Rehabilitative treatment of patients with COVID-19 infection: the P.A.R.M.A. evidence based clinical practice protocol.

BACKGROUND: The impact of the SARS-CoV-2 on the National Health System (NHS) required a reorganization of the various levels of care, which also involved the rehabilitation reality. AIM OF THE WORK: A clinical practice review of the literature was conducted to provide operational-rehabilitation guidelines adapted to the local reality and to the recent corporate reorganization in the context of the COVID-19 emergency. METHODS: A practice review of the available scientific evidence was regularly conducted from the start of the COVID-19 pandemic to periodically update the clinical practice guidelines. Articles that met the following inclusion criteria were included: studies conducted on human adult subjects with COVID-19 infection, undergoing rehabilitation in any hospitalization setting. RESULTS: The results of this clinical practice update were periodically discussed with colleagues and collaborators in a multi-professional team, in order to guarantee a good clinical practice protocol, named P.A.R.M.A. CONCLUSIONS: The P.A.R.M.A. protocol is the result of a periodic review literature update, which has allowed us to take charge of patients affected by COVID-19 according to the most up-to-date clinical evidences, guaranteeing a shared and uniform treatment within a local reality in an era of health emergency.

Sensory modulation of voluntary and TMS-induced activation in hand muscles.

Nociceptive suppression of tonic voluntary electromyographic (EMG) activity in human hand muscles (cutaneous silent period, CSP) is in its functional organization consistent with a spinal protective reflex. Motoneuronal excitability and its modulation may also be investigated by conditioned motor evoked potentials (MEPs). To date, effects of exteroceptive stimuli on tonic EMG and on MEPs have been compared mainly using innocuous stimuli, while noxious stimuli have not been studied in great detail. In ten subjects, we recorded CSPs induced in volitionally activated flexor pollicis brevis muscle (FPB) by noxious digit II (D2) stimulation, and in first dorsal interosseous muscle (FDI) following noxious D2 and digit V (D5) stimulation. Then, transcranial magnetic stimulation (TMS) was used to evoke MEPs in the same hand muscles at rest--conditioned by equal noxious D2 or D5 stimulation and individually delayed--so that the MEPs occurred at times corresponding to immediately before, during, and immediately after the CSP in each subject. Immediately before the CSP, there was no significant difference between nociceptive MEP modulation and tonic EMG modulation in any muscle-finger-combination. In the middle of the CSP, noxious finger stimulation exerted suppression of TMS-induced MEPs in all the three muscle-finger-combinations, but less so as compared to corresponding tonic EMG levels. After the CSP, MEPs remained suppressed when corresponding tonic EMG levels were significantly enhanced. Notably, MEPs were also suppressed in cases when occurring at times corresponding to the excitatory long-loop reflex. Incomplete MEP suppression during the CSP may allow for an "emergency grip" even during noxious stimulation. MEP suppression outlasting the CSP is compatible with a "passive" re-synchronization of volitionally activated motor units rather than an "active" reflex involving recruitment of corticospinal motoneurons. The differences in tonic EMG and MEP modulation favors an effect of noxious digital nerve stimulation on interneurons responsible for presynaptic inhibition rather than a postsynaptic inhibitory effect on the motoneuron pool. The present findings caution against the use of nociceptive MEP modulation at rest to substitute for tonic EMG modulation as tested in CSP studies.