivors and reported the following prevalence rates: 20% for post-traumatic stress disorder, 22% for anxiety, 36% for psychological distress, and 21% for depression. In the context of a multi-disciplinary follow-up project, we already investigated the mid-term (4 months) psychiatric outcomes in a sample of COVID-19 survivors. Patients were re-assessed after 1-year since hospital discharge.

Methods

Follow-up conducted after 1 year involved 196 individuals recovered from COVID-19. Patients were assessed with a multi-disciplinary approach; including both a clinical interview performed by an experienced psychiatrist, trained in the use of the Mini-International Neuropsychiatric Interview (MINI) to assess the presence of anxiety, stress, and depressive symptoms and the following self-administered questionnaires: Beck Anxiety Inventory, Beck Depression Inventory-II, Resilience Scale for Adults, Impact of Event Scale, and COVID-19 Peritraumatic Distress Index (CPDI).

Results

Anxiety (p < 0.0001) and depressive (p < 0.0003) symptoms registered at the clinical interview showed a significant improvement from the 4 to 12-months follow-up. Logistic regression model showed that female gender (p = 0.006), arterial hypertension (p = 0.01), obesity (0.04), anxiety (p < 0.0001), and depressive (p = 0.02) symptoms at 4-months follow-up were associated with persistence of anxiety symptoms at 12 months. At logistic regression analysis female gender (p = 0.02) and depressive symptoms at 4-months follow-up (p = 0.01) were associated with depressive symptoms after 12 months.

Conclusion

Severity of the disease in the acute phase, in this study, was not a determining factor in identifying subjects at risk of developing clinically relevant anxiety and depression as a consequence of COVID-19 disease. Findings from the logistic regressions suggest that the factors most affecting depression and anxiety in COVID survivors after 12 months were female gender, the presence of anxiety and depression after 4 months and some physical symptoms, not necessarily COVID-related. Impact of infection and consequent hospitalization for COVID-19 did no longer represent a relevant issue for depressive symptoms, compared to other general factors.

Multidimensional Effectiveness of Botulinum Toxin in Neuropathic Pain: A Systematic Review of Randomized Clinical Trials

Although botulinum toxin (BoNT) has been suggested as a treatment to counter neuropathic pain, no previous systematic reviews investigated the multidimensional effects of BoNT on pain relief and Health-Related Quality of Life (HR-QoL). The aim of this systematic review is to summarize the current evidence on the effectiveness of BoNT treatment for neuropathic pain, and to characterize its multidimensional effectiveness in order to guide physicians in clinical practice. Five databases were systematically searched up to 4 April 2022, to identify randomized controlled trials satisfying the following criteria: adults suffering from neuropathic pain, BoNT administration, any comparator, multidimensional assessment of pain as primary outcome, HR-QoL, physical function, anxiety and depression, and sleep quality as secondary outcomes. Twelve studies were included. The multidimensional pain scales used were short-form McGill Pain Questionnaire, Neuropathic pain scale, Neuropathic Pain Symptom Inventory, International SCI Pain Basic Data Set, West Haven-Yale Multidimensional Pain Inventory, Brief Pain Inventory, and Douleur Neuropathique 4. These scales highlighted the positive effects of BoNT administration. According to the Jadad scale, all the RCTs included were high-quality studies. BoNT administration might be effectively introduced in the comprehensive management of neuropathic pain. Further research should focus on optimal and cost-effective therapeutic protocols.

Long-lasting consequences of Coronavirus disease 19 pneumonia: a systematic review

INTRODUCTION

Coronavirus Disease 19 (Covid-19) is an infectious disease caused by the newly discovered severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We have plenty of data about the clinical features of the disease's acute phase, while little is known about the long-term consequences on survivors.

EVIDENCE ACQUISITION

We aimed to review systematically emerging evidence about clinical and functional consequences of Covid-19 pneumonia months after hospital discharge.

EVIDENCE SYNTHESIS

Current evidence supports the idea that a high proportion of Covid-19 survivors complain of symptoms months after the acute illness phase, being fatigue and reduced tolerance to physical effort the most frequently reported symptom. The strongest association for these symptoms is with the female gender, while disease severity seems less relevant. Respiratory symptoms are associated with a decline in respiratory function and, conversely, seem to be more frequent in those who experienced a more severe acute pneumonia. Current evidence highlighted a persistent motor impairment which is, again, more prevalent among those survivors who experienced a more severe acute phase of the disease. Additionally, the persistence of symptoms is a primary determinant of mental health outcome, with anxiety, depression, sleep disturbances, and post-traumatic stress symptoms being commonly reported in Covid-19 survivors.

CONCLUSIONS

Current literature highlights the importance of a multidisciplinary approach to Coronavirus Disease 19 since the sequelae appear to involve different organs and systems. Given the pandemic outbreak's size, this is a critical public health issue: a better insight on this topic should inform clinical decisions about the modalities of follow-up for Covid-19 survivors.

Short-wave diathermy for spastic equinus foot in chronic stroke patients: a proof-of-concept pilot study

BACKGROUND

Physical modalities may be useful to manage post-stroke spasticity. Shortwave diathermy has been demonstrated to improve extensibility of the myotendinous tissue. Spasticity may alter morphology of the muscle and its elastic properties. Our main aim was to evaluate the effects of shortwave diathermy on spastic equinus foot in stroke patients.

METHODS

Ten chronic stroke patients with spastic equinus foot received 10 shortwave diathermy sessions, 5 days/week for 2 consecutive weeks to the spastic calf muscles. Clinical (modified Ashworth scale and ankle dorsiflexion passive range of motion) and ultrasound (spastic gastrocnemius muscle echo intensity and hardness percentage measured by sonoelastography) evaluation was done before, after treatment, and at two weeks of follow-up.

RESULTS

A significant difference in calf muscle spasticity (P=0.004), ankle passive range of motion (P=0.014), and spastic gastrocnemius muscle hardness percentage (P=0.004) was found after treatment. A significant difference in calf muscle spasticity (P=0.004) was found also at the follow-up evaluation.

CONCLUSIONS

Our preliminary findings support the hypothesis that shortwave diathermy might improve calf muscle tone, ankle passive range of motion, and gastrocnemius muscle elasticity in chronic stroke patients with spastic equinus. This might be due to the deep thermal effects coupled with the rheological direct action of shortwave diathermy on spastic muscles.

Optimization of transdisciplinary management of elderly with femur proximal extremity fracture: A patient-tailored plan from orthopaedics to rehabilitation

Fractures of femur proximal extremity (FFPE) are the most common fragility fractures requiring hospitalization, with a high risk of mortality, low independence in the activities of daily living and severe consequences on health-related quality of life. Timing for surgery has a key role in the management of elderly patients with FFPE as recommended by the Australian and New Zealand guidelines and the National Institute for Health and Care Excellence guidelines. Early surgery (within 48 h from hospital admission) allows significant benefits in terms of lower rates of postoperative complications and risk of death and can provide better functional outcomes. Therefore, time for surgery could be considered as a comorbidity marker. The choice between conservative or surgical approach surprisingly seems to be still not strongly supported by available literature, but it seems that both 30 d and 1 year risk of mortality is higher with the conservative treatment rather than with surgery. In light of these considerations, the optimization of FFPE management care is mandatory to improve functional outcomes and to reduce sanitary costs. Albeit it is widely accepted that transdisciplinary approach to patients suffering from FFPE is mandatory to optimize both short-term and long-term outcomes, the feasibility of a comprehensive approach in clinical practice is still a challenge. In particular, the large variability of figures involved could be considered both a resource and an additional disadvantage taking into account the difficulty to coordinate multidisciplinary approach covering care in all settings. Therefore, the aim of the present article was to summarize current evidence supporting transdisciplinary management of patients with FFPE, highlighting the benefits, feasibility and limitations of this approach.

Real-World Adherence to OnabotulinumtoxinA Treatment for Spasticity: Insights From the ASPIRE Study

OBJECTIVE

To identify baseline characteristics and treatment-related variables that affect adherence to onabotulinumtoxinA treatment from the Adult Spasticity International Registry (ASPIRE) study.

DESIGN

Prospective, observational registry (NCT01930786).

SETTING

International clinical sites.

PARTICIPANTS

Adults with spasticity (N=730).

INTERVENTIONS

OnabotulinumtoxinA at clinician's discretion.

MAIN OUTCOME MEASURES

Clinically meaningful thresholds used for treatment adherent (≥3 treatment sessions during 2-year study) and nonadherent (≤2 sessions). Data analyzed using logistic regression and presented as odds ratios (ORs) with 95% confidence intervals (CIs). Treatment-related variables assessed at sessions 1 and 2 only.

RESULTS

Of the total population, 523 patients (71.6%) were treatment adherent with 5.3±1.6 sessions and 207 (28.4%) were nonadherent with 1.5±0.5 sessions. In the final model (n=626/730), 522 patients (83.4%) were treatment adherent and 104 (16.6%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=1.84; CI, 1.06-3.21; P=.030) and use of orthotics (OR=1.88; CI, 1.15-3.08; P=.012). Baseline characteristics associated with nonadherence: history of diplopia (OR=0.28; CI, 0.09-0.89; P=.031) and use of assistive devices (OR=0.51; CI, 0.29-0.90; P=.021). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.43; CI, 0.26-0.72; P=.001) and clinician dissatisfaction with onabotulinumtoxinA to manage pain (OR=0.18; CI, 0.05-0.69; P=.012). Of the population with stroke (n=411), 288 patients (70.1%) were treatment adherent with 5.3±1.6 sessions and 123 (29.9%) were nonadherent with 1.5±0.5 session. In the final stroke model (n=346/411), 288 patients (83.2%) were treatment adherent and 58 (16.8%) were nonadherent. Baseline characteristics associated with adherence: treated in Europe (OR=2.99; CI, 1.39-6.44; P=.005) and use of orthotics (OR=3.18; CI, 1.57-6.45; P=.001). Treatment-related variables associated with nonadherence: treatment interval ≥15 weeks (OR=0.42; CI, 0.21-0.83; P=.013) and moderate/severe disability on upper limb Disability Assessment Scale pain subscale (OR=0.40; CI, 0.19-0.83; P=.015).

CONCLUSIONS

These ASPIRE analyses demonstrate real-world patient and clinical variables that affect adherence to onabotulinumtoxinA and provide insights to help optimize management strategies to improve patient care.

Mid-term Psychiatric Outcomes of Patients Recovered From COVID-19 From an Italian Cohort of Hospitalized Patients

Background: Although the usual primary clinical manifestation of Coronavirus disease (COVID-19) is respiratory, several non-respiratory symptoms have been described, including neuropsychiatric ones. The aim of this study was to investigate the mid-term mental health outcomes in patients recovered from COVID-19, 3-4 months after discharge from the University Hospital Maggiore della Carità, Novara, Italy. Furthermore, we investigated the possible association of the mid-term mental health consequences of the COVID-19 infection with patients' clinical current status, persistent physical impairment and severity of acute phase of the disease. Methods: Prospective study involving 238 individuals recovered from COVID-19. In the context of a multi-disciplinary approach, patients' assessment included both a clinical interview performed by an experienced psychiatrist, trained in the use of the Mini-International Neuropsychiatric Interview to assess the presence of anxiety and depressive symptoms and self-administered questionnaires: Beck Anxiety Inventory (BAI), Beck Depression Inventory-II (BDI-II), Resilience Scale for Adults (RSA), Impact of Event Scale (IES). Results: At the psychiatric assessment 32.9 and 29.5% of participants showed anxiety and depressive symptoms, respectively. Changes in appetite and sleep patterns emerged for 15.6 and 31.2% of patients. According to the self-administered questionnaires, 7.1% of participants had moderate-severe anxiety levels (BAI), while 10.5% had mild to severe depression (BDI-II). Twenty-six (11%) participants were referred to further psychiatric consultation. Psychiatric symptoms showed no correlation with acute COVID-19 severity; in our sample patients with depressive symptoms at the clinical interview, as well as those with mild to severe levels of depression according to BDI-II scores, had lower forced expiratory volume in the 1st second (FEV1) values than those without and greater odds for persistent, poor tolerance for physical efforts. Conclusions: As could be expected, an approach including both a psychiatric interview and the use of self-administered questionnaires is likely to capture the psychiatric outcome of patients recovered from COVID-19 better than questionnaires alone. Anxiety and depressive symptoms at follow-up had no correlation with the severity of COVID acute manifestations, but rather with ongoing and persistent physical symptoms. Further studies and longer follow-up duration will allow a better understanding of the complex relationship between residual physical symptoms, quality of life and psychological health.

Can scoliosis lead to spinal cord ischaemia? Early diagnosis and rehabilitation: A paradigmatic case report and literature review

INTRODUCTION

Scoliosis is frequently associated with pain and radiculopathy, but it is not considered a possible cause of acute spinal cord injury (SCI). Here we present a case report in which scoliosis was apparently linked to spinal cord ischaemia.

CASE PRESENTATION

A 20-year-old woman with conservatively treated severe scoliosis presented with acute spinal cord infarction, which occurred during a spinal flexion while she was tidying up the bed. Other causes of SCI were excluded. Early rehabilitation was started and the patient progressively regained motor and sensory functions, with an AIS reduction from A to C. Bowel and bladder disorders persisted and were autonomously managed with a trans-anal irrigation device and intermittent catheterisation after voluntary micturition.

DISCUSSION

Early detection and management of spinal curvature disorders are essential in preventing long-term complications of scoliosis. Although the aetiology of spinal cord ischaemia in severe scoliosis should be better clarified, this rare case report suggests that scoliosis might be involved in its pathogenesis. Thus, we recommend early diagnosis of spinal curvature disorders and adequate rehabilitative treatment in order to prevent potential subsequent neurological complications.

Differentiation among bio- and augmented- feedback in technologically assisted rehabilitation

Introduction: In rehabilitation practice, the term 'feedback' is often improperly used, with augmented feedback and biofeedback frequently confused, especially when referring to the human-machine interaction during technologically assisted training. The absence of a clear differentiation between these categories represents an unmet need for rehabilitation, emphasized by the advent of new technologies making extensive use of video feedback, exergame, and virtual reality.Area covered: In this review we tried to present scientific knowledge about feedback, biofeedback, augmented feedback and neurofeedback, and related differences in rehabilitation settings, for a more proper use of this terminology. Despite the continuous expansion of the field, few researches clarify the differences among these terms. This scoping review was conducted through the searching of current literature up to May 2020, using following databases: PUBMED, EMBASE and Web of Science. After literature search a classification system, distinguishing feedback, augmented feedback, and biofeedback, was applied.Expert opinion: There is a need for clear definitions of feedback, biofeedback, augmented feedback, and neurofeedback in rehabilitation, especially in the technologically assisted one based on human-machine interaction. In fact, the fast development of new technologies requires to be based on solid concepts and on a common terminology shared among bioengineers and clinicians.

Functional status and oral health in patients with amyotrophic lateral sclerosis: A cross-sectional study

BACKGROUND

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease affecting upper and lower motor neurons. The current practice of caring for patients affected by ALS involves a multidisciplinary team without any indication about oral health care.

OBJECTIVE

We sought to investigate the functional status and oral health in patients with ALS to define a specific multidisciplinary management.

METHODS

In this cross-sectional study, we included patients affected by ALS, evaluating their functional status, using the Revised ALS Functional Rating Scale (ALSFRS-R) and their oral health status through specific parameters, including Brief Oral Health Status Examination (BOHSE), Winkel Tongue Coating Index (WTCI), and Oral Food Debris Index (OFDI).

RESULTS

All 37 patients (mean age: 61.19±11.56 years) showed a poor oral status, independent from the functional status and strictly correlated to the severity of sialorrhea (p = 0.01). OFDI index was negatively correlated with the ALSFRS-R upper limb (p = 0.03). Patients with bulbar onset had significantly lower ability to perform adequate tongue movements in terms of protrusion (p = 0.006) and lateralization (p < 0.001). Significant negative correlations between survival rate and BOHSE (p = 0.03) was found.

CONCLUSIONS

Taken together, our findings showed that a poor oral health status might be correlated to a worse functional status and survival time. Thus, an adequate oral health care and rehabilitation should be considered as crucial in the multidisciplinary management of patients with ALS.

Effects of robot-assisted gait training on postural instability in Parkinson's disease: a systematic review

INTRODUCTION

Postural instability is a cardinal feature of Parkinson's disease, together with rest tremor, rigidity and bradykinesia. It is a highly disabling symptom that becomes increasingly common with disease progression and represents a major source of reduced quality of life in patients with Parkinson's disease. Rehabilitation aims to enable patients with Parkinson's disease to maintain their maximum level of mobility, activity and independence. To date, a wide range of rehabilitation approaches has been employed to treat postural instability in Parkinson's disease, including robotic training. Our main aim was to conduct a systematic review of current literature about the effects of robot-assisted gait training on postural instability in patients with Parkinson's disease.

EVIDENCE ACQUISITION

A systematic search using the following MeSH terms "Parkinson disease," "postural balance," "robotics," "rehabilitation" AND string "robotics [mh]" OR "robot-assisted" OR "electromechanical" AND "rehabilitation [mh]" OR "training" AND "postural balance [mh]" was conducted on PubMed, Cochrane Library and Pedro electronic databases. Full text articles in English published up to December 2020 were included. Data about patient characteristics, robotic devices, treatment procedures and outcome measures were considered. Every included article got checked for quality. Level of evidence was defined for all studies.

EVIDENCE SYNTHESIS

Three authors independently extracted and verified data. In total, 18 articles (2 systematic reviews, 9 randomized controlled trials, 4 uncontrolled studies and 3 case series/case reports) were included. Both end-effector and exoskeleton devices were investigated as to robot-assisted gait training modalities. No clear relationship between treatment parameters and clinical conditions was observed. We found a high level of evidence about the effects of robot-assisted gait training on balance and freezing of gait in patients with Parkinson's disease.

CONCLUSIONS

This systematic review provides to the reader a complete overview of current literature and levels of evidence about the effects of robot-assisted gait training on postural instability issues (static and dynamic balance, freezing of gait, falls, confidence in activities of daily living and gait parameters related to balance skills) in patients with Parkinson's disease.

BoNT-A for Post-Stroke Spasticity: Guidance on Unmet Clinical Needs from a Delphi Panel Approach

There is extensive literature supporting the efficacy of botulinum toxin (BoNT-A) for the treatment of post-stroke spasticity, however, there remain gaps in the routine management of patients with post-stroke spasticity. A panel of 21 Italian experts was selected to participate in this web-based survey Delphi process to provide guidance that can support clinicians in the decision-making process. There was a broad consensus among physicians that BoNT-A intervention should be administered as soon as the spasticity interferes with the patients' clinical condition. Patients monitoring is needed over time, a follow-up of 4-6 weeks is considered necessary. Furthermore, physicians agreed that treatment should be offered irrespective of the duration of the spasticity. The Delphi consensus also stressed the importance of patient-centered goals in order to satisfy the clinical needs of the patient regardless of time of onset or duration of spasticity. The findings arising from this Delphi process provide insights into the unmet needs in managing post-stroke spasticity from the clinician's perspective and provides guidance for physicians for the utilization of BoNT-A for the treatment of post-stroke spasticity in daily practice.

Transcranial Direct Current Stimulation Combined with Botulinum Neurotoxin Type A Injections for Treatment of Upper Limb Intention Tremor in Multiple Sclerosis: A Case Report

Upper limb intention tremor is a common cause of disability in multiple sclerosis (MS). Transcranial direct current stimulation (tDCS) is an emerging form of brain stimulation used to improve sensorimotor impairments in many neurological disorders. Here, we describe a combined therapeutic approach with botulinum neurotoxin type A (BoNT-A) and tDCS for the treatment of upper limb tremor in a patient with MS. We administered a cathodal tDCS 15 days after the injections of BoNT-A. Both post-injection and post-stimulation evaluation revealed a considerable improvement of the tremor. This approach positively affected the patient's activities of daily living. Our case report shows a safe and beneficial effect of tDCS in the treatment of action tremor in MS especially as a possible adjunctive synergic treatment with BoNT-A injections.

Midterm functional sequelae and implications in rehabilitation after COVID-19: a cross-sectional study

BACKGROUND

COVID-19 has been mainly investigated concerning the acute and subacute phase implications and management. Meanwhile, few studies focused on the midterm sequelae, which still remain largely unknown.

AIM

To assess the physical performance of COVID-19 survivors at 3 to 6 months from Hospital discharge.

DESIGN

A cross-sectional study focused on mid-term functional outcomes evaluation in COVID-19 survivors.

SETTING

Outpatients who had been previously hospitalized due to COVID-19 from March to May 2020 at the University Hospital of Novara, Italy.

POPULATION

We enrolled 204 patients, of which 60% were men, with the mean age of 57.9 years.

METHODS

Patients firstly underwent the short physical performance battery test (SPPB), which is composed of a series of physical tests assessing the lower limb function and the functional status of the subjects. Subsequently, based on SPPB results, patients' cardiorespiratory fitness performance was further investigated. Patients with normal SPPB score (SPPB>10) underwent the 2-minute walking test (2MWT) whereas, in order to safely test the cardiorespiratory function, in patients with abnormal SPPB score (SPPB≤10) the 1-minute sit-to-stand test (1MSTST) was performed. It should be noted that the 1MSTST can be safely performed even by subjects with compromised walking ability.

RESULTS

Overall, 66 patients (32% of our sample) showed an impaired physical performance at 3 to 6 months after hospital discharge. In particular, 29 patients presented an SPPB score ≤10, and the 1MSTST confirmed this status in the whole group (100%) compared to the reference values for age and sex. Besides, among patients with a normal SPPB score, 37 showed a lower sex- and age-matched 2MWT score. Finally, a significant association between Intensive Care Unit hospitalization or mechanical ventilation and physical impairment was observed together with a significant association between the walking ability (measured with SPPB and 2MWT) and the number of comorbidities.

CONCLUSIONS

A residual physical and functional impairment was observed in COVID-19 survivors at mid-term evaluation after hospitalization.

CLINICAL REHABILITATION IMPACT

Considering the current COVID-19 epidemiology, we might expect a tremendous burden of disability in the next future. Thus, an appropriate clinical rehabilitation pathway must be implemented.

Respiratory and Psychophysical Sequelae Among Patients With COVID-19 Four Months After Hospital Discharge

IMPORTANCE

Although plenty of data exist regarding clinical manifestations, course, case fatality rate, and risk factors associated with mortality in severe coronavirus disease 2019 (COVID-19), long-term respiratory and functional sequelae in survivors of COVID-19 are unknown.

OBJECTIVE

To evaluate the prevalence of lung function anomalies, exercise function impairment, and psychological sequelae among patients hospitalized for COVID-19, 4 months after discharge.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study at an academic hospital in Northern Italy was conducted among a consecutive series of patients aged 18 years and older (or their caregivers) who had received a confirmed diagnosis of severe acute respiratory coronavirus 2 (SARS-CoV-2) infection severe enough to require hospital admission from March 1 to June 29, 2020. SARS-CoV-2 infection was confirmed via reverse transcription-polymerase chain reaction testing, bronchial swab, serological testing, or suggestive computed tomography results.

EXPOSURE

Severe COVID-19 requiring hospitalization.

MAIN OUTCOMES AND MEASURES

The primary outcome of the study was to describe the proportion of patients with a diffusing lung capacity for carbon monoxide (Dlco) less than 80% of expected value. Secondary outcomes included proportion of patients with severe lung function impairment (defined as Dlco <60% expected value); proportion of patients with posttraumatic stress symptoms (measured using the Impact of Event Scale-Revised total score); proportion of patients with functional impairment (assessed using the Short Physical Performance Battery [SPPB] score and 2-minute walking test); and identification of factors associated with Dlco reduction and psychological or functional sequelae.

RESULTS

Among 767 patients hospitalized for severe COVID-19, 494 (64.4%) refused to participate, and 35 (4.6%) died during follow-up. A total of 238 patients (31.0%) (median [interquartile range] age, 61 [50-71] years; 142 [59.7%] men; median [interquartile range] comorbidities, 2 [1-3]) consented to participate to the study. Of these, 219 patients were able to complete both pulmonary function tests and Dlco measurement. Dlco was reduced to less than 80% of the estimated value in 113 patients (51.6%) and less than 60% in 34 patients (15.5%). The SPPB score was suggested limited mobility (score <11) in 53 patients (22.3%). Patients with SPPB scores within reference range underwent a 2-minute walk test, which was outside reference ranges of expected performance for age and sex in 75 patients (40.5%); thus, a total of 128 patients (53.8%) had functional impairment. Posttraumatic stress symptoms were reported in a total of 41 patients (17.2%).

CONCLUSIONS AND RELEVANCE

These findings suggest that at 4 months after discharge, respiratory, physical, and psychological sequelae were common among patients who had been hospitalized for COVID-19.

Discontinuation of botulinum neurotoxin type-A treatment during COVID-19 pandemic: an Italian survey in post stroke and traumatic brain injury patients living with spasticity

BACKGROUND

The COVID-19 pandemic has affected health-care systems worldwide, including the outpatient spasticity care with botulinum neurotoxin toxin type A (BoNT-A).

AIM

The aim of this study was to investigate the impact of discontinuation of BoNT-A treatment on patients living with spasticity during the COVID-19 quarantine.

DESIGN

A multicentric cross-sectional study.

SETTING

Outpatients setting.

POPULATION

Patients with spasticity after stroke and traumatic brain injury treated with BoNT-A.

METHODS

A phone-based survey was conducted from March to May, 2020. Based on the International Classification of Functioning, Disability and Health (ICF), an ad hoc questionnaire CORTOX (CORonavirus TOXin survey) was developed to investigate patients' experiences following the discontinuation of their usual treatment for spasticity due to the lockdown and its implication on their health perception. It assessed patients' condition and explored different ICF domains related to spasticity: unpleasant sensations, mobility, self-care, facilitators and psychosocial factors. The sum of those represented the CORTOX score (Max 142). The questionnaire also collected data about the impact of COVID-19 on patients' wellbeing (mood, sleep, relationships, community life, motivation).

RESULTS

A total of 151 participants completed the survey. Most participants (72.2%) experienced a worsening in perceived spasticity, 53% got worse in independence and 70.9% had a negative impact on quality of life. The mean CORTOX score was 52.85±27.25, reflecting a perceived worsening in all ICF domains investigated. Moderate to strong correlations were found between different sub-scores of the questionnaire and severity of spasticity (P<0.001). COVID-19 psychosocial related factors were associated with loss of independence (P<0.05) but only mood was associated with worsening of spasticity (P<0.001). The lack of rehabilitation therapy was significantly associated with the worsening of independence but not with the worsening of spasticity. Finally, respondents reported that BoNT-A was useful to their condition and should not be discontinued.

CONCLUSIONS

The discontinuation of BoNT-A treatment was associated with worsening of activities and participation and perceived spasticity. COVID-19 related problems and rehabilitation showed an association with loss of independence.

CLINICAL REHABILITATION IMPACT

This study will provide useful information in the field of spasticity management using a patient's centred approach, with consistent quantitative and qualitative information.

Long-term effects of intra-articular oxygen-ozone therapy versus hyaluronic acid in older people affected by knee osteoarthritis: A randomized single-blind extension study

BACKGROUND

There is little evidence on intra-articular (IA) treatment in knee osteoarthritis (KOA) and there is a lack of long-term follow-up studies.

OBJECTIVE

To assess the long-term effectiveness and safety of IA oxygen-ozone (O2O3) and hyaluronic acid (HA) in terms of functioning in KOA patients over a 31-week period.

METHODS

Patients aged ⩾ 60 years with KOA were randomly allocated to receive 4 IA knee injections (1/week) of O2O3 or HA (T0-T3) and a follow-up visit 4 weeks after the fourth injection (T4). In this extension study we assessed VAS and safety in patients with Visual Analogue Scale (VAS) ⩾ 4 at the at 6-month follow-up visit (T5), undergoing a second treatment cycle (T5-T8) and 1-month follow-up visit (T9).

RESULTS

Forty-two patients (aged 70.5 ± 5.8 years) were randomly allocated to O2O3 (n= 22) or HA group (n= 20). Twenty-three underwent another IA cycle: 12 (54.6%) in the O2O3 group and 11 (55.0%) in the HA group. Both groups showed significant reduction in VAS (p< 0.013) compared to baseline during both cycles. At follow-up visits (T4 and T9), VAS was significantly lower in the HA group (p< 0.013). There were no differences in adverse events occurrence between groups.

CONCLUSIONS

IA O2O3 might be comparable to HA in terms of effectiveness and safety in reducing pain in KOA patients, although at both follow-up visits (T4 and T9) VAS was significantly lower in the HA group.

Myostatin as a potential biomarker to monitor sarcopenia in hip fracture patients undergoing a multidisciplinary rehabilitation and nutritional treatment: a preliminary study

Hip fractures are the most common osteoporotic fractures related to disability in older adults, requiring surgery and a subsequent rehabilitation treatment. Sarcopenia is currently considered as a predictive of worse outcome in hip fracture patients and myostatin has been recently proposed a potential biomarker of this condition. Twenty hip fracture patients after total hip replacement (mean aged 75.9 ± 2.4 years) were randomly divided into two groups of ten subjects (groups A and B). Both groups performed a rehabilitation program (5 sessions of 40 min/week for 2 weeks, followed by home-based exercise protocol). Group A received also 2-month amino acid supplementation. Serum myostatin levels significantly decreased after 2 months in both group A (p = 0.01) and group B (p = 0.03) in sarcopenic patients only in group A (p = 0.04). These results suggest that myostatin might be considered a promising biomarker of sarcopenia in hip fracture older adults' patients undergoing rehabilitation and amino acid supplementation.

AbobotulinumtoxinA and rehabilitation vs rehabilitation alone in post-stroke spasticity: A cost-utility analysis

OBJECTIVE

To investigate costs and quality-adjusted life years of rehabilitation combined with abobotulinumtoxinA (aboBoNT-A) (rehab/aboBoNT-A) vs rehabilitation alone (rehab) in post-stroke spasticity in Italy.

DESIGN

Based on both Italian National Health Service and societal perspectives, a 2-year cost-utility analysis model was performed. Subject/patients: The cost-utility analysis model considered hypothetical patients.

METHODS

The cost-utility analysis model was populated with data concerning demographics, disease severity, healthcare and non-healthcare resource consumption. Data were collected via a questionnaire administered to 3 highly experienced Italian physiatrists (864 out of 930 post-stroke spasticity patients on rehab/aboBoNT-A in total). Costs are expressed in Euro (€) based on the year 2018.

RESULTS

The cost to society (rounded to the nearest whole €) was €22,959 (rehab/aboBoNT-A) vs €11,866 (rehab). Italian National Health Service-funded cost was €7,593 (rehab/aboBoNT-A) vs €1,793 (rehab). Over a period of 2 years rehab/aboBoNT-A outperforms rehab in terms of quality-adjusted life years gained (1.620 vs 1.150). The incremental cost-utility ratio was €12,341 (Italian National Health Service viewpoint) and €23,601 (societal viewpoint). Sensitivity analyses confirmed the robustness of the baseline results.

CONCLUSION

Despite some limitations, the higher number of quality-adjusted life years gained vs rehab and the high probability of reaching a cost-utility ratio lower than the Italian informal acceptability range (€25,000-40,000) make rehab/aboBoNT-A a cost-effective healthcare programme for treating patients with post-stroke spasticity in Italy.

Spinal Cord Injury as a Model of Bone-Muscle Interactions: Therapeutic Implications From in vitro and in vivo Studies

Spinal cord injuries (SCIs) represent a variety of conditions related to the damage of the spinal cord with consequent musculoskeletal repercussions. The bone and muscle tissues share several catabolic pathways that lead to variable degrees of disability in SCI patients. In this review article, we provide a comprehensive characterization of the available treatment options targeting the skeleton and the bone in the setting of SCI. Among the pharmacological intervention, bisphosphonates, anti-sclerostin monoclonal antibodies, hydrogen sulfide, parathyroid hormone, and RANKL pathway inhibitors represent valuable options for treating bone alterations. Loss phenomena at the level of the muscle can be counteracted with testosterone, anabolic-androgenic steroids, and selective androgen receptor modulators. Exercise and physical therapy are valuable strategies to increase bone and muscle mass. Nutritional interventions could enhance SCI treatment, particularly in the setting of synergistic and multidisciplinary interventions, but there are no specific guidelines available to date. The development of multidisciplinary recommendations is required for a proper clinical management of SCI patients.

Botulinum Toxin Type A for the Treatment of Lower Limb Spasticity after Stroke

Post-stroke lower limb spasticity impairs balance and gait leading to reduced walking speed, often increasing wheelchair use and caregiver burden. Several studies have shown that appropriate treatments for lower limb spasticity after stroke include injections of botulinum toxin type A (BoNT-A), phenol or alcohol, surgical correction and a rehabilitation program. In the present article, we review the safety and effectiveness of BoNT-A for the treatment of lower limb spasticity after stroke, with a focus on higher doses of BoNT-A. The cumulative body of evidence coming from the randomized clinical trials and open-label studies selected in the article suggest BoNT-A to be safe and efficacious in reducing lower limb spasticity after stroke. Studies of high doses of BoNT-A also showed a greater reduction of severe post-stroke spasticity. In stroke survivors with spasticity of the ankle plantar-flexor muscles, a combined approach between surgery and BoNT-A can be indicated. However, controversy remains about improvement in motor function relative to post-stroke spasticity reduction after BoNT-A treatment.

Power Doppler Ultrasound Findings before and after Focused Extracorporeal Shock Wave Therapy for Achilles Tendinopathy: A Pilot Study on Pain Reduction and Neovascularization Effect

Extracorporeal shock wave therapy (ESWT) has been found to have a positive effect in the treatment of pain in Achilles tendinopathy, although the exact mechanism is not yet completely understood. Among the mechanisms suggested to underlie ESWT effects are direct stimulation of healing, neovascularization and direct suppressive effects on nociceptors and hyperstimulation, which would block the gate-control system. The neovascularization observed in flogistic tissue is associated with stimulated nerve fibers around tendons and induces a painful condition. The objectives of the present study were to evaluate the effect of ESWT on pain and function in patients with non-insertional Achilles tendinopathy (NIAT) and to assess the neovascularization phenomenon using power Doppler ultrasound (PDU). Twelve patients with NIAT underwent five sessions of focused ESWT over 5 wk. Outcome measures were the visual analogue scale, the Victorian Institute of Sport Assessment-Achilles questionnaire and active dorsiflexion and plantar flexion ankle articular range of motion. Moreover, the patients' clinical impressions of treatment results after ESWT were investigated using the Roles and Maudsley score. Patients were assessed at baseline and 1 and 3 mo after treatment. They had a significant reduction in pain with improvement of arthrokinematic motion and functionality and a positive clinical impression of treatment outcome (50% of patients considered their clinical picture as good/excellent after 3 mo). However, the pulse Doppler ultrasound exam did not reveal neovascularization in 91.7% of the patients 1 and 2 mo after focused ESWT, and in some patients there was a reduction in blood vessels related to flogistic processes. The present observational study confirmed the efficacy of ESWT in pain reduction in NIAT, with a higher degree of patient satisfaction, although doubt persists over the neovascularization effect on the Achilles tendons treated.

Management of spasticity with onabotulinumtoxinA: practical guidance based on the italian real-life post-stroke spasticity survey

The present paper provides practical guidance on the management of adult spasticity with OnabotulinumtoxinA. Advisory Board members reviewed the available evidence and discussed their personal experiences in order to address the unmet needs in the management of spasticity with botulinum toxin type A identified by the recent Italian Real-Life Post-Stroke Spasticity Survey. Stroke patients should be referred to spasticity services that have adequate facilities and multidisciplinary teams with the necessary training, competence and expertise. The current literature shows a strong correlation between the development of post-stroke spasticity and the degree of central sensorimotor system destruction/disorganization. Use of tools such as the Poststroke Checklist may help clinicians in the long-term follow-up of stroke patients. The maximum dose of onabotulinumtoxinA - according to the current literature this ranges from 300U to 400U for upper limb and from 500U to 600U for lower limb aggregate postures - should be re-considered. In addition, there is a need for future consensus (also based on pharmacoeconomic considerations) on consistent clinical care models for the management of patients with post-stroke spasticity.

Low back pain related to a sacral insufficiency fracture: role of paravertebral oxygen-ozone therapy in a paradigmatic case of nociplastic pain

We describe the case of a 68-year-old woman with an acute episode of severe low back pain (LBP) resistant to opioids, who had experienced a sacral insufficiency fracture (SIF) two years earlier. At clinical examination, patient reported constant, dull, non-localizable pain at lumbar and sacral level, exacerbated by paravertebral palpation, particularly at L4-L5 and the sacroiliac joint, with a concomitant and remittent neuropathic component, difficult to localize at lumbar and sacral level. The latest magnetic resonance imaging study revealed disc herniations at L3-L4, L4-L5, and L5-S1 levels. The patient was treated with intramuscularparavertebral injections of oxygen-ozone (O2O3) mixture for 4 weeks (once a week), using a O3 concentration of 20 mcg/mL (5 mL in L4-L5 zone and 5 mL in L5-S1 zone, bilaterally). At 1 week after the first injection, the pain (assessed by Numerical Pain Rating Scale and Brief Pain Inventory) was considerably reduced and the patient's health-related quality of life (assessed by Short Form 12-Item Health Survey and European Quality of Life Index) had improved; these findings were confirmed at follow-up 1 month after the last injection. This paradigmatic case of nociplastic pain successfully treated by paravertebral O2O3 therapy might be a starting point for further studies on the effects of this treatment in terms of decreasing pain and improving HRQoL in patients affected by opioid-resistant LBP.

Adjuvant treatments associated with botulinum toxin injection for managing spasticity: An overview of the literature

BACKGROUND AND OBJECTIVE

A wide range of adjunct therapies after botulinum toxin administration have been proposed. The aim of the present paper is to provide an overview of major writings dealing with adjuvant (non-pharmacological) treatments associated with botulinum toxin for managing spasticity in order to provide some up-to-date information about the usefulness of the most commonly used procedures.

METHODS

The literature in PubMed was searched with the MeSH terms botulinum toxins, muscle spasticity, physical therapy modalities, and rehabilitation. The results were limited to studies focusing on adjuvant treatments associated with botulinum toxin for managing spasticity. We excluded papers on the use of non-drug treatments for spasticity not associated with botulinum toxin serotype A (BoNT-A) injection. Relevant literature known to the authors along with this complementary search represented the basis for this overview of the literature.

RESULTS

Adhesive taping and casting effectively improved the botulinum toxin effect in patients with upper- and lower-limb spasticity. There is level 1 evidence that casting is better than taping for outcomes including spasticity, range of motion and gait. However, consensus about their most appropriate timing, duration, target and material is lacking. In terms of physical modalities combined with botulinum toxin injection, we found level 1 evidence that extracorporeal shock wave therapy is better than electrical stimulation for some post-injection outcomes including spasticity and pain. Furthermore, electrical stimulation of injected muscles might be useful to boost the toxin effect. However, the best stimulation protocol has not been defined. In addition, we found level 2b evidence that whole-body vibration therapy might reduce spasticity with cerebral palsy.

CONCLUSION

Future research in this field should focus on investigating the most appropriate post-injection treatment protocol for each goal to achieve.

Recovery from vegetative state of patients with a severe brain injury: a 4-year real-practice prospective cohort study

Patients who have suffered severe traumatic or nontraumatic brain injuries can show a progressive recovery, transitioning through a range of clinical conditions. They may progress from coma to a vegetative state (VS) and/or a minimally conscious state (MCS). A longer duration of the VS is known to be related to a lower probability of emergence from it; furthermore, the literature seems to lack evidence of late improvements in these patients. This real-practice prospective cohort study was conducted in inpatients in a VS following a severe brain injury, consecutively admitted to a vegetative state unit (VSU). The aim of the study was to assess their recovery in order to identify variables that might increase the probability of a VS patient transitioning to MCS. Rehabilitation treatment included passive joint mobilisation and helping/placing patients into an upright sitting position on a tilt table. All the patients underwent a specific assessment protocol every month to identify any emergence, however late, from the VS. Over a 4-year period, 194 patients suffering sequelae of a severe brain injury, consecutively seen, had an initial Glasgow Coma Scale score ≤ 8. Of these, 63 (32.5%) were in a VS, 84 (43.3%) in a MCS, and 47 (24.2%) in a coma; of the 63 patients admitted in a VS, 49 (57.1% males and 42.9% females, mean age 25.34 ± 19.12 years) were transferred to a specialist VSU and put on a slow-to-recover brain injury programme. Ten of these 49 patients were still in a VS after 36 months; of these 10, 3 recovered consciousness, transitioning to a MCS, 2 died, and 5 remained in a VS during the last 12 months of the observation. Univariate analysis identified male sex, youth, a shorter time from onset of the VS, diffuse brain injury, and the presence of status epilepticus as variables increasing the likelihood of transition to a MCS. Long-term monitoring of patients with chronic disorders of consciousness should be adequately implemented in order to optimise their access to rehabilitation services.

The Italian real-life post-stroke spasticity survey: unmet needs in the management of spasticity with botulinum toxin type A

The present national survey seeking to identify unmet needs in the management of spasticity with botulinum toxin type A focused on the use of OnabotulinumoxinA, since this is the brand with the widest range of licensed indications in Italy. Physicians from twenty-four Italian neurorehabilitation units compiled a questionnaire about "real-life" post-stroke spasticity management. OnabotulinumtoxinA was reported to be used in the following average doses: upper limb 316.7 ± 79.1 units; lower limb 327.8 ± 152.3; upper and lower limb 543.7 ± 123.7 units. Of the physicians surveyed, 37.5% felt that increasing the frequency of OnabotulinumtoxinA injection would improve its efficacy; 70.8% use electrical stimulation/electromyography guidance (one fourth of injections with no instrumental guidance). Instrumental evaluation was used by 41.7% of the physicians. The participants expressed the view that early identification of post-stroke spasticity would be facilitated by the availability of a post-stroke checklist, and that this should be used by physiotherapists (91.7%), physiatrists (58.3%), family doctors (50%), stroke unit physicians (25%), patients and caregivers (79.2%). According to our findings, the management of poststroke spasticity has several unmet needs that, were they addressed, might improve these patients' clinical outcomes and quality of life. These needs concern patient follow-up, where a clearly defined pathway is lacking; furthermore, there is a need to use maximum doses per treatment and to ensure early intervention on post-stroke spasticity.