L’efficacia della Mirror Therapy nel trattamento del dolore da arto fantasma. Una Revisione Sistematica della Letteratura.

Background. Il dolore da arto fantasma ha un forte impatto su benessere e stile di vita dei soggetti amputati. Obiettivi. Valutare l’efficacia del trattamento con mirror therapy in termini di miglioramento del dolore da arto fantasma nei pazienti amputati rispetto ad altre tipologie di trattamento o al trattamento placebo. Disegno dello studio. Revisione sistematica di efficacia. Criteri di eleggibilità. Sono stati inclusi i Trial Clinici Randomizzati in lingua inglese e italiana, che indagassero l’efficacia del trattamento con mirror therapy confrontandolo con il trattamento placebo o altri trattamenti in termini di intensità del dolore. L’outcome primario doveva essere misurato con scala NRS, VAS o altra scala specifica. Fonti di ricerca. PUBMED, PEDro, Embase, Scopus. La letteratura grigia è stata valutata tramite ricerca in Google Scholar. Risultati. Sono stati analizzati 149 articoli e al termine dell’iter di selezione 9 sono stati inclusi nella presente revisione, di cui 7 sono stati utilizzati per la metanalisi. In 7 studi, la mirror therapy produceva miglioramenti statisticamente significativi a breve termine sull’intensità del dolore. Tuttavia, i risultati della metanalisi evidenziano come sia impossibile giungere a conclusioni di certezza, a seguito dell’alta eterogeneità riscontrata nelle analisi. Alla sottoanalisi condotta con gli studi di maggior qualità metodologica l’eterogeneità diminuiva, ma il risultato di efficacia per la mirror therapy non era statisticamente significativo. Conclusioni. Sebbene la mirror therapy mostri in più studi risultati incoraggianti, la metanalisi suggerisce cautela nell’analisi di tali dati, mostrando un’elevata eterogeneità e risultati non statisticamente significativi. Ulteriori studi sono necessari per approfondire i risultati ottenuti, con campioni più ampi, una metodologia più rigorosa e modalità di erogazione del trattamento maggiormente standardizzate.

Chronic phantom limb pain: the effects of calcitonin, ketamine, and their combination on pain and sensory thresholds

BACKGROUND: Calcitonin was effective in a study of acute phantom limb pain, but it was not studied in the chronic phase. The overall literature on N-methyl-D-aspartate antagonists is equivocal. We tested the hypothesis that calcitonin, ketamine, and their combination are effective in treating chronic phantom limb pain. Our secondary aim was to improve our understanding of the mechanisms of action of the investigated drugs using quantitative sensory testing. METHODS: Twenty patients received, in a randomized, double-blind, crossover manner, 4 i.v. infusions of: 200 IE calcitonin; ketamine 0.4 mg/kg (only 10 patients); 200 IE of calcitonin combined with ketamine 0.4 mg/kg; placebo, 0.9% saline. Intensity of phantom pain (visual analog scale) was recorded before, during, at the end, and the 48 h after each infusion. Pain thresholds after electrical, thermal, and pressure stimulation were recorded before and during each infusion. RESULTS: Ketamine, but not calcitonin, reduced phantom limb pain. The combination was not superior to ketamine alone. There was no difference in basal pain thresholds between the amputated and contralateral side except for pressure pain. Pain thresholds were unaffected by calcitonin. The analgesic effect of the combination of calcitonin and ketamine was associated with a significant increase in electrical thresholds, but with no change in pressure and heat thresholds. CONCLUSIONS: Our results question the usefulness of calcitonin in chronic phantom limb pain and stress the potential interest of N-methyl-D-aspartate antagonists. Sensory assessments indicated that peripheral mechanisms are unlikely important determinants of phantom limb pain. Ketamine, but not calcitonin, affects central sensitization processes that are probably involved in the pathophysiology of phantom limb pain.

The value of adding mirror therapy for upper limb motor recovery of subacute stroke patients: a randomized controlled trial.

BACKGROUND: Upper limb paresis remains a relevant challenge in stroke rehabilitation. AIM: To evaluate if adding mirror therapy (MT) to conventional therapy (CT) can improve motor recovery of the upper limb in subacute stroke patients. DESIGN: Prospective, single-center, single-blind, randomised, controlled trial. SETTING: Subacute stroke patients referred to a Physical and Rehabilitation Medicine Unit between October 2009 and August 2011. POPULATION: Twenty-six subacute stroke patients (time from stroke <4 weeks) with upper limb paresis (Motricity Index â0/00¤ 77). METHODS: Patients were randomly allocated to the MT (N.=13) or to the CT group (N.=13). Both followed a comprehensive rehabilitative treatment. In addition, MT Group had 30 minutes of MT while the CT group had 30 minutes of sham therapy. Action Research Arm Test (ARAT) was the primary outcome measures. Motricity Index (MI) and the Functional Independence Measure (FIM) were the secondary outcome measures. RESULTS: After one month of treatment patients of both groups showed statistically significant improvements in all the variables measured (P<0.05). Moreover patients of the MT group had greater improvements in the ARAT, MI and FIM values compared to CT group (P<0.01, Glass's Î" Effect Size: 1.18). No relevant adverse event was recorded during the study. CONCLUSION: MT is a promising and easy method to improve motor recovery of the upper limb in subacute stroke patients. CLINICAL REHABILITATION IMPACT: While MT use has been advocated for acute patients with no or negligible motor function, it can be usefully extended to patients who show partial motor recovery. The easiness of implementation, the low cost and the acceptability makes this therapy an useful tool in stroke rehabilitation.

Mirror therapy in children with hemiplegia: a pilot study.

Mirror therapy, which provides the visual illusion of a functional paretic limb by using the mirror reflection of the non-paretic arm, is used in the rehabilitation of hemiparesis after stroke in adults. We tested the effectiveness and feasibility of mirror therapy in children with hemiplegia by performing a pilot crossover study in ten participants (aged 6-14 y; five males, five females; Manual Ability Classification System levels: one at level I, two at level II, four at level III, three at level IV) randomly assigned to 15 minutes of daily bimanual training with and without a mirror for 3 weeks. Assessments of maximal grasp and pinch strengths, and upper limb function measured by the Shriner's Hospital Upper Extremity Evaluation were performed at weeks 0 (baseline), 3, 6 (intervention), and 9 (wash-out). Testing of grasp strength behind the mirror improved performance by 15% (p=0.004). Training with the mirror significantly improved grasp strength (with mirror +20.4%, p=0.033; without +5.9%, p>0.1) and upper limb dynamic position (with mirror +4.6%, p=0.044; without +1.2%, p>0.1), while training without a mirror significantly improved pinch strength (with mirror +6.9%, p>0.1; without +21.9%, p=0.026). This preliminary study demonstrates the feasibility of mirror therapy in children with hemiplegia and that it may improve strength and dynamic function of the paretic arm.

Upper limb robot mediated stroke therapy - GENTLE/s approach

Stroke is a leading cause of disability in particular affecting older people. Although the causes of stroke are well known and it is possible to reduce these risks, there is still a need to improve rehabilitation techniques. Early studies in the literature suggest that early intensive therapies can enhance a patient's recovery. According to physiotherapy literature, attention and motivation are key factors for motor relearning following stroke. Machine mediated therapy offers the potential to improve the outcome of stroke patients engaged on rehabilitation for upper limb motor impairment. Haptic interfaces are a particular group of robots that are attractive due to their ability to safely interact with humans. They can enhance traditional therapy tools, provide therapy "on demand" and can present accurate objective measurements of a patient's progression. Our recent studies suggest the use of tele-presence and VR-based systems can potentially motivate patients to exercise for longer periods of time. The creation of human-like trajectories is essential for retraining upper limb movements of people that have lost manipulation functions following stroke. By coupling models for human arm movement with haptic interfaces and VR technology it is possible to create a new class of robot mediated neuro rehabilitation tools. This paper provides an overview on different approaches to robot mediated therapy and describes a system based on haptics and virtual reality visualisation techniques, where particular emphasis is given to different control strategies for interaction derived from minimum jerk theory and the aid of virtual and mixed reality based exercises.

Modelling human dynamics in-situ for rehabilitation and therapy robots

This paper outlines some rehabilitation applications of manipulators and identifies that new approaches demand that the robot make an intimate contact with the user. Design of new generations of manipulators with programmable compliance along with higher level controllers that can set the compliance appropriately for the task, are both feasible propositions. We must thus gain a greater insight into the way in which a person interacts with a machine, particularly given that the interaction may be non-passive. We are primarily interested in the change in wrist and arm dynamics as the person co-contracts his/her muscles. It is observed that this leads to a change in stiffness that can push an actuated interface into a limit cycle. We use both experimental results gathered from a PHANToM haptic interface and a mathematical model to observe this effect. Results are relevant to the fields of rehabilitation and therapy robots, haptic interfaces, and telerobotics

Advances in upper limb stroke rehabilitation: a technology push

Strokes affect thousands of people worldwide leaving sufferers with severe disabilities affecting their daily activities. In recent years, new rehabilitation techniques have emerged such as constraint-induced therapy, biofeedback therapy and robot-aided therapy. In particular, robotic techniques allow precise recording of movements and application of forces to the affected limb, making it a valuable tool for motor rehabilitation. In addition, robot-aided therapy can utilise visual cues conveyed on a computer screen to convert repetitive movement practice into an engaging task such as a game. Visual cues can also be used to control the information sent to the patient about exercise performance and to potentially address psychosomatic variables influencing therapy. This paper overviews the current state-of-the-art on upper limb robot-mediated therapy with a focal point on the technical requirements of robotic therapy devices leading to the development of upper limb rehabilitation techniques that facilitate reach-to-touch, fine motor control, whole-arm movements and promote rehabilitation beyond hospital stay. The reviewed literature suggest that while there is evidence supporting the use of this technology to reduce functional impairment, besides the technological push, the challenge ahead lies on provision of effective assessment of outcome and modalities that have a stronger impact transferring functional gains into functional independence.

Mastication Movements And Sleep Quality Of Patients With Myofascial Pain: Occlusal Device Therapy Improvements.

Patients with myofascial pain experience impaired mastication, which might also interfere with their sleep quality. The purpose of this study was to evaluate the jaw motion and sleep quality of patients with myofascial pain and the impact of a stabilization device therapy on both parameters. Fifty women diagnosed with myofascial pain by the Research Diagnostic Criteria were enrolled. Pain levels (visual analog scale), jaw movements (kinesiography), and sleep quality (Epworth Sleepiness Scale; Pittsburgh Sleep Quality Index) were evaluated before (control) and after stabilization device use. Range of motion (maximum opening, right and left excursions, and protrusion) and masticatory movements during Optosil mastication (opening, closing, and total cycle time; opening and closing angles; and maximum velocity) also were evaluated. Repeated-measures analysis of variance in a generalized linear mixed models procedure was used for statistical analysis (α=.05). At baseline, participants with myofascial pain showed a reduced range of jaw motion and poorer sleep quality. Treatment with a stabilization device reduced pain (P<.001) and increased both mouth opening (P<.001) and anteroposterior movement (P=.01). Also, after treatment, the maximum opening (P<.001) and closing (P=.04) velocities during mastication increased, and improvements in sleep scores for the Pittsburgh Sleep Quality Index (P<.001) and Epworth Sleepiness Scale (P=.04) were found. Myofascial pain impairs jaw motion and quality of sleep; the reduction of pain after the use of a stabilization device improves the range of motion and sleep parameters.

Role of physical exercise in low back pain rehabilitation: a randomized controlled trial of a three-month exercise program in patients who have completed multidisciplinary rehabilitation.

STUDY DESIGN: Randomized controlled trial with 1-year follow-up. OBJECTIVE: To analyze the effects of an exercise program or routine follow-up on patients with chronic low back pain who have completed functional multidisciplinary rehabilitation. The short- and long-term outcome in terms of symptoms and physical and social functioning was compared. SUMMARY OF BACKGROUND DATA: Systematic reviews have shown that functional multidisciplinary rehabilitation improves physical function and reduces pain in patients with chronic low back pain. However, long-term maintenance of these improvements is inconsistent and the role of exercise in achieving this goal is unclear. METHODS: One hundred five chronic patients with low back pain who had completed a 3-week functional multidisciplinary rehabilitation program were randomized to either a 3-month exercise program (n = 56) or routine follow-up (n = 49). The exercise program consisted of 24 training sessions during 12 weeks. Patients underwent evaluations of trunk muscle endurance, cardiovascular endurance, lumbar spine mobility (flexion and extension range-of-motion, fingertip-to-floor distance), pain and perceived functional ability at the beginning and the end of functional multidisciplinary rehabilitation, at the end of the exercise program (3 months) and at 1-year follow-up. Disability was also assessed at the same time points except at the beginning of functional multidisciplinary rehabilitation. RESULTS: At the end of the functional multidisciplinary rehabilitation, both groups improved significantly in all physical parameters except flexion and extension range-of-motion. At the 3 month and 1 year follow-up, both groups maintained improvements in all parameters except for cardiovascular endurance. Only the exercise program group improved in disability score and trunk muscle endurance. No differences between groups were found. CONCLUSION: A favorable long-term outcome was observed after functional multidisciplinary rehabilitation in both patient groups. Patients who participated in an exercise program obtained some additional benefits. The relevance of these benefits to overall health status need to be further investigated.

Pain in photodynamic therapy: mechanism of action and management strategies

Photodynamic therapy involves administration of a photosensitizing drug and its subsequent activation by irradiation with a light source at wavelengths matching the absorption spectrum of the photosensitizer. In many countries around the world, topical photodynamic therapy has been approved for treatment of cutaneous oncologic conditions such as actinic keratosis, Bowen's disease, and superficial basal cell carcinoma. Multicenter, randomized, controlled studies have confirmed its efficacy and superior cosmetic outcomes compared to conventional therapies. Nevertheless, this therapeutic method presents some adverse effects, such as erythema, edema, pigmentation, pustules, and pain. There is no doubt that pain is the most severe of the adverse effects, being sometimes responsible for definitive treatment interruption. The pain mechanism has not yet been fully understood, which makes complete pain control a challenge to be conquered. In spite of that, this literature review presents some useful pain management strategies as well as the most important pain-related factors in photodynamic therapy.

MODIFICATION AND IMPLEMENTATION OF THE RPC HETEROGENEOUS THORAX PHANTOM FOR VERIFICATION OF PROTON THERAPY TREATMENT PROCEDURES

The Radiological Physics Center (RPC) provides heterogeneous phantoms that are used to evaluate radiation treatment procedures as part of a comprehensive quality assurance program for institutions participating in clinical trials. It was hypothesized that the existing RPC heterogeneous thorax phantom can be modified to assess lung tumor proton beam therapy procedures involving patient simulation, treatment planning, and treatment delivery, and could confirm agreement between the measured dose and calculated dose within 5%/3mm with a reproducibility of 5%. The Hounsfield Units (HU) for lung equivalent materials (balsa wood and cork) was measured using a CT scanner. The relative linear stopping power (RLSP) of these materials was measured. The linear energy transfer (LET) of Gafchromic EBT2 film was analyzed utilizing parallel and perpendicular orientations in a water tank and compared to ion chamber readings. Both parallel and perpendicular orientations displayed a quenching effect underperforming the ion chamber, with the parallel orientation showing an average 31 % difference and the perpendicular showing an average of 15% difference. Two treatment plans were created that delivered the prescribed dose to the target volume, while achieving low entrance doses. Both treatment plans were designed using smeared compensators and expanded apertures, as would be utilized for a patient in the clinic. Plan 1a contained two beams that were set to orthogonal angles and a zero degree couch kick. Plan 1b utilized two beams set to 10 and 80 degrees with a 15 degree couch kick. EBT2 film and TLD were inserted and the phantom was irradiated 3 times for each plan. Both plans passed the criteria for the TLD measurements where the TLD values were within 7% of the dose calculated by Eclipse. Utilizing the 5%/3mm criteria, the 3 trial average of overall pass rate was 71% for Plan 1a. The 3 trial average for the overall pass rate was 76% for Plan 1b. The trials were then analyzed using RPC conventional lung treatment guidelines set forth by the RTOG: 5%/5mm, and an overall pass rate of 85%. Utilizing these criteria, only Plan 1b passed for all 3 trials, with an average overall pass rate of 89%.

Evidence-based practice and rehabilitation: occupational therapy in Australia and New Zealand experiences

Evidence-based practice has become the dominant paradigm in the delivery of rehabilitation programme. However, occupational therapists in Australia and New Zealand have been slow in making the transition to become evidence-based practitioners. Collaboration between the university/ tertiary institute and clinical setting is one way that clinicians can be assisted with incorporating research into their practice. Two case examples are presented outlining how collaborative practice can result in improved out.. comes for all concerned.