Neurorehabilitation in Multiple Sclerosis: insights into fatigue and motor function

About this work This doctoral project aims to improve the overall knowledge on the effects of neurorehabilitation in People with Multiple Sclerosis (PwMS), by providing more insights on fatigue and the relationship between fatigue and motor functional aspects. The general introduction provides background information on the main topics of this doctoral project. In the first part, the specific disease characteristics of Multiple Sclerosis are described. In the second part, the current status of fatigue and motor impairment and a focus on the management are presented. Finally, the aims and outline thesis are reported. Four studies were conducted and reported in 4 different chapters. The first study provides information about the cardiac autonomic function during rest, postural changes and exercise and the relationship between autonomic modulation of heart rate and the perceived fatigue. The second study investigates the effect of an experimental rehabilitation protocol which combines aerobic training and task oriented exercises aimed to reduce fatigue and improve upper limb impairments and function. The third study provides information about preliminary effects of a high-intensity rehabilitative multimodal training protocol carried out on a treadmill aimed at improving mobility and balance. The fourth study shows the effectiveness of functional electrical stimulation on reducing falls, improving gait kinematics and promoting energy recovery. Lastly, general conclusions, including main findings and clinical implications, are provided at the end of the doctoral thesis

Intensive Multimodal Training to Improve Gait Resistance, Mobility, Balance and Cognitive Function in Persons With Multiple Sclerosis: A Pilot Randomized Controlled Trial

Introduction: Persons with multiple sclerosis (MS) have deficits in many aspects of physical and cognitive functioning that can impact on mobility and participation in daily life. The effect of a 4 week intensive multimodal treadmill training on functional mobility, balance, executive functions and participation in persons with MS with moderate to severe disability was investigated.Methods: Thirty eight persons with MS admitted to a rehabilitation center participated in a two arm randomized 2:1 controlled trial. Participants in the experimental group received supervised intensive treadmill training including cognitive and motor dual tasks (DT-group, N = 26), 5 sessions per week and a control group received the same amount of supervised strength training (S-group, N = 12). The participants were assessed before and after the rehabilitation period with the 2 Minutes Walking Test (2MWT), speed and, static and dynamic balance measures, the Frontal Assessment Battery and the Short Form-12 questionnaire. The main hypothesis was related to the superiority of the treadmill intervention based on a greater proportion of people making a clinically relevant gain (15% increase on 2MWT) in gait resistance following treatment. ANCOVA (Analysis of covariance) models adjusting for baseline measurement of the respective outcome variable, as well as sex and age, were used to evaluate differences in efficacy for all variables. P was set at 0.05.Results: Nineteen out of 26 persons in the DT-group made a clinically relevant gain and two out of 12 in the S-Group (P = 0.001). The DT-group improved more in gait resistance, speed and mobility (P < 0.01). Balance and executive functions instead improved moderately in both groups following training while perception of health remained similar in both groups.Conclusion: A four week multimodal training on treadmill was highly effective in augmenting gait resistance and mobility in moderately to severely affected persons with MS

Electromechanical and robotic devices for gait and balance rehabilitation of children with neurological disability: a systematic review

In the last two decades, a growing interest has been focused on gait and balance robot-assisted rehabilitation in children with neurological disabilities. Robotic devices allow the implementation of intensive, task-specific training fostering functional recovery and neuroplasticity phenomena. However, limited attention has been paid to the protocols used in this research framework. This systematic review aims to provide an overview of the existing literature on robotic systems for the rehabilitation of gait and balance in children with neurological disabilities and their rehabilitation applications. The literature search was carried out independently and synchronously by three authors on the following databases: MEDLINE, Cochrane Library, PeDro, Institute of Electrical and Electronics Engineers, ScienceDirect, and Google Scholar. The data collected included three subsections referring to clinical, technical, and regulatory aspects. Thirty-one articles out of 81 found on the primary literature search were included in the systematic review. Most studies involved children with cerebral palsy. Only one-third of the studies were randomized controlled trials. Overall, 17 devices (nine end-effector systems and eight exoskeletons) were investigated, among which only 4 (24%) were bore the CE mark. Studies differ on rehabilitation protocols duration, intensity, and outcome measures. Future research should improve both rehabilitation protocols\u2019 and devices\u2019 descriptions

Development and application of Green Management in a Public Authority

The objective of this work is to present a model of "Green Management" applicable to service companies and public authorities, in order to help them take the path of sustainability, highlighting the new types of waste on which they should focus in order to be considered by the whole community, "green activities". In this article are presented the criteria applicable to each green waste applying to a case study in a Municipality of Veneto

Predictors of mobility domain of health-related quality of life after rehabilitation in Parkinson’s disease: a pilot study

Abstract Background Parkinson’s disease impacts health-related quality of life (HRQoL), however no studies inquired on predictors of HRQoL changes after rehabilitation. This study assessed the relationship between mobility domain of HRQoL measured by Parkinson’s Disease Questionnaires-39 (PDQ-39) and clinical-demographic characteristics and developed a model predicting changes after rehabilitation. Methods Subjects with Parkinson’s disease underwent rehabilitation treatment and completed the following predictors: 10-m walking test (10MWT), Timed Up and Go (TUG), Berg Balance scale (BBS), Activities-specific Balance Confidence scales (ABC), Freezing of Gait (FOGQ) and PDQ-39. Two general linear models were calculated to predict the relationship between HRQoL at baseline and to predict HRQoL changes after rehabilitation. Results Forty-two subjects (age 74.9 ± 7.3 years, Hoehn&Yahr 2.8 ± 0.6) completed the baseline evaluation. The first model (multiple R2 = 0.59, F = 5.86, P < 0.001) showed that ABC (B = − 0.51, CI = − 0.86 to 0.15, R2 = 0.41, P = 0.005) and FOGQ (B = 2.38, CI = 1.03 to 3.73, R2 = 0.07, P = 0.001) were statistically significant predictors of mobility aspect of HRQoL at baseline. Thirty seven subjects completed the rehabilitation sessions, data were entered in the second model (multiple R2 = 0.40, F = 4.24, P < 0.004) showing that gender (B = − 5.12, CI = − 9.86 to − 0.39, R2 = 0.23, P = 0.034), Hoehn&Yahr (B = 10.93, CI = + 3.27 to + 18.61, R2 = 0.22, P = 0.006) and PDQ-39 mobility at baseline (B = − 0.38, CI = − 0.63 to − 0.14, R2 = 0.55, P = 0.002) were statistically significant predictors of changes of the mobility aspect of HRQoL. Conclusions Balance confidence and Freezing of Gait are associated with the mobility aspect of HRQoL. Changes in mobility domain of HRQoL (as assessed by PDQ-39) are likely to be greater in males, in people at higher stages of the disease and in people with more severe limitation in mobility domain of HRQoL (as assessed by PDQ-39) before rehabilitation. Results might be different when considering different outcomes or different measures for the same outcome (performance mobility test instead of self-report questionnaires). Further investigations are needed to better understand other components of HRQoL in addition to mobility. Trial registration NCT02713971 registered March 8, 2016

Effect of arm cycling and task-oriented exercises on fatigue and upper limb performance in multiple sclerosis: a randomized crossover study

Rehabilitation treatments have been proven to be a viable way to reduce fatigue and upper limb impairments in people with multiple sclerosis (PwMS). Our aim was to examine which treatment has better short-term and carryover effects on fatigue and manual dexterity in multiple sclerosis population. Twenty PwMS participated in a 16-week randomized crossover study composed of 20 sessions. The participants were divided into two groups (group A and group B). Sessions containing combined arm cycling and task-oriented exercises were administered by a physical therapist in hospital setting. Each group received 20 sessions of aerobic training and task-oriented exercises and then an 8-week rest period or vice versa with group A receiving sessions first. Fatigue was assessed by using the Modified Fatigue Impact Scale (MFIS) and Motor Fatigability Index (MFI), which was assessed using an engineered glove during a fatiguing finger tapping task. To measure manual dexterity, the nine hole peg test (NHPT) and a rate of tapping at maximum velocity task (RATE-MV) were utilized. Treatment effects were assessed by t-test or Mann-Whitney test at the end of both periods checking for carryover effects. After treatment the combined (Groups A and B) between-period differences were MFIS: 5.2 (10.7) points, P = 0.05; MFI: -0.007 (&lt;0.001)Hz/s, P = 0.05 and RATE-MV: 0.2 (0.4) Hz/s, P = 0.05 in favor of the treatment period. No statistically significant between-period differences were found for the NHPT: 3.6 (25.0) s, P = 0.63. No carryover effects (P &gt; 0.05) were observed. In conclusion, sessions of arm cycling and tailored task-oriented exercises have shown to be a viable resource for treating manual dexterity and fatigue in PwMS

Validation of the Arm Profile Score in assessing upper limb functional impairments in people with multiple sclerosis

Background Although upper limb (UL) impairments are widespread in people with Multiple Sclerosis (pwMS), there is limited quantitative evidence concerning their specific features. The aim of this study is to validate a synthetic measure based on kinematic data to define the degree of deviation from a physiologic pattern during the “hand to mouth” (HTM) task. Methods Twenty pwMS (mean age 51.2 SD 11.1) years, Expanded Disability Status Scale (EDSS) score in the range 2–6.5), underwent a kinematic analysis of the HTM task using a motion capture system. Spatio-temporal parameters and synthetic indexes (Arm Variable Score, AVS and Arm Profile Score, APS) were calculated and compared with those of age-matched healthy individuals. Kinematic data were correlated with the EDSS score and clinical tests such as the Nine Hole Peg Test (NHPT) and hand-grip strength (HGS). Findings PwMS exhibit reduced velocity, increased movement duration, sway of adjusting and frequency of direction changes as well as higher APS values (15.4° vs. 8.6°, P < 0.001) with respect to controls due to alterations in trunk flexion-extension, shoulder abduction-adduction, flexion-extension and rotation and elbow flexion-extension. Moderate-to-large correlations were found between APS and EDSS (rho = 0.609, P < 0.001), NHPT (rho = 0.468, P = 0.03) and HGS (rho = − 0.627 P < 0.001). Interpretation The kinematic analysis of HTM provides useful information in quantifying UL impairments in pwMS. The APS index appears suitable to represent UL movement deviations from the physiological pattern in pwMS and to assess disease progression or effectiveness of pharmacologic and rehabilitative treatments effectiveness

Are Modular Activations Altered in Lower Limb Muscles of Persons with Multiple Sclerosis during Walking? Evidence from Muscle Synergies and Biomechanical Analysis

Background: Persons with Multiple Sclerosis frequently have gait deficits that lead to diminished activities of daily living. Identification of motoneuron activity patterns may elucidate new insight into impaired locomotor coordination and underlying neural systems. The aim of the present study was to investigate muscle synergies, identified by motor modules and their activation profiles, in persons with Multiple Sclerosis (PwMS) during walking compared to those of healthy subjects (HS), as well as, exploring relationship of muscle synergies with walking ability of PwMS. Methods: Seventeen PwMS walked at their natural speed while 12 HS walked at slower than their natural speeds in order to provide normative gait values at matched speeds (spatio-temporal, kinematic, and kinetic parameters and electromyography signals). Non-negative matrix factorization was used to identify muscle synergies from eight muscles. Pearson's correlation coefficient was used to evaluate the similarity of motor modules between PwMS and HS. To assess differences in module activations, each module's activation timing was integrated over 100% of gait cycle and the activation percentage was computed in six phases. Results: Fifty-nine% of PwMS and 58% of HS had 4 modules while the remaining of both populations had 3 modules. Module 2 (related to soleus, medial, and lateral gastrocnemius primarily involved in mid and terminal stance) and Module 3 (related to tibialis anterior and rectus femoris primarily involved in early stance, and early and late swing) were comparable across all subjects regardless of synergies number. PwMS had shorter stride length, longer double support phase and push off deficit with respect to HS (p < 0.05). The alterations of activation timing profiles of specific modules in PwMS were associated with their walking deficits (e.g., the reduction of Module 2 activation percentage index in terminal stance, PwMS 35.55 ± 13.23 vs. HS 50.51 ± 9.13% p < 0.05, and the push off deficit, PwMS 0.181 ± 0.136 vs. HS 0.291 ± 0.062 w/kg p < 0.05). Conclusion: During gait PwMS have synergies numbers similar to healthy persons. Their neurological deficit alters modular control through modifications of the timing activation profiles rather than module composition. These changes were associated with their main walking impairment, muscle weakness, and prolonged double support.Italy. Ministry of Healt

Wearable Devices for Biofeedback Rehabilitation: A Systematic Review and Meta-Analysis to Design Application Rules and Estimate the Effectiveness on Balance and Gait Outcomes in Neurological Diseases

Wearable devices are used in rehabilitation to provide biofeedback about biomechanical or physiological body parameters to improve outcomes in people with neurological diseases. This is a promising approach that influences motor learning and patients’ engagement. Nevertheless, it is not yet clear what the most commonly used sensor configurations are, and it is also not clear which biofeedback components are used for which pathology. To explore these aspects and estimate the effectiveness of wearable device biofeedback rehabilitation on balance and gait, we conducted a systematic review by electronic search on MEDLINE, PubMed, Web of Science, PEDro, and the Cochrane CENTRAL from inception to January 2020. Nineteen randomized controlled trials were included (Parkinson’s n = 6; stroke n = 13; mild cognitive impairment n = 1). Wearable devices mostly provided real-time biofeedback during exercise, using biomechanical sensors and a positive reinforcement feedback strategy through auditory or visual modes. Some notable points that could be improved were identified in the included studies; these were helpful in providing practical design rules to maximize the prospective of wearable device biofeedback rehabilitation. Due to the current quality of the literature, it was not possible to achieve firm conclusions about the effectiveness of wearable device biofeedback rehabilitation. However, wearable device biofeedback rehabilitation seems to provide positive effects on dynamic balance and gait for PwND, but higher-quality RCTs with larger sample sizes are needed for stronger conclusions