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In 2017, the Committee for Classification of Vestibular Disorders of the Barany Society unified four dizziness disorders under the definition of persistent postural perceptual dizziness (PPPD). Currently, the efficacy of vestibular training (VR) in treating patients with PPPD is still under debate. The aim of this scoping review is to evaluate the possible clinical application of VR alone or in combination with other therapy in patients with PPPD. Electronic databases searched in May 2021 were PubMed/MEDLINE, Cochrane Library and Physiotherapy Evidence Database and the data selection was conducted in accordance with the PRISMA-ScR extension for scoping reviews. Electronic searches identified 41 studies and after the selection process 7 studies met the inclusion criteria and were included. We reported a narrative summary of results and presented the overall clinical parameters and outcomes of all included studies in a tabular format. An accurate instrumental assessment of the vestibular function is needed to guide the clinical reasoning in the management of patients with PPPD. Considering the lack of RCTs, a consensus is needed to develop a shared and robust framework to find the best rehabilitative treatment for individuals with PPPD.

Purpose:The aim of this systematic review was to evaluate the clinical application potential of the video head impulse test (vHIT) in diagnosing vestibular neuritis (VN). Methods:An electronic search was conducted in the following databases: Embase, MEDLINE, ScienceDirect, Google scholar, and the Cochrane Database of Systematic Reviews. Clinical studies were included in which an evaluation was made using vHIT either alone or in combination with other tests or bedside algorithms. Evaluations that were carried out using unvalidated tools were excluded. Only studies of patients with VN (superior, inferior, or in toto) were included. Screening of titles, abstracts, full texts, and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using a modified version of the Newcastle-Ottawa scale. Results:Results were reported according to the preferred reporting items for systematic reviews and meta-analyses. Our search yielded 1309 unique records, 21 of which remained after screening titles and abstracts. Sixteen studies were included, i.e., for a total of 933 patients including 474 patients with a diagnosis of VN. Conclusions:The diagnostic value of vHIT is high for VN, as it is a high-frequency measurement tool. vHIT is a useful complement or alternative to caloric and rotational tests as an indicator of lesions of vestibular canal functioning, especially at the time of onset. This tool can provide useful clues about the clinical progress of recovery from the lesion through the value of the vestibulo ocular reflex gain and the consequent evolution of the saccade pattern, which allows the patient to stabilize vision on the retina.

Difficulties in gait and balance disorders are among the most common mobility limitations in multiple sclerosis (MS), mainly due to a damage of cerebellar circuits. Moreover, the cerebellum plays a critical role in promoting new motor tasks, which is an essential function for neurorehabilitation. In this study, we investigated the effects of cerebellar intermittent theta burst stimulation (c-iTBS), a high-frequency rTMS protocol able to increase cerebellar activity, on gait and balance in a sample of 20 hospitalized participants with MS, undergoing vestibular rehabilitation (VR), an exercise-based program primarily designed to reduce vertigo and dizziness, gaze instability, and/or imbalance and falls in MS. Patients were assigned to receive either c-iTBS or sham iTBS before being treated with VR during 2 weeks. VR consisted of two types of training: gaze stability and postural stability exercises. The primary outcome measure was the change from baseline in the Tinetti Balance and Gait scale (TBG). The secondary outcome measures were changes from baseline in Berg Balance Scale (BBS), Fatigue Severity Scale (FSS), Two Minute Walking Test (2MWT), and Timed 25-ft walk test (T25FW) scales. MS patients treated with c-iTBS-VR showed a significant improvement in the TBG as compared to patients treated with sham iTBS-VR. Moreover, MS patients in the c-iTBS groups showed better performances in the vestibular-ocular reflex exercises. Combined c-iTBS and VR improves gait and balance abilities more than standard VR treatment in MS patients with a high level of disability.

Context Patellofemoral pain syndrome (PFPS) is one of the most common determinants of knee pain. The causes of PFPS are multifactorial, and most treatment approaches are conservative. There are many kinds of therapy for this syndrome, which are based on building strength, flexibility, proprioception, and endurance. Training is functional and progression is gradual. Our hypothesis is that total-body osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) focused on the management of somatic dysfunctions could be useful for managing the pain of patients with PFPS. Objective To investigate the effect of OMTh on pain reduction in patients with PFPS. Methods This pilot study was randomized, controlled, and single-blinded with 2 months of follow-up. Qualified participants were randomly assigned to 1 of 2 groups: OMTh group or placebo group. Each participant received either 4 sessions of OMTh or 4 sessions of manual placebo intervention that consisted of passive touching without joint mobilization in a protocolled order. A visual analogue scale (VAS) was used to assess general knee pain, peripatellar pain, pain after prolonged sitting, pain during the patellar compression test, and pain during stair ascent and descent. Pain assessment was performed before the baseline (T0), second (T1), third (T2), and fourth (T3) sessions, and follow-up (T4) was performed 8 weeks after T3. Results Thirty-five participants were enrolled the study. The VAS score was significantly reduced and clinically relevant in the OMTh group after each treatment and after 2 months of follow-up. The change in the VAS score before each treatment indicates that the most improved areas at T1 compared with T0 were lumbar and sacral with improvements in 83% and 40% of patients, respectively. At T2 compared with T1, the most improved areas were cervical and sacral with improvements found in 58% and 36% of patients, respectively. The number of dysfunctions that were diagnosed decreased during the baseline to T3 period (40% change). The correlation analysis showed significant results for the dysfunction and the compression test at T2 (P=.01, ρ=0.543). Conclusion Significant differences in VAS scores were found between the OMTh and placebo groups. These findings underline how OMTh can lead to reduced pain in patients with PFPS.

Introduction:Non-specific low back pain (NS-LBP) is one of the most common musculoskeletal conditions related to medical expenses and disability. Evidence suggests that changes in motion patterns could induce trunk instability and impaired postural control. Therefore, this systematic review investigated the effects of exercise on balance in patients with NS-LBP. Evidence acquisition:A systematic review and meta-analysis were conducted. Findings were reported following the 2020 PRISMA statement and the main databases were searched for RCTs. Studies were independently screened through a standardized form and their internal validity assessed by using the Cochrane risk of bias (RoB) tool. Pooled effects were calculated at post-treatment and quality of evidence was assessed through the GRADE framework. Evidence synthesis:Twelve articles were included in the review, eight in the meta-analysis. None of the studies were judged at low RoB. There is very low quality evidence that exercise is effective in reducing Centre of Pressure (CoP) displacement [-16.99 (-27.29, -6.68); p=0.001] and in improving single-leg stance test performance [-28.7 (-48.84, -8.67); p=0.005] and dynamic balance [-4.74 (-8.02, -1.46); p=0.005]. Conversely, no significant results were observed in "ellipse area" and in "limits of stability" indexes. Other results were summarized in a qualitative synthesis. Conclusions:Exercise could be effective in improving both static and dynamic balance in patients with NS-LBP over a short-term period. However, quality of evidence was estimated as very low, hence further double-blinded, high-quality RCTs are needed to address clinical practice and research.

Introduction:The music as a powerful, and versatile stimulus for the brain, is at the date sometimes used in neurorehabilitation and proposed as a promising complementary strategy provided in combination with other therapy in individuals with neurological disorders. Different techniques and devices have been developed in the field of the music-based neurorehabilitation.Areas covered:This scoping review analyzes the current scientific literature concerning the different techniques and devices used in the music-supported neurorehabilitation, also focusing on the devices used in music-based therapies in patients with neurological disorders: 46 studies met the inclusion criteria and were included.Expert opinion:Included studies, highlight the potentiality and the versatility of the music-based therapy in the rehabilitation of neurological disorders. The variety of existing techniques allow to applied the music-based therapy in different situations and conditions. Moreover, the wide range of used devices that ranging from the simple musical instruments to the more advanced technologies, allows to develop customized exercises based on the needs of the patient. This review may be considered as a starting point to better design future RCTs that would investigate the effectiveness of music therapy on neurological disorders.

Patient’s active participation in therapy is a key component of successful rehabilitation. In fact, low participation has been shown to be a prognostic factor of poor outcome; however, participation is rarely assessed in clinical settings. The Pittsburgh Rehabilitation Participation Scale (PRPS) is a validated, quick, and accurate measure of participation, relying on clinicians’ observation, and not requiring any self-report by patients. The aim of this study was to validate an Italian version of the PRPS. Following forward and back-translation of PRPS into Italian, the translated version was validated in a total of 640 therapy sessions, related to a cohort of 32 patients admitted to an Italian hospital. It was tested for concurrent validity, finding significant correlations with Barthel Index (R > 0.58, p < 0.001) and SF-36 Physical and Mental Health (R > 0.4, p < 0.02), for predictive validity, finding significant correlation with the effectiveness of rehabilitation (R = 0.358, p = 0.045), and for inter-rater and intra-rater reliability, computing an Intra-class correlation coefficient (ICC = 0.926 and 0.756, respectively). These psychometric properties results were similar to those of the original version of this scale. The proposed PRPS can be helpful for Italian clinicians in the assessment of patient’s participation during rehabilitation.

OBJECTIVES: We retrospectively evaluated a chart review of 3,525 patients evaluated for any acute disturbance. A total of 1,504 patients with acute vestibular syndrome (AVS) received an instrumental vestibular assessment within 72 h from the onset of the symptoms evaluated using simultaneously a combination of ocular vestibular-evoked myogenic potential (oVEMPs), cervical vestibular-evoked myogenic potential (cVEMPs), video head-impulse test (vHIT), and subjective visual vertical (SVV) were included in this study. MATERIALS and METHODS: A total of 41 patients with AVS that showed a normal horizontal canal function tested with vHIT, a normal cVEMP function, unilaterally reduced or absent oVEMP n10, and an altered SVV were enrolled. RESULTS: We found that although these patients referred acute vertigo and presented spontaneous nystagmus, they showed physiological values of vHIT and a normal saccular function, as shown by symmetrical cVEMPs. CONCLUSION: Our findings support the hypothesis that a percentage of patients evaluated during an AVS using an instrumental vestibular assessment could present selective utricular macula dysfunction

Background: Balance disorders are among the most frequent reasons for consultation and referral to specialist care. Osteopathic Manipulative Treatment (OMT) can influence the proprioceptive system by inducing alterations in the proprioceptive stimuli, hence affecting postural control. Objective: The present systematic review aimed to explore the effects of OMT in managing patients with vertigo and balance disorders. Methods: MEDLINE (PubMed), ScienceDirect, and Google Scholar were searched. Clinical trials and prospective observational studies were considered. Only studies that considered OMT as the main intervention, provided alone or combined with other interventions, were included. The methodological quality of the evidence was assessed with a modified version of the Newcastle-Ottawa Scale. Results: Five studies that enrolled a total of 114 subjects met our inclusion criteria. Overall, it has been observed that there is a positive effect on balance disorders through different outcomes in all of the included studies. Only two studies (9 subjects) mentioned low to moderate adverse events after OMT. Conclusions: OMT showed weak positive effects on balance function, encouraging the connection of conventional medicine and evidence-based complementary medicine for integrative clinical practice and interprofessional work. However, full-sized adequately powered randomized trials are required to determine the effectiveness of OMT for vertigo and balance disorders.

Postural instability and fear of falling represent two major causes of decreased mobility and quality of life in cerebrovascular and neurologic diseases. In recent years, rehabilitation strategies were carried out considering a combined sensorimotor intervention and an active involvement of the patients during the rehabilitation sessions. Accordingly, new technological devices and paradigms have been developed to increase the effectiveness of rehabilitation by integrating multisensory information and augmented feedback promoting the involvement of the cognitive paradigm in neurorehabilitation. In this context, the vibrotactile feedback (VF) could represent a peripheral therapeutic input, in order to provide spatial proprioceptive information to guide the patient during task-oriented exercises. The present systematic review and metanalysis aimed to explore the effectiveness of the VF on balance and gait rehabilitation in patients with neurological and cerebrovascular diseases. A total of 18 studies met the inclusion criteria and were included. Due to the lack of high-quality studies and heterogeneity of treatments protocols, clinical practice recommendations on the efficacy of VF cannot be made. Results show that VF-based intervention could be a safe complementary sensory-motor approach for balance and gait rehabilitation in patients with neurological and cerebrovascular diseases. More high-quality randomized controlled trials are needed.

BACKGROUND A lack of evidence on the reliability limits the utility of the Sunnybrook Facial Grading System (SFGS) in individuals affected by stroke both in clinical and research settings. AIM To examine the test-retest reliability and the inter-rater reliability of the SFGS in patients affected by subacute stroke. DESIGN A repeated-assessments design (fifteen days apart) was used to examine the test-retest reliability of the SFGS. SETTING Inpatient Rehabilitation Unit. POPULATION Thirty-two inpatients with subacute stroke. METHODS Thirty-two inpatients with subacute stroke participated in the test-retest reliability study. All patients were video recorded in sitting position and uncovered face for about two minutes, in static position to evaluate symmetry at rest, then assessing symmetry of voluntary movement and synkinesis. For the inter-rater reliability, fifteen experts in neurorehabilitation were selected as raters. The facial function was assessed using the Italian version of the SFGS was used as grading system on a recorded video of each patient. The inter-rater reliability was carried out through the ICC, Intraclass Correlation Coefficient, while the intra-rater reliability was assessed comparing for each rater the scores evaluated at T0 and T1 using Wilcoxon signed-rank test. RESULTS Evaluations at T0 and T1 showed a significant correlation with a total ICC (T0+T1) of 0.901 (95% CI: 0.852-0.942; P

After a stroke event, most survivors suffer from arm paresis, poor motor control and other disabilities that make activities of daily living difficult, severely affecting quality of life and personal independence. This randomized controlled trial aimed at evaluating the efficacy of a music-based sonification approach on upper limbs motor functions, quality of life and pain perceived during rehabilitation. The study involved 65 subacute stroke individuals during inpatient rehabilitation allocated into 2 groups which underwent usual care dayweek) respectively of standard upper extremity motor rehabilitation or upper extremity treatment with sonification techniques. The Fugl-Meyer Upper Extremity Scale, Box and Block Test and the Modified Ashworth Scale were used to perform motor assessment and the McGill Quality of Life-it and the Numerical Pain Rating Scale to assess quality of life and pain. The assessment was performed at baseline, after 2 weeks, at the end of treatment and at follow-up (1 month after the end of treatment). Total scores of the Fugl-Meyer Upper Extremity Scale (primary outcome measure) and hand and wrist sub scores, manual dexterity scores of the affected and unaffected limb in the Box and Block Test, pain scores of the Numerical Pain Rating Scale (secondary outcomes measures) significantly improved in the sonification group compared to the standard of care group (time*group interaction

Gait and balance assessment in the clinical context mainly focuses on straight walking. Despite that curved trajectories and turning are commonly faced in our everyday life and represent a challenge for people with gait disorders. The adoption of curvilinear trajectories in the rehabilitation practice could have important implications for the definition of protocols tailored on individual’s needs. The aim of this study was to contribute toward the quantitative characterization of straight versus curved walking using an ecological approach and focusing on healthy and neurological populations. Twenty healthy adults (control group (CG)) and 20 patients with Traumatic Brain Injury (TBI) (9 severe, sTBI-S, and 11 very severe, sTBI-VS) performed a 10 m and a Figure-of-8 Walk Test while wearing four inertial sensors that were located on both tibiae, sternum and pelvis. Spatiotemporal and gait quality indices that were related to locomotion stability, symmetry, and smoothness were obtained. The results show that spatiotemporal, stability, and symmetry-related gait patterns are challenged by curved walking both in healthy subjects and sTBI-S, whereas no difference was displayed for sTBI-VS. The use of straight walking alone to assess gait disorders is thus discouraged, particularly in patients with good walking abilities, in favor of the adoption of complementary tests that were also based on curved paths.

Robot devices may be good candidates for neuromotor rehabilitation of people with Multiple Sclerosis, especially for treating upper extremities function limitations (76% of MS patients). The PABLO®-Tyromotion is a sensor-based device characterized by interactive therapy games with audio-visual feedback. The aim of this study was to evaluate the effects of robotic-trained motor rehabilitation as a support of the conventional neurorehabilitation, on increasing upper limbs functions of MS patients. An experimental group that performed the PABLO-Tyromotion training and a control group that performed conventional rehabilitation were compared. PABLO-Tyromotion training consisted of 40min twelve sessions of upper limb training, three times a week, in addition to the conventional therapy. All patients were evaluated before treatment (T0) and after 4 weeks of training (T1). The results showed substantial improvements in the experimental group, compared to the control group, especially regarding muscular recruitment (such as shoulder and elbow flex-extension, forearm pronation and supination, thumb and little-finger op-position) and handgrips strength (such as thumb-index grip, thumb-middle finger grip, tridigital grip). These results underline the effectiveness of robot-assisted treatment in upper limb’s recovery in patients with MS.&nbsp

Cerebrovascular diseases, including stroke, are historically considered diseases of old adults so only in a few studies has &ldquo, return to work&rdquo, (RTW) been considered as an index of rehabilitative outcome. At the moment, data on RTW in patients with stroke are highly variable: four different reviews reported the following ranges: 11&ndash, 85%, 19&ndash, 73%, 22&ndash, 53%, and 40&ndash, 45%. The absence of re-integration to work after a stroke is shown to be associated with an increase of cardiac disorders and depression, with a higher level of mortality, with social isolation and with insufficient adaptive skills. The aim of this study was to verify the effectiveness of technological treatment, performed with optic (SonicHand) and wearable (Riablo&trade, ) systems providing auditory and visual biofeedback, on RTW in patients with stroke. RTW was found to be associated with a higher independence in the activities of daily living (assessed by the Modified Barthel Index). No significant differences were found between technological versus conventional rehabilitation in terms of RTW, despite the former showing a higher odds ratio than the latter (OR = 9 vs. 6). Assistive devices were mainly used in patients who had not returned to work. Finally, quality of life was found higher in those patients who returned to work with the same conditions (work duties and time) as before stroke.

Purpose:Evaluate the potential clinical application of the Suppression Head Impulse Paradigm (SHIMP) in evaluating the vestibulo-saccadic interaction in patients with vestibular neuritis (VN). Methods:A retrospective study was performed. Fifteen patients diagnosed with unilateral VN were identified from a database of ENT vestibular clinic from January 2011 to February 2020. Medical records were reviewed to determine clinical presentation, vestibular testing results, treatment, and recovery. Results:Fifteen patients (7 left ear, 8 right ear, mean age 58.73 ± 10.73, six female) met the inclusion criteria and were enrolled in the study. Significant differences were found in the within-subjects analysis at T1 in DHI score (p = 0.001), VOR gain (p < 0.005), and in the percentages of impulses containing a SHIMPs saccade when the head is passively turned toward the affected side (p = 0.001). Conclusions:SHIMPs paradigm provides useful information about the value of vestibulo-saccadic interaction as new recovery strategies in patients with VN

Introduction:Osteopathic care may support an individual's adaptive capacity, including allostatic regulation and tissue changes in both health and disease. The palpatory findings which osteopaths claim are related to tissue changes may be linked to allostatic load. However, this putative link has not been formally investigated. Methods:We conducted a scoping review to critically appraise the relevant literature on the relationship between allostatic processes and tissue alterations. This review evaluates the use and relevance of palpatory findings in osteopathic care. We searched on PubMed, EMBASE, Cochrane library for research exploring the links between tissue adaptation, allostasis and osteopathic palpatory findings (OPF). Results:Recent studies provide insights into the role of allostatic regulation on body systems' responses related to tissue alterations. These results provide new insights into the relevance of OPF to clinical practice.Discussion:We build upon the findings of our review to propose a putative model for OPF in clinical practice. Conclusion:Although the clinical phenomena associated with OPF may be biologically plausible, it lacks the necessary underpinning research evidence. Arguably, the classical focus on the diagnosis of palpable tissue changes fails to integrate biological, social and neuropsychological aspects such as stress responses. Tissue alterations related to stress and allostatic load markers have been less studied. Tissue changes involved in the adaptive process may be useful to practitioners in the field of manual therapy, particularly in osteopathy. We propose that OPF are one of the multidimensional aspects that may inform osteopathic decision-making. However, they should be considered within a biopsychosocial perspective and taking into account concepts of allostatic load and regulation.

BACKGROUND Balance disorders are present in patients with Multiple Sclerosis and part of these disorders could be of vestibular origin. Vestibular Rehabilitation was found to be effective in improving balance in patients with central vestibular dysfunction. OBJECTIVE To investigate the clinical effects of vestibular rehabilitation on balance skills and secondly on fatigue and activity of daily living in highly disabled multiple sclerosis people. METHODS Thirty hospitalized participants with severe multiple sclerosis (EDSS 6-7) were randomly assigned to the experimental group (15 patients -9F-; mean age 50.64±11.73) and the control group (15 patients -8F-; mean age 45.77±10.91). All patients were evaluated before and after treatment with the Expanded Disability Status Scale, Barthel Index Tinetti Balance and Gait scale, Berg Balance Scale, Fatigue Severity Scale, Two Minute Walking Test and Timed 25-foot walk test. Two follow-ups (i.e., at 30 and 60 days after treatment) were carried out with Barthel Index. RESULTS Significant improvement was found in the experimental group with respect to the control group (p < 0,05) in balance, fatigue perception, activities of daily living and short distance gait. No significant improvements were found for gait endurance as measured by Two Minute Walking Test. CONCLUSIONS Four weeks of Vestibular Rehabilitation training results in less fatigue, improved balance and performance of the activities of daily living in patients with severe Multiple Sclerosis.

Background: Sleep occupies one-third of human life and is essential for health and for emotional, physical, and cognitive well-being. Poor or insufficient sleep is associated with a wide range of dysfunctions that involve different body systems, such as the endocrine, metabolic, and immune systems, thus compromising the higher cortical functions, cognitive performance, mood, and post-physical activity recovery. The present systematic review and meta-analysis aimed to explore the effectiveness of physical therapy exercises on sleep disorders in patients with neurological disorders. Our systematic review identified 10 articles that investigated the effects of physical therapy on sleep disorders in patients with neurological disorders, 6 of which were included in the meta-analysis. Results suggest that physical therapy exercises are a safe and useful strategy for managing sleep disorders in neurorehabilitation.

Background:Cerebral palsy (CP) has been defined as a nonprogressive disease of movement and posture development. Physical therapy techniques use different forms of sensory stimulation to improve neuromotor development.Aim:The aim of this study was to assess the efficacy of a vestibular stimulation training in improving motor functions in cerebral palsy.Population:Fourteen children with CP were randomly separated into two different groups in a cross-over trial.Methods:Over a period of 10 weeks, each group performed 10 sessions of 50 min of neurodevelopmental treatment (NDT) and 10 sessions of vestibular training (VR). Children were evaluated with the Gross Motor Function Measurement-88 scale, the Goal Attainment Scale and the root mean square of head accelerations.Results:A significant improvement in the GAS-score (p = .003) was noted after NDT+VR.Conclusions:Vestibular stimulation integrated with NDT proved to be an effective complementary strategy for facilitating motor functioning.

Context The substantial functional impairment associated with migraine has both physical and emotional ramifications. Mood disorders are often comorbid in patients with migraine and are known to adversely affect migraine activity. Objectives To explore the effects of osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) on pain and mood disorders in patients with high-frequency migraine. Methods Retrospective review of the medical records of patients with high-frequency migraine who were treated with OMTh at the Headache Istituto di Ricovero e Cura a Carattere Scientifico Fondazione Santa Lucia from 2011 to 2015. Clinical assessments were made using the Headache Disability Inventory (HDI), the Headache Impact Test (HIT-6), the Hamilton Depression Rating Scale (HDRS), and the State-Trait Anxiety Inventory (STAI) forms X-1 and X-2. Results Medical records of 11 patients (6 women; mean age, 47.5 [7.8] years) with a diagnosis of high-frequency migraine who participated in an OMTh program met the inclusion criteria and were included in the study. When the questionnaire scores obtained at the first visit (T0) and after 4 OMTh sessions (T1) were compared, significant improvement in scores were observed on STAI X-2 (T0: 43.18 [2.47]; T1: 39.45 [2.52]; PPP Conclusion This preliminary study revealed that patients with high-frequency migraine and comorbid mood disorders showed significant improvement after four 45-minute OMTh sessions. Further investigation into the effects of OMTh on pain and mood disorders in patients with high-frequency migraine is needed.

Background:Recently, the potential rehabilitation value of music has been examined and music-based interventions and techniques such as the Negative Mismatch (MMN) have been increasingly investigated in the neurological rehabilitation context.Objective:The aim of this study was to investigate the effectiveness of a negative mismatch-based therapy on the disability and quality of life in patients with stroke in sub-acute phase. Methods:Thirty patients with a stroke diagnosis in sub-acute phase were randomly assigned to one of two groups: Mismatch (Mg) or Control (CTRLg) group. Both groups used an innovative Android application: Temporal Musical Patterns Organisation (Te.M.P.O). The Disability Rating Scale (DRS), the Modified Barthel Index (MBI) and the Stroke Specific Quality of Life scale (SSQoL) were used at the baseline (T0) and after four weeks of training (T1), in order to assess changes over time. Results:Statistical analysis was performed using the data of 24 (Mg = 12, CTRLg = 12) subjects. The results show a major improvement of the Mg with respect to the CTRLg in all clinical scales score. Conclusion:The temporal negative mismatch-based therapy performed with the Te.M.P.O. application could be useful in improving the disability and the quality of life in stroke survivors in a sub-acute phase.

Background:Sensor-based technological therapy devices may be good candidates for neuromotor rehabilitation of people with Multiple Sclerosis (MS), especially for treating upper extremities function limitations. The sensor-based device rehabilitation is characterized by interactive therapy games with audio-visual feedback that allows training the movement of shoulders, elbows, and wrist, measuring the strength and the active range of motion of upper limb, registering data in an electronic database to quantitatively monitoring measures and therapy progress. Objective:This study aimed to investigate the effects of sensor-based motor rehabilitation in add-on to the conventional neurorehabilitation, on increasing the upper limb functions of patients with MS. Methods:Thirty patients were enrolled in the study and randomly assigned to the experimental group and the control group. The training consisting of twelve sessions of upper limb training was compared with twelve sessions of upper limb sensory-motor training, without robotic support. Both rehabilitation programs were performed for 40 minutes three times a week, for 4 weeks, in addition to conventional therapy. All patients were evaluated at the baseline (T0) and after 4 weeks of training (T1). Results:The within-subject analysis showed a statistically significant improvement in both groups, in the Modified Barthel Index and in the Rivermead Mobility Index scores and a significant improvement in Multiple Sclerosis Quality of Life-54 in the experimental. The analysis of effectiveness revealed that, compared with baseline (T0), the improvement percentage in all clinical scale scores was greater in the experimental group than the control group. Conclusions:Proposed training provides an intensive and functional-oriented rehabilitation that objectively evaluates achieved progress through exercises. Therefore, it can represent a good complementary strategy for hand rehabilitation in MS patients.

Objective:The primary aim is to verify the effectiveness of an aquatic training (AT) in inpatients with severe Traumatic Brain Injury (sTBI) on balance. The secondary aims are to explore the effects on gait, activities of daily living, and quality of life, comparing to a land-based conventional protocol. Methods:Two-arm, randomized controlled trial. Twenty inpatients with sTBI, Glasgow Coma Scale score ≤8, and Level of Cognitive Functioning ≥7 were recruited and randomly assigned to the aquatic therapy group (ATG) or to the Conventional Training Group (CTG). Patients underwent 12 individual rehabilitation sessions (3 days/week, 4 weeks), in a rehabilitation pool during the post-acute intensive neurorehabilitation. The primary outcome measure was the Berg Balance Scale (BBS). Secondary outcome measures were the Modified Barthel Index (MBI), Disability Rating Scale (DRS), Tinetti Gait Balance Scale (TBG) and Quality of Life After Brain Injury (QOLIBRI). All the evaluations were performed at the baseline and after 4 weeks of training. Results:The within-subjects analysis showed a significant improvement both in ATG and CTG in MBI, BBS, TBG, and QOLIBRI. Conclusion:Our results may support the use of AT during post-acute phase to improve motor functions and quality of life in patients with sTBI.

The cerebellum plays a critical role in promoting learning of new motor tasks, which is an essential function for motor recovery. Repetitive transcranial magnetic stimulation (rTMS) of the cerebellum can be used to enhance learning. In this study, we investigated the effects of cerebellar intermittent theta burst stimulation (c-iTBS), a high-frequency rTMS protocol, on visuo-motor learning in a sample of hemiparetic patients due to recent stroke in the territory of the contralateral middle cerebral artery. Eight stroke patients were enrolled for the purposes of the study in the chronic stage of recovery (i.e., at least 6 months after stroke). In two sessions, Patients were randomly assigned to treatment with real or sham c-iTBS applied over the cerebellar hemisphere ipsilateral to the affected body side. c-iTBS was applied immediately before the learning phase of a visuo-motor adaptation task. Real, but not sham, c-iTBS improved visuo-motor learning as revealed by an increased performance in of the learning phase of the visuo-moto adaptation task. Moreover, we also found that real but not sham c-iTBS induced a sustained improvement in the re-adaptation of the recently learned skill (i.e., when patients were re-tested after 30 min). Taken together, these data point to c-iTBS as a potential novel strategy to promote motor learning in patients with stroke.

Despite existing evidence that gait disorders are a common consequence of severe traumatic brain injury (sTBI), the literature describing gait instability in sTBI survivors is scant. Thus, the present study aims at quantifying gait patterns in sTBI through wearable inertial sensors and investigating the association of sensor-based gait quality indices with the scores of commonly administered clinical scales. Twenty healthy adults (control group, CG) and 20 people who suffered from a sTBI were recruited. The Berg balance scale, community balance and mobility scale, and dynamic gait index (DGI) were administered to sTBI participants, who were further divided into two subgroups, severe and very severe, according to their score in the DGI. Participants performed the 10 m walk, the Figure-of-8 walk, and the Fukuda stepping tests, while wearing five inertial sensors. Significant differences were found among the three groups, discriminating not only between CG and sTBI, but also for walking ability levels. Several indices displayed a significant correlation with clinical scales scores, especially in the 10 m walking and Figure-of-8 walk tests. Results show that the use of wearable sensors allows the obtainment of quantitative information about a patient&rsquo, s gait disorders and discrimination between different levels of walking abilities, supporting the rehabilitative staff in designing tailored therapeutic interventions.

Somatosensory information arising from the foot has an important role in posture as well as visual and vestibular cues. Our hypothesis is that the effects of prolonged stimulation are greater than those of short stimulation and that varying the plantar location can affect postural control. Forty healthy participants were recruited and randomly assigned to four different plantar location groups: Lateral Insert (LI), Medial Insert (MI), Disharmonious Insert (DI), and Central Insert (CI). An instrumental assessment was performed before the plantar stimulation (T0), immediately after the positioning of the inserts (T1), and after 7 days of daily stimulation (T7). A follow-up was performed 15 days after (T15). The following stabilometric parameters were considered for both open eyes (OE) and closed eyes (CE) conditions: length of the sway (L) of the Center of Pressure (CoP); CoP maximum movements in the medio-lateral (X), and antero-posterior directions (Y). Comparing the effects of different plantar insert locations, the MI and CI groups were significantly different in the follow-up measures at T15, specifically for closed eyes measures. When we compared measures across time within each location group, CI group increased measures of X and Y data at T7 compared to other assessment times (T0, T1, and T15). In both MI and LI groups, L was significantly reduced, and X significantly increased at the T7 assessment compared to the T0, T1, and T15 assessments. The prolonged use of exteroceptive plantar stimulation and the location of plantar inserts may have a role to reshape postural control.

Vestibular neuritis (VN) is one of the most common causes of acute vestibular syndrome (AVS). Quantifying the vestibulo-ocular reflex (VOR) gain by the video Head Impulse Test (vHIT) could provide useful information to diagnose VN. This study aims to retrospectively evaluate the VOR gain values during the acute and subacute stages of the VN and to correlate these values with the patients’ dizziness-related handicap. Medical record of 28 patients with VN were reviewed. Patients were assigned to two groups according to the time since the acute vestibular syndrome (AVS). One group with patients assessed within seventy-two hours since the AVS (AVSg) and one group with patients evaluated from four days to six weeks since the AVS (PAVSg). VOR gain was evaluated in all selected patients and correlated to Dizziness Handicap Inventory (DHI). Significant differences were found in the between-subjects analysis in DHI score (p= 0.000) and in the ipsilesional hVOR gain values (p= 0.001). The correlation analysis showed significant results (p= 0.017) between DHI score (40 ± 16.08) and ipsilesional VOR gain (0.54 ± 0.09) in the PAVSg. Patients evaluated within 72 h since the AVS showed anticompensatory saccades (AcS) turning the head toward the contralesional side. Patients with unilateral Superior VN (SVN) could have dissimilar hVOR gain values and DHI score according to the damage of the VIII pair of cranial nerves. AcS in the contralesional side is a sign of acute phase in patients with unilateral SVN.&nbsp

Falls in the elderly may have adverse physical, medical, psychological, social and economic consequences. Falls in older adults are a significant public health concern, especially as more than 30% of this section of the population experience one or more falls each year. To date there has been no exhaustive review that has fully captured the various aspects of this problem (epidemiology, aetiology and prevention), although there is evidence to suggest that it is an issue that deserves attention. The aim of this chapter is to analyse, through a literature review, the following aspects: risk factors for falls in the elderly, strategies to prevent them, clinical and multifactorial assessment of patients at risk of falls, and the use of technology to boost fall prevention.

Background Recent evidence supports the hypothesis that rehabilitative strategies based on sensorimotor stimulation in the neurorehabilitation of Parkinson's disease (PD) may be useful to improve gait in PD patients. Aim We supposed that sensorimotor stimulation produces modulation of anticipatory postural adjustments (APAs) arising from the supplementary motor area (SMA). We aimed to investigate the clinical and neurophysiological effects of a blindfolded balance training (BBT). Design Randomized controlled trial. Setting Italian hospital. Population Sixteen PD patients. Methods The patients were randomized in two groups, one group treated with two-weeks BBT and one group treated with two-weeks of physical therapy (PT). We assessed gait parameters (swing, stance, double stance phase of cycle gait) and neurophysiological measurement (functional connectivity between SMA and motor area M1) before and after treatments. Results We found a decrease of stance and double stance phase and increase of swing phase respect to gait cycle, in BBT group compared to PT group, paralleled by a selective modulation in functional connectivity between M1 and SMA for BBT group. Conclusions Our findings support that BBT represents a complementary rehabilitative strategy, based on visual deprivation and proprioceptive perturbation in recovery of gait in PD patients, in short time window, likely involving vestibular system and its connections with motor areas. Clinical rehabilitation impact The use of vestibular system stimulation, involving SMA-M1 circuits, may be useful to improve gait control in PD patients.

Aim. Recent evidence suggested that the use of treadmill training may improve gait parameters. Visual deprivation could engage alternative sensory strategies to control dynamic equilibrium and stabilize gait based on vestibulospinal reflexes (VSR). We aimed to investigate the efficacy of a blindfolded balance training (BBT) in the improvement of stride phase percentage reliable gait parameters in patients with Parkinson’s Disease (PD) compared to patients treated with standard physical therapy (PT).Methods. Thirty PD patients were randomized in two groups of 15 patients, one group treated with BBT during two weeks and another group treated with standard PT during eight weeks. We evaluated gait parameters before and after BBT and PT interventions, in terms of double stance, swing, and stance phase percentage.Results. BBT induced an improvement of double stance phase as revealed (decreased percentage of double stance phase during the gait cycle) in comparison to PT. The other gait parameters swing and stance phase did not differ between the two groups.Discussion. These results support the introduction of complementary rehabilitative strategies based on sensory-motor stimulation in the traditional PD patient’s rehabilitation. Further studies are needed to investigate the neurophysiological circuits and mechanism underlying clinical and motor modifications.

Background Vestibular rehabilitation (VR) consists in a customized exercise program patient-centred that includes a combination of different exercise components with the aim to promote gaze stability, improve balance and gait, and facilitate somatosensory integration. Objective The aim of this study was to investigate the effect of customized vestibular rehabilitation training on gait stability of patients with subacute stroke. Methods Twenty-five inpatients (12 M, age: 64.1±12.1 years) with diagnosis of subacute stroke were enrolled and randomized in two groups. All patients were evaluated before and after 4 weeks of training sessions. An instrumented 10-Meter Walk Test together with traditional clinical scales were used to assess VR effects. To investigate if any fall event occurred after patients' dismissal, they were followed-up at three and twelve months after dismissal. Results Higher values of walking speed and stride length were observed in the VR group. Conversely, no significant difference was found in terms of trunk stability. The results of between-group comparison highlight significant differences between the two groups for different clinical scale scores. Conclusion VR could be included into a rehabilitation program for patients with stroke for improving their gait and dynamic balance acting on their vestibular system as facilitator of recovery.

The maintenance of the upright posture during dynamic balance requires the integration of sensory inputs regulated by the brain. After a neurological event, the assessment of balance control impairments is crucial for supporting health professionals in the design of personalized rehabilitation protocols. A commonly used test to assess balance ability is the Fukuda Stepping Test (FST). However, the clinical parameters traditionally considered are not fully representative of the patient's motor ability. The purpose of this study was to devise an instrumented version of the FST (iFST) that embodies inertial sensors and allows to obtain individual motor strategy information. Twenty-seven sub-acute stroke patients and 18 healthy adults performed a repeated stepping task with closed eyes wearing five inertial sensors located on both distal tibiae and at pelvis, sternum, and head levels. From final foot position, body rotation and linear displacements were measured. A set of indices related to upper-body stability were estimated from pelvis, sternum, and head accelerations: Root Mean Square, Attenuation Coefficients, and improved Harmonic Ratio. Two additional parameters based on upper-body angular velocities were devised to assess step-by-step repeatability and inter-segment velocity variations. The results suggest that the clinical parameters do not provide enough information about the two groups' motor strategies. Conversely, five iFST parameters were identified as predictors of patients' motor ability, discriminating not only between healthy and pathological subjects, but also between different motor deficit levels within the same pathology. The iFST could be included in the clinical routine assessment of balance impairments, supporting the design of personalized treatments.

Background Pain is a very common condition in patient undergoing rehabilitation for neurological disease; however the presence of primary headaches and other cranio-facial pains, particularly when they are actually or apparently independent from the disability for which patient is undergoing rehabilitation, is often neglected. Diagnostic and therapeutic international and national guidelines, as well as tools for the subjective measure of head pain are available and should also be applied in the neurorehabilitation setting. This calls for searching the presence of head pain, independently from the rehabilitation needs, since pain, either episodic or chronic, interferes with patient performance by affecting physical and emotional status. Pain may also interfere with sleep and therefore hamper recovery. Methods In our role of task force of the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN), we have elaborated specific recommendations for diagnosing and treating head pains in patients undergoing rehabilitation for neurological diseases. Results and Conclusion In this narrative review, we describe the available literature that has been evaluated in order to define the recommendations and outline the needs of epidemiological studies concerning headache and other cranio-facial pain in neurorehabilitation.

The capacity to maintain upright balance by minimising upper body oscillations during walking, also referred to as gait stability, has been associated with a decreased risk of fall. Although it is well known that fall is a common complication after stroke, no study considered the role of both trunk and head when assessing gait stability in this population. The primary aim of this study was to propose a multi-sensor protocol to quantify gait stability in patients with subacute stroke using gait quality indices derived from pelvis, sternum, and head accelerations. Second, the association of these indices with the level of walking ability, with traditional clinical scale scores, and with fall events occurring within the six months after patients' dismissal was investigated. The accelerations corresponding to the three abovementioned body levels were measured using inertial sensors during a 10-Meter Walk Test performed by 45 inpatients and 25 control healthy subjects. A set of indices related to gait stability were estimated and clinical performance scales were administered to each patient. The amplitude of the accelerations, the way it is attenuated/amplified from lower to upper body levels, and the gait symmetry provide valuable information about subject-specific motor strategies, discriminate between different levels of walking ability, and correlate with clinical scales. In conclusion, the proposed multi-sensor protocol could represent a useful tool to quantify gait stability, support clinicians in the identification of patients potentially exposed to a high risk of falling, and assess the effectiveness of rehabilitation protocols in the clinical routine.

Dual task paradigm is a common mechanism of daily life, and it is often used for investigating the effect on cognitive processing of motor behavior.In the present study we investigate the dual task interference during walking on upright gait stability.Cross-sectional study.Inpatient neurorehabilitation unit and children neurorehabilitation unit.Eighty-five subjects were enrolled, divided into five groups: healthy young, healthy elderly, children with typical development, children with cerebral palsy and adults with stroke in subacute phase.All subjects had to walk through a pathway during which they had to hear a sound, turn the head to watch a number and verbalize it. Subjects wore an accelerometer on their lumbar spine to measure upright gait stability have been assessed by means of the Root Mean Square (RMS) of the trunk acceleration.All subjects showed a reduced speed when performing a dual task with respect to single task. This reduction was significantly different among groups (F(4,81)=12.253, P0.001, effect size 0.377). The RMS appeared to be increased along the latero-lateral axis, and reduced along the anterio-posterior and the cranio-caudal axes during the dual task walking.These accelerations were significantly related to the changes in speed that were managed in a different way in subjects affected by cerebral palsy and stroke.The information obtained in this study may be used to support specific rehabilitation techniques in subjects with poor balance ability.

Context Osteopathic manipulative therapy (OMTh; manipulative care provided by foreign-trained osteopaths) is effective in managing pain caused by a variety of clinical conditions. Nevertheless, the physiologic mechanisms at the basis of the clinical improvement are poorly understood. Objective To investigate the effects of OMTh, muscle stretching, and soft touch interventions on motor cortical excitability through a rapid-rate paired associative stimulation (PAS) protocol. Methods In this crossover study, participants underwent OMTh, muscle stretching, and soft touch interventions. A rapid-rate PAS transcranial magnetic stimulation protocol was performed immediately after each intervention session, which consisted of 600 pairs of stimuli continuously delivered to the left primary motor cortex and to the right median nerve at a rate of 5 Hz for 2 minutes. The interstimulus intervals between the peripheral stimulus and the transcranial magnetic stimulation was set at 25 milliseconds. Before and after rapid-rate PAS (immediately after and 15 minutes after), changes in the amplitude of the motor evoked potentials were measured in the right abductor pollicis brevis and the right first dorsal interosseous. Results Of the potential 15 participants initially recruited, 12 fit the inclusion criteria. Two of the 12 participants were excluded from the final analysis because of excessive artifact movements. Rapid-rate PAS induced a more pronounced, longer-lasting increase in cortical excitability in the abductor pollicis brevis muscle in patients 15 minutes after the OMTh intervention than after the muscle stretching or sham interventions (P=.016). Conclusion Results of the current study provide support for the effects of OMTh on cortical plasticity.

Increasing evidence suggests that motor rehabilitation may delay Parkinson’s disease (PD) progression. Moreover, parallel treatments in animals up-regulate brain-derived neurotrophic factor (BDNF). Thus, we investigated the effect of a motor rehabilitation protocol on PD symptoms and BDNF serum levels. Motor rehabilitation training consisted of a cycle of 20 days/month of physiotherapy divided in 3 daily sessions. Clinical data were collected at the beginning, at the end, and at 90 days follow-up. BDNF serum levels were detected by ELISA at 0, 7, 14, 21, 30, and 90 days. The follow-up period had a duration of 60 days (T30–T90). The results showed that at the end of the treatment (day 30), an improvement in extrapyramidal signs (UPDRS III; UPDRS III – Gait and Balance items), motor (6 Minute Walking Test), and daily living activities (UPDRS II; PDQ-39) was observed. BDNF levels were increased at day 7 as compared with baseline. After that, no changes in BDNF were observed during the treatment and in the successive follow-up. This study demonstrates that motor rehabilitation training is able to ameliorate PD symptoms and to increase temporarily BDNF serum levels. The latter effect may potentially contribute to the therapeutic action.

The video game-based therapy emerged as a potential valid tool in improving balance in several neurological conditions with controversial results, whereas little information is available regarding the use of this therapy in subacute stroke patients. The aim of this study was to investigate the efficacy of balance training using video game-based intervention on functional balance and disability in individuals with hemiparesis due to stroke in subacute phase. Fifty adult stroke patients participated to the study: 25 subjects were randomly assigned to balance training with Wii Fit, and the other 25 subjects were assigned to usual balance therapy. Both groups were also treated with conventional physical therapy (40 min 2 times/day). The main outcome was functional balance (Berg Balance Scale-BBS), and secondary outcomes were disability (Barthel Index-BI), walking ability (Functional Ambulation Category), and walking speed (10-meters walking test). Wii Fit training was more effective than usual balance therapy in improving balance (BBS: 53 versus 48,P=0.004) and independency in activity of daily living (BI: 98 versus 93,P=0.021). A balance training performed with a Wii Fit as an add on to the conventional therapy was found to be more effective than conventional therapy alone in improving balance and reducing disability in patients with subacute stroke.

This report examines hand hygiene practices among 171 therapists from an Italian hospital for neuromotor rehabilitation, the Fondazione Santa Lucia of Rome. Compliance with hand hygiene measures was assessed by direct observation during daily neurorehabilitative activities. This study highlights that attention to this task is generally poor among therapists. Copyright (c) 2013 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Headaches and other cranio-oro-facial pains are widely distributed in the general population. Unfortunately, there is very little evidence regarding the impact of these conditions in patients admitted to rehabilitation units, regardless of the disease or syndrome requiring rehabilitation. The availability of diagnostic and therapeutic guidelines, as well as the increasing number of data coming from controlled clinical trials, should be implemented in these patients to reduce the burden of pain and improve their global outcome. The Italian Society for Neurorehabiltation, in collaboration with the Italian Society of Physical Medicine and Rehabilitation, has promoted the Consensus Conference on Pain with the aim to foster attention on pain also in the rehabilitative field (http://www.doloreinneuroriabilitazione.it/). The working group has proposed the following recommendations: - Standard methods or criteria exist to evaluate head and cranio-facial pain in terms of intensity (B); - Standard methods exist to evaluate migraine in terms of disability (A); - It is important to evaluate the impact of cephalic and cranio-facial pain in neurorehabilitation (D); - Standard methods or criteria exist to diagnose head and cranio-facial pain (GL); - It is important to identify predictive factors associated with the development of cephalic and cranio-facial pain in association with a condition requiring neurorehabilitation (D); - Effective pharmacological treatment exists for primary headaches and for trigeminal neuralgia (GL); - Manual therapy is indicated in the management of migraine and tension-type headache (GL); - Manual therapy may be effective in TMD-associated pain (D); - Botulinum toxin A is effective in the treatment of idiopathic trigeminal neuralgia (B); - Botulinum toxin A is effective in the treatment of hemifacial spasm (B); - Topical capsaicin is effective in chronic neuropathic pain (B); - Evidence is needed to evaluate the impact of treating cephalic and cranio-facial pain on the outcome of patients undergoing neurorehabilitation (D). The recommendations are presently under evaluation by the Consensus Conference panel.