Pietro Fiore

Lifestyle-related factors in predementia and dementia syndromes

Cognitive decline and dementia have a deep impact on the health and quality of life of older subjects and their caregivers. Since the therapeutic options currently available have demonstrated limited efficacy, the search for preventive strategies for cognitive decline and dementia are mandatory. A possible role of lifestyle-related factors was recently proposed for age-related changes of cognitive function, predementia syndromes and the cognitive decline of degenerative (Alzheimer’s disease [AD]) or vascular origin. At present, cumulative evidence suggests that vascular risk factors may be important in the development of mild cognitive impairment (MCI), dementia and AD. Moderate alcohol drinking has been proposed as a protective factor against MCI and dementia in several longitudinal studies, but contrasting findings also exist. The Mediterranean diet could therefore be an interesting model with which to further study the association between dietary patterns and cognitive functioning, given the suggested role of many components of this diet (monounsaturated fatty acids, polyunsaturated fatty acids, cereals and red wine) in contrasting cognitive impairment and dementia. The association between low education and predementia and dementia syndromes is supported by the majority of studies, but very few studies have investigated whether this association may be attributed with lifestyle factors that covary with education. Studies in the literature seem to identify in physical exercise one promising strategy in decreasing cognitive decline, but some of the limitations of these studies do not allow us to draw definite conclusions. At present, in older subjects, healthy diets, antioxidant supplements, the prevention of nutritional deficiencies, and moderate physical activity could be considered the first line of defense against the development and progression of predementia and dementia syndromes. However, in most cases, these were only observational studies, and results are awaited from large multicenter randomized clinical trials in older persons that may clarify the possible synergy, for example, between moderate exercise, physical activity and healthy Mediterranean diet on cognition in the elderly.

Short-term Effects of High-Intensity Laser Therapy Versus Ultrasound Therapy in the Treatment of People With Subacromial Impingement Syndrome: A Randomized Clinical Trial

Background: Subacromial impingement syndrome (SAIS) is a painful condition resulting from the entrapment of anatomical structures between the anteroinferior corner of the acromion and the greater tuberosity of the humerus. Objective: The aim of this study was to evaluate the short-term effectiveness of high-intensity laser therapy (HILT) versus ultrasound (US) therapy in the treatment of SAIS. Design: The study was designed as a randomized clinical trial. Setting: The study was conducted in a university hospital. Patients: Seventy patients with SAIS were randomly assigned to a HILT group or a US therapy group. Intervention: Study participants received 10 treatment sessions of HILT or US therapy over a period of 2 consecutive weeks. Measurements: Outcome measures were the Constant-Murley Scale (CMS), a visual analog scale (VAS), and the Simple Shoulder Test (SST). Results: For the 70 study participants (42 women and 28 men; mean [SD] age=54.1 years [9.0]; mean [SD] VAS score at baseline=6.4 [1.7]), there were no between-group differences at baseline in VAS, CMS, and SST scores. At the end of the 2-week intervention, participants in the HILT group showed a significantly greater decrease in pain than participants in the US therapy group. Statistically significant differences in change in pain, articular movement, functionality, and muscle strength (force-generating capacity) (VAS, CMS, and SST scores) were observed after 10 treatment sessions from the baseline for participants in the HILT group compared with participants in the US therapy group. In particular, only the difference in change of VAS score between groups (1.65 points) surpassed the accepted minimal clinically important difference for this tool. Limitations: This study was limited by sample size, lack of a control or placebo group, and follow-up period. Conclusions: Participants diagnosed with SAIS showed greater reduction in pain and improvement in articular movement functionality and muscle strength of the affected shoulder after 10 treatment sessions of HILT than did participants receiving US therapy over a period of 2 consecutive weeks.

Influence of nutritional status on cognitive, functional and neuropsychiatric deficits in Alzheimer's disease

Nutrition is an important issue for elderly people, especially in patients with dementia. It is also related to clinical outcome, such as cognition, autonomy and behavior. The present study investigated the role of nutritional status on cognitive, functional and neuropsychiatric deficits in patients with Alzheimers disease (AD). Forty-nine patients underwent neuropsychological, nutritional and neuropsychiatric assessments. The sample was divided into at risk of malnutrition (21 patients) and well-nourished (28 patients) according to the Mini Nutritional Assessment (MNA) score. The groups were similar for clinical and demographic variables, except for MNA score and age. The mean body mass index (BMI) was higher than the normal range. Patients at risk of malnutrition showed greater impairment, both in simple and instrumental activities of daily living (ADL and IADL) and a more severe ideomotor praxis deficit than well-nourished patients. Neuropsychiatric symptoms showed significant differences in hallucination, apathy, aberrant motor behavior and night-time subscales of Neuropsychiatric Inventory (NPI). These symptoms were more severe in patients at risk of malnutrition. Logistic regression analysis showed that malnutrition was an important risk factor for the onset of apathy. We hypothesized that changes in dietary habits and intake and the onset of these disorders reflect the involvement of a common neuroanatomical network.

ACOUSTIC ANALYSIS OF SWALLOWING SOUNDS: A NEW TECHNIQUE FOR ASSESSING DYSPHAGIA

OBJECTIVE To perform acoustic analysis of swallowing sounds, using a microphone and a notebook computer system, in healthy subjects and patients with dysphagia affected by neurological diseases, testing the positive/negative predictive value of a pathological pattern of swallowing sounds for penetration/aspiration. DESIGN Diagnostic test study, prospective, not blinded, with the penetration/aspiration evaluated by fibreoptic endoscopy of swallowing as criterion standard. SUBJECTS Data from a previously recorded database of normal swallowing sounds for 60 healthy subjects according to gender, age, and bolus consistency was compared with those of 15 patients with dysphagia from a university hospital referral centre who were affected by various neurological diseases. METHODS Mean duration of the swallowing sounds and post-swallowing apnoea were recorded. Penetration/aspiration was verified by fibreoptic endoscopy of swallowing in all patients with dysphagia. RESULTS The mean duration of swallowing sounds for a liquid bolus of 10 ml water was significantly different between patients with dysphagia and healthy patients. We also described patterns of swallowing sounds and tested the negative/positive predictive values of post-swallowing apnoea for penetration/aspiration verified by fibreoptic endoscopy of swallowing (sensitivity 0.67 (95% confidence interval 0.24-0.94); specificity 1.00 (95% confidence interval 0.56-1.00)). CONCLUSION The proposed technique for recording and measuring swallowing sounds could be incorporated into the bedside evaluation, but it should not replace the use of more diagnostic and valuable measures.

High and low frequency transcutaneous electrical nerve stimulation inhibits nociceptive responses induced by CO2 laser stimulation in humans.

The aim of the study was to evaluate the effects of transcutaneous electric nerve stimulation (TENS) on CO(2) laser evoked potentials (LEPs) in 16 normal subjects. The volar side of the forearm was stimulated by 10 Hz TENS in eight subjects and by 100 Hz TENS in the remainder; the skin of the forearm was stimulated by CO(2) laser and the LEPs were recorded in basal conditions and soon after and 15 min after TENS. Both low and high frequency TENS significantly reduced the subjective rating of heat stimuli and the LEPs amplitude, although high frequency TENS appeared more efficacious. TENS seemed to exert a mild inhibition of the perception and processing of pain induced by laser Adelta fibres activation; the implications of these effects in the clinical employment of TENS remain to be clarified.

Can botulinum toxin type A injection technique influence the clinical outcome of patients with post-stroke upper limb spasticity? A randomized controlled trial comparing manual needle placement and ultrasound-guided injection techniques

BACKGROUND Botulinum toxin type A is a first-line treatment for post-stroke focal spasticity, and the accuracy in delivering the toxin to the target muscles may influence the treatment outcome. Our aim was to compare the reduction of spasticity and the related finger position at rest improvement in post-stroke patients treated with botulinum toxin type A in upper limb muscles using ultrasound guidance and manual needle placement. METHODS In a randomized clinical trial, two groups of 15 stroke patients were treated with botulinum toxin type A injections in the wrist and finger flexor muscles of the affected upper limb using ultrasound guidance or manual needle placement. The Modified Ashworth Scale and the finger position at rest were measured at baseline and one month after toxin injections. RESULTS After one month of follow-up from toxin injections, the Modified Ashworth Scale and finger position at rest significantly improved in both treatment groups, although these clinical outcomes were significantly better in patients treated under ultrasound guidance than in patients injected using manual needle placement. CONCLUSION Ultrasound guidance for botulinum toxin type A injections could improve clinical outcome measures better than manual needle placement in post-stroke patients with spasticity.

Vascular risk factors, alcohol intake, and cognitive decline

Since the therapeutic options currently available have demonstrated limited efficacy, the search for preventive strategies for cognitive decline and dementia is mandatory. A possible role of vascular and lifestyle-related factors was recently proposed for age-related changes of cognitive function, predementia syndromes, and cognitive decline of degenerative (Alzheimer’s disease, AD) or vascular origin. At present, cumulative evidence suggested that vascular risk factors may be important in the development of mild cognitive impairment (MCI), dementia, and AD. Among vascular-related factors, metabolic syndrome has been associated with the risk of cognitive decline and overall dementia. Moderate alcohol drinking has been proposed as a protective factor against MCI and dementia in several longitudinal studies, but contrasting findings also exist. However, in most cases, these were only observational studies, and results are awaited from large multicenter randomized clinical trials in older persons. At present, vascular risk factor management, lifestyle changes, and drugs could be employed together to delay the onset of dementia syndromes.

Effectiveness of the Frequency Rhythmic Electrical Modulation System for the Treatment of Chronic and Painful Venous Leg Ulcers in Older Adults

Frequency rhythmic electrical modulation system (FREMS) is an innovative type of transcutaneous electrotherapy used in a rehabilitation setting for the treatment of pain, especially in diabetic patients. In a randomized clinical trial, we tested the hypothesis that FREMS is effective in the treatment of chronic and painful venous leg ulcers in 20 older patients. Group A (10 patients) received FREMS and topical treatment, whereas group B (10 patients) received topical treatment alone. Over a period of 3 consecutive weeks, 15 treatment sessions were done for each group. Wound healing and tissue repair were evaluated with the Visitrack digital planimetry system and photos. Pain was evaluated using the Visual Analogic Scale (VAS). The measurements were done at baseline and after 5, 10, and 15 days of treatment, with follow-up measurements after 15 and 30 days from the last treatment session. Group A showed a statistically significant decrease in ulcer area during the treatment and follow-up. The VAS score showed a statistically significant decrease after 5 and 10 days of treatment. Group B showed a statistically decrease in ulcer area after 5, 10, and 15 days of treatment with a reduction of VAS score only at 15 days of follow-up. At the end of the treatment, the comparison of the change in ulcer area and the change in VAS score of each group showed a statistically significant difference between groups, suggesting the therapeutic and analgesic efficacy of FREMS in reducing pain and area of chronic venous leg ulcers in older adults. Further investigation is needed to determine its reproducibility in larger case series or randomized clinical trials with longer follow-up periods.

Extracorporeal shock wave therapy for the treatment of poststroke plantar-flexor muscles spasticity: a prospective open-label study.

Abstract Objectives: To assess the use of extracorporeal shock wave therapy (ESWT) for the treatment of equinus foot after stroke and to correlate the ESWT effect on spastic plantar-flexor muscles with echo intensity on the Heckmatt scale. Methods: The prospective open-label study examined 23 patients with poststroke lower limb spasticity. Adults with spastic equinus foot after stroke received one ESWT session on hypertonic plantar-flexor muscles. The effect on spasticity, degree of passive ankle dorsiflexion, and neurophysiological values were evaluated. Before treatment, participants underwent a sonography evaluation of calf muscles to identify echo intensity on the Heckmatt scale. Results: Immediately after the session, ESWT induced a statistically significant reduction in muscle tone, increasing passive ankle dorsiflexion motion. At 30 days of follow-up, the effect persisted only in patients with echo intensity of spastic plantar-flexor muscles graded I, II, or III on the Heckmatt scale without any action related to spinal excitability. Mild adverse events were reported after the treatment but were resolved in a few days. Conclusions: ESWT is safe and efficacious for the treatment of poststroke plantar-flexor muscles spasticity, reducing muscle tone and improving passive ankle dorsiflexion motion. The effect was long lasting in subjects with echo intensity of calf muscles graded I, II, or III but was brief for echo intensity graded IV on the Heckmatt scale. The ESWT effect did not appear to be related to spinal excitability.

Effect of botulinum toxin type A and modified constraint-induced movement therapy on motor function of upper limb in children with obstetrical brachial plexus palsy

Motor disorders and loss of functional movement are common consequences of obstetric brachial plexus palsy (OBPP) [1], related to muscle contractures, impairment movements, and motor weakness following brachial plexus damage and compromising quality of life. Many rehabilitation programs for the upper extremity in OBPP patients have been proposed, not only to increase the active range of movement of involved limb but also to improve the functional recovery. Limits to move the affected arm are caused by paresis, motor weakness, and muscle and joint contractures. Moreover, it cannot be excluded that the impossibility to move the affected limb can determine a cortical underdevelopment as occurs for brain damage in cerebral palsy and stroke patients. Actually, new techniques based on practical applications of the concept of brain plasticity for children and adults are still under evaluation. One such technique, “constraintinduced movement therapy” (CIMT), is based on the concept that underuse of the affected arm is a negative learning phenomenon called “learned non-use”, which leads to a progressive suppression of movements of the affected arm [2]. This type of rehabilitation program consists of constraining the unaffected arm in order to stimulate the use of the affected arm by means of a splint or sling worn for 90% of waking hours and of a concurrent supervised intensive practice (6 h/day for 10 days) [3]. Related to the CIMT is the “neuroplasticity”, term to summarize the possibility that neuronal circuits can be activated to relieve damaged neurons by several injuries creating new functioning synapses. In fact, the efficacy of this type of rehabilitation and plastic brain changes have been demonstrated in several studies not only with the employment of outcome measures but also with the use of transcranial magnetic stimulation and functional magnetic resonance imaging (fMRI) [4, 5]. Limitations of motor rehabilitation for OBPP patients, especially in children with incomplete recovery, are the muscular contractures and co-contracture phenomena related to muscle denervation of involved arm both into agonist and antagonist muscles causing limited active range of motion. This can be explained as the consequences of axonal repair with axonal splitting and aberrant nerve outgrowth [6]. Management of co-contraction phenomena and imbalance of muscle groups is considered essential in the prevention of deformities and to improve function. At present, botulinum toxin type A (BTX-A) represents the best therapeutic option to treat muscular hyperactivity. In fact, from classical indications, such as muscle spasticity, dystonia, and the management of wrinkles, the use of BTX-A has spread to many medical fields. In recent years, it has also been demonstrated to be effective to treat co-contraction improving functional performance for OBPP patients [7–10]. A. Santamato (*) : P. Fiore Department of Physical Medicine and Rehabilitation—“OORR Hospital”, University of Foggia, Foggia, Italy e-mail: a.santamato@unifg.it