E. Giannotti

Effects of physical therapy for the management of patients with ankylosing spondylitis in the biological era.

Exercise is considered a fundamental tool for the management of ankylosing spondylitis (AS), in combination with pharmacological therapy that with the advent of biological therapy has improved dramatically the control of signs and symptoms of this challenging disease. Current evidence shows that a specific exercise protocol has not been validated yet. The purpose of this review is to update the most recent evidence (July 2010–November 2013) about physiotherapy in AS, analyzing the possible role and synergistic interactions between exercise and biological drugs. From 117 studies initially considered, only 15 were included in the review. The results support a multimodal approach, including educational sessions, conducted in a group setting, supervised by a physiotherapist and followed by a maintaining home-based regimen. Spa exercise and McKenzie, Heckscher, and Pilates methods seem promising in AS rehabilitation, but their effectiveness should be further investigated in future randomized controlled trials (RCTs). When performed in accordance with the American College of Sports Medicine guidelines, cardiovascular training has been proven safe and effective and should be included in AS rehabilitation protocols. Exercise training plays an important role in the biological era, being now applicable to stabilized patients, leading ultimately to a better management of AS by physiatrists and rheumatologists throughout the world. On the basis of the current evidence, further research should aim to determine which exercise protocols should be recommended.

Medium-/Long-Term Effects of a Specific Exercise Protocol Combined with Patient Education on Spine Mobility, Chronic Fatigue, Pain, Aerobic Fitness and Level of Disability in Fibromyalgia

Objective. To propose a rehabilitation protocol able to produce immediate and long-term beneficial effects on level of disability and overall performance in ADLs. Materials and Methods. Forty-one FM patients were randomized to an exercise and educational-behavioral programme group (experimental group, EG = 21) or to a control group (CG = 20). Each subject was evaluated before, at the end (T1), and after 6 months (T6) from the conclusion of the rehabilitation treatment using the Fibromyalgia Impact Questionnaire (FIQ), the visual analogue scale (VAS), the Health Assessment Questionnaire (HAQ), the fatigue severity scale (FSS), the 6-minute walking test (6MWT), tender points count (TPC), and spinal active range of motion. The exercise protocol included 20 sessions consisting in self-awareness, stretching, strengthening, spine flexibility, and aerobic exercises, which patients were subsequently educated to perform at home. Results. The two groups were comparable at baseline. At T1, the EG showed a positive trend in FIQ, VAS, HAQ, and FSS scales and significant improvement in 6MWT and in most spinal active range of motion measurements (P between 0.001 and 0.04). The positive results were maintained at the follow-up. Conclusion. The proposed programme was well tolerated and produced immediate and medium-term beneficial effects improving function and strain endurance. This trial is registered with DRKS00005071 on DRKS.

Platelet rich plasma intra-articular injections: a new therapeutic strategy for the treatment of knee osteoarthritis in sport rehabilitation. A systematic review

Osteoarthritis (OA) is the most common joint disease and the prevalence of knee OA among athletes is higher than in the general population, especially after injury or in association with high-impact sport. We evaluated the clinical evidence and the persistence of the beneficial effects of intraarticular injections of platelet-rich plasma (PRP) in patients affected by knee OA. A systematic computerized literature search of following databases was conducted: PubMed, Medline, Cochrane, CINAHL, Embase, SportDiscus, Pedro and Google scholar. PRP has been shown to be an effective and well-tolerated treatment option in OA, with greater and longer effects in young men with a low degree of cartilage degeneration. The role of growth factors and inflammatory mediators in the pathophysiology of OA suggest that PRP may be useful in the early stages to modulate inflammatory processes. Although current studies are encouraging, more data and long-term follow-up are required before PRP can be recommended in the treatment of OA. Future PRP research should involve questions regarding the mechanism of actions, formulation, and number and timing of injections to better identify patient selection criteria.

Age explains limited hip extension recovery at one year from total hip arthroplasty

BACKGROUND To investigate the dependency of the one-year recovery in gait after total hip arthroplasty on age and preoperative conditions. METHODS Longitudinal retrospective study on 20 elderly patients with unilateral total hip arthroplasty consequent to hip osteoarthritis, assessed by gait analysis before surgery (T0), 2weeks (T1), 6 (T2) and 12months (T3) post-surgery. A set of variables assessing primary gait deviations and compensatory mechanisms were extracted from gait analysis data. Their variations throughout the one-year period were analyzed through a repeated measures ANOVA. Their dependency on preoperative conditions (age, hip passive limitations and Thomas Test) at one year after surgery were assessed through a correlation analysis and an ANCOVA. FINDINGS Hip sagittal range significantly increased (P<0.05) after each measurement session from mean 21 (SD 10) degrees at T0, to 31 (6) at T1, to 34 (6) at T2 until 36 (4) degrees at T3. The peak of hip and ankle power generation significantly increased from T0 to T3, with a progressive reduction of compensatory mechanisms towards normal values. At T3, preoperative hip passive extension and Thomas Test score did not affect hip sagittal range during gait, while age did (P<0.05, R2=0.36). Ankle and hip peak powers were also correlated with age (P=0.033 and P=0.008, respectively). In our sample, age was the main cause of hip sagittal joint range limitation. INTERPRETATION At one year from total hip arthroplasty, age affects hip joint limitations and gait recovery more than preoperative passive restrictions due to muscle shortening.

Functional surgery and early rehabilitation treatment in hemiplegic patients

Advances in the therapy of patients with neurological disorders have resulted in a large and growing population of subjects with dysfunction and deformity of the extremities secondary to a central nervous system lesion (upper motor neuron syndrome, UMNS). Traumatic brain injuries (TBIs) and cerebral vascular accidents (CVAs), or strokes, can have profound effects both on the patient and on society. Stroke is currently the third leading cause of mortality and is a common cause of long-term disability, generating increasing annual healthcare costs. Approximately 60% of these patients survive, and half of them may have residual hemiparesis. Due to the central nervous system damage, stroke patients show muscle weakness, abnormal muscle tone, and disorders of balance and posture control, which lead to difficulty controlling movements, limb spasticity and limb deformities (Keenan et al. in J Neuro Rehabil I2:119–143, 1999 [1]; Banks in Clin Orthop Relat Res 122:70–76, 1977 [2]). Limb deformities are commonly the result of both static and dynamic phenomena. The former include heterotopic ossification, fracture malunion and soft tissue contractures, and the latter weakness, spasticity, rigidity and impaired motor control. In more than 80% of hemiplegic patients, equinovarus foot deformity (EVFD), resulting in abnormal walking patterns, is the main factor limiting post-stroke gait (Lin et al. in Arch Phys Med Rehabil 87:562–568, 2006 [3]). It usually results from spasticity of the plantar flexor and invertor muscles, associated with a deficit of the dorsiflexors, their antagonists. Specifically, deformity of the foot can be seen in the presence of combined spasticity of several different muscles, including the gastrocnemius, soleus, tibialis anterior (TA), tibialis posterior (TP), flexor hallucis longus (FHL), and flexor digitorum longus (FDL), while associated weakness can be recorded in the peroneal muscles. Foot deformities interfere with toe clearance in the swing phase, with correct pre-positioning of the foot at the end of the swing phase, with loading of the stance leg, and with ankle stability during the stance phase (Keenan et al. in J Neuro Rehabil I2:119–143, 1999 [1]). Consequently, neurological patients with EVFD are often unable to walk unassisted, requiring either an orthotic device or crutches (Keenan et al. in Foot Ankle 5:35–41, 1984 [4]).

Electromyographic activity of the vastus intermedius muscle in patients with stiff-knee gait after stroke. A retrospective observational study

Stiff-knee gait (SKG) in hemiplegic patients is often due to an inappropriate activity of the quadriceps femoris. However, there are no studies in literature addressing the vastus intermedius (VI) involvement in SKG. In this study, VI activity was analyzed in a sample of 46 chronic stroke patients with SKG, during spontaneous gait. VI activity was recorded by fine-wire electrodes inserted under ultrasound guidance then confirmed by electrical stimulation. The measured VI activity was compared to the normal reference pattern reported in literature and classified (e.g. premature, prolonged). The occurrences of abnormal activations during each sub-phase of the gait cycle were assessed. VI activity presented an abnormal timing in 96% of the sample. The most common pathological pattern (in 46% of the sample) was the combination of premature and prolonged VI activation. Nearly 20% of patients presented a continuous activity. A pathological activation in patients was found for 91% in mid stance, for more than 50% in terminal stance and pre-swing and for 37% and 70% in initial- and mid-swing. Results indicate that abnormal VI activity is frequent in patients with SKG. Hence, VI activity should be included in the assessment of SKG to assist in the clinical decision-making processes.