OBJECTIVE:Due to the aging population, the incidence of stroke is steadily increasing. In patients with stroke outcomes, sensory, motor and cognitive problems limit the performance of activities of daily living. The development of new technologies in rehabilitation is improving the quality and efficiency of functional recovery. Hunova robotic platform (Movendo Technology, srl, Genoa, Italy) is a robotic device for functional assessment and rehabilitation of balance. The purpose of this study is to evaluate the effects of rehabilitation with Hunova on cognitive function and balance in older adults with stroke.PATIENTS AND METHODS:This is a randomized, controlled, single-blind study. Twenty-four older adults with stroke outcomes were randomized into the Hunova group (HuG), which performed a specific rehabilitation program for balance using Hunova for 12 sessions in addition to conventional rehabilitation, and the control group (CoG), which performed only conventional rehabilitation. All patients underwent a clinical cognitive, balance, quality of life and fatigue assessment, and an instrumental balance assessment with Hunova at the beginning and end of treatment.RESULTS:Statistical analysis showed significant improvements in most clinical scales in both groups. Comparing the groups, HuG showed greater improvements in executive functions, speed of information processing, attention and discrimination of multiple stimuli, static and dynamic balance and autonomy in daily activities, standing postural sway, and trunk control in static and dynamic conditions.CONCLUSIONS:Data analysis showed that elderly with stroke who underwent balance technology treatment with Hunova in combination with conventional treatment had a greater improvement in cognitive functions, balance and reduced risk of falling.

OBJECTIVE: The advent of the SARS-CoV-2 pandemic has resulted in an increase in sedentary behavior, with consequences on cardiopulmonary capacity, especially in the elderly population. Prehabilitation is a strategy usually used before a surgical procedure to improve functional capacity: however, it can be used for non-surgical patients and not in the acute phase of disease. The purpose of this study is to evaluate the effectiveness of a prehabilitation program. using telerehabilitation, in frail elderly patients with chronic heart failure. PATIENTS AND METHODS: This is a randomized, controlled, single-blind study. Fifteen patients with chronic heart failure were randomized into three groups: two active groups (telerehabilitation and in-person) and the control group. Patients in the active groups underwent a rehabilitation program divided into two 4-week periods, for 45-60 minutes per day, 2 days per week. RESULTS: In the Study Group, the quality of life significantly improved (EQoL-5D), and between the two groups a statistically significant difference in the motor dimension of SF-36 was identified. CONCLUSIONS: The telerehabilitation prehabilitation program for patients with chronic heart failure was confirmed to be effective and not inferior to a prehabilitation program performed in-person, avoiding the worsening of some domains of quality of life and motor performance, and leading to the improvement of others.

Stroke is the leading cause of disability worldwide, with a significant individual, family and economic impact. Restoring balance and a more fluid, safe and correct gait is a prerequisite for the patient to recover autonomy in activities of daily life. Furthermore, a consequence of impaired gait recovery in stroke patients is the high risk of falls, which worsens their quality of life [1]. Since many falls are predictable, early identification of the risk of falls is crucial for developing tailored interventions to prevent such falls. Recently, an instrumental fall risk assessment index was developed using the Hunova® robotic platform (Silver Index - Movendo Technology, srl, Genoa, IT) with the aim of giving an early indication of this risk using numerical data of both static and dynamic balance [2]. In order to combine an instrumental assessment of balance and walking with a clinical evaluation, the aim of this study is to evaluate the correlation between the Silver Index and gait analysis parameters in order to be able to propose more personalized rehabilitation training. We enrolled 12 stroke patients, aged between 70 and 95 years. The risk of falls evaluation was performed by Hunova® robotic platform computing the Silver Index. The gait was analyzed by an optoelectronic system with 8 infrared cameras (SMART-DX500 – BTS Bioengineering, Milan, IT). We used the Davis protocol that includes 22 markers. For each patient we calculated the mean values as well as the coefficient of variation (CV) and the multiple correlation coefficient (CMC) of spatio-temporal parameters and joint kinematic parameters. We assessed CV and CMC to quantify variability of the discrete and continuous variables, respectively [3]. We used Spearman test to calculate the correlation between the Silver Index and the gait analysis parameters. The correlation analysis shows a statistically significant correlation between the Silver Index and the stance phase of the unaffected side (%) (p=0.036, ρ=0.700) and between the Silver Index and the swing phase of the unaffected side (%) (p=0.036, ρ=-0.700). Furthermore, the Silver Index correlates with the variability of step width (p=0.007, ρ=-0.816). These preliminary results show that the risk of falling is higher in patients who have a longer stance phase of the unaffected limb and a shorter duration of the swing phase always of the unaffected limb. Furthermore, our results show that patients who fall more have less variability in step width. This could be an indication that these patients are unable to make the continuous adjustments that occur physiologically during gait and thus fail to produce dynamic adaptation during walking.

Dear Editor, We would like to thank Nakao et al1 for their interesting suggestion about our study2. In our paper, we analyzed the role of physical activity and educational/counselling training – considered as a pre-rehabilitation (prehabilitation) treatment – in older adults with chronic heart failure3. A recent meta-analysis4 showed evidence about the positive impact of exercise training on Quality of Life (QoL) in aging, and this effect is particularly relevant when they are affected by chronic heart failure. QoL represents the principal outcome of health interventions for the older adults. There are several studies investigating the association between QoL and drugs5, body composition6, physical performance7 in aging. However, little is known about the determinants of QoL in this fragile population8. For this reason, the dimension that we have decided to explore in our study is the self-perceived mental and physical health status assessed by the Mental Component Summary (MCS) and the Physical Component Summary (PCS) subscales derived from the Short Form-36 Health Survey (SF-36), as reported in methods section2. SF-36 MCS showed a not statistically significant improvement in the study group, probably due to the small sample size. In the light of these results, we tried to analyze any changes in the Mini Mental State Examination (MMSE), a more specific test of cognitive status, before and after the treatment. The MMSE was only available for some patients, not being among the tests included in the battery of scales to be administered to the entire sample before and after rehabilitation treatment, as per the methodological section2. As suggested by Nakao et al1, the observed trend of improvement leads us to consider it for carrying out further studies. Moreover, a systematic review and meta-analysis9 showed that nearly one fifth of frail older adults present with ischemic heart disease (IHD) and the same proportion of IHD elderly present with frailty. Thus, the condition of frailty can be properly considered as a significant predictor of cardiovascular diseases. Lastly, the Six Minutes Walking Test (6MWT) represents the gold standard in assessing functional capacity of patients with heart failure10. Considering the individuals evaluated in our studied, the evolution of 6MWT at baseline and after the intervention showed an improvement2, but the size of our sample does not allow data to reach a statistical significance. Moreover, 6MWT should be carefully used: it could be particularly useful in patients with severe heart failure, but it resulted less discriminating in patients with mild heart failure, so other measures should be considered in those case11. Due to the importance of the topic of prehabilitation, especially in older adults, and to the mutual relationship between motor and cognitive function, a larger sample and further studies, as recommended by authors1,2, should be performed.

OBJECTIVEPrehabilitation, intended as a multidisciplinary approach where physical training is combined with educational and counselling training, in cardiology could optimizing care, and has been shown to be able to reduce morbidity and mortality in several diseases. The present study aims to assess the effectiveness of a prehabilitation program in elderly patients (over 65) with chronic heart failure and to evaluate functional and quality indices of life.PATIENTS AND METHODSThis is randomized, single blind controlled trial. Fourteen older adult patients diagnosed with chronic heart failure were enrolled. Patients were randomly assigned into the study or the control group. Patients in the study group underwent physical training organized into 10 twice-weekly meetings, nutritional and lifestyle counseling.RESULTSIn the Study Group, the quality of life improved significantly (EQoL-5D), and between the two groups there is a statistically significant difference in the motor dimension of SF-36.CONCLUSIONSBecause of our preliminary results, prehabilitation program should be included among the management strategies of in elderly patients with chronic heart failure to better manage their disease and to improve their Quality of Life.

Background and purposeLimited data are available in the literature for upper limb impairment in multiple sclerosis (MS). This study aimed to report the distribution of values of hand grip strength (HGS), of the box and block test (BBT) and of the nine‐hole peg test (9HPT) correlated with demographic and clinical data in subjects with MS.MethodsThis study involved five Italian neurological centres. The inclusion criteria were age ≥ 18, MS diagnosis, stable disease phase, right‐hand dominance. All subjects underwent HGS, BBT and 9‐HPT evaluation.ResultsIn all, 202 subjects with MS were enrolled: 137 females; mean age 48.4 years; mean Expanded Disability Status Scale (EDSS) 4.17; mean disease duration 14.12 years; disease course 129 relapsing–remitting, 21 primary progressive and 52 secondary progressive MS subjects; mean right HGS 25.3 kg, left 23.2 kg; mean right BBT 45.7 blocks, left 44.9 blocks; mean right 9‐HPT 30.7 s, left 33.4 s. All results were statistically significantly different compared to healthy controls. HGS, BBT and 9‐HPT were associated with age, EDSS and disease duration, whilst disease course correlated with BBT and 9‐HPT. The BBT and 9‐HPT scores significantly differed according to level of disability (EDSS ≤3.0, 3.5–5.5, ≥6.0).ConclusionHand grip strength and BBT value distribution in a large MS population is reported. Correlations between HGS, BBT and 9‐HPT were generally low.

Focal muscular vibration (FMV) is a non-invasive technique that showed positive effects on spasticity of the upper limb in stroke subjects but different protocols have been proposed so the studies are not comparable and, to date, it is not clear which muscles should be treated, agonist, or antagonist muscles to obtain the better result on spasticity. The objective of this study is to evaluate the effects on spasticity of FMV on the upper limb flexor spastic muscles compared to the effects of FMV on the upper limb extensor muscles in subacute stroke patients. We treated 28 subacute stroke patients (mean age 64.28±13.79) randomized into two groups: Group A and Group B. Group A was treated by applying FMV to the flexor muscles of the upper limb, while Group B was treated by applying FMV to the extensor muscles of the upper limb. The effects on spasticity were assessed by Modified Ashworth Scale (primary outcome) and the upper limb motor function by instrumental robotic outcomes; moreover, muscle strength and pain were evaluated using Motricity Index and Numerical Rating Scale, respectively (secondary outcomes). Patients were subjected to FMV for three consecutive days and were evaluated three times: before treatment (T0), after a week (T1) and after a month (T2) from the end of treatment. Within group, analysis showed statistically significant changes over time of the MAS at the three joints (shoulder, elbow and wrist) in both groups, but post-hoc analysis showed that, only in Group A, MAS was significantly lower at T2, when compared with T0 at the shoulder and elbow. NRS, significantly changed over time only in the Group B. Motricity Index, did not change over time neither in the Group A, nor in the Group B. No statistically significant differences were detected in the between group analysis. Regarding the instrumental robotic outcomes, we detected a statistically significant reduction of the time required to complete the task (Duration) in both group a T2. In conclusion, this study highlighted how the same treatment protocol can determine an improvement in muscle tone and in the Duration to perform a task, regardless of the muscles treated, while the pain improves if we treat the agonist muscles.

The aim of this work was to determine the cumulative incidence and independent risk factors of prediabetes and type 2 diabetes (T2DM) in a well-characterized cohort of Malays in Singapore.We included 1137 participants (mean age [SD]: 55 (10) years; 53.6% female) without diabetes (DM) at baseline from the Singapore Malay Eye Study, a population-based longitudinal study with baseline (2004–2006), and follow-up (2010–2013) examinations. Prediabetes was defined as an HbA1c between 5.7% and 6.4%, with no self-reported DM history or insulin/DM medication use. T2DM was defined as a random glucose level ≥200 mg/dL or HbA1c > 6.4% or use of insulin/DM medication. Age-standardized cumulative incidence was calculated as the crude 6-year cumulative incidence standardized to Singapore's Malay population census. Multivariable modified poisson regression models were utilized to determine the risk factors of incident prediabetes and T2DM.The age-standardized 6-year cumulative incidence was 11.2% (95% CI 9.5, 13.1%) for T2DM, and 20.4% (95% CI 16.4, 25.2%) for prediabetes. Hypertension, higher body mass index (BMI) and higher Hba1c levels were associated with increased risk of T2DM, while older age and higher high density lipoprotein (HDL) cholesterol were protective (all P < 0.05). Only higher BMI and HbA1c levels were independently associated with incident prediabetes (all P ≤ 0.001).While only one in ten adult Malays developed T2DM over 6-years, one in five developed prediabetes over the same time period. Our results suggest that evidence-based interventions addressing modifiable risk factors (obesity, prediabetes, hypertension, low HDL cholesterol) are needed to delay or prevent their onset.

QoS-aware service composition aims to satisfy users’ quality of services (QoS) needs during service composition. Traditional methods simply attempt to maximize user satisfaction by provisioning the composite service instance with the best QoS. These “best-effort” methods fail to take into account that there also exist other consumers competing for the service resources and their decisions of service selection/composition can impact on QoS. Since user's QoS needs can be met once the demanded level is reached, in this paper, we propose an “on-demand” strategy for QoS-aware service composition to replace the traditional “best-effort” strategy. The service broker is introduced to facilitate implementation of this strategy: it first purchases a number of service instances for each component from providers and then provisions the composite services with different QoS classes to consumers. This paper focuses on how the broker follows the service level agreement (SLA) to provision composite services in the “on-demand” manner. This problem is formally expressed as the minimization of the QoS distance function between SLA and QoS of composite service instances, under a series of constraints. Heuristic approaches are proposed for the problem and experiments are conducted at last to verify their effectiveness and efficiency.