Sofia Straudi

Does robot-assisted gait training ameliorate gait abnormalities in multiple sclerosis? A pilot randomized-control trial.

BACKGROUND Gait disorders are common in multiple sclerosis (MS) and lead to a progressive reduction of function and quality of life. OBJECTIVE Test the effects of robot-assisted gait rehabilitation in MS subjects through a pilot randomized-controlled study. METHODS We enrolled MS subjects with Expanded Disability Status Scale scores within 4.5-6.5. The experimental group received 12 robot-assisted gait training sessions over 6 weeks. The control group received the same amount of conventional physiotherapy. Outcomes measures were both biomechanical assessment of gait, including kinematics and spatio-temporal parameters, and clinical test of walking endurance (six-minute walk test) and mobility (Up and Go Test). RESULTS 16 subjects (n = 8 experimental group, n = 8 control group) were included in the final analysis. At baseline the two groups were similar in all variables, except for step length. Data showed walking endurance, as well as spatio-temporal gait parameters improvements after robot-assisted gait training. Pelvic antiversion and reduced hip extension during terminal stance ameliorated after aforementioned intervention. CONCLUSIONS Robot-assisted gait training seems to be effective in increasing walking competency in MS subjects. Moreover, it could be helpful in restoring the kinematic of the hip and pelvis.

tDCS and Robotics on Upper Limb Stroke Rehabilitation: Effect Modification by Stroke Duration and Type of Stroke

Objective. The aim of this exploratory pilot study is to test the effects of bilateral tDCS combined with upper extremity robot-assisted therapy (RAT) on stroke survivors. Methods. We enrolled 23 subjects who were allocated to 2 groups: RAT + real tDCS and RAT + sham-tDCS. Each patient underwent 10 sessions (5 sessions/week) over two weeks. Outcome measures were collected before and after treatment: (i) Fugl-Meyer Assessment-Upper Extremity (FMA-UE), (ii) Box and Block Test (BBT), and (iii) Motor Activity Log (MAL). Results. Both groups reported a significant improvement in FMA-UE score after treatment (p < 0.01). No significant between-groups differences were found in motor function. However, when the analysis was adjusted for stroke type and duration, a significant interaction effect (p < 0.05) was detected, showing that stroke duration (acute versus chronic) and type (cortical versus subcortical) modify the effect of tDCS and robotics on motor function. Patients with chronic and subcortical stroke benefited more from the treatments than patients with acute and cortical stroke, who presented very small changes. Conclusion. The additional use of bilateral tDCS to RAT seems to have a significant beneficial effect depending on the duration and type of stroke. These results should be verified by additional confirmatory studies.

The effects of robot-assisted gait training in progressive multiple sclerosis: A randomized controlled trial

Background: Gait and mobility impairments are common in progressive multiple sclerosis (MS), leading to reduced quality of life (QoL). Objective: In this randomized controlled study, we tested the effects of robot-assisted gait training (RAGT) and compared it to conventional physiotherapy, measuring walking ability, depression, fatigue, and QoL in patients with progressive MS and severe gait disability. Methods: Fifty-two participants (Expanded Disability Status Scale score 6–7) completed the study protocol. They received two sessions/week over 6 weeks of RAGT or conventional walking therapy. Outcome measures were Six-Minute Walk Test, Ten-Meter Walk Test, Timed Up and Go Test, Berg Balance Scale, Fatigue Severity Scale, Patient Health Questionnaire, and Short Form 36. They were performed pre-treatment, post-treatment, and at 3 months. Results: Walking endurance (p < 0.01) and balance (p < 0.01) were improved among those in the RAGT group. Positive effects on depression in both treatment groups were highlighted. However, only among those in the RAGT group was perceived physical functioning QoL increased. No significant effects on fatigue were found. Conclusion: RAGT is a treatment option in progressive MS patients with severe gait impairments to induce short-lasting effects on mobility and QoL.

Robotic Gait Training in an Adult With Cerebral Palsy: A Case Report

Improved treatments and rehabilitation for cerebral palsy (CP) have led to an increased number of children with CP surviving into adulthood. Adults with CP show an increased prevalence of pain, fatigue, and musculoskeletal dysfunction, leading to a decrease in ambulatory function. Recent work has demonstrated the potential benefits of intensive task‐specific gait training, including the use of robotic‐driven gait orthoses, on motor recovery in children with CP [ 1,2 ]. In contrast, reports of interventions aimed at improving motor function in adults with CP are lacking. This case study reports on the outcomes of a 6‐week intervention of robotic‐assisted gait training administered to a 52‐year‐old woman with right hemiplegia attributable to CP. Improvements were noted in balance, walking speed, and time to negotiate stairs at posttraining and follow‐up. Gait analysis showed an increase in step length and a reduction in the period of double support. In conclusion, robotic‐assisted gait training may be beneficial in enhancing locomotor function in adults with CP.

A task-oriented circuit training in multiple sclerosis: a feasibility study.

BackgroundThe aim of this study was to evaluate the safety, feasibility and preliminary effects of a high-intensity rehabilitative task-oriented circuit training (TOCT) in a sample of multiple sclerosis (MS) subjects on walking competency, mobility, fatigue and health-related quality of life (HRQoL).Methods24 MS subjects (EDSS 4.89 ± 0.54, 17 female and 7 male, 52.58 ± 11.21 years, MS duration 15.21 ± 8.68 years) have been enrolled and randomly assigned to 2 treatment groups: (i) experimental group received 10 TOCT sessions over 2 weeks (2 hours/each session) followed by a 3 months home exercise program, whereas control group did not receive any specific rehabilitation intervention. A feasibility patient-reported questionnaire was administered after TOCT. Functional outcome measures were: walking endurance (Six Minute Walk Test), gait speed (10 Meter Walk Test), mobility (Timed Up and Go test) and balance (Dynamic Gait Index). Furthermore, self-reported questionnaire of motor fatigue (Fatigue Severity Scale), walking ability (Multiple Sclerosis Walking Scale – 12) and health-related quality of life (Multiple Sclerosis Impact Scale – 29) were included. Subjects’ assessments were delivered at baseline (T0), after TOCT (T1) and 3 months of home-based exercise program (T2).ResultsAfter TOCT subjects reported a positive global rating on the received treatment. At 3 months, we found a 58.33% of adherence to the home-exercise program. After TOCT, walking ability and health-related quality of life were improved (p < 0.05) with minor retention after 3 months. The control group showed no significant changes in any variables.ConclusionsThis two weeks high-intensity task-oriented circuit class training followed by a three months home-based exercise program seems feasible and safe in MS people with moderate mobility impairments; moreover it might improve walking abilities.Trial registrationNCT01464749

Clinicoradiographic Assessment of Flexible Flatfoot in Children

BACKGROUND Radiographic assessment is still used to evaluate flexible flatfoot in children. METHODS To find a set of radiologic parameters for assessing this disease, we studied 53 children aged 10 to 14 years. The degree of plantar collapse was measured by Viladots classification (grades 0-4). The degree of valgus deformity measured in the heel in a standing position, the presence of painful points, and functional limitation during daily-living activities were also reported. The children underwent standard radiography of the foot under load. On the dorsoplantar view, the talocalcaneal, hallux metatarsophalangeal, and first intermetatarsal angles were measured. On the lateral view, the talocalcaneal, Costa Bertani, talometatarsal, talonavicular, and tibiotalar angles were measured. The radiographic measurements were compared with the data reported in the literature and were correlated with the clinical parameters studied (degree of flatfoot, valgus deviation of the heel, pain, and functional limitation). RESULTS The radiographic measures that resulted increased with respect to the reference values reported in the literature for the Costa Bertani (93.1% of feet), talometatarsal (93.5%), talonavicular (89.1%), and tibiotalar (69.7%) angles, all in the lateral view. Of the angles assessed in the dorsoplantar view, the hallux metatarsophalangeal (11.1%) and first intermetatarsal (24.2%) angles were increased. The degree of flatfoot was correlated with the Costa Bertani angle (P < .0005). In the group with pain, the lateral talocalcaneal (P = .016) and first intermetatarsal (P = .02) angles were increased compared within the group without pain. CONCLUSIONS Despite technical limitations, we still consider standard radiography of the foot, combined with clinical examination, to be a valid tool for assessing flexible flatfoot in children, especially when surgical treatment is expected and when a basic measure of the structural setup of the foot is necessary.

Use of Nintendo Wii Balance Board for posturographic analysis of Multiple Sclerosis patients with minimal balance impairment

BackgroundThe Wii Balance Board (WBB) has been proposed as an inexpensive alternative to laboratory-grade Force Plates (FP) for the instrumented assessment of balance. Previous studies have reported a good validity and reliability of the WBB for estimating the path length of the Center of Pressure. Here we extend this analysis to 18 balance related features extracted from healthy subjects (HS) and individuals affected by Multiple Sclerosis (MS) with minimal balance impairment.MethodsEighteen MS patients with minimal balance impairment (Berg Balance Scale 53.3 ± 3.1) and 18 age-matched HS were recruited in this study. All subjects underwent instrumented balance tests on the FP and WBB consisting of quiet standing with the eyes open and closed. Linear correlation analysis and Bland-Altman plots were used to assess relations between path lengths estimated using the WBB and the FP. 18 features were extracted from the instrumented balance tests. Statistical analysis was used to assess significant differences between the features estimated using the WBB and the FP and between HS and MS. The Spearman correlation coefficient was used to evaluate the validity and the Intraclass Correlation Coefficient was used to assess the reliability of WBB measures with respect to the FP. Classifiers based on Support Vector Machines trained on the FP and WBB features were used to assess the ability of both devices to discriminate between HS and MS.ResultsWe found a significant linear relation between the path lengths calculated from the WBB and the FP indicating an overestimation of these parameters in the WBB. We observed significant differences in the path lengths between FP and WBB in most conditions. However, significant differences were not found for the majority of the other features. We observed the same significant differences between the HS and MS populations across the two measurement systems. Validity and reliability were moderate-to-high for all the analyzed features. Both the FP and WBB trained classifier showed similar classification performance (>80%) when discriminating between HS and MS.ConclusionsOur results support the observation that the WBB, although not suitable for obtaining absolute measures, could be successfully used in comparative analysis of different populations.

Effects of low-intensity endurance and resistance training on mobility in chronic stroke survivors. A pilot, randomized, controlled study.

BACKGROUND Chronic stroke survivors are exposed to long-term disability and physical deconditioning, effects that may impact their independence and quality of life. Community-based programs optimizing the dose of exercise therapy that are simultaneously low risk and able to achieve high adherence should be identified. AIM We tested the hypothesis that an 8-week, community-based, progressive mixed endurance-resistance exercise program at lower cardiovascular and muscular load yielded more mobility benefits than a higher-intensity program in chronic stroke survivors. DESIGN A two-arm, parallel-group, pilot randomized, controlled clinical trial. SETTING Hospital (recruitment); community-based adapted physical activity center (training). POPULATION Thirty-five chronic stroke patients (mean age: 68.4±10.4 years; 27 males). METHODS Participants were randomized to a low-intensity experimental (LI-E; N.=18) or a high-intensity active control group (HI-C; N.=17). Patients in the LI-E group performed over-ground intermittent walking (weeks 1-8) and muscle power training with portable tools (weeks 5-8); patients in the HI-C group executed treadmill walking (weeks 1-8) and strength training with gym machines (weeks 5-8). Changes in mobility, assessed using the 6-Minute Walking Distance test, were the primary outcome. Secondary outcomes included quality of life (Short-Form-36 Questionnaire), gait speed (10-Meter Walking Test), balance (Berg Balance Scale) and muscle performance of the lower limbs (strength and power of the quadriceps and femoral biceps). RESULTS After 8 weeks, the 6MWD revealed more improvement for the LI-E group than the HI-C group (P=0.009). The SF36 physical activity domain (P=0.012) and peak power of the femoral quadriceps and biceps were also significantly improved for the LI-E group (P=0.008 and P<0.001, respectively) compared with the HI-C. Gait speed, balance and lower-limb strength increased in both groups; no significant differences were noted. The muscle power of the affected limb was the muscle parameter most correlated with mobility in the entire population. CONCLUSIONS A low-intensity exercise program exhibited better results in terms of mobility, quality of life and muscle power compared with a higher-intensity program. Data need to be confirmed in a larger trial. CLINICAL REHABILITATION IMPACT The effectiveness, low-intensity and possible implementation in poorly equipped community-based settings make the LI-E program potentially suitable for stroke survivors and frail individuals.

Coagulation Factor XII Levels and Intrinsic Thrombin Generation in Multiple Sclerosis

Background Factor XII (FXII) activation initiates the intrinsic (contact) coagulation pathway. It has been recently suggested that FXII could act as an autoimmunity mediator in multiple sclerosis (MS). FXII depositions nearby dentritic cells were detected in the central nervous system of MS patients and increased FXII activity has been reported in plasma of relapsing remitting and secondary progressive MS patients. FXII inhibition has been proposed to treat MS. Objective To investigate in MS patients multiple FXII-related variables, including the circulating amount of protein, its pro-coagulant function, and their variation over time. To explore kinetic activation features of FXII in thrombin generation (TG). Methods In plasma from 74 MS patients and 49 healthy subjects (HS), FXII procoagulant activity (FXII:c) and FXII protein (FXII:Ag) levels were assessed. Their ratio (FXII:ratio) values were derived. Intrinsic TG was evaluated by different triggers. Results Higher FXII:Ag levels (p = 0.003) and lower FXII:ratio (p < 0.001) were detected in MS patients compared with HS. FXII variables were highly correlated over four time points, which supports investigation of FXII contribution to disease phenotype and progression. A significant difference over time was detected for FXII:c (p = 0.031). In patients selected for the lowest FXII:ratio, TG triggered by ellagic acid showed a trend in lower endogenous thrombin potential (ETP) in MS patients compared with HS (p = 0.042). Intrinsic triggering of TG by nucleic acid addition produced longer time parameters in patients than in HS and substantially increased ETP in MS patients (p = 0.004) and TG peak height in HS (p = 0.008). Coherently, lower FXII:ratio and longer lag time (p = 0.02) and time to peak (p = 0.007) point out a reduced response of FXII to activation in part of MS patients. Conclusion In MS patients, factor-specific and modified global assays suggest the presence of increased FXII protein level and reduced function within the intrinsic coagulation pathway. These novel findings support further investigation by multiple approaches of FXII contribution to disease phenotype and progression.

Home-based exercise for elderly patients with intermittent claudication limited by osteoarticular disorders – feasibility and effectiveness of a low-intensity programme

BACKGROUND Peripheral arterial disease (PAD) is a common cardiovascular pathology affecting mobility in elderly. Osteoarticular diseases (ODs), responsible for functional limitations and confounding leg symptoms, may interfere with exercise therapy. This study evaluates the feasibility and effectiveness of a structured home-based exercise programme on rehabilitative outcomes in a cohort of elderly PAD patients with and without coexisting ODs. PATIENTS AND METHODS Patients were enrolled from 2002 to 2016 in an exercise programme prescribed and controlled at the hospital and based on two daily 10-minute home walking sessions below the self-selected speed. The presence and localization of ODs at baseline were derived from consultation of medical documents. The ankle-brachial index and functional outcomes, defined as speed at the onset of claudication and attainable maximal speed by an incremental treadmill test, were assessed at baseline and discharge. Feasibility was determined according to dropout rate, number of visits, duration of the programme, and adherence. RESULTS A total of 1,251 PAD patients were enrolled (931 men; 71 ± 9 years; 0.63 ± 0.19 ankle-brachial index). Eight hundred sixty-four patients were free of ODs (ODfreePAD, 69 %), whereas 387 were affected by ODs (ODPAD, 31 %), predominantly located in the spine (72 %). In the logistic regression models, the presence of ODs was associated with female sex, overweight, sedentary and/or driving professions. At discharge, ODPAD and ODfreePAD did not differ in dropout rates (12 % each), programme duration (378 ± 241 vs. 390 ± 260 days), number of visits (7 ± 3 each), and adherence (80 % each). Similar improvements for ODPAD and ODfreePAD were observed for the ankle-brachial index (0.06 ± 0.12 each), the speed at onset of claudication (0.7 ± 0.7 vs. 0.7 ± 0.8 kmh-1; p = 0.70), and maximal speed (0.4 ± 0.6 vs. 0.4 ± 0.6 kmh-1; p = 0.77). CONCLUSIONS Equally satisfactory rehabilitative outcomes were observed in elderly patients with claudication limited by ODs who completed a well-tolerated, low-impact structured exercise programme.