Valter Santilli

Mirror Therapy in Complex Regional Pain Syndrome Type 1 of the Upper Limb in Stroke Patients

Background. Complex regional pain syndrome type 1 (CRPSt1) of the upper limb is a painful and debilitating condition, frequent after stroke, and interferes with the rehabilitative process and outcome. However, treatments used for CRPSt1 of the upper limb are limited. Objective. This randomized controlled study was conducted to compare the effectiveness on pain and upper limb function of mirror therapy on CRPSt1 of upper limb in patients with acute stroke. Methods. Of 208 patients with first episode of unilateral stroke admitted to the authors’ rehabilitation center, 48 patients with CRPSt1 of the affected upper limb were enrolled in a randomized controlled study, with a 6-month follow-up, and assigned to either a mirror therapy group or placebo control group. The primary end points were a reduction in the visual analogue scale score of pain at rest, on movement, and brush-induced tactile allodynia. The secondary end points were improvement in motor function as assessed by the Wolf Motor Function Test and Motor Activity Log. Results. The mean scores of both the primary and secondary end points significantly improved in the mirror group (P < .001). No statistically significant improvement was observed in any of the control group values (P > .001). Moreover, statistically significant differences after treatment (P < .001) and at the 6-month follow-up were found between the 2 groups. Conclusions. The results indicate that mirror therapy effectively reduces pain and enhances upper limb motor function in stroke patients with upper limb CRPSt1.

Natural History and Manifestations of the Hypermobility Type Ehlers-Danlos Syndrome: A Pilot Study on 21 Patients

Hypermobility type Ehlers–Danlos syndrome (HT‐EDS) is a relatively frequent, although commonly misdiagnosed variant of Ehlers–Danlos syndrome, mainly characterized by marked joint instability and mild cutaneous involvement. Chronic pain, asthenia, and gastrointestinal and pelvic dysfunction are characteristic additional manifestations. We report on 21 HT‐EDS patients selected from a group of 40 subjects with suspected mild hereditary connective tissue disorder. General, mucocutaneous, musculoskeletal, cardiovascular, neurologic, gastrointestinal, urogynecological, and ear–nose–throat abnormalities are investigated systematically and tabulated. Six distinct clinical presentations of HT‐EDS are outlined, whose tabulation is a mnemonic for the practicing clinical geneticist in an attempt to diagnose this condition accurately. With detailed clinical records and phenotype comparison among patients of different ages, the natural history of the disorder is defined. Three phases (namely, hypermobility, pain, and stiffness) are delineated based on distinguishing manifestations. A constellation of additional, apparently uncommon abnormalities is also identified, including dolichocolon, dysphonia, and Arnold–Chiari type I malformation. Their further investigation may contribute to an understanding of the pathogenesis of the protean manifestations of HT‐EDS, and a more effective approach to the evaluation and management of affected individuals.

Peroneus Longus Muscle Activation Pattern During Gait Cycle in Athletes Affected by Functional Ankle Instability A Surface Electromyographic Study

Background Functional ankle instability is a clinical syndrome that may develop after acute lateral ankle sprain. Although several causes of this functional instability have been suggested, it is still unclear what the activation pattern of the peroneus longus muscle is in patients with functional ankle instability. Hypothesis Peroneus longus activation patterns differ in the injured side and the uninjured side in subjects with functional ankle instability. Study Design Descriptive laboratory study. Methods The authors examined 14 subjects with functional ankle instability by using surface electromyography during walking. Activation time of the peroneus longus muscle was expressed as a percentage of the stance phase of the gait cycle. Results A statistically significant decrease in peroneus longus muscle activity was found in the injured side compared with the uninjured side (22.8% ± 4.25% vs 37.6% ± 3.5%, respectively). Conclusions Results obtained in this study show a change in peroneus longus muscle activation time after injury. Independent of the origin of this change, which could only be surmised, the decrease in peroneus longus muscle activity may result in reduced protection against lateral sprains. Clinical Relevance The assessment of peroneus longus activation pattern during gait is useful to design an appropriate rehabilitation program in athletes suffering from functional ankle instability.

Extracorporeal Shock-Wave Therapy Compared with Surgery for Hypertrophic Long-Bone Nonunions

BACKGROUND The authors of several studies have recommended extracorporeal shock-wave therapy as an alternative to surgical treatment for long-bone nonunions. This study was performed to compare the results of extracorporeal shock-wave therapy produced by two different devices with those of surgical treatment in the management of long-bone nonunions. METHODS One hundred and twenty-six patients with a long-bone nonunion were randomly assigned to receive either extracorporeal shock-wave therapy (Groups 1 and 2) or surgical treatment (Group 3). The patients in the shock-wave groups received four treatments with 4000 impulses of shock waves with an energy flux density of 0.40 mJ/mm(2) (Group 1) or 0.70 mJ/mm(2) (Group 2). The patients in the three groups had similar demographic characteristics, durations of nonunion, and durations of follow-up. Radiographic results (the primary outcome) and clinical results (the secondary outcomes) were determined before and three, six, twelve, and twenty-four months after treatment. RESULTS The radiographic findings did not differ among the three groups of patients. At six months, 70% of the nonunions in Group 1, 71% of the nonunions in Group 2, and 73% of the nonunions in Group 3 had healed. Three and six months after treatment, the clinical outcomes in the two shock-wave groups were significantly better than those in the surgical group (p < 0.001). However, at both twelve and twenty-four months after treatment, there were no differences among the three groups, with the exception of the DASH score, which differed significantly between Groups 1 and 3 (p = 0.038) and between Groups 2 and 3 (p = 0.021) at twelve months. CONCLUSIONS Extracorporeal shock-wave therapy is as effective as surgery in stimulating union of long-bone hypertrophic nonunions and yields better short-term clinical outcomes.

Reliability of transcranial magnetic stimulation-related measurements of tibialis anterior muscle in healthy subjects.

OBJECTIVE The main purpose of this study was to determine the reliability of transcranial magnetic stimulation (TMS)-related measurements linked to the corticospinal control of the tibialis anterior (TA) muscle in healthy subjects. METHODS Inter-investigator and intra-investigator (within-session with a 1.5-h interval; between-session with a 4-week interval) reliability of the motor threshold, recruitment curve with its slope and MEP area at the plateau, MEP latency, maximum MEP (MEPmax) area, and duration of the maximum and minimum silent period (SPmax and SPmin) were assessed in 50 (29 men and 21 women) healthy subjects (mean age 44.8 years, range 22-74 years) using intraclass correlation coefficients (ICC), standard error of measurement (SEM) and smallest real difference (SRD). RESULTS The high ICC values and lower SEM and SRD values indicate a good intra- and inter-investigator reliability for motor threshold (ICC range 0.94-0.98), MEP latency (ICC range 0.79-0.93), SPmax (ICC range 0.89-0.95) and SPmin (ICC range 0.79-0.81) in healthy subjects. CONCLUSIONS These results suggest that the TMS-related measurements investigated are reliable in healthy subjects. SIGNIFICANCE These data could be useful in further studies on cortical excitability changes, such as those induced by therapeutic interventions (e.g. rehabilitative treatment).

Shockwave Therapy for the Treatment of Chronic Proximal Hamstring Tendinopathy in Professional Athletes

Background: Chronic proximal hamstring tendinopathy is an overuse syndrome that is usually managed by nonoperative methods. Shockwave therapy has proved to be effective in many tendinopathies. Hypothesis: Shockwave therapy may be more effective than other nonoperative treatments for chronic proximal hamstring tendinopathy. Study Design: Randomized controlled clinical study; Level of evidence, 1. Methods: Forty professional athletes with chronic proximal hamstring tendinopathy were enrolled between February 1, 2004, and September 30, 2006. Patients were randomly assigned to receive either shockwave therapy, consisting of 2500 impulses per session at a 0.18 mJ/mm2 energy flux density without anesthesia, for 4 weeks (SWT group, n = 20), or traditional conservative treatment consisting of nonsteroidal anti-inflammatory drugs, physiotherapy, and an exercise program for hamstring muscles (TCT group, n = 20). Patients were evaluated before treatment, and 1 week and 3, 6, and 12 months after the end of treatment. The visual analog scale (VAS) score for pain and Nirschl phase rating scale (NPRS) were used as primary outcome measures. Results: The patients were observed for a mean of 10.7 months (range, 1-12 months). Six patients were lost to follow-up because they underwent a surgical intervention: 3 (all in TCT group) were lost at 3 months; 2 (1 in each group), at 6 months; and 1 (in the TCT group), at 12 months. Primary follow-up was at 3 months after the beginning of treatment. The VAS scores in the SWT and TCT groups were 7 points before treatment (P = .84), and 2 points and 5 points, respectively, 3 months after treatment (P < .001). The NPRS scores in the SWT and TCT groups were 5 points in either group before treatment (P = .48), and 2 points and 6 points, respectively, 3 months after treatment (P < .001). At 3 months after treatment, 17 of the 20 patients (85%) in the SWT group and 2 of the 20 patients (10%) in the TCT group achieved a reduction of at least 50% in pain (P < .001). There were no serious complications in the SWT group. Conclusion: Shockwave therapy is a safe and effective treatment for patients with chronic proximal hamstring tendinopathy.

Quality of life in patients with Charcot-Marie-Tooth disease.

The authors evaluated quality of life in Charcot–Marie–Tooth disease by administering the Medical Outcome Study Short Form-36 (SF-36) questionnaire to 121 Italian patients. Patients scored lower on all of the SF-36 scales compared with Italian normative data. Scores were lower in nonworking vs working patients, women vs men, and older vs younger patients, but not between patients with demyelinating vs axonal forms or between patients who had undergone orthopedic foot surgery vs those who had not.

Robot-Assisted Gait Training in Patients With Parkinson Disease A Randomized Controlled Trial

Background. Gait impairment is a common cause of disability in Parkinson disease (PD). Electromechanical devices to assist stepping have been suggested as a potential intervention. Objective. To evaluate whether a rehabilitation program of robot-assisted gait training (RAGT) is more effective than conventional physiotherapy to improve walking. Methods. A total of 41 patients with PD were randomly assigned to 45-minute treatment sessions (12 in all), 3 days a week, for 4 consecutive weeks of either robotic stepper training (RST; n = 21) using the Gait Trainer or physiotherapy (PT; n = 20) with active joint mobilization and a modest amount of conventional gait training. Participants were evaluated before, immediately after, and 1 month after treatment. Primary outcomes were 10-m walking speed and distance walked in 6 minutes. Results. Baseline measures revealed no statistical differences between groups, but the PT group walked 0.12 m/s slower; 5 patients withdrew. A statistically significant improvement was found in favor of the RST group (walking speed 1.22 ± 0.19 m/s [P = .035]; distance 366.06 ± 78.54 m [P < .001]) compared with the PT group (0.98 ± 0.32 m/s; 280.11 ± 106.61 m). The RAGT mean speed increased by 0.13 m/s, which is probably not clinically important. Improvements were maintained 1 month later. Conclusions. RAGT may improve aspects of walking ability in patients with PD. Future trials should compare robotic assistive training with treadmill or equal amounts of overground walking practice.

Influence of Kinesio Taping applied over biceps brachii on isokinetic elbow peak torque. A placebo controlled study in a population of young healthy subjects

OBJECTIVES To investigate the effect of Kinesio Taping (KT) applied over the biceps brachii on maximal isokinetic elbow torque. DESIGN This study followed a single-blinded, placebo controlled, repeated measures design. METHODS Isokinetic eccentric and concentric elbow peak torques were evaluated without taping (NT), with KT or placebo taping (PT) in 20 healthy participants. Furthermore, all the participants were required to perform a proprioceptive task of elbow joint position sense (JPS) in the same experimental conditions. RESULTS A significant effect of taping condition was found for concentric elbow peak torque (p=0.01). Post hoc analysis revealed a statistically significant concentric elbow peak torque improvement between NT and KT (p<0.05) but not between NT and PT. As regards eccentric elbow peak torque, we found a significant effect of taping condition (p<0.0001). Significant eccentric elbow peak torque differences were observed between NT and PT (p<0.01) and between KT and PT (p<0.001), while the increase observed from NT to KT conditions failed to reach significance at a post hoc analysis. CONCLUSIONS When applied over the biceps brachii, KT increases concentric elbow peak torque in a population of healthy participants, if compared with a PT.

Intramuscular oxygen-ozone therapy in the treatment of acute back pain with lumbar disc herniation: A multicenter, randomized, double-blind, clinical trial of active and simulated lumbar paravertebral injection

Study Design. Multicenter randomized, double-blind, simulated therapy-controlled trial in a cohort of patients with acute low back pain (LBP) due to lumbar disc herniation (LDH). Objective. To assess the benefit of intramuscular-paravertebral injections of an oxygen-ozone (O2O3) mixture. Summary of Background Data. Recent findings have shown that O2O3 therapy can be used to treat LDH that fails to respond to conservative management. However, these findings are based on intradiscal/intraforaminal O2O3 injection, whereas intramuscular-paravertebral injection is the technique used most in clinical practice in Italy and other Western countries. Methods. Sixty patients suffering from acute LBP caused by LDH was randomized to an intramuscular O2O3 or control group. Patients were observed up to assess pain intensity, LBP-related disability, and drug intake (15 [V2] and 30 [V3] days after treatment started, and 2 weeks [V4], and 3 [V5] and 6 [V6] months after treatment ended). Results. A significant difference between the 2 groups in the percentage of cases who had become pain-free (61% vs. 33%, P < 0.05) was observed at V6. Patients who received O2O3 had a lower mean pain score than patients who received simulated therapy throughout the observation period. A significant improvement was observed in LBP-related disability in the study group patients when compared with the control group patients. Active O2O3 therapy was followed by a significantly lower number of days on nonsteroidal anti-inflammatory drugs at V2 and V3 and by a lower number of days at V4. No adverse events were reported. Conclusion. Treatment of LBP and sciatica is a major concern. Although the natural history of acute LBP is often self-limiting, conservative therapies are not always effective; in such cases, O2O3 intramuscular lumbar paravertebral injections, which are minimally invasive, seem to safely and effectively relieve pain, as well as reduce both disability and the intake of analgesic drugs.