A novel neurocognitive rehabilitation tool in the recovery of hemiplegic hand grip after stroke: a case report.

Stroke has significant physical, psychological and social consequences. Recent rehabilitation approaches suggest that cognitive exercises with dual-task (sensory-motor) exercises positively influence the recovery and function of the hemiplegic hand grip. The purpose of this study was to describe a rehabilitation protocol involving the use of a new neurocognitive tool called "UOVO" for hand grip recovery after stroke. A 58-year-old right-handed male patient in the chronic stage of stroke, presenting with left-sided hemiparesis and marked motor deficits at the level of the left hand and forearm, was treated with the UOVO, a new rehabilitation instrument based on the neurocognitive rehabilitation theory of Perfetti. The patient was evaluated at T0 (before treatment), T1 (after treatment) and T2 (2 months of follow-up). At T2, the patient showed improvements of motor functions, shoulder, elbow and wrist spasticity, motility and performance. This case report explores the possibility of improving traditional rehabilitation through a neurocognitive approach with a dual-task paradigm (including motor and somato-sensory stimulation), specifically one involving the use of an original rehabilitation aid named UOVO, which lends itself very well to exercises proposed through the use of motor imagery. The results were encouraging and showed improvements in hemiplegic hand grip function and recovery. However, further studies, in the form of randomized controlled trials, will be needed to further explore and confirm our results.

Zika in Rio de Janeiro: Assessment of basic reproduction number and comparison with dengue outbreaks.

Zika virus infection was declared a public health emergency of international concern in February 2016 in response to the outbreak in Brazil and its suspected link with congenital anomalies. In this study, we use notification data and disease natural history parameters to estimate the basic reproduction number (R 0) of Zika in Rio de Janeiro, Brazil. We also obtain estimates of R 0 of dengue from time series of dengue cases in the outbreaks registered in 2002 and 2012 in the city, when DENV-3 and DENV-4 serotypes, respectively, had just emerged. Our estimates of the basic reproduction number for Zika in Rio de Janeiro based on surveillance notifications (R 0 = 2·33, 95% CI: 1·97-2·97) were higher than those obtained for dengue in the city (year 2002: R 0 = 1·70 [1·50-2·02]; year 2012: R 0 = 1·25 [1·18-1·36]). Given the role of Aedes aegypti as vector of both the Zika and dengue viruses, we also derive R 0 of Zika as a function of both dengue reproduction number and entomological and epidemiological parameters for dengue and Zika. Using the dengue outbreaks from previous years allowed us to estimate the potential R 0 of Zika. Our estimates were closely in agreement with our first Zika's R 0 estimation from notification data. Hence, these results validate deriving the potential risk of Zika transmission in areas with recurring dengue outbreaks. Whether transmission routes other than vector-based can sustain a Zika epidemic still deserves attention, but our results suggest that the Zika outbreak in Rio de Janeiro emerged due to population susceptibility and ubiquitous presence of Ae. aegypti.

Multidrug-resistant tuberculosis in the Amazonas State, Brazil, 2000-2011.

SETTINGS: Amazonas is facing increasing challenges in tuberculosis (TB) control, with nearly 3000 cases per year, and multidrug-resistant TB (MDR-TB) may jeopardise the TB control programme. OBJECTIVE: To assess the number of MDR-TB cases in the Amazonas and to improve estimates of the burden of TB. DESIGNS: The Brazilian National Mandatory Disease Reporting System (SINAN) and the Brazilian Epidemiological Surveillance System of Multidrug Resistance (TBMR) were searched for MDR-TB cases in the State of Amazonas from 2000 to 2011. RESULTS: Eighty-one MDR-TB cases were notified. The rates of primary MDR-TB, initial MDR-TB during the first treatment regimen and acquired MDR-TB were respectively 3.8%, 13.7% and 82.7%; 26.9% of previously treated patients had ⩾ 4 treatment cycles. The MDR-TB cases reported 263 contacts, only 35.0% of whom were examined. The cure and death rates among the 81 patients with MDR-TB were respectively 45.7% and 25.9%. CONCLUSIONS: The number of MDR-TB cases seems incompatible with the high TB prevalence in the Amazonas. Most patients were unaware of contact with TB patients. TB is endemic in the Amazonas. This highlights the need for improving resistance investigation among all TB cases.

Cost-effectiveness of tuberculosis screening and isoniazid treatment in the TB/HIV in Rio (THRio) Study.

OBJECTIVE: To estimate the incremental cost-effectiveness of tuberculosis (TB) screening and isoniazid preventive therapy (IPT) among human immunodeficiency virus (HIV) infected adults in Rio de Janeiro, Brazil. DESIGN: We used decision analysis, populated by data from a cluster-randomized trial, to project the costs (in 2010 USD) and effectiveness (in disability-adjusted life years [DALYs] averted) of training health care workers to implement the tuberculin skin test (TST), followed by IPT for TST-positive patients with no evidence of active TB. This intervention was compared to a baseline of usual care. We used time horizons of 1 year for the intervention and 20 years for disease outcomes, with all future DALYs and medical costs discounted at 3% per year. RESULTS: Providing this intervention to 100 people would avert 1.14 discounted DALYs (1.57 undiscounted DALYs). The median estimated incremental cost-effectiveness ratio was $2273 (IQR $1779-$3135) per DALY averted, less than Brazil's 2010 per capita gross domestic product (GDP) of $11,700. Results were most sensitive to the cost of providing the training. CONCLUSION: Training health care workers to screen HIV-infected adults with TST and provide IPT to those with latent tuberculous infection can be considered cost-effective relative to the Brazilian GDP per capita.

Cross-cultural adaptation and reliability of the Italian version of the Foot Function Index (FFI-I) for patients with plantar fasciitis.

AIM: The aim of this paper was to translate and cross-culturally adapt the FFI to the Italian language, and to assess the reliability of the Italian version of the FFI (FFI-I) for plantar fasciitis. METHODS: Fifty symptomatic patients affected by plantar fasciitis completed the FFI-I scale twice, at interval of one week. The translation of the FFI was performed according to international standards for translation of questionnaires. Test-retest reliability was evaluated using intraclass correlation coefficient (ICC). Internal consistency was measured by Cronbach α coefficient. Ceiling and floor effects were assessed. RESULTS: The process resulted in an intelligible version of the questionnaire. The reliability of the FFI-I was adequate, with an ICC ranging from 0.86 to 0.98 for test-retest reliability. The FFI-I showed an excellent internal consistency, ranging from 0.93 to 0.99 for all subscales. Three items involving disability and four items involving activities restrictions had highest proportion of floor score. CONCLUSION: The FFI-I is a reliable and valid instrument to assess clinical severity in patients with plantar fasciitis and it is suitable for daily practice. We suggest evaluating the total FFI-I score along with the distinct scores of the three subscales of the FFI-I in order to interpret more correctly minor changes in patient status during repetitive outcome assessments.

Why evidence-based medicine is an insufficient approach to physical and rehabilitation medicine. Antithesis.

When philosophers of science demolished the myth of objectivity in the early decades of the 20th century, they undermined the theoretical certainty that a knowledge system comes from the cumulative development of scientific observations: here we find a criticality inherent to evidence-based medicine in relation to its claim of universality and objectivity. EBM relies on quantitative statistical models to define a treatment's effectiveness, and it has an universal character: the treatment effect is measured against the global characteristics of the general population rather than the individuals. Contemporary cognitive neuroscience takes a naturalized approach to mind and behavior, opening new inroads into investigating consciousness, motor image, bodily awareness, and intention. Common to these issues is the emphasis on the importance the person, with his or her own biology and history, as a unique and unrepeatable entity. Hence, its original aim to protect patients against arbitrary treatment notwithstanding, EBM has become largely inadequate to serve physical and rehabilitation medicine (PRM) owing to the peculiarities of its historical and narrative contents. PRM, because of its unique knowledge base, can be fully considered a science anchored in the basic sciences that underlie rehabilitation procedures. Accordingly, PRM exists within a mutual relationship with physics and biology, from which the biomedical model (well represented by EBM) originates, and is interrelated with other disciplines such as philosophy or psychology, from which the bio-psycho-social model was developed in the 1980s, leading to a comprehensive approach to health and disease. Further critical points in clinical practice include: how to translate evidence into clinical decision making; the inability to generalize experimental evidence because most studies involve selected patient samples. Despite the more than 20 years of EBM, long-established therapeutic approaches lacking scientific evidence still survive in rehabilitation. We must strive for an integrative approach to EBM, which would enable PRM, by virtue of its multifaceted theoretical and methodological approaches to persons with disability, to take the lead in redefining biomedical knowledge and, by applying this understanding, put its science into clinical practice and, perhaps, more generally, into outlining a new "ideal of science".

Chronic pain and motor imagery: a rehabilitative experience in a case report.

BACKGROUND: The "neuromatrix" theory of Melzack and the studies of Decety on motor imagery have opened the way to an alternative rehabilitation method in chronic pain. AIM: To evaluate the role of motor imagery in chronic shoulder pain rehabilitation. DESIGN: Case report. SETTING: University outpatient rehabilitation. POPULATION: A 49-year-old female with chronic shoulder pain. METHODS: Neurocognitive approach, which involves the use of a new tool called "naval battle" to achieve chronic pain relief as assessed by the Visual Analogic Scale (VAS) and McGill Pain Questionnaire (MPQ). The Shoulder Rating Questionnaire (SRQ) and Constant Scale (CS) were used to measure functional improvement. RESULTS: The results indicate significant pain relief (71%) and improvement in functionality (50%). CONCLUSION: The results seem to confirm the accuracy of the hypothesis on the genesis of chronic pain as a perceptive "discoherency" and that motor imagery can remake a coherence of afferences at central level in chronic pain. CLINICAL REHABILITATION IMPACT: The use of motor imagery in rehabilitation can be a viable alternative in chronic shoulder pain resistant to other rehabilitation protocols.

Neurocognitive therapeutic exercise improves pain and function in patients with shoulder impingement syndrome: a single-blind randomized controlled clinical trial.

BACKGROUND: Traditional rehabilitation improves pain and function in patients with shoulder impingement syndrome. Neurocognitive rehabilitation has shown to be highly effective after surgical reconstruction of the anterior cruciate ligament. However, its effects in patients with shoulder impingement syndrome have not yet been established. AIM: The aim of the study was to compare the effects of neurocognitive therapeutic exercise, based on proprioception and neuromuscular control, on pain and function in comparison to traditional therapeutic exercise in patients with shoulder impingement syndrome. DESIGN: Single-blind randomized, non-inferiority clinical trial. SETTING: Outpatient clinic of Geriatrics and Physiatrics, University Hospital. POPULATION: Forty-eight patients with shoulder impingement syndrome (Neer stage I) and pain lasting for at least three months. METHODS: Participants were randomly allocated (1:1) to either neurocognitive therapeutic exercise or traditional therapeutic exercise. Both treatments were provided one-hour session, three times a week for five weeks. The primary outcome measure was the short form of the Disability of the Arm, Shoulder and Hand Questionnaire (Quick-DASH questionnaire) for the assessment of physical ability and symptoms of the upper extremity. SECONDARY OUTCOME MEASURES: Constant-Murley shoulder outcome score for the determination of range of motion, pain and strength; American Shoulder and Elbow Surgeons Society standardized shoulder assessment form for the evaluation of physical ability in daily-living tasks; a visual analogue scale for pain assessment at rest and during movements; Likert score for the estimation of participant satisfaction. ENDPOINTS: before treatment, end of treatment, 12 and 24 weeks after the completion of each intervention for all outcome measures, except for the Likert score that was evaluated only at the end of treatment. FOLLOW-UP: 24 weeks. RESULTS: At the end of treatment and at follow-up, both treatment groups experienced improvements in all outcomes measures relative to baseline values, except for the visual analogue scale at rest that was unaffected by traditional therapeutic exercise. For all outcome measures, changes over time were greater in the neurocognitive therapeutic exercise group relative to the traditional therapeutic exercise group. The level of satisfaction with treatment was higher for participants in the neurocognitive therapeutic exercise group. CONCLUSION: Neurocognitive rehabilitation is effective in reducing pain and improving function in patients with shoulder impingement syndrome, with benefits maintained for at least 24 weeks. CLINICAL REHABILITATION IMPACT: skills and function of the shoulder can greatly benefit from neurocognitive rehabilitation.

Cryoultrasound therapy in the treatment of chronic plantar fasciitis with heel spurs. A randomized controlled clinical study.

BACKGROUND: Plantar fasciitis is one of the most common causes of pain in the inferior heel and is very frequent in some running sports. It affects up to 10% of general population and accounts for 11% to 15% of all foot pain symptomatology. Several treatments have been suggested, but there is no evidence supporting a specific conservative management strategy. AIM: Evaluation of the efficacy of combined cryoultrasound therapy on chronic plantar fasciitis with heel spurs resistant to pharmacological and instrumental therapies. DESIGN: Single-blind randomized clinical trial. POPULATION: 102 consecutive patients affected by chronic plantar fasciitis with painful symptomatology for at least 6 months, intensity of pain higher than 5 on the VAS score, presence of heel spurs, use of plantar orthoses and ineffectiveness of previous therapies. METHODS: The patients were randomized into two groups: Group A treated with cryoultrasound therapy and Group B with cryotherapy. Our protocol was based on 10 daily treatments, lasting 20 minutes. Each participant was evaluated using VAS score before (T0) the treatment and 3 months (T1), 12 months (T2) and 18 months (T3) after. Effectiveness index was calculated from T1 to T3. RESULTS: Both treatments have been found effective. The difference in pain intensity on the VAS scale between the two groups at T2 was 4.35 points in favor of Group A (IC 95% 3.75; 4.95; P<0.001), reaching the primary end point. The difference in pain intensity on the VAS scale between the two groups at T1, T2 and T3 was 3.00, 4.35 and 4.81 respectively, showing a statistically significant difference between VAS average scores at all follow-ups in favor of Group A. Scores of at least 66% at the effectiveness index were only achieved in Group A (P values <0.001). CONCLUSION: Cryoultrasound therapy could be an efficient treatment option for chronic plantar fasciitis. CLINICAL REHABILITATION IMPACT: Cryoultrasound therapy promises an effective and long-lasting clinical improvement in patients with chronic plantar fasciitis, granted its high therapeutic efficiency, patients' satisfaction, its limited cost and its short and repeatable protocol of use.

Tuberculosis control in a socially vulnerable area: a community intervention beyond DOT in a Brazilian favela.

OBJECTIVES: To evaluate the population-based impact of a comprehensive intervention to strengthen tuberculosis (TB) control in Rocinha, the largest urban slum in Rio de Janeiro, Brazil. DESIGN: In July 2003, 40 lay persons were hired and trained as community health workers to supervise treatment, implement educational activities and establish a supportive social network for anti-tuberculosis treatment. Between July 2005 and June 2008, a door-to-door active case finding campaign was conducted. Data were obtained from the Brazilian National Reporting System, which collects information from the TB notification form for every reported case. RESULTS: Between January 2001 and December 2008, 2623 TB cases were reported, 852 before and 1771 after the start of the program. Following the intervention, treatment success rates increased (67.6% vs. 83.2%, P < 0.001) and default rates dropped (17.8% vs. 5.5%, P < 0.001). Compared to the pre-intervention period, the TB case rate declined by an average of 39 cases per 100,000 population per 6 months (P = 0.003) in the post-intervention period, although this may have been due to secular trends already in place at the start of the intervention. Case rates declined from 591/100,000 in 2001 to 496/100,000 in 2008. CONCLUSION: With proper planning and effective community involvement, a successful intervention can lead to high cure rates and may contribute to a decrease in TB notification rates.

Effect of Chêneau brace on postural balance in adolescent idiopathic scoliosis: a pilot study.

BACKGROUND: Adolescents with idiopathic scoliosis show a postural instability compared with healthy subjects. DESIGN TYPE. Case control study. SETTING: Outpatient clinic of the Complex Operative Unit of Physical Medicine and Rehabilitation of Policlinico Umberto I Hospital. POPULATION: Thirteen patients (11 females and 2 males, mean age 13.3±1.7 years, mean Cobb angle 32±9, median Risser sign 2) and thirteen healthy adolescents (8 females and 5 males, mean age: 13.0±1.6 years) as age-matched control group were enrolled. METHODS: Postural ability of the participants was assessed with stabilometry (under open eyes and closed eyes conditions), computing sway length, sway ellipse area, and sway velocities. Static and dynamic baropodometry (open eyes only) was used to measure the limb load, and to compute: walking speed, step length, step cadence and step width. The symmetry of left and right limb values was also investigated. RESULTS: Patient's group was characterized by significantly higher postural instability than control group (P<0.05) that decreased with brace in terms of limb load symmetry (-12% in eyes open condition), sway length (-12%), velocity in anteroposterior (-16%) and latero-lateral directions (-10%). Significant correlations were found between the changes occurred when wearing Chêneau brace on load symmetry during standing and those on symmetry of gait (R>0.5, P<0.05). CONCLUSION AND CLINICAL REHABILITATION IMPACT: Our results show slight changes in terms of posture when wearing Chêneau brace according with the severity of pathology and significantly affecting gait parameters. For these reasons, use of postural balance evaluation should be objectively used to verify the efficacy of Cheneau brace on body functioning of adolescents with idiopathic scoliosis.

Entrapment neuropathies and polyneuropathies in joint hypermobility syndrome/Ehlers-Danlos syndrome.

OBJECTIVE: This study aims to investigate the involvement of the peripheral nervous system in Ehlers-Danlos syndromes/hypermobility type patients with particular attention to entrapment syndromes. METHODS: We consecutively enrolled Ehlers-Danlos syndromes/hypermobility type patients. Patients underwent clinical, neurophysiological and ultrasound evaluations. Dynamic ultrasound evaluation was also performed in healthy subjects as control group. RESULTS: Fifteen Ehlers-Danlos syndromes/hypermobility type patients and fifteen healthy subjects were enrolled. Most of patients presented tingling, numbness, cramps in their hands or feet. Clinical evaluation was normal in all patients. One patient was affected with carpal tunnel syndrome and one with ulnar nerve entrapment at elbow. One patient had an increased and hypoechoic ulnar nerve at elbow at ultrasound evaluation. Dynamic ultrasound evaluation of ulnar nerve at elbow showed, in patients, twelve subluxations and three luxations. In the control group dynamic evaluation showed one case of ulnar nerve luxation. CONCLUSION: Statistical analysis showed a significant difference in the occurrence of ulnar nerve subluxation and luxation between patients and control subjects. SIGNIFICANCE: The study shows an inconsistency between symptoms and neurophysiological and ultrasound evidences of focal or diffuse nerve involvement. The high prevalence of ulnar nerve subluxation/luxation at elbow in Ehlers-Danlos syndromes/hypermobility type patients could be explained by the presence of Osborne ligament laxity.

Neck balance system in the treatment of chronic mechanical neck pain: a prospective randomized controlled study.

BACKGROUND: Chronic mechanical neck pain (MNP) is a very common condition, that may occur in general population. There is a lack of evidence for most therapies except for exercise therapy with combining methods, whose effectiveness is still moderate. AIM: The aim of this study was to determine the effect of a novel neck balance system-Dal Monte 2(NBS-DM2) incorporated into a special cap on pain in sufferers of MNP after treatment and at three months follow-up. DESIGN: Prospective randomized controlled trial. SETTING: Outpatient clinic of the University of Rome "Foro Italico". POPULATION: Forty-five volunteers of both sexes affected by grade II MNP were enrolled. METHODS: NBS-DM2/RW (regular weight), NBS-DM2/NW (negligible weight) and Pulsed Electromagnetic Fields (PEMF) have been used for 8 weeks. Neck Disability Index (NDI), Neck Pain and Disability Scale (NDPS) questionnaires and Visual Analogic Scale (VAS) score were evaluated before, after the treatment period and 3 months after the end of treatment. RESULTS: NBS-DM2/RW compared with NBS-DM2/NW and PEMF group performed better in the reduction of the three measures at the end and at short term run (p ≤ 0.05). CONCLUSION AND CLINICAL REHABILITATION IMPACT: When applied to grade II MNP patients, NBS-DM2/RW leads to pain relief and reduction of disability. These effects persist over a short term follow-up period. PEMF therapy was found to have no significant effect on reduction of pain and disability in this study.

Perceptive rehabilitation of patients with non-specific chronic low back pain: the role of body midline. A randomized controlled trial.

BACKGROUND: Surface for perceptive rehabilitation (Su-Per treatment) is a hopeful therapeutic system in the treatment of non-specific chronic low back pain (CLBP). During treatment, some patients poorly tolerate the presence of the less elastic cones at the back midline. AIM: To assess the importance of an increased awareness of body midline through higher stimulus at interspinous line during Su-Per treatment for non-specific CLBP. DESIGN: Single-blind, randomized, controlled trial. SETTING: Outpatient academic hospital. POPULATION: Forty patients with non-specific CLBP, for at least 12 weeks before treatment. METHODS: The patients were distributed in 2 groups: Group A (20 patients) received standard Su-Per treatment; Group B (20 patients) received Su-Per treatment without higher stimulus at interspinous line. Pain was assessed using the Visual Analogue Scale and the Present Pain Intensity and Pain Rating Index of the McGill Pain Questionnaire. Disability was evaluated using the Oswestry Disability Index. RESULTS: In both groups, a significant reduction of pain and disability scores was observed at the first follow-up (end of treatment), and was maintained at later evaluations (4-weeks, and 12-weeks follow up). No significant difference was observed between the two groups in all outcome measures at all time points (P>0.05 for all). CONCLUSION: Su-Per treatment is a valid modality in a cognitive-perceptive therapeutic concept for non-specific CLBP. It does not necessarily require external stimulation of the body midline to be effective. CLINICAL REHABILITATION IMPACT: Modifying the standard distribution of the cones, without less deformable cones along interspinous line, makes the Su-Per treatment more acceptable to patients.

Cerebral venous thrombosis revealing primary sjögren syndrome: report of 2 cases.

Sjögren syndrome (SS) is an autoimmune disease of the exocrine glands, characterized by focal lymphocytic infiltration and destruction of these glands. Neurologic complications are quite common, mainly involving the peripheral nervous system (PNS). The most common central nervous system (CNS) manifestations are myelopathy and microcirculation vasculitis. However, specific diagnostic criteria for CNS SS are still lacking. We report two cases of primary SS in which the revealing symptom was cerebral venous thrombosis (CVT) in the absence of genetic or acquired thrombophilias.

Quality of life among people treated for tuberculosis and human immunodeficiency virus in Rio de Janeiro, Brazil.

We measured quality of life (QOL) among individuals receiving treatment for human immunodeficiency virus (HIV; n = 45), active tuberculosis (TB; n = 44) and both TB and HIV (n = 9) in Rio de Janeiro, Brazil. Active treated TB was associated with lower physical health (absolute decrease of 0.95 standard deviation in summary score), but not mental health, among people being treated for HIV. Visual analogue scale scores were similar across all three populations, and corresponded closely to standard disability weights used in the literature. Among patients receiving treatment, those with HIV, active TB and both conditions together appear to have similar QOL.