Spinal cord injury (SCI) causes severe motor and sensory deficits, and there are currently no approved treatments for recovery. Nearly 70% of patients with SCI experience pathological muscle cocontraction and spasticity, accompanied by clinical signs such as patellar hyperreflexia and ankle clonus. The integration of epidural electrical stimulation (EES) of the spinal cord with rehabilitation has substantial potential to improve recovery of motor functions; however, abnormal muscle cocontraction and spasticity may limit the benefit of these interventions and hinder the effectiveness of EES in promoting functional movements. High-frequency excitation block introduced in peripheral nerve stimulation could reduce abnormal activity and lead to more physiological activation patterns. Here, we evaluated the application of high-frequency EES (HF-EES) in alleviating undesired muscular cocontraction and spasticity in two patients with motor incomplete SCI implanted with a commercial 32-channel EES paddle commonly used for pain therapy. To design custom HF-EES protocols, we first mapped the muscles targeted by different EES configurations. Our results showed that HF-EES substantially reduced patellar reflex in one participant and eliminated both patellar reflex and ankle clonus in the other participant. By combining HF-EES and low-frequency EES (LF-EES) to enhance functional movements with intensive rehabilitation, we observed notable improvements in lower limb kinematics, muscle strength, and clinical lower limb motor assessments over the trial period. This study suggests that HF-EES could be an important supplementary tool in SCI treatment, emphasizing the importance of personalized rehabilitation approaches and advanced tools to optimize EES treatments and offering hope for individuals with SCI-related motor deficits.

BACKGROUND: Lateral epicondylitis, commonly known as tennis elbow, is a prevalent musculoskeletal condition characterized by pain and functional impairment of the lateral elbow. Among conservative treatments, both acupuncture and therapeutic ultrasound are widely used, yet their comparative effectiveness remains unclear. This study aimed to evaluate the clinical outcomes of manual and electroacupuncture versus therapeutic ultrasound in patients with chronic lateral epicondylitis. METHODS: This pilot case-control study included 30 outpatients with chronic lateral epicondylitis, divided into two groups: one treated with a combination of manual acupuncture and electroacupuncture, and the other with therapeutic ultrasound. Each group received 10 treatment sessions over two weeks. Outcomes were assessed at baseline, immediately post-treatment, and at 2-and 4-weeks follow-up. The primary outcome was pain intensity measured by the Visual Analogue Scale. Secondary outcomes included functional disability (Disabilities of the Arm, Shoulder and Hand questionnaire and Patient-Rated Tennis Elbow Evaluation), grip strength, and quality of life (EuroQol-5D). Between-group comparisons were performed using the Mann-Whitney U Test. RESULTS: Both treatments led to improvements in pain and function. However, the acupuncture group showed greater reductions in pain intensity and superior gains in grip strength, particularly at short-term follow-up. No adverse events were reported in either group. CONCLUSIONS: Acupuncture, combining manual and electroacupuncture, appears to be more effective than therapeutic ultrasound in reducing pain and improving grip strength in patients with chronic lateral epicondylitis. These findings support its use as a safe and effective conservative treatment option.

BACKGROUND: Persistent non-specific neck pain (NP) is a widespread condition described as a complex biopsychosocial disorder, characterized by physical and psychological symptoms. Virtual reality (VR) shows promise in NP treatment, potentially reducing pain, kinesiophobia, and improving range of motion (ROM) and motor control. AIM: The primary aim of the study was to assess the effectiveness of VR sensorimotor training, combined with manual therapy, in reducing the level of disability in persistent non-specific NP individuals. The secondary aim was to determine if this VR-enhanced approach also contributes to improvement in overall function, pain perception and kinesiophobia. DESIGN: Monocentric, single-blind, randomized controlled trial. SETTING: We conducted this trial at San Raffaele Scientific Institute, Department of Rehabilitation and Functional Recovery, Milan, Italy. POPULATION: Forty NP participants were enrolled in the study and randomly allocated into two groups. METHODS: The study involved a 6 -week rehabilitation program, comprising 12 sessions of 45 minutes each, twice weekly. Both intervention groups underwent manual therapy as a consistent component of their treatment. The Experimental Group (VRT) was additionally engaged in sensorimotor rehabilitation exercises using Virtual Reality, whereas the Control Group (CT) performed the same exercises without VR. We assessed subjects at baseline (T0) and after six weeks of rehabilitation (T1). The primary outcome was the disability (Neck Disability Index) while the secondary outcomes were: pain perception (Numeric Rating Scale, NP and Disability Scale, Central Sensitization Inventory) function (Cervical Kinematics) and kinesiophobia (Tampa Scale of Kinesiophobia). RESULTS: Both groups demonstrated significant reduction in level of disability, pain perception, and kinesiophobia. Significant advancements in kinematics were observed: VRT group showed enhanced ROM during craniocervical rotation (P=0.039), lateral bending (P=0.001), flexionextension (P=0.009), and mean velocity across movements (P<0.001), whereas CT group improved in maximal ROM during lateral bending rotation (P=0.001). Between -group analysis, after Bonferroni's correction for multiple comparisons, revealed that VRT group had significantly better outcomes in ROM during rotation (P=0.040), ratio of the primary over the secondary movement while performing rotation (P=0.021), and mean velocity during lateral bending (P=0.031). CONCLUSIONS: Sensorimotor training, combined with manual therapy, could enhance kinematic outcomes for NP patients, supporting the potential of VR in rehabilitation.

Objective: We aimed to investigate the clinical symptoms and specific care requirements of SARSCoV-2 patients who were admitted to a COVID-19 Rehabilitation Unit while still infectious for SARSCoV-2 and in the subacute phase of the disease. Methods: Patients admitted to our COVID-19 Rehabilitation Unit from March 2020 to December 2020 were evaluated for sarcopenia, and they also completed the following assessments: functional independence measure, short physical performance battery and Hamilton Rating Scale for Depression. Age and body mass index and symptoms of dysosmia or dysgeusia were also recorded. Results: A total of 126 patients were enrolled (50 women, median age 72 years, 18.7 years), of whom 82% of patients presented with low grip strength. Sarcopenia was diagnosed in 52 patients. Sarcopenic patients were older than nonsarcopenic ones (median age 73.4 years, IQR 13.2 vs 63.9 years, IQR 14.5, respectively, p = 0.014). Sarcopenia was associated with the presence of depression (p = 0.008), was more common in women (p = 0.023) and was associated with greater functional deficits (functional independence measure and short physical performance battery analyses, p < 0.05). Sarcopenic patients also had a lower body mass index than other patients (p < 0.01). Conclusion: More than 40% of our patients suffered from sarcopenia, which was associated with ageing, depression, low body mass index, reduction in functional autonomy and being a woman. Such data provide evidence for the need to assist hospitalized COVID-19 patients by means of a multidisciplinary specialist team. LAY ABSTRACT Many COVID-19 patients who require hospitalization in the first phase of the disease benefit from respiratory, motor or cognitive rehabilitation before being dismissed from the hospital. During this rehabilitative phase, these patients are still positive for SARS-CoV-2 and potentially infectious, although their symptoms might differ from the symptoms they encountered in the first days. The objective of this study was to examine the clinical condition of 126 COVID-19 patients in a COVID-19 rehabilitation ward. Our data demonstrated that 41% of these patients presented with sarcopenia, which represents a drastic loss of muscle mass. We noticed that the risk factors associated with sarcopenia were ageing, depression, being a woman and having more issues with being independent in daily life. These results reveal the importance of providing such COVID-19 patients with specific care by multidisciplinary teams of healthcare professionals.

Objective: To evaluate the clinical characteristics and rehabilitation management of patients who undergo amputation for COVID-19-associated coagulopathy. Methods: Clinical and laboratory data for 3 patients were analysed and their rehabilitative management discussed. Results: The medical records of 3 patients who had undergone amputation due to acute lower extremity ischaemia and who were provided with rehabilitation in our COVID-19 unit were reviewed. Conclusion: Coagulation changes related to SARS-CoV-2 may complicate recovery from this devastating disease. The rehabilitation management of amputated patients for COVID-19 acute lower extremity ischaemia is based on a multilevel approach for clinical, functional, nutritional and neuropsychological needs. Based on this limited experience, a dedicated programme for this specific group of patients seems advantageous to warrant the best functional outcome and quality of life.

ObjectivesCoronavirus disease 2019 (COVID‐19) is a viral illness caused by severe acute respiratory syndrome coronavirus 2. With the increasing number of improved and discharged patients with COVID‐19, the definition of an adequate follow‐up strategy is needed. The purpose of this study was to assess whether lung ultrasound (LUS) is an effective indicator of subclinical residual lung damage in patients with COVID‐19 who meet discharge criteria.MethodsWe prospectively enrolled 70 consecutive patients with COVID‐19 who had a prolonged hospitalization with inpatient rehabilitation between April 6 and May 22, 2020. All of the patients underwent an LUS evaluation at discharge. Data of patients with more severe disease during the acute phase (ie, required ventilatory support) were compared to those of patients with milder disease.ResultsAmong the 70 patients with COVID‐19 (22 women and 48 men; mean age ± SD, 68 ± 13 years), the LUS score before discharge was still frankly pathologic and higher in patients who had more severe disease during the acute phase compared to patients with milder disease (median [interquartile range], 8.0 [5.5–13.5] versus 2.0 [1.0–7.0]; P < .001), even when both categories met internationally defined discharge criteria.ConclusionsLung ultrasound can identify the persistence of subclinical residual lung damage in patients with severe COVID‐19 even if they meet discharge criteria. Considering the low cost, easy application, and lack of radiation exposure, LUS seems the ideal tool to be adopted in outpatient and primary care settings for the follow‐up of patients with COVID‐19.

Objective: The COVID-19 pandemic has caused significant motor, cognitive, psychological, neurological and cardiological disabilities in many infected patients. Functional rehabilitation of infectious COVID-19 patients has been implemented in the acute care wards and in appropriate, ad hoc, multidisciplinary COVID-19 rehabilitation units. However, because COVID-19 rehabilitation units are a clinical novelty, clinical and organizational benchmarks are not yet available. The aim of this study is to describe the organizational needs and operational costs of such a unit, by comparing its activity, organization, and costs with 2 other functional rehabilitation units, in San Raffaele Hospital, Milan, Italy. Methods: The 2-month activity of the COVID-19 Rehabilitation Unit at San Raffaele Hospital, Milan, Italy, which was created in response to the emergency need for rehabilitation of COVID-19 patients, was compared with the previous year’s activity of the Cardiac Rehabilitation and Motor Rehabilitation Units of the same institute. Results: The COVID-19 Rehabilitation Unit had the same number of care beds as the other units, but required twice the amount of staff and instrumental equipment, leading to a deficit in costs. Discussion: The COVID-19 Rehabilitation Unit was twice as expensive as the 2 other units studied. World health systems are organizing to respond to the pandemic by expanding capacity in acute intensive care and sub-intensive care units. This study shows that COVID-19 rehabilitation units must be organized and equiped according to the clinical and rehabilitative needs of patients, following specific measures to prevent the spread of infection amongs patients and workers.

The rapid evolution of the health emergency linked to the spread of severe acute respiratory syndrome coronavirus 2 requires specifications for the rehabilitative management of patients with coronavirus disease 2019 (COVID-19). The symptomatic evolution of patients with COVID-19 is characterized by 2 phases: an acute phase in which respiratory symptoms prevail and a postacute phase in which patients can show symptoms related to prolonged immobilization, to previous and current respiratory dysfunctions, and to cognitive and emotional disorders. Thus, there is the need for specialized rehabilitative care for these patients. This communication reports the experience of the San Raffaele Hospital of Milan and recommends the setup of specialized clinical pathways for the rehabilitation of patients with COVID-19. In this hospital, between February 1 and March 2, 2020, about 50 patients were admitted every day with COVID-19 symptoms. In those days, about 400 acute care beds were created (intensive care/infectious diseases). In the following 30 days, from March 2 to mid-April, despite the presence of 60 daily arrivals to the emergency department, the organization of patient flow between different wards was modified, and several different units were created based on a more accurate integration of patients’ needs. According to this new organization, patients were admitted first to acute care COVID-19 units and then to COVID-19 rehabilitation units, post-COVID-19 rehabilitation units, and/or quarantine/observation units. After hospital discharge, telemedicine was used to follow-up with patients at home. Such clinical pathways should each involve dedicated multidisciplinary teams composed of pulmonologists, physiatrists, neurologists, cardiologists, physiotherapists, neuropsychologists, occupational therapists, speech therapists, and nutritionists.

BACKGROUND:Prone positioning improves oxygenation in adult respiratory distress syndrome. This procedure has been widely used during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. However, this procedure can also be responsible for nerve damage and plexopathy. METHODS:We retrospectively reviewed a series of 7 infectious patients with coronavirus disease 2019 who underwent prone positioning ventilation at the San Raffaele Hospital of Milan, Italy, during the SARS-CoV-2 pandemic. RESULTS:Clinical and neurophysiological data of 7 patients with nerve compression injuries have been reported. CONCLUSIONS:Health care workers should take into consideration the risk factors for prone positioning-related plexopathy and nerve damage, especially in patients with coronavirus disease 2019, to prevent this type of complication.

The coronavirus-2 (SARS-CoV-2) pandemic has dramatically transformed the organization of public and private health organizations of the Lombardy region, the Italian region where the viral spread has been more quick and intense (1).According to the data available on the 8 th of April 2020 from the beginning of the epidemic at the end of February, 139,422 cases and 17,669 deaths have been reported in Italy, which may underestimate the real incidence.The rapid spread of the virus has upset all hospital organizations.The Rehabilitation Hospitals, as well as the rehabilitation units of multidisciplinary institutes, have considerably changed their activity.The need for medical assistance to an increasingly higher number of patients forced the hospitals to improve the volume of intensive care beds and to convert the rehabilitation departments in COVID-19 beds.San Raffaele Scientific Institute, a large tertiary hospital and research centre in Milan, Italy, was immediately involved in the management of the public health emergency (1).After the first COVID-19 case of San Raffaele Scientific Institute of Milan, dated back on 25 th February, the 3 Rehabilitation Units were merged to create dedicated beds for coronavirus cases in less than one week.Furthermore, regional laws relieved the outpatient activities of the Rehabilitation Departments to reduce the viral spread.The nurse staff have been sent to the new COVID-19 Rehabilitation Department created for those patients coming from the Intensive Care Units.At this moment, about 40 patients are hospitalized in the Rehabilitation Department at San Raffaele Hospital.The acute respiratory syndrome caused by SARS-CoV-2 syndrome may be characterized by mild respiratory diseases or moderate-to-severe pneumonia, which can cause Acute Respiratory Distress Syndrome (ARDS) and multi-organ failure.In SARS-CoV-2 pneumonia, bilateral interstitial infiltration with serious alteration of the ventilationperfusion ratio and probably shunt, cause hypoxic respiratory insufficiency (2).Acute hypoxemia may cause obstinate dyspnoea with the need of oxygen therapy administration through High-flow nasal oxygen (HFNO), or through the application of a non-invasive positive pressure, c-PAP or NIV (with oronasal or face masks, helmets) (2, 3).Unfortunately, in case of O 2 saturation worsening, orotracheal intubation and invasive mechanical ventilation are mandatory.The pulmonary parenchyma presents focal haemorrhages and necrosis, even up to a haemorrhagic infarction.The alveolar exudate can consolidate causing

BACKGROUND:Preliminary evidence showed additional effects of anodal transcranial direct current stimulation over the damaged cerebral hemisphere combined with cathodal transcutaneous spinal direct current stimulation during robot-assisted gait training in chronic stroke patients. This is consistent with the neural organization of locomotion involving cortical and spinal control. The cerebellum is crucial for locomotor control, in particular for avoidance of obstacles, and adaptation to novel conditions during walking. Despite its key role in gait control, to date the effects of transcranial direct current stimulation of the cerebellum have not been investigated on brain stroke patients treated with robot-assisted gait training.OBJECTIVE:To evaluate the effects of cerebellar transcranial direct current stimulation combined with transcutaneous spinal direct current stimulation on robot-assisted gait training in patients with chronic brain stroke.METHODS:After balanced randomization, 20 chronic stroke patients received ten, 20-minute robot-assisted gait training sessions (five days a week, for two consecutive weeks) combined with central nervous system stimulation. Group 1 underwent on-line cathodal transcranial direct current stimulation over the contralesional cerebellar hemisphere + cathodal transcutaneous spinal direct current stimulation. Group 2 received on-line anodal transcranial direct current stimulation over the damaged cerebral hemisphere + cathodal transcutaneous spinal direct current stimulation. The primary outcome was the 6-minute walk test performed before, after, and at follow-up at 2 and 4 weeks post-treatment.RESULTS:The significant differences in the 6-minute walk test noted between groups at the first post-treatment evaluation (p = 0.041) were not maintained at either the 2-week (P = 0.650) or the 4-week (P = 0.545) follow-up evaluations.CONCLUSION:Our preliminary findings support the hypothesis that cathodal transcranial direct current stimulation over the contralesional cerebellar hemisphere in combination with cathodal transcutaneous spinal direct current stimulation might be useful to boost the effects of robot-assisted gait training in chronic brain stroke patients with walking impairment.

BACKGROUND:Chronic migraine is a disabling disorder associated with myofascial and trigger point disorders in the neck. Pharmacological management is the first line of treatment; however, rehabilitation procedures aimed at lessening symptoms of myofascial and trigger point disorders may add value in the management of headache symptoms.AIM:The aim of this study was to evaluate the feasibility of myofascial and trigger point treatment in chronic migraine patients receiving prophylactic treatment with onabotulinumtoxinA. To evaluate the treatment effects on headache frequency and intensity, analgesic consumption, cervical range of motion, trigger point pressure pain threshold, quality of life, and disability.DESIGN:Pilot, single-blind randomized controlled trial with two parallel groups.SETTING:Neurorehabilitation Unit.POPULATION:Twenty-two outpatients with chronic migraine.METHODS:Patients were randomly assigned to receive either cervicothoracic manipulative treatment (N.=12) or transcutaneous electrical nerve stimulation (TENS) in the upper trapezius (N.=10). Treatment consisted of 4 sessions (30 min/session, 1 session/week for 4 weeks). A rater blinded to treatment allocation evaluated outcomes before treatment, during treatment, and 1 month after the end of treatment. Consistent with the pilot nature of the study, feasibility was considered the primary outcome and efficacy the secondary outcome.RESULTS:All patients completed the study. No adverse events were reported. No significant between-group differences in pain intensity were observed during the study period. At post-treatment evaluation, the total consumption of analgesics (P=0.02) and non-steroidal anti-inflammatory (P=0.02) drugs was significantly lower in the manipulative treatment group than in the TENS group. These effects paralleled significant improvements in trigger point sensitivity and cervical active range of motion.CONCLUSIONS:Manipulative techniques aimed at reducing peripheral nociceptive triggers might add value in the management of chronic migraine symptoms and lower acute medication use.CLINICAL REHABILITATION IMPACT:An interdisciplinary approach comprising pharmacological and non-pharmacological strategies can reduce analgesic consumption and myofascial dysfunction symptoms in chronic migraine patients.

OBJECTIVE To examine the relationship between patient-rated physician empathy and outcome of botulinum toxin treatment for post-stroke upper limb spasticity. DESIGN Cohort study. SUBJECTS Twenty chronic stroke patients with upper limb spasticity. METHODS All patients received incobotulinumtoxinA injection in at least one muscle for each of the following patterns: flexed elbow, flexed wrist and clenched fist. Each treatment was performed by 1 of 5 physiatrists with equivalent clinical experience. Patient-rated physician empathy was quantified with the Consultation and Relational Empathy Measure immediately after botulinum toxin treatment. Patients were evaluated before and at 4 weeks after botulinum toxin treatment by means of the following outcome measures: Modified Ashworth Scale; Wolf Motor Function Test; Disability Assessment Scale; Goal Attainment Scaling. RESULTS Ordinal regression analysis showed a significant influence of patient-rated physician empathy (independent variable) on the outcome (dependent variables) of botulinum toxin treatment at 4 weeks after injection, as measured by Goal Attainment Scaling (p<0.001). CONCLUSION These findings support the hypothesis that patient-rated physician empathy may influence the outcome of botulinum toxin treatment in chronic stroke patients with upper limb spasticity as measured by Goal Attainment Scaling.

Spasticity is common in stroke and multiple sclerosis. To treat spasticity we have a wide range of interventions, whose application may depend not only on the severity of spasticity but also on its etiology. Consequently, a better understanding of muscle spasticity in different neurological diseases may inform clinicians as to the more appropriate therapeutic approach. Our aim was to compare the clinical and ultrasonographic features of spastic equinus in patients with chronic stroke and multiple sclerosis. Thirty-eight patients with secondary progressive multiple sclerosis and 38 chronic stroke patients with spastic equinus were evaluated at the affected ankle according to the following outcomes: modified Ashworth scale, Tardieu scale, passive range of motion, spastic gastrocnemius muscle echo intensity and thickness. Affected calf muscles tone was significantly greater in patients with chronic stroke (modified Ashworth scale P=0.008; Tardieu scale angle P=0.004) as well as spastic gastrocnemius muscle echo intensity (P<0.001). Affected ankle range of motion was significantly greater in patients with multiple sclerosis (P<0.001) as well as spastic gastrocnemius muscle thickness (medialis: P=0.003; lateralis: P=0.004). Our findings evidenced that the same pattern of spasticity (equinus foot) has some different features according to its etiology. This may help the management of spasticity.

PURPOSE:Preliminary evidence has shown no additional effects of transcranial direct current stimulation (tDCS) on robotic gait training in chronic stroke, probably due to the neural organization of locomotion involving cortical and spinal control. Our aim was to compare the combined effects of tDCS and transcutaneous spinal direct current stimulation (tsDCS) on robotic gait training in chronic stroke. METHODS:Thirty chronic stroke patients received ten 20-minute robot-assisted gait training sessions, five days a week, for 2 consecutive weeks combined with anodal tDCS + sham tsDCS (group 1; n = 10) or sham tDCS + cathodal tsDCS (group 2; n = 10) or tDCS + cathodal tsDCS (group 3; n = 10). The primary outcome was the 6-minute walk test (6MWT) performed before, after, 2 weeks and 4 weeks post-treatment. RESULTS:Significant differences in the 6MWT distance were noted between group 3 and group 1 at the post-treatment and 2-week follow-up evaluations (post-treatment P = 0.015; 2-week follow-up P = 0.001) and between group 3 and group 2 (post-treatment P = 0.010; 2-week follow-up P =  .015). No difference was found between group 2 and group 1. CONCLUSIONS:Our preliminary findings support the hypothesis that anodal tDCS combined with cathodal tsDCS may be useful to improve the effects of robotic gait training in chronic stroke.