Robotic versus Conventional Overground Gait Training in Subacute Stroke Survivors: A Multicenter Controlled Clinical Trial

BACKGROUND

Although stroke survivors can benefit from robotic gait rehabilitation, stationary robot-assisted gait training needs further investigation. In this paper, we investigated the efficacy of this approach (with an exoskeleton or an end-effector robot) in comparison to the conventional overground gait training in subacute stroke survivors.

METHODS

In a multicenter controlled clinical trial, 89 subacute stroke survivors conducted twenty sessions of robot-assisted gait training (Robotic Group) or overground gait training (Control Group) in addition to the standard daily therapy. The robotic training was performed with an exoskeleton (RobotEXO-group) or an end-effector (RobotEND-group). Clinical outcomes were assessed before (T0) and after (T1) the treatment. The walking speed during the 10-Meter Walk Test (10 MWT) was the primary outcome of this study, and secondary outcomes were the 6-Minute Walk Test (6 MWT), Timed Up and Go test (TUG), and the modified Barthel Index (mBI).

RESULTS

The main characteristics assessed in the Robotic and Control groups did not differ at baseline. A significant benefit was detected from the 10 MWT in the Robotic Group at the end of the study period (primary endpoint). A benefit was also observed from the following parameters: 6 MWT, TUG, and mBI. Moreover, patients belonging to the Robot Group outperformed the Control Group in gait speed, endurance, balance, and ADL. The RobotEND-group improved their walking speed more than the RobotEXO-group.

CONCLUSION

The stationary robot-assisted training improved walking ability better than the conventional training in subacute stroke survivors. These results suggest that people with subacute stroke may benefit from Robot-Assisted training in potentiating gait speed and endurance. Our results also support that end-effector robots would be superior to exoskeleton robots for improving gait speed enhancement.

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of robot-assisted arm therapy in stroke rehabilitation: An overview of systematic reviews

BACKGROUND

Robot-assisted arm therapy (RAT) has been used mainly in stroke rehabilitation in the last 20 years with rising expectations and growing evidence summarized in systematic reviews (SRs).

OBJECTIVE

The aim of this study is to provide an overview of SRs about the effectiveness, within the ICF domains, and safety of RAT in the rehabilitation of adult with stroke compared to other treatments.

METHODS

The search strategy was conducted using search strings adapted explicitly for each database. A screening base on title and abstract was realized to find all the potentially relevant studies. The methodological quality of the included SRs was assessed using AMSTAR-2. A pre-determined standardized form was used to realize the data extraction.

RESULTS

18 SRs were included in this overview. Generally, positive effects from the RAT were found for motor function and muscle strength, whereas there is no agreement for muscle tone effects. No effect was found for pain, and only a SR reported the positive impact of RAT in daily living activity.

CONCLUSION

RAT can be considered a valuable option to increase motor function and muscle strength after stroke. However, the poor quality of most of the included SRs could limit the certainty around the results.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of robotic upper limb treatment after stroke on cognitive patterns: A systematic review

BACKGROUND

Robotic therapy (RT) has been internationally recognized for the motor rehabilitation of the upper limb. Although it seems that RT can stimulate and promote neuroplasticity, the effectiveness of robotics in restoring cognitive deficits has been considered only in a few recent studies.

OBJECTIVE

To verify whether, in the current state of the literature, cognitive measures are used as inclusion or exclusion criteria and/or outcomes measures in robotic upper limb rehabilitation in stroke patients.

METHODS

The systematic review was conducted according to PRISMA guidelines. Studies eligible were identified through PubMed/MEDLINE and Web of Science from inception to March 2021.

RESULTS

Eighty-one studies were considered in this systematic review. Seventy-three studies have at least a cognitive inclusion or exclusion criteria, while only seven studies assessed cognitive outcomes.

CONCLUSION

Despite the high presence of cognitive instruments used for inclusion/exclusion criteria their heterogeneity did not allow the identification of a guideline for the evaluation of patients in different stroke stages. Therefore, although the heterogeneity and the low percentage of studies that included cognitive outcomes, seemed that the latter were positively influenced by RT in post-stroke rehabilitation. Future larger RCTs are needed to outline which cognitive scales are most suitable and their cut-off, as well as what cognitive outcome measures to use in the various stages of post-stroke rehabilitation.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robot-assisted rehabilitation for children with neurological disabilities: Results of the Italian consensus conference CICERONE

BACKGROUND

The use of robotic technologies in pediatric rehabilitation has seen a large increase, but with a lack of a comprehensive framework about their effectiveness.

OBJECTIVE

An Italian Consensus Conference has been promoted to develop recommendations on these technologies: definitions and classification criteria of devices, indications and limits of their use in neurological diseases, theoretical models, ethical and legal implications. In this paper, we present the results for the pediatric age.

METHODS

A systematic search on Cochrane Library, PEDro and PubMed was performed. Papers published up to March 1st, 2020, in English, were included and analyzed using the methodology of the Centre for Evidence-Based Medicine in Oxford, AMSTAR2 and PEDro scales for systematic reviews and RCT, respectively.

RESULTS

Some positives aspects emerged in the area of gait: an increased number of children reaching the stance, an improvement in walking distance, speed and endurance. Critical aspects include the heterogeneity of the studied cases, measurements and training protocols.

CONCLUSION

Many studies demonstrate the benefits of robotic training in developmental age. However, it is necessary to increase the number of trials to achieve greater homogeneity between protocols and to confirm the effectiveness of pediatric robotic rehabilitation.

Reference theories and future perspectives on robot-assisted rehabilitation in people with neurological conditions: A scoping review and recommendations from the Italian Consensus Conference on Robotics in Neurorehabilitation (CICERONE)

BACKGROUND

Robot-based treatments are developing in neurorehabilitation settings. Recently, the Italian National Health Systems recognized robot-based rehabilitation as a refundable service. Thus, the Italian neurorehabilitation community promoted a national consensus on this topic.

OBJECTIVE

To conceptualize undisclosed perspectives for research and applications of robotics for neurorehabilitation, based on a qualitative synthesis of reference theoretical models.

METHODS

A scoping review was carried out based on a specific question from the consensus Jury. A foreground search strategy was developed on theoretical models (context) of robot-based rehabilitation (exposure), in neurological patients (population). PubMed and EMBASE® databases were searched and studies on theoretical models of motor control, neurobiology of recovery, human-robot interaction and economic sustainability were included, while experimental studies not aimed to investigate theoretical frameworks, or considering prosthetics, were excluded.

RESULTS

Overall, 3699 records were screened and finally 9 papers included according to inclusion and exclusion criteria. According to the population investigated, structured information on theoretical models and indications for future research was summarized in a synoptic table.

CONCLUSION

The main indication from the Italian consensus on robotics in neurorehabilitation is the priority to design research studies aimed to investigate the role of robotic and electromechanical devices in promoting neuroplasticity.

Upper Limb Robotic Rehabilitation for Patients with Cervical Spinal Cord Injury: A Comprehensive Review

The upper extremities limitation represents one of the essential functional impairments in patients with cervical spinal cord injury. Electromechanics assisted devices and robots are increasingly used in neurorehabilitation to help functional improvement in patients with neurological diseases. This review aimed to systematically report the evidence-based, state-of-art on clinical applications and robotic-assisted arm training (RAT) in motor and functional recovery in subjects affected by cervical spinal cord injury. The present study has been carried out within the framework of the Italian Consensus Conference on “Rehabilitation assisted by robotic and electromechanical devices for persons with disability of neurological origin” (CICERONE). PubMed/MEDLINE, Cochrane Library, and Physiotherapy Evidence Database (PEDro) databases were systematically searched from inception to September 2021. The 10-item PEDro scale assessed the study quality for the RCT and the AMSTAR-2 for the systematic review. Two different authors rated the studies included in this review. If consensus was not achieved after discussion, a third reviewer was interrogated. The five-item Oxford CEBM scale was used to rate the level of evidence. A total of 11 studies were included. The selected studies were: two systematic reviews, two RCTs, one parallel-group controlled trial, one longitudinal intervention study and five case series. One RCT was scored as a high-quality study, while the systematic review was of low quality. RAT was reported as feasible and safe. Initial positive effects of RAT were found for arm function and quality of movement in addition to conventional therapy. The high clinical heterogeneity of treatment programs and the variety of robot devices could severely affect the generalizability of the study results. Therefore, future studies are warranted to standardize the type of intervention and evaluate the role of robotic-assisted training in subjects affected by cervical spinal cord injury.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Robot-assisted arm therapy in neurological health conditions: rationale and methodology for the evidence synthesis in the CICERONE Italian Consensus Conference

BACKGROUND

Robot-assisted Arm Therapy (RAT) has been increasingly applied in the last years for promoting functional recovery in patients with disabilities related to neurological health conditions. Evidence of a knowledge-to-action gap for applying robot-assisted technologies in the rehabilitation of patients with neurological health conditions and the difficulty to apply and tailor the knowledge to the local contexts solicited the need for a national consensus conference on these interventions.

AIM

This paper aims to explain the methodology used by the working group dedicated to synthesize evidence on the effectiveness of RAT in neurological health conditions in the context of the CICERONE Italian Consensus Conference.

DESIGN

The methodological approach of the working group.

SETTING

All rehabilitation settings.

POPULATION

Patients with disability following a neurological health condition.

METHODS

Following the indications proposed by the Methodological Manual published by the Italian National Institute of Health, a Promoting Committee and a Technical Scientific Committee have been set up. Six working groups (WGs) have been composed to collect evidence on different questions, among which WG2.2 was focused on the effectiveness of RAT in neurological health conditions.

RESULTS

WG2.2 started its work defining the specific research questions. It was decided to adopt the ICF as the reference framework for the reporting of all outcomes. Literature search, data extraction and qualitative assessment, evidence analysis and synthesis have been performed.

CONCLUSIONS

This paper summarizes the methodological approaches used by the WG2.2 of the CICERONE Italian Consensus Conference to define the effectiveness of RAT in the management of patients with neurological health conditions.

CLINICAL REHABILITATION IMPACT

WG2.2 synthesis might help clinicians, researchers, and all rehabilitation stakeholders to address the use of RAT in the Individualized Rehabilitation Plan, to guide the allocation of resources and define clinical protocols and indications for the management of patients with different neurological health conditions.

State of the art and challenges for the classification of studies on electromechanical and robotic devices in neurorehabilitation: a scoping review

INTRODUCTION

The rapid development of electromechanical and robotic devices has profoundly influenced neurorehabilitation. Growth in the scientific and technological aspects thereof is crucial for increasing the number of newly developed devices, and clinicians have welcomed such growth with enthusiasm. Nevertheless, improving the standard for the reporting clinical, technical, and normative aspects of such electromechanical and robotic devices remains an unmet need in neurorehabilitation. Accordingly, this study aimed to analyse the existing literature on electromechanical and robotic devices used in neurorehabilitation, considering the current clinical, technical, and regulatory classification systems.

EVIDENCE ACQUISITION

Within the CICERONE Consensus Conference framework, studies on electromechanical and robotic devices used for upper- and lower-limb rehabilitation in persons with neurological disabilities in adulthood and childhood were reviewed. We have conducted a literature search using the following databases: MEDLINE, Cochrane Library, PeDro, Institute of Electrical and Electronics Engineers, Science Direct, and Google Scholar. Clinical, technical, and regulatory classification systems were applied to collect information on the electromechanical and robotic devices. The study designs and populations were investigated.

EVIDENCE SYNTHESIS

Overall, 316 studies were included in the analysis. More than half (52%) of the studies were randomised controlled trials (RCTs). The population investigated the most suffered from strokes, followed by spinal cord injuries, multiple sclerosis, cerebral palsy, and traumatic brain injuries. In total, 100 devices were described; of these, 19% were certified with the CE mark. Overall, the main type of device was an exoskeleton. However, end-effector devices were primarily used for the upper limbs, whereas exoskeletons were used for the lower limbs (for both children and adults).

CONCLUSIONS

The current literature on robotic neurorehabilitation lacks detailed information regarding the technical characteristics of the devices used. This affects the understanding of the possible mechanisms underlying recovery. Unfortunately, many electromechanical and robotic devices are not provided with CE marks, strongly hindering the research on the clinical outcomes of rehabilitation treatments based on these devices. A more significant effort is needed to improve the description of the robotic devices used in neurorehabilitation in terms of the technical and functional details, along with high-quality RCT studies.

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

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

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.

What is the impact of robotic rehabilitation on balance and gait outcomes in people with multiple sclerosis? A systematic review of randomized control trials

INTRODUCTION

In recent years, robot-assisted gait training (RAGT) has been proposed as therapy for balance and gait dysfunctions in people with multiple sclerosis (PwMS). Through this systematic review, we aimed to discuss the impact of RAGT on balance and gait outcomes. Furthermore, characteristics of the training in terms of robots used, participants characteristics, protocols and combined therapeutic approaches have been described.

EVIDENCE ACQUISITION

As part of the Italian Consensus on robotic rehabilitation "CICERONE" a systematic search was provided in PubMed, the Cochrane Library and PEDro to identify relevant studies published before December 2019. Only randomized control trials (RCT) involving RAGT for PwMS were included. PEDro scale was used to assess the risk of bias and the Oxford Center for Evidence-Based Medicine (OCEBM) was used to assess level of evidence of included studies.

EVIDENCE SYNTHESIS

The search on databases resulted in 336 records and, finally, 12 studies were included. RAGT was provided with Exoskeleton in ten studies (6-40 session, 2-5 per week) and with end-effector in two studies (12 sessions, 2-3 per week) with large variability in terms of participants' disability. All the exoskeletons were combined with bodyweight support treadmill and movement assistance varied from 0% to 100% depending on participants' disability, two studies combined exoskeleton with virtual reality. The end-effector speed ranged between 1.3 and 1.8 km/h, with bodyweight support starting from 50% and progressively reduced. In seven out of twelve studies RAGT was provided in a multimodal rehabilitation program or in combination with standard physical therapy. There is level 2 evidence that RAGT has positive impact in PwMS, reaching the minimally clinically importance difference in Berg Balance Scale, six-minute walking test and gait speed.

CONCLUSIONS

In available RCT, RAGT is mostly provided with exoskeleton devices and improves balance and gait outcomes in a clinically meaningful way. Considering several advantages in terms of safety, motor assistance and intensity of training provided, RAGT should be promoted for PwMS with severe disability in a multimodal rehabilitation context as an opportunity to maximize recovery.

Systematic review of guidelines to identify recommendations for upper limb robotic rehabilitation after stroke

INTRODUCTION

Upper limb motor impairment is one of the most frequent stroke consequences. Robot therapy may represent a valid option for upper limb stroke rehabilitation, but there are still gaps between research evidence and their use in clinical practice. The aim of this study was to determine the quality, scope, and consistency of guidelines clinical practice recommendations for upper limb robotic rehabilitation in stroke populations.

EVIDENCE ACQUISITION

We searched for guideline recommendations on stroke published between January 1st, 2010 and January 1st, 2020. Only the most recent guidelines for writing group were selected. Electronic databases (N.=4), guideline repertories and professional rehabilitation networks (N.=12) were searched. We systematically reviewed and assessed guidelines containing recommendation statements about upper limb robotic rehabilitation for adults with stroke (PROSPERO registration number: CRD42020173386).

EVIDENCE SYNTHESIS

Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument, and textual syntheses were used to appraise and compare recommendations. From 1324 papers that were screened, eight eligible guidelines were identified from six different regions/countries. Half of the included guidelines focused on stroke management, the other half on stroke rehabilitation. Rehabilitation assisted by robotic devices is generally recommended to improve upper limb motor function and strength. The exact characteristics of patients who could benefit from this treatment as well as the correct timing to use it are not known.

CONCLUSIONS

This systematic review has identified many opportunities to modernize and otherwise improve stroke patients' upper limb robotic therapy. Rehabilitation assisted by robot or electromechanical devices for stroke needs to be improved in clinical practice guidelines in particular in terms of applicability.

Occurrence and predictive factors of heterotopic ossification in severe acquired brain injured patients during rehabilitation stay: cross-sectional survey

OBJECTIVES

To report occurrence and identify patient's features and risk factors of heterotopic ossifications in patients with severe acquired brain injury in intensive rehabilitation centres.

DESIGN

Multicentre cross-sectional survey.

SETTING

A total of 48 severe acquired brain injury rehabilitation institutes.

PARTICIPANTS

Traumatic and non-traumatic severe brain-injured patients ( N = 689) in rehabilitation centres on 28 May 2016.

MAIN OUTCOME MEASURE

Occurrence of heterotopic ossifications diagnosed by standard radiological and/or sonographic evaluation on the basis of clinical suspicion.

RESULTS

Heterotopic ossification occurred around one or more joints in 94/689 patients (13.6%) with a significantly higher prevalence in young males. Occurrence did not significantly differ in relation to aetiology (16.3% traumatic, 19.2% anoxic, 11.7% vascular and 11.5% other). Prevalence was significantly higher in patients with diffuse (23.3%) rather than focal brain lesions (12.4%) or unspecified lesions (11.2%; chi-square = 7.81, df = 2, P = 0.020); longer duration of coma ( P = 0.0016) and ventilation support ( P = 0.0145); paroxysmal sympathetic hyperactivity (22.6% versus 11.6%; chi-square = 10.81, df = 1, P = 0.001); and spasticity (22.7% versus 10.1%; chi-square = 18.63, df = 1, P < 0.0001). A longer interval between acute brain injury and admission to rehabilitation centre was significantly associated with higher frequency of heterotopic ossifications.

CONCLUSION

Occurrence of heterotopic ossifications is frequent in patients with severe traumatic and non-traumatic brain-injury in rehabilitation centres. Our study confirms male gender, young age, paroxysmal sympathetic hyperactivity, spasticity, longer duration of coma and ventilation and longer interval between brain injury onset and admission to rehabilitation centre as possible risk factors. Further studies are necessary to investigate the role of early appropriate rehabilitation pathways to reduce occurrence of heterotopic ossifications.

Groin Pain Syndrome Italian Consensus Conference on terminology, clinical evaluation and imaging assessment in groin pain in athlete

The nomenclature and the lack of consensus of clinical evaluation and imaging assessment in groin pain generate significant confusion in this field. The Groin Pain Syndrome Italian Consensus Conference has been organised in order to prepare a consensus document regarding taxonomy, clinical evaluation and imaging assessment for groin pain. A 1-day Consensus Conference was organised on 5 February 2016, in Milan (Italy). 41 Italian experts with different backgrounds participated in the discussion. A consensus document previously drafted was discussed, eventually modified, and finally approved by all members of the Consensus Conference. Unanimous consensus was reached concerning: (1) taxonomy (2) clinical evaluation and (3) imaging assessment. The synthesis of these 3 points is included in this paper. The Groin Pain Syndrome Italian Consensus Conference reached a consensus on three main points concerning the groin pain syndrome assessment, in an attempt to clarify this challenging medical problem.

Early rehabilitation for severe acquired brain injury in intensive care unit: multicenter observational study

BACKGROUND

The increased survival after a severe acquired brain injury (sABI) raise the problem of making most effective the treatments in Intensive Care Unit (ICU)/Neurointensive Care Unit (NICU), also integrating rehabilitation care. Despite previous studies reported that early mobilization in ICU was effective in preventing complications and reducing hospital stay, few studies addressed the rehabilitative management of sABI patients in ICU/NICU.

AIM

To collect clinical and functional data about the early rehabilitative management of sABI patients during ICU/NICU stay.

DESIGN

Prospective, observational, multicenter study.

SETTING

Fourteen facilities supplied by intensive neurorehabilitation units and ICU/NICUs.

POPULATION

Consecutive sABI patients admitted to ICU/NICU.

METHODS

Patients were evaluated at admission and then every 3-5 days. Clinical, functional and rehabilitative data, including Glasgow Coma Scale (GCS), Disability Rating Scale (DRS), The Rancho Los Amigos Levels of Cognitive Functioning Scale (LCF), Early Rehabilitation Barthel Index (ERBI), Glasgow Outcome scale (GOS) and Functional Independence Measure (FIM) were collected.

RESULTS

One hundred and two patients (F/M 44/58) were enrolled. The mean duration of ICU stay was 24.7±13.9 days and the first rehabilitative evaluation occurred after 8.7±8.8 days. Regular postural changes and multijoint mobilization were prescribed in 63.7% and 64.7% cases, respectively. The mean session duration was 38±11.5 minutes. Swallowing evaluation was performed in 14.7% patients, psychological support was provided to 12.7% of patients' caregivers, while 17.6% received a psycho-educational intervention, and 28.4% were involved in interdisciplinary team meetings. The main discharge destinations were Severe Acquired Brain Injury rehabilitation units for 43.7%, intensive neurorehabilitation units for 20.7%.

CONCLUSIONS

Data showed that early rehabilitation was not diffusely performed in sABI subjects in ICU/NICU and rehabilitative interventions were variable; one-third of subjects were not referred to dedicated rehabilitation unit at discharge.

CLINICAL REHABILITATION IMPACT

The study stresses the need to spread and implement a rehabilitative culture also for critical ill patients due to neurological diseases.

How could robotic training and botolinum toxin be combined in chronic post stroke upper limb spasticity? A pilot study

BACKGROUND

Spasticity has a role of primary importance in functional motor recovery of upper limb after a stroke. The widespread intervention is the botulinum toxin neurolysis, however robotic training could have a role as useful addition to this conventional therapy.

AIM

The aim of this study was to verify how the combination of a short robotic training and chemical neurolysis reduces spasticity and improves function in chronic post-stroke patients.

DESIGN

Prospective single blind randomized controlled clinical trial.

SETTING

Post-stroke outpatients.

POPULATION

Fifteen chronic post-stroke outpatients with severe upper limb spastic paresis.

METHODS

Two experimental groups underwent ten sessions of robotic training, alone (Group A) or with Botulinum toxin neurolysis (Group B). Evaluation of motor function with Fugl Meyer Upper Limb Assessment Scale (FMA) and Box & Block Test (B&B), disability with Functional Indipendence Measure (FIM), spasticity with Modified Ashworth Scale (MAS), and the Quality of Life (Euro-Qol) and muscular recruitment pattern with dynamic surface electromyography were carried out before and after the interventions.

RESULTS

Both groups showed improvement in FMA (Group A 8.25 and Group B 5.29). Higher improvement in B&B was detected in the group A (2.62 versus 0,14 in Group B). MAS was improved more in the Group B (-0,86 versus -0,14 in Group A). In both groups, sEMG showed a reduction of co-contractions and an increase of agonist muscles recruitment during the reaching movement and the robotic exercises.

CONCLUSION

The demonstrated improvement in motor function and in muscular activation pattern suggests how a short robotic training could be effective in chronic post-stroke spasticity of upper limb and in less severe spasticity the only robotic treatment could be effective.

CLINICAL REHABILITATION IMPACT

With the limits of small sample, the results showed some equivalence between these two approaches with respect to motor recovery and spasticity reduction suggesting that the cost effectiveness of each treatment may have an important role in this choice.

Lower urinary tract symptoms associated with neurological conditions: Observations on a clinical sample of outpatients neurorehabilitation service

OBJECTIVES

The overall aims of this study were to investigate the lower urinary tract symptoms (LUTS) associated with neurological conditions and their prevalence and impact on a clinical sample of outpatients of a neurorehabilitation service.

MATERIALS AND METHODS

We reviewed the files of 132 patients treated in our neurorehabilitation service from December 2012 to December 2013. Patients were divided into several subgroups based on the neurological diagnosis: Multiple Sclerosis (MS), other demyelinating diseases, Peripheral Neuropathy, neurovascular disorders (ND), neoplastic disease, traumatic brain injury (TBI), Parkinson and Parkinsonism, spinal cord injuries (SCI). Urinary status was based on medical evaluations of history of LUTS, type, degree, onset and duration of symptoms. We tried to analyze prevalence, kind of disorder, timing of presentation (if before or after the neurological onset) and eventual persistence of urological disorders (in the main group and in all subgroups).

RESULTS

At the time of admission to our rehabilitation service, LUTS were observed in 14 out of 132 cases (11%). A high proportion of these outpatients (64.2%) presented bothersome urinary symptoms such as incontinence, frequency and urgency (storage LUTS). The most frequent symptom was urinary urge incontinence (42.8%). This symptom was found to be prevalent in the multiple sclerosis and neurovascular disorders. In 93% the urinary symptoms arose as a result of neurologic conditions and 78.5% did not present a complete recovery of urological symptoms in spite of improved self-reported functional activity limitations. None of these patients performed urological rehabilitation.

CONCLUSIONS

Neurological disorders are a significant issue in rehabilitation services and it can lead to lower tract dysfunction, which causes LUTS. Storage symptoms are more common, especially urge incontinence. Current literature reports that a further optimization of the rehabilitation potential of neurologically ill patients is possible through an implementation of urological basic measures into the neurological treatment routine.

Is CIMT a rehabilitative practice for everyone? Predictive factors and feasibility

BACKGROUND

Constraint Induced Movement Therapy (CIMT) in hemiplegic patient is an efficacious method for upper limb rehabilitation.

AIM

To verify the applicability of CIMT in post stroke inpatients and to verify the predictive value of some clinical and functional independent variables on the outcomes, in order to identify a population of subjects to which this technique can be more effective.

DESIGN

Non-controlled clinical study.

SETTING

Seven Italian, non-experimental, Rehabilitation Departments.

MATERIALS AND METHODS

All post-stroke inpatients (subacute and chronic), consecutively admitted in 7 Rehabilitation Departments, were screened according to our inclusion criteria. The eligible population was assessed according to selected clinical and functional variables at the baseline, and it was evaluated with Wolf Motor Function Test (WMFT-FAS and WMFT-PTT) and Motor Activity Log (MAL-AOU and MAL-QOM), before treatment (T0), after treatment (T1) and at a 3-month follow up (T2). Patients underwent 2 weeks of CIMT from T0.

RESULTS

Of the 600 inpatients screened, 44 were admitted in the CIMT protocol and were evaluated at T0 and T1; just 24 completed the assessment at T2. At the end of treatment NIHSS and Motricity Index (MI) were predictive factors of MAL scores, while Geriatric Depression Scale (GDS), Modified Barthel Inedx (MBI) and MI were predictive factors of WMFT scores. At the follow up NIHSS and GDS remained predictive factors of MAL scores, and MBI was predictive of WMFT FAS score.

CONCLUSION

CIMT efficacy did not result to be related to patient's age, mild cognitive deficit, time since stroke. Depression and pinch ability are the main predictors of motor recovery. Despite the demonstrated efficacy, CIMT feasibility still needs to be demonstrated, considering the low percentage (6.5%) of eligibility among all stroke inpatients.

CLINICAL REHABILITATION IMPACT

CIMT requires high costs and resources; therefore it is valuable to know the predictive factors which help select the eligible patients. It is then useful to recognize the risk factors of developing Learned Non Use after stroke.

The Italian Society of Physical and Rehabilitation Medicine (SIMFER) recommendations for neck pain

The paper represents the Italian Society of Physical " and Rehabilitation Medicine (SIMFER) recommendations to Neck Pain. We searched the principal scientific databases for papers concerning the main approaches to NP, including international guidelines, clinical trials of high methodological value and systematic reviews without any temporal limits. The recommendations were graded on the basis of the National Plan for Guidelines of the Italian Istituto Superiore di Sanità, which includes the level of evidence and strength of the recommendation. The principal sections of the recommendations deal with the Evaluation and Therapy for Neck Pain. The first describes the main evidence concerning the evaluation of patients with NP with or without limb involvement and/or headache: medical history, physical examination, neurological examination, laboratory tests, electrodiagnostics, diagnostic imaging and self-administered questionnaires. The second describes the best evidence synthesis concernig the therapy for Neck Pain: education, exercise, medical therapy, manual therapy, traction, physical therapy, acupuncture, orthoses, multimodal treatment, behavioural treatment.

Cardiorespiratory comorbidity: a new challenge for physical and rehabilitation medicine specialist

BACKGROUND

The cardiorespiratory comorbidity can reduce the participation in the rehabilitation project of patients with motor disorders.

AIM

The first aim of the study was to assess the frequency of cardiopulmonary comorbidity in inpatient rehabilitation units in Italy. The second aim was to evaluate the influence of cardiorespiratory comorbidity on some process and outcome indicators.

DESIGN

Data collection with a questionnaire sent to Physical and Rehabilitation Medicine specialists.

SETTING

Inpatient Rehabilitation Units.

POPULATION

Patients admitted to Rehabilitation Units with neurological and orthopedic disability.

METHODS

A questionnaire was sent to 33 Rehabilitation Units in Italy.

OUTCOME

Length of stay in hospital (LOS), percentage of transfer to acute wards, level of satisfaction of the Physicians related to the degree of functional recovery of patients with cardiopulmonary comorbidity. In a subgroup of patients with and without cardiopulmonary comorbidity indicators were also used to retrospectively assess functional recovery during the hospitalization.

RESULTS

Analysis were made on 16 complete responses received. Data of 909 subjects were evaluated. The mean incidence of cardiovascular and respiratory diseases is high: 61.50%. The length of hospitalization (LOS) in patients with cardiac and respiratory comorbidity is significantly longer than in subjects without associated disease (46.55, SD 21.00 days vs. 37.26, SD 18.97; P<0.05). The number of transfers to acute wards is significantly higher in subjects with cardiorespiratory comorbidity (8.62% vs. 2.44%; P<0.05). Eleven out of 16 medical doctors (69%) said they were "quite satisfied" for the degree of functional recovery of patients with comorbidity. A group of patients with neurological disabilities associated with cardiorespiratory disease had significantly lower Functional Independence Measure (FIM) score at admission (55.36, SD 20.62, vs. 73.72, SD 22.15; P<0.05) than these without comorbidity. At discharge the subjects of the two groups assessed, independently from the presence of cardiorespiratory comorbidity, present no statistically significant difference of FIM scale values.

CONCLUSION

The high frequency of cardiorespiratory comorbidity in patients with motor disorders negatively influenced the LOS and percentage of transfer to acute wards but not necessarily the functional results. It is, therefore, necessary to train the medical doctor who specializes in physical and rehabilitation medicine also in the clinical management of complex patients.

CLINICAL REHABILITATION IMPACT

The results of the survey suggest that rehabilitation is useful even in patients with motor disorders and cardiorespiratory comordibity.

Acute medical complications in patients admitted to a stroke unit and safe transfer to rehabilitation

Acute medical complications often prevent patients with stroke from being transferred from stroke units to rehabilitation units, prolonging the occupation of hospital beds and delaying the start of intensive rehabilitation. This study defined incidence, timing, duration and risk factors of these complications during the acute phase of stroke. A retrospective case note review was made of hospital admissions of patients with stroke not associated with other disabling conditions, admitted to a stroke unit over 12 months and requiring rehabilitation for gait impairment. In this cohort, a search was made of hypertension, oxygen de-saturation, fever, and cardiac and pulmonary symptoms requiring medical intervention. Included were 135 patients. Hypertension was the most common complication (16.3%), followed by heart disease (14.8%), oxygen de-saturation (7.4%), fever (6.7%) and pulmonary disease (5.2%). Heart disease was the earliest and shortest complication. Most complications occurred during the first week. Except for hypertension, all complications resolved within 2 weeks.

The constraint induced movement therapy: a systematic review of randomised controlled trials on the adult stroke patients

AIM

The aim of this study was to analyse the evidence of effectiveness on adult stroke patients of the Constraint Induced Movement Therapy (CIMT), an original rehabilitation method that consists in strongly encouraging patients to use the affected arm, mainly immobilising the unaffected arm.

METHODS

We only took into account the randomised controlled trials on CIMT where the experimental treatment was compared with a conventional treatment without any discrepancy of organization or session duration. As we could not measure the statistical significance of differences between treated and control patients, we compared their respective post-treatment percent changes and computed the minimal clinically important difference (MCID), defined as a change of at least 10% of the maximum score of the scale used.

RESULTS

The literature search found 13 randomised controlled trials (RCTs), 4 of which were excluded because they aimed at comparing different intensity of CIMT. The 9 RCTs finally included into the review applied the CIMT in either acute, subacute or chronic stroke patients and according to different modalities. Findings were positive in all studies, but the MCID was reached only in smaller ones, which may have been influenced by patients' characteristics.

CONCLUSION

Although all studies achieved positive results, it is impossible to draw any clear-cut conclusion on the effectiveness of the CIMT. The main limitations are the lack of homogeneity in the outcome measures used, the inadequacy of data provided and the small samples' size. Multicentre studies, using robust outcome measures and considering both motor- and sensory-disabled patients are needed.

The conclusions of the systematic revision with the results from the major clinical and experimental studies

In this issue, we would complete the conclusions of the systematic revision with the results from the major clinical and experimental studies. First of all, we outline that the use of bone mineral density is controversial and opposed of the major studies in the field that show that the bone density is only one of the factors which describe bone resistance, and not the bone quality. In fact, often, a dramatic variation of bone strength is linked to the fact that the newly bone is located in the only in the surfaces where mechanical stress is greatest and this doesn't change completely the density. To study the optimal exercises program we have to remember that the ideal timing in the remodelling unit of the bone was estimated at 4-6 months: therefore any treatment which has the aim of preventing bone loss should last at least 2-3 times this period to ensure that the registered effect on bone density is evaluated in a period of balance. According to Frost, the strength of the bone is determined by 4 factors: the mechanical property characteristic of bony tissue, the amount of micro damage from fatigue, bone mass factors (amount and type of bone in the bone) and the size and shaper of the bone (architectural factors). Moreover, it is very important the role of muscular strength on the bone: the muscles work like a lever in such a manner that to move every kilo of body weight, the muscular force is usually over 2 kg. This explains why strong muscles are usually associated with strong bones. About the specific role of the strain on the bone, from studies of the past 10 years there seems to be more precise and useful information for our queries: new formation of bone took place in rabbits only with dynamic stimuli and not static, and it is very important also the frequency of the stimulus and the speed. Moreover, some authors have shown that the stimuli of ostegoenesis depends on the fluid shear stresses though the lacunar-canalicular network system. So: exercises at high impact which can produce significant deformation of the bone matrix, better carry the fluid through the canalicular network and furthermore the strains applied at high frequency stimulate in a effective manner osteogenesis. Therefore, the mechanical strain necessary to begin osteogenesis decreases with the increase of the frequency of the strain. Rubin and Lanyon have shown that the prolongation of the stimulation with strain the osteogenic response did non increase if the regimen is prolonged more. In fact, Turner demonstrated that the bone presents a phenomenon of desensitisation following a prolonged strain stimulus. He proposed the osteogenic index of exercises like the osteogenic response to exercise which could be increased in a regimen of exercises which foresee also a period of rest between brief sessions of significant strain. So, concerning the effects of exercises, the stimulus produced by the strain must be such that it exceeds a threshold of a minimum effective stimulus, must be applied in a intermittent and dynamic manner, should produce a stimulus which is distributed differently to the norm, should be applied with high speed and few repetitions.

Manual autotraction: preliminary study on the effectiveness of a new device for back pain treatment

AIM

The aim of this study is to assess the efficacy of a new, simple and cheap device of manual autotraction (MAT), in comparison with Natchev's autotraction system.

METHODS

Fifty-four patients, with lumbalgia or sciatalgia for more than 4 months and disc herniation or protrusion at computed tomography (CT) or nuclear magnetic resonance (NRM), have been selected, at random, in a randomized control trial. Patients have been treated by MAT or by Natchev's autotraction. Treatments' efficacy has been assessed through the differences in visual analogic scale (VAS) for pain, and Backill scale for disability, before and after therapy (diffVAS and diffBi). The results of the 2 autotraction's devices have been compared in order to distinguish their differences. The results have been considered significant if p<0.05.

RESULTS

Both treatments proved to be effective (MAT: diffVAS p<0.0001, diffBackill p<0.001; Natchev's group: diffVAS p<0.0001, diffBackill p<0.001). No significant difference of efficacy emerges between the treatments in diffVAS (p=0.199) and diffBi (p=0.906), and a greater efficacy of both in case of pain with nocturnal aggravation (MAT group: diffVAS: p=0.001; Natchev's group: p=0.001).

CONCLUSIONS

The results of this study show an equal efficacy of MAT compared to the known Natchev's system, so it could be equally proposed like a simple conservative treatment in disc protrusion or herniation without surgery indication.

Exercise for preventing and treating osteoporosis in postmenopausal women

BACKGROUND

Osteoporosis is a condition resulting in an increased risk of skeletal fractures due to a reduction in the density of bone tissue. Prevention of osteoporotic-related fractures is dependent on the ability to detect individuals with low bone mass, including those women who are asymptomatic. Treatment of osteoporosis involves the use of either anti-resorptive (e.g. estrogen and bisphosphonate) or bone formation agents (e.g. fluoride and PTH). The value of exercise as an intervention for the prevention of postmenopausal bone loss is a controversial subject.

OBJECTIVES

To examine the effectiveness of exercise therapy at preventing bone loss and fractures in postmenopausal women.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group's specialised register, MEDLINE, EMBASE, Current Contents and the Cochrane Controlled Trials Registry up to January 2000 according to the methods suggested by Dickersin et al and Haynes et al and the Cochrane Handbook. We hand searched reference lists and consulted content experts.

SELECTION CRITERIA

This review was proceeded by a peer reviewed protocol published in the Cochrane Library. Two reviewers independently selected all randomized controlled trials (RCTs) which met our predetermined inclusion criteria.

DATA COLLECTION AND ANALYSIS

The same two reviewers abstracted the data using predetermined forms and assessed trial quality using a validated assessment tool. For dichotomous outcomes (fractures), relative risks were calculated using fixed effects models. For continuous data, weighted mean differences (WMD) of the percentage change from baseline were calculated. Where heterogeneity existed (determined by a chi square test), a random effects model was used.

MAIN RESULTS

Eighteen randomized controlled trials (RCTs) met the inclusion criteria. The trials had a mean methodological quality score of 2.53. Aerobics, weight bearing and resistance exercises were all effective on the BMD of the spine. The WMD for the combined aerobics and weight bearing program on the spine was 1.79 [95%CI (0.58, 3.01)]. The analyzed results showed walking to be effective on both BMD of the spine 1.31[95%CI (-0.03, 2.65) and the hip 0.92[95%CI (0.21, 1.64). Aerobic exercise was effective in increasing BMD of the wrist 1.22[95%CI (0.71, 1.74)].

REVIEWER'S CONCLUSIONS

Aerobics, weight bearing and resistance exercises are all effective in increasing the BMD of the spine in postmenopausal women. Walking is also effective on the hip. The quality of the reporting of the trials in the meta-analysis was low, in particular, in the areas of allocation concealement and blinding.

Clinical trials among worker populations: the value and significance of anamnestic findings and clinical and instrumental tests for diagnosing work-related musculoskeletal disorders of the upper limbs (WMSDs)

The authors discuss the value and significance of symptoms in WMSDs, in view of the fact that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculoskeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.

[Sacralization of the 5th lumbar vertebra and backache: what's the possible relationship?]

Transitional vertebrae is a controversial problem in occupational health and in forensic medicine, in view of its prognostic value and especially because of the implications of law 626/94 which requires a worker assessment for manual handling tasks. The purpose of this review was to assess the relationship between transitional vertebrae and low back pain. Data sources comprised computer-aided search of published studies on Medline and Embase. There were seven studies evaluating the prevalence of the abnormality, the relationship with low back pain and the different aspects of spinal degeneration. Only two studies indicated a positive relationship with low back pain. Four studies reported absence of any prognostic value of this vertebral abnormality. One study examined a twenty year old population: even if it did not show a relationship with a higher incidence of disc degeneration with MRI, we did not include it in our review because of the young age of the samples. It is concluded that present knowledge does not reveal any correlation between transitional vertebrae and low back pain. Further studies are needed to support any conclusion about this important issue.

The affective dimension of low-back pain: its influence on the outcome of back school

OBJECTIVE

Back School is a rehabilitation treatment for back pain that requires patients to understand an educational message and motivate themselves to modify their behavior to prevent relapses. In examining failed cases, the question arose as to whether the failures could be attributed to affective dimensions of pain that could be reducing tolerance to the pain itself and jeopardizing patients' compliance. We studied the role of the affective component of back pain in Back School failures to see whether this component can be used to predict the treatment's negative results and whether it can be conditioned by the treatment itself.

DESIGN

Inception cohort.

SETTING

Forty-two subjects with low back pain were treated with Back School at our rehabilitation department.

MAIN OUTCOME MEASURES

Evaluation was carried out before Back School treatment and after 2 months, through functional clinical examination and Short Form-McGill Pain Questionnaire (affective and sensory pain indexes).

RESULTS

As outcome of the treatment, we considered the modification of spontaneous and evoked pain and the motility of the spine. Unexpectedly, the nonparametric tests did not show a significant correlation between the affective indicators before and after the treatment. As expected, the two dimensions of pain, affective and sensory, are significantly related to each other, both before and after treatment, but this correlation increases after treatment (from r = .50 to r = 88).

CONCLUSIONS

The initial hypothesis was not proven. These results show that high affective scores before Back School do not influence the success of the treatment and that the Back School itself is able to modify both the sensorial and affective pain descriptors.

[Clinical studies in working populations: value and significance of anamnestic findings, clinical tests and instrumental tests for the diagnosis of musculoskeletal disorders of the upper extremities]

The authors discuss the value and significance of symptoms in WMSDs, considering that the anamnestic threshold proposed in epidemiological investigations cannot be used as clinical and diagnosing criteria. Some useful clinical procedures are suggested for cases where there is a suspicion of musculo-skeletal disorders of the cervical spine and upper limbs, bearing in mind that they are to be applied within the framework of health surveillance programmes undertaken by health care practitioners who are not specialists in orthopaedics, physiatrics or neurology. The recommendations for instrumental tests and specialist referrals are also discussed for the various disorders. The authors also provide flow charts for the diagnostic procedures pertaining to WMSDs. The Appendix shows a sample patient chart illustrating the proposed procedures; it also permits the findings to be encoded so that they can be stored in a dedicated database. The codes for diagnosing WMSDs are also reported for the same epidemiological purposes.

[Diseases of the dorsal-lumbar spine and manual handling of loads: guidelines for fitness assessment]

In occupational medicine, degenerative diseases and malformations of the spine are one of the main reasons for requests for fitness assessment for specific jobs, especially among workers involved in manual handling tasks. By means of a selected review of the specialised literature, the authors identify analysis procedures and precise criteria for assessing compatibility between the clinical condition of the spine and manual handling tasks. Attention is drawn in particular to the diseases caused or at least aggravated by mechanical overloading of the spine. For each of these a set of diagnostic criteria is established which could be useful in defining the various levels of severity. On another front, by using tried and tested methods and criteria to identify the weight limits that can be lifted by healthy subjects in various manual handling situations, an approach was developed that can be applied to establish the weight limits that can be lifted by subjects with spinal diseases. By combining the two factors, risk level and damage level, a set of disorders was established that correspond to three different fitness levels. At each level, manual load handling was only allowed up to certain weights and for handling conditions that became increasingly stringent as the severity of the disorder increased. The paper outlines the clinical protocols and the protocols for reconstructing work exposure. The procedural differences involved in the case of fitness assessments in the pre-employment stage are also briefly discussed.

[The assessment of the lumbago patient in the work environment: the diagnostic aspects and forensic medical reflections]

In occupational health the assessment of subjects suffering from lumbago in the case of job fitness certificates is complicated not only because of the obvious possibility of the influence of simulation, but also because of the poor specificity of diagnostic possibilities for spinal disorders. An assessment was made of the reliability of traditional clinical procedures and the most common protocols and the possibility of using them in this context.

[Degenerative changes in the coxofemoral articulation due to occupational causes. I. Radiological description of a control population]

With a view to initiating epidemiological studies aimed at demonstrating the causal or concausal role of certain working activities in degenerative diseases of the coxo-femoral articulations, the authors report data from a radiological study of a reference population and the necessary conditions for their correct use. Statistical analysis of the descriptive features leads to some interesting observations on the evolution with age of the radiological picture of the coxo-femoral joints (and on the aging of these joints). There was an increase with advancing age of some of the alterations that are characteristic of degenerative articular processes, such as sclerosis and osteophytosis. Reduction of articular "rima", however, occurs suddenly between the ages of 36 and 45 and does not seem to subsequently undergo any statistically significant evolution.

[Impairment of the osteoarticular and musculoligamentous components in bill posters: an example of the thoracic outlet syndrome]

The authors analysed the risks and associated damage in bill posters on the basis of a case history description. Biomechanical analysis of the job revealed in particular the involvement of the musculoligamentous structure of the cervical spine and shoulder, mostly during the actual posting of bills. The authors propose a clinical-functional definition of the pain and paresthetic symptoms of the upper limbs which are frequently encountered in this category of workers.