Assessment of Axial Postural Abnormalities in Parkinsonism: Automatic Picture Analysis Software

BackgroundSoftware-based measurements of axial postural abnormalities in Parkinson's disease (PD) are the gold standard but may be time-consuming and not always feasible in clinical practice. An automatic and reliable software to accurately obtain real-time spine flexion angles according to the recently proposed consensus-based criteria would be a useful tool for both research and clinical practice. ObjectiveWe aimed to develop and validate a new software based on Deep Neural Networks to perform automatic measures of PD axial postural abnormalities. MethodsA total of 76 pictures from 55 PD patients with different degrees of anterior and lateral trunk flexion were used for the development and pilot validation of a new software called AutoPosturePD (APP); postural abnormalities were measured in lateral and posterior view using the freeware NeuroPostureApp (gold standard) and compared with the automatic measurement provided by the APP. Sensitivity and specificity for the diagnosis of camptocormia and Pisa syndrome were assessed. ResultsWe found an excellent agreement between the new APP and the gold standard for lateral trunk flexion (intraclass correlation coefficient [ICC] 0.960, IC95% 0.913-0.982, P < 0.001), anterior trunk flexion with thoracic fulcrum (ICC 0.929, IC95% 0.846-0.968, P < 0.001) and anterior trunk flexion with lumbar fulcrum (ICC 0.991, IC95% 0.962-0.997, P < 0.001). Sensitivity and specificity were 100% and 100% for detecting Pisa syndrome, 100% and 95.5% for camptocormia with thoracic fulcrum, 100% and 80.9% for camptocormia with lumbar fulcrum. ConclusionsAutoPosturePD is a valid tool for spine flexion measurement in PD, accurately supporting the diagnosis of Pisa syndrome and camptocormia

Four-week trunk-specific exercise program decreases forward trunk flexion in Parkinson's disease: A single-blinded, randomized controlled trial

INTRODUCTION: Pathological forward trunk flexion is a disabling and drug-refractory motor complication of Parkinson's disease (PD) leading to imbalance, pain, and fall-related injuries. Since it might be reversible, early and multidisciplinary management is emphasised. The primary aim was to compare the effects of a four-week trunk-specific rehabilitation program on the severity of the forward trunk flexion. The secondary aim was to compare the training effects on the motor impairments, dynamic and static balance, pain, falls, and quality of life. METHODS: 37 patients with PD (H&Y\u202f 64\u202f4) and forward trunk flexion were randomized in the experimental (n\u202f=\u202f19) or control group (n\u202f=\u202f18). The former consisted of active self-correction exercises with visual and proprioceptive feedback, passive and active trunk stabilization exercises and functional tasks. The latter consisted of joint mobilization, muscle strengthening and stretching, gait and balance exercises. Protocols lasted 4 weeks (60\u202fmin/day, 5 days/week). Before, after, and at 1-month follow-up, a blinded examiner evaluated patients using primary and secondary outcomes. The primary outcome was the forward trunk flexion severity (degree). Secondary outcomes were the UPDRS III, dynamic and static balance, pain falls, and quality of life assessment. RESULTS: The experimental group reported a significantly greater reduction in forward trunk flexion than the control group from T0 to both T1 (p\u202f=\u202f0.003) and T2 (p\u202f=\u202f0.004). The improvements in dynamic and static balance were significantly greater for the experimental group than the control group from T0 to T2 (p\u202f=\u202f0.017 and 0.004, respectively). Comparable effects were reported on the other outcomes. Pre-treatment forward trunk flexion values were highly correlated to post-treatment trunk deviation changes. CONCLUSION: The four-week trunk-specific rehabilitation training decreased the forward trunk flexion severity and increased postural control in patients with PD. NCT03741959

Robot-assisted vs. sensory integration training in treating gait and balance dysfunctions in patients with multiple sclerosis: a randomized controlled trial.

Background: Extensive research on both healthy subjects and patients with central nervous damage has elucidated a crucial role of postural adjustment reactions and central sensory integration processes in generating and "shaping" locomotor function, respectively. Whether robotic-assisted gait devices might improve these functions in Multiple sclerosis (MS) patients is not fully investigated in literature. Purpose: The aim of this study was to compare the effectiveness of end-effector robot-assisted gait training (RAGT) and sensory integration balance training (SIBT) in improving walking and balance performance in patients with MS. Methods: Twenty-two patients with MS (EDSS: 1.5-6.5) were randomly assigned to two groups. The RAGT group (n = 12) underwent end-effector system training. The SIBT group (n = 10) underwent specific balance exercises. Each patient received twelve 50-min treatment sessions (2 days/week). A blinded rater evaluated patients before and after treatment as well as 1 month post treatment. Primary outcomes were walking speed and Berg Balance Scale. Secondary outcomes were the Activities-specific Balance Confidence Scale, Sensory Organization Balance Test, Stabilometric Assessment, Fatigue Severity Scale, cadence, step length, single and double support time, Multiple Sclerosis Quality of Life-54. Results: Between groups comparisons showed no significant differences on primary and secondary outcome measures over time. Within group comparisons showed significant improvements in both groups on the Berg Balance Scale (P = 0.001). Changes approaching significance were found on gait speed (P = 0.07) only in the RAGT group. Significant changes in balance task-related domains during standing and walking conditions were found in the SIBT group. Conclusion: Balance disorders in patients with MS may be ameliorated by RAGT and by SIBT

Systematic review of outcome measures of walking training using electromechanical and robotic devices in patients with stroke

n/

Changes in locomotory functioning after repetitive locomotor training in patients affected by cerebral palsy

Purpose: The primary aim of the present randomized controlled trial was to evaluate whether repetitive locomotor training with the Gait Trainer (GT I) can improve walking speed and endurance in ambulatory children with Cerebral Palsy (CP). The secondary aim was to assess whether training can also have a positive impact on kinematic and spatiotemporal gait parameters and on daily-life disability. Relevance: The reduced gait performance in children affected by CP leads to low levels of social relationships and life quality. Recent gait rehabilitation methods in patients with neurological impairment rely on technological devices which drive the patient's gait in a body-weight support condition and emphasize the beneficial role of repetitive practice in gait rehabilitation. The rationale for these approaches derives from animal studies which have shown that repetition of gait movements may enhance spinal and supraspinal locomotor circuits. Early studies on their use in the rehabilitation of CP with patients were carried out with partial body-weight support treadmill training and robotic-assisted treadmill therapy. Several studies on a new electromechanical gait trainer (GTI) in adult patients who have experienced a stroke, have shown that training with the device may significantly improve gait performance. Despite the clinical impact of this new rehabilitative procedure, no studies have been conducted to date on its use in children with CP. Description: Eighteen patients with CP were recruited from the Developmental Age Unit, “C. Santi”, Polyfunctional Centre Don Calabria, Verona, Italy, from January to October 2009. Inclusion criteria were: bilateral lower limb (diplegic or tetraplegic) CP, age 10 to 18 years, GMFCS levels II to IV, ability to walk by themselves for at least 10 meters, keep a sitting position without assistance. Exclusion criteria were: lower limb spasticity >2 on the Modified Ashworth Scale, severe lower limb contractures. Before the start of the study, the patients were randomly assigned to an experimental (EC) or a control group (CG). The EC received 30 minutes of repetitive locomotor training with the GTI, plus 10 minutes of passive joint mobilization and stretching exercises. The CG received 40 minutes of conventional physiotherapy. Each subject underwent a total of 10 treatment sessions over a 2-week period. Evaluation: Before and after treatment and then at 1-month follow-up assessment, the patients were evaluated by the same examiner who was unaware of treatment allocation. The assessment procedures, consisting of clinical (10-meter walking test, 6-minute walking test, WEE-FIM) scale and instrumental (gait analysis) evaluations. Conclusions: Our results show that repetitive locomotor gait training with an electromechanical body-weight support machine can significantly improve gait velocity and endurance in ambulatory children with diplegic and tetraplegic CP and that the improvements can be maintained for at least 1 month post-treatment. Improvements were also seen in proximal lower limb gait kinematics and in spatiotemporal parameters (gait speed and step length). Implications: The GTI device could be a feasible instrument that can be integrated into routinely rehabilitative programs. A repetitive locomotor training program performed with this device could improve gait performance, cinematic and spatiotemporal gait parameters in children with CP

Does the Degree of Trunk Bending Predict Patient Disability, Motor Impairment, Falls, and Back Pain in Parkinson's Disease?

Background: Postural abnormalities in Parkinson's disease (PD) form a spectrum of functional trunk misalignment, ranging from a “typical” parkinsonian stooped posture to progressively greater degrees of spine deviation. Objective: To analyze the association between degree of postural abnormalities and disability and to determine cut-off values of trunk bending associated with limitations in activities of daily living (ADLs), motor impairment, falls, and back pain. Methods: The study population was 283 PD patients with ≥5° of forward trunk bending (FTB), lateral trunk bending (LTB) or forward neck bending (FNB). The degrees were calculated using a wall goniometer (WG) and software-based measurements (SBM). Logistic regression models were used to identify the degree of bending associated with moderate/severe limitation in ADLs (Movement Disorders Society Unified PD Rating Scale [MDS-UPDRS] part II ≥17), moderate/severe motor impairment (MDS-UPDRS part III ≥33), history of falls (≥1), and moderate/severe back pain intensity (numeric rating scale ≥4). The optimal cut-off was identified using receiver operating characteristic (ROC) curves. Results: We found significant associations between modified Hoehn & Yahr stage, disease duration, sex, and limitation in ADLs, motor impairment, back pain intensity, and history of falls. Degree of trunk bending was associated only with motor impairment in LTB (odds ratio [OR] 1.12; 95% confidence interval [CI], 1.03–1.22). ROC curves showed that patients with LTB of 10.5° (SBM, AUC 0.626) may have moderate/severe motor impairment. Conclusions: The severity of trunk misalignment does not fully explain limitation in ADLs, motor impairment, falls, and back pain. Multiple factors possibly related to an aggressive PD phenotype may account for disability in PD patients with FTB, LTB, and FNB

Validity of the wall goniometer as a screening tool to detect postural abnormalities in Parkinson's disease

none24INTRODUCTION: Software-based measurements of postural abnormalities in Parkinson's disease (PD) are the gold standard but may be time-consuming and not always feasible in clinical practice. Wall goniometer (WG) is an easier, quicker, and inexpensive instrument for screening patients with postural abnormalities, but no studies have investigated its validity so far. The aim of this study was to investigate the validity of the WG to measure postural abnormalities. METHODS: A total of 283 consecutive PD outpatients with ≥5° forward trunk, lateral trunk or forward neck bending (FTB, LTB, FNB, respectively) were recruited from seven centers for movement disorders. Postural abnormalities were measured in lateral and posterior view using a freeware program (gold standard) and the WG. Both angles were expressed in degrees (°). Sensitivity and specificity for the diagnosis of camptocormia, Pisa syndrome, and anterocollis were assessed. RESULTS: WG showed good to excellent agreement (intraclass correlation coefficient from 0.80 to 0.98) compared to the gold standard. Bland-Altman plots showed a mean difference between the methods from -7.4° to 0.4° with limits of agreements from -17.7° to 9.5°. Sensitivity was 100% for the diagnosis of Pisa syndrome, 95.74% for anterocollis, 76.67% for upper camptocormia, and 63.64% for lower camptocormia. Specificity was 59.57% for Pisa syndrome, 71.43% for anterocollis, 89.80% for upper camptocormia, and 100% for lower camptocormia. Overall, the WG underestimated measurements, especially in lower camptocormia with an average of -8.7° (90% of cases). CONCLUSION: WG is a valid tool for screening Pisa syndrome and anterocollis, but approximately 10° more should be added for camptocormia.openTinazzi M.; Gandolfi M.; Artusi C.A.; Lanzafame R.; Zanolin E.; Ceravolo R.; Capecci M.; Andrenelli E.; Ceravolo M.G.; Bonanni L.; Onofrj M.; Telese R.; Bertolotti C.; Polverino P.; Manganotti P.; Mazzucchi S.; Giannoni S.; Vacca L.; Stocchi F.; Casali M.; Zibetti M.; Lopiano L.; Fasano A.; Geroin C.Tinazzi, M.; Gandolfi, M.; Artusi, C. A.; Lanzafame, R.; Zanolin, E.; Ceravolo, R.; Capecci, M.; Andrenelli, E.; Ceravolo, M. G.; Bonanni, L.; Onofrj, M.; Telese, R.; Bertolotti, C.; Polverino, P.; Manganotti, P.; Mazzucchi, S.; Giannoni, S.; Vacca, L.; Stocchi, F.; Casali, M.; Zibetti, M.; Lopiano, L.; Fasano, A.; Geroin, C

Do demographic and clinical features and comorbidities affect the risk of spread to an additional body site in functional motor disorders?

The aim of this study is to assess changes in the body distribution and the semeiology of functional motor disorder (FMD) in patients who reported only one or more than one body site affected at FMD onset. Data were obtained from the Italian Registry of Functional Motor Disorders, which included patients with a diagnosis of clinically definite FMDs. The relationship between FMD features and spread to other body sites was estimated by multivariate Cox regression analysis. We identified 201 (49%) patients who reported only one body site affected at FMD onset and 209 (51%) who reported multiple body sites affected at onset. FMD spread from the initial site to another site in 43/201 (21.4%) patients over 5.7 ± 7.1 years in those with only one site affected at FMD onset; FMD spread to an another body site in 29/209 (13.8%) over 5.5 ± 6.5 years. The spread of FMD was associated with non-motor functional symptoms and psychiatric comorbidities only in the patients with one body site affected at FMD onset. Our findings provide novel insight into the natural history of FMD. The number of body sites affected at onset does not seem to have a consistent influence on the risk of spread. Furthermore, our findings suggest that psychiatric comorbidities and non-motor functional symptoms may predict the spread of FMD symptoms, at least in patients with one body site affected at onset

Functional motor phenotypes: to lump or to split?

Introduction Functional motor disorders (FMDs) are usually categorized according to the predominant phenomenology; however, it is unclear whether this phenotypic classification mirrors the underlying pathophysiologic mechanisms. Objective To compare the characteristics of patients with different FMDs phenotypes and without co-morbid neurological disorders, aiming to answer the question of whether they represent different expressions of the same disorder or reflect distinct entities. Methods Consecutive outpatients with a clinically definite diagnosis of FMDs were included in the Italian registry of functional motor disorders (IRFMD), a multicenter data collection platform gathering several clinical and demographic variables. To the aim of the current work, data of patients with isolated FMDs were extracted. Results A total of 176 patients were included: 58 with weakness, 40 with tremor, 38 with dystonia, 23 with jerks/facial FMDs, and 17 with gait disorders. Patients with tremor and gait disorders were older than the others. Patients with functional weakness had more commonly an acute onset (87.9%) than patients with tremor and gait disorders, a shorter time lag from symptoms onset and FMDs diagnosis (2.9 ± 3.5 years) than patients with dystonia, and had more frequently associated functional sensory symptoms (51.7%) than patients with tremor, dystonia and gait disorders. Patients with dystonia complained more often of associated pain (47.4%) than patients with tremor. No other differences were noted between groups in terms of other variables including associated functional neurological symptoms, psychiatric comorbidities, and predisposing or precipitating factors. Conclusions Our data support the evidence of a large overlap between FMD phenotypes

Do demographic and clinical features and comorbidities affect the risk of spread to an additional body site in functional motor disorders?

The aim of this study is to assess changes in the body distribution and the semeiology of functional motor disorder (FMD) in patients who reported only one or more than one body site affected at FMD onset. Data were obtained from the Italian Registry of Functional Motor Disorders, which included patients with a diagnosis of clinically definite FMDs. The relationship between FMD features and spread to other body sites was estimated by multivariate Cox regression analysis. We identified 201 (49%) patients who reported only one body site affected at FMD onset and 209 (51%) who reported multiple body sites affected at onset. FMD spread from the initial site to another site in 43/201 (21.4%) patients over 5.7 ± 7.1 years in those with only one site affected at FMD onset; FMD spread to an another body site in 29/209 (13.8%) over 5.5 ± 6.5 years. The spread of FMD was associated with non-motor functional symptoms and psychiatric comorbidities only in the patients with one body site affected at FMD onset. Our findings provide novel insight into the natural history of FMD. The number of body sites affected at onset does not seem to have a consistent influence on the risk of spread. Furthermore, our findings suggest that psychiatric comorbidities and non-motor functional symptoms may predict the spread of FMD symptoms, at least in patients with one body site affected at onset