Andrea Bernetti

Does giving segmental muscle vibration alter the response to botulinum toxin injections in the treatment of spasticity in people with multiple sclerosis? A single-blind randomized controlled trial

Objective: To determine if segmental muscle vibration and botulinum toxin-A injection, either alone or in combination, reduces spasticity in a sample of patients with multiple sclerosis. Design: Single-blind, randomized controlled trial. Setting: Physical medicine and rehabilitation outpatients service. Subjects: Forty-two patients affected by the secondary progressive form of multiple sclerosis randomized to group A (30 minutes of 120 Hz segmental muscle vibration over the rectus femoris and gastrocnemius medial and lateral, three per week, over a period of four weeks), group B (botulinum toxin in the rectus femoris, gastrocnemius medial and lateral and soleus, and segmental muscle vibration) and group C (botulinum toxin). Main measures: Modified Ashworth Scale at knee and ankle, and Fatigue Severity Scale. All the measurements were performed at baseline (T0), 10 weeks (T1) and 22 weeks (T2) postallocation. Results: Modified Ashworth Scale at knee and ankle significantly decreased over time (p < 0.001) in all groups. Patients in group C displayed a significant increase of knee and ankle spasticity at T2 when compared with T1 (p < 0.05). Fatigue Severity Scale values in groups A and C were significantly higher at T0 [A: 53.6 (2.31); C: 48.5 (2.77)] than at either T1 [A: 48.6 (2.21); p = 0.03; C: 43.5 (3.22); p = 0.03] or T2 [A: 46.7 (2.75); p = 0.02; 42.5 (2.17); p = 0.02], while no differences were detected in group B [T0: 43.4 (3.10); T1: 37.3 (3.15); T2: 39.7 (2.97)]. Conclusion: Segmental muscle vibration and botulinum toxin-A reduces spasticity and improves fatigue in the medium-term follow-up in patients with multiple sclerosis.

Kinematic and kinetic modifications in walking pattern of hip osteoarthritis patients induced by intra-articular injections of hyaluronic acid

BACKGROUND A growing body of evidence points to the efficacy of intra-articular injections of hyaluronic acid, in dealing with pain and function in hip osteoarthritis. To date, however, no data exist as to this treatments effect on walking pattern. METHODS We performed a prospective, open study in order to verify, in a group of 20 hip osteoarthritis patients (12 men, 8 women, mean age 60.5, range 47-73), the clinical effects of 3 intra-articular injections of 2 ml of hyaluronic acid in the hip (1/week) in terms of pain and function at 1 (T1), 3 (T2) and 6-month (T3) follow-ups, as well as changes in the kinematics and kinetics of gait at 6-month follow-up. FINDINGS Pain as measured with visual analog scale significantly dropped after this procedure (P<0.0001). A significant improvement was noted regarding stiffness (P=0.005) and disability (P=0.04), as measured by the Western Ontario and McMaster Universities osteoarthritis index. As regards gait analysis, patients at T3 walked with higher cadence (P=0.004) and stride length (P=0.02) compared to T0. Moreover, a significant increase for the pelvic tilt at heel contact (P=0.0004) and for hip flexion-extension moment at loading response sub-phases of gait cycle (P=0.02) was noted at T3. INTERPRETATION In line with current literature, our patients display clinical improvement 6 months after intra-articular injections of hyaluronic acid, accompanied by changes in walking pattern, as measured by instrumental gait analysis. The kinematic and kinetic changes observed may be the consequence of the therapeutic effect of intra-articular injections of hyaluronic acid.

Misdiagnosis of plexiform neurofibroma of the medial plantar nerve: case report.

Plexiform neurofibromas are benign tumors of the peripheral nerve. Diagnosis may be challenging, if they present mimicking other peripheral nerve pathologies. We report the case of a patient who had severe foot pain, which progressively hampered her walking ability, erroneously attributed to recurrent Mortons neuroma. Diagnosis of plexiform neurofibroma of her right medial plantar nerve was made 15 years after the appearance of symptoms. Pain and function recovered after radical neurotomy of the medial plantar nerve. A correct diagnosis is an essential starting point in the treatment of neurofibromas and a misdiagnosis may lead to an inappropriate treatment.

Appropriateness and efficacy of Spa therapy for musculoskeletal disorders. A Delphi method consensus initiative among experts in Italy

OBJECTIVE The aim of the study was to identify the main aspects concerning appropriateness and efficacy of Spa therapy for musculoskeletal pathologies. METHODS A committee of 8 experts from Italian universities, public hospitals, territorial services, research institutes and patient associations was set up. Clinicians from Italian medical centers specialized in rheumatology, rehabilitation and thermal medicine took part in a Delphi process aimed at obtaining consensus statements among the participants. RESULTS Large consensus was obtained for statements grouped under the following main themes: treatment indications; choice of treatment modality and treatment efficacy. CONCLUSIONS The experts developed a number of consensus statements which may be used as a practical reference to guide the choice of physicians to treat musculoskeletal diseases with Spa therapy.

Assessing the Cervical Range of Motion in Infants With Positional Plagiocephaly.

Purpose:To determine if infants with positional plagiocephaly have limitations of active and passive cervical range of motion measured with simple and reliable methods. Methods:The examiners assessed bilateral active and passive cervical rotations and passive cervical lateral flexion. Cervical assessment was performed twice by 2 different physicians to assess intertester reliability. To assess intratester reliability the first investigator performed a second examination 48 hours after the first one. Results:One-hundred nine subjects were analyzed; 70.7% of the sample had head positional preference on the right, while 29.3% had head positional preference on the left (&khgr;2 35.52, P <0.001). Cervical rotations and lateral flexion showed reliable levels of agreement for intra and intertester reliability. Conclusions:The most limited range of motion in infants with positional plagiocephaly was cervical active rotation which affected more than 90% of patients. Passive cervical rotations and lateral flexion were limited in more than 60% of patients.

Appropriateness of clinical and organizational criteria for intra-articular injection therapies in osteoarthritis: A Delphi method consensus initiative among experts in Italy

OBJECTIVE The aim of the study was to identify the main aspects involved in patient selection, the choice of therapeutic agents and the safety profile, as well as the medico-legal and organizational aspects of intra-articular injection therapies for osteoarthritis. METHODS A committee of 10 experts from Italian universities, public hospitals, territorial services, research institutes and patient associations was set up. Fifty-two clinicians from a large number of Italian medical centers specialized in intra-articular injection therapy took part in a Delphi process aimed at obtaining consensus statements among the participants. RESULTS Large consensus was obtained for statements grouped under the following main themes: treatment indications; drug/medical device choice; treatment efficacy; and appropriate setting. CONCLUSIONS The consensus statements developed by a large number of experts may be used as a practical reference tool to help physicians treat osteoarthritis patients by means of intra-articular injection therapies.

Reliability of the Cervical Spine Device for the Assessment of Cervical Spine Range of Motion in Asymptomatic Participants

Objective: The purpose of this study was to assess the inter‐ and intra‐assessor reliability of the cervical spine device (Formetric, DIERS International GmbH, Schlangenbad, Germany) in measuring cervical range of motion. Methods: The cervical spine device was used to measure the cervical range of motion of 65 asymptomatic participants. Flexion‐extension, right and left rotation, and right and left lateral flexion were analyzed. Two different assessors performed the measurements on the same day to estimate inter‐assessor reliability and 2 days later to examine intra‐assessor reliability. Intra‐assessor and inter‐assessor reliability was assessed using the intraclass correlation coefficient (ICC). The standard error of measurement (SEM) and the smallest detectable difference (SDD) were also estimated. Results: Inter‐assessor reliability ICCs for flexion + extension and total lateral flexion movements were >0.90. The ICCs for rotation movements and for left lateral flexion were >0.70. The ICCs for flexion (0.64), extension (0.58), and right lateral flexion (0.56) indicated moderate correlation. Mean SEMs ranged from 2.28° (SDD = 6.31°) for left rotation to 8.08° (SDD = 22.38°) for total rotation. As for intra‐assessor test‐retest reliability, all ICCs were >0.70. Mean SEMs ranged from 3.14° (SDD = 8.70°) for total lateral flexion to 7.50° (SDD = 20.77°) for extension. Conclusion: Both inter‐ and intra‐observer reproducibility correlation values are moderate to high for measurements obtained using the cervical spine device.

Comment on “Early Efficacy of Intra-Articular HYADD® 4 (Hymovis®) Injections for Symptomatic Knee Osteoarthritis”

We read with great interest the study by Priano titled “Early efficacy of intra-articular HYADD® 4 (Hymovis®) injections for symptomatic knee osteoarthritis.”1 The author would like to explore the efficacy of intra-articular HYADD 4 (Hymovis) injections for symptomatic knee osteoarthritis. Results from this study are very interesting and promising from a clinical aspect; however, we believe that studying patient’s clinical status with visual analog scale and Western Ontario and McMaster Universities Arthritis Index scale should be supported by biomechanical information. From this point of view, to have more data that could influence the clinical practice, it is important to note the possible action that intraarticular injections of different kinds of hyaluronic acid could have on walking biomechanics using an objective measurement tool as gait analysis. In our opinion, thework by Priano1 is promising because it investigates the efficacy of a new formulation of hyaluronic acid. Nowadays, many hyaluronic acid formulations are approved for clinical use in Europe and the United States. Furthermore, hyaluronic acid injections’ efficacy has been demonstrated also in hip osteoarthritis.2 However, even if these formulations differ in their chemical– physical properties, joint space half-life, rheological properties, and clinical efficacy, there are few studies that investigate hyaluronic acid’s possible action from a biomechanical point of view.3,4 From this point of view, we believe that osteoarthritis management and rehabilitation should be prescribed after an objective analysis of functional walking alterations using gait analysis instrumentations. The use of gait analysis should be desirable during diagnosis and follow-up. In fact, it is capable to identify different walking patterns in patient with osteoarthritis of the lower limbs, whereas the radiology can evaluate the status of the joint’s structures. Moreover, gait analysis can find the exact altered phase of the walking cycle, guaranteeing a precise prescrip-

Comment on “Efficacy of a single intra-articular injection of ultra-high molecular weight hyaluronic acid for hip osteoarthritis: a randomized controlled study”

The original version of this article unfortunately contained a mistake. The first and last names of the authors were interchanged. The correct author names are given below.

Ultrasound to depict anatomical abnormality: An example of potential alliance of rehabilitation professionals

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