Faculty Bibliography

Background: Walking impairments are one of the most impactful consequences of multiple sclerosis (MS). Recently, physical rehabilitation research has focused on developing synergistic protocols to enhance clinical benefit. Recent studies have shown that transcranial direct current stimulation (tDCS) and aerobic physical activity (PA) have converging activation pathways and when completed simultaneously, they may promote cortical neuroplasticity.
Objective(s): To harness cortical plasticity to improve gait for individuals with MS.
Aim(s): To investigate the effects of multiple sessions of PA with simultaneously administered tDCS on walking abilities.
Method(s): MS participants (EDSS: 1-6.5, Relapsing-Remitting or Secondary-Progressive subtype) with clinically significant gait deviations were recruited for a randomized controlled trial of 10 sessions of either active or sham tDCS paired with unloaded cycling for 20 minutes. Stimulation was administered over the primary motor cortex (2.5 mA-2.0 mA; anode over C3/cathode over FP2). Walking speed was assessed quantitatively by using a single inertial sensor placed on the lower back and perceived walking abilities were evaluated using the 12-Item MS Walking Scale (MSWS-12), a self-report questionnaire. Measurements were collected at baseline, the end of tDCS intervention, and 4-weeks post-intervention. Two-way repeated measures-ANOVA (Time, Treatment) was performed to investigate differences between active and sham conditions.
Result(s): Thirty-two participants were enrolled in the study, 22 underwent active treatment. No demographic differences were detected between active and sham groups (active:EDSS 4.3+/-1.2, age 55.5+/-10.3; sham:EDSS 4.5+/-1.5, age 49.7+/-13.9). Statistical analysis showed significant Treatment by Time interactions for gait speed and MSWS-12 score. Post-hoc analysis revealed that gait speed increased significantly after active treatment (Baseline vs. End Treatment, 0.98 vs. 1.16 m/s, p< 0.001; Baseline vs. Follow-up, 0.98 vs. 1.20 m/s, p< 0.001). Active group further reported significant improvement in self-report measure (Baseline vs. End Treatment, 58.04 vs. 49.73, p< 0.05). No significant difference was detected after sham stimulation.
Conclusion(s): Our results indicate that multiple sessions of tDCS administered simultaneously with PA induce cumulative and selfreport improvement in walking and benefits persisted until 4-week post-intervention

BACKGROUND:Older age is associated with higher stride time variability in female and male gait, which may have a neuromuscular origin. We sought to determine how older age and sex affect muscle activation variability during gait, and how these patterns relate to stride time variability. METHODS:Ninety-three adults (51 females; aged 20-82 years) completed six gait trials at their self-selected speed. Cycle-to-cycle variabilities (CCVs) were calculated for stride time, and for amplitude of electromyography (EMG) of the rectus femoris (RF), tibialis anterior (TA), and gastrocnemius lateralis (GL) recorded over different gait phases. Statistical models tested for Age × Sex × Muscle effects and for relationships between EMG CCVs and stride time CCVs. RESULTS:Significant Age and Age × Muscle effects on EMG CCV were observed in several phases of gait (p < .05), where each year of age was associated with 0.11-0.18% higher EMG CCV, generally in the RF. A significant Age × Sex × Muscle effect on EMG CCV at mid-stance (p < .05) indicated that, in females, each year of age was associated with 0.11% lower GL CCV. Significant but low strength correlations (ρ = 0.298-0.351) were found between EMG CCV and stride time CCV. CONCLUSIONS:Associations between older age and higher muscle activation variability were generally sex-independent. A sex-dependency in GL activation variability may contribute to gait instability in aging females. Individual variabilities of muscle activation were not strongly related to stride time variability.

Parkinson's Disease (PD) is a neurological disorder characterized by motor symptoms and other clinical conditions, such as cognitive impairment, negative mood, anxiety. The present study explored the impact of PD on self-reported physical and mental health, objective cognition and postural control. The relationship among these variables was examined in order to understand the impact on quality of life. Fifty-four participants, 27 with and 27 without PD, were recruited in Sardinia - an area with an atypical prevalence of PD and psychological characteristics that might mitigate the impact of PD on life quality. Participants completed objective tests of cognitive ability and postural control and self-report measures of physical and mental health. The detrimental effect of PD was evident across all outcomes. Self-reported physical and mental health were both related to postural control. Variance in perceived physical health was explained, not only by PD itself and postural control but also by participation in leisure activities. Self-report outcomes related to life quality are related not only by motor disturbances associated with PD but also with lifestyle activities. In conclusion, social contexts promoting socially-oriented activities, such as that found in Sardinia, may, therefore, mitigate some of the detrimental consequences of PD.

Parkinson's Disease (PD) is a progressive neurological condition characterized by motor and non-motor symptoms impacting life quality. The main aim of the current study was to investigate the effect of PD on objective (i.e., working memory and semantic memory) and subjective memory (i.e., self-reported seriousness of forgetting, mnemonic usage and actual memory efficiency) controlling for the effect of depressive symptomatology. The relationship of working memory performance to gait and mobility indices was also examined, as well as the factors predicting subjective memory were explored. Fifty-four community-dwelling adults (mean age = 72.3 years, SD = 8.8) were recruited in Sardinia, an Italian island located in the Mediterranean Sea. Specifically, 27 non-demented adults with mild, early-stage PD were matched for years of education, age, and gender with a sample of healthy individuals. Participants completed a test battery assessing objective memory, subjective memory, and depressive symptoms, and an instrumental analysis of gait and functional mobility was performed. Participants with PD had poorer objective memory across all indices measured and displayed a restricted set of gait and posture impairments. Working memory performance was selectively related to gait and posture measures. Moreover, participants with PD had lower trust in their memory efficiency relative to the past than the control healthy group. Finally, 22% of the variance in seriousness of the consequences of forgetting was predicted by education and general cognitive efficiency. Overall, the present findings confirm the presence of changes in both objective and subjective memory in PD, independent from depressive symptoms.

BACKGROUND:In children with spastic cerebral palsy (CP), the treatment of equinus foot with Achilles tendon lengthening (ATL) surgery is associated with high incidence of overcorrection, which may result in crouch gait. AIM/OBJECTIVE:We aimed to assess if gait pattern in preoperative time could be a predictor of the surgery outcome. DESIGN/METHODS:Cross-sectional retrospective study. SETTING/METHODS:Movement Analysis Lab of IRCCS San Raffaele Pisana Hospital in Rome (Italy). POPULATION/METHODS:Eighteen children (mean age 9.6±4.7 years) with spastic diplegia CP who underwent bilateral ATL surgery to correct equinus foot were involved. METHODS:Participants underwent 3D gait analysis before and approximately 12 months after surgery. Primary measures were spatiotemporal, kinematic (summarized by Gait Variable Scores, GVSs) and kinetic parameters. The gait patterns for each leg was defined from kinematic data, using a quantitative classification: plantar flexor knee extension (PFKE) index. The CP group was split into true equinus and jump gait. RESULTS:The equinus foot was successfully corrected as demonstrated by the improvement of GVS ankle dorsi-plantarflexion. However, there was a high rate of overcorrection in the true equinus, characterized by increases in knee flexion-extension GVS (8.7° pre vs. 16.7° post P<0.05) and knee flexion angle at initial contact (5.2° vs. 20.6° P<0.05) and by a decrease in the maximum ankle power generated at push-off (1.49 vs. 0.83 W/kg P<0.05). CONCLUSIONS:Assessment of motor phenotype in preoperative time are good predictors of the results of ATL surgery. In children with true equinus gait, the increase of knee flexion subsequent to ATL is an early indicator that this technique will lead to crouch gait. These results show the influence of true equinus and jump gait patterns on the outcomes of the ATL. CLINICAL REHABILITATION IMPACT/CONCLUSIONS:Therefore, we propose that this approach could have clinical value to evaluate and prescribe rehabilitation in children with CP disease, proposing different solutions depending on motor phenotype.

BACKGROUND:Progressive cerebellar ataxia is a neurodegenerative disorder without effective treatment options that seriously hinders quality of life. Previously, transcranial direct current stimulation (tDCS) has been demonstrated to benefit cerebellar functions (including improved motor control, learning and emotional processing) in healthy individuals and patients with neurological disorders. While tDCS is an emerging therapy, multiple daily sessions are needed for optimal clinical benefit. This case study tests the symptomatic benefit of remotely supervised tDCS (RS-tDCS) for a patient with cerebellar ataxia. METHODS:We report a case of a 71-year-old female patient with progressive cerebellar ataxia, who presented with unsteady gait and balance impairment, treated with tDCS. tDCS was administered using our RS-tDCS protocol and was completed daily in the patient's home (Monday - Friday) with the help of a trained study technician. tDCS was paired with 20 min of simultaneous cognitive training, followed by 20 min of physical exercises directed by a physical therapist. Stimulation consisted of 20 min of 2.5 mA direct current targeting the cerebellum via an anodal electrode and a cathodal electrode placed over the right shoulder. The patient completed baseline and treatment end visits with neurological, cognitive, and motor (Lafayette Grooved Pegboard Test, 25 ft walk test and Timed Up and Go Test) assessments. RESULTS:The patient successfully completed sixty tDCS sessions, 59 of which were administered remotely at the patient's home with the use of real time supervision as enabled by video conferencing. Mild improvement was observed in the patient's gait with a 7% improvement in walking speed, which she completed without a walking-aid at treatment end, which was in stark contrast to her baseline assessment. Improvements were also achieved in manual dexterity, with an increase in pegboard scores bilaterally compared to baseline. CONCLUSIONS:Results from this case report suggest that consecutively administered tDCS treatments paired with cognitive and physical exercise hold promise for improving balance, gait, and manual dexterity in patients with progressive ataxia. Remotely supervised tDCS provides home access to enable the administration over an extended period. Further controlled study in a large group of those with cerebellar ataxia is needed to replicate these findings. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov Identifier: NCT03049969 . Registered 10 February 2017- Retrospectively registered.

OBJECTIVES/OBJECTIVE:To assess the effect of competitive level on dynamic postural stability in young elite and sub-elite soccer players. DESIGN/METHODS:Cross-sectional study. SETTING/METHODS:Laboratory. PARTICIPANTS/METHODS:Fifty-four male soccer players of Under 16 and Under 17 categories (mean age 15.9 ± 0.6), divided into two groups who regularly compete at national (n = 28) and regional (n = 26) levels. MAIN OUTCOME MEASURES/METHODS:Dynamic Postural Stability Index (DPSI) and vertical Time to Stabilization (vTTS) for a forward-jump landing. Static postural sway was calculated on the basis of center-of-pressure trajectories for a 20 s one-legged stance. RESULTS:Players at national level exhibit better dynamic postural control than those at regional level, as indicated by the significantly lower DPSI (0.327 vs. 0.373, p < 0.001) and vTTS (0.887 vs. 1.158 s, p = 0.003). In contrast, no differences between groups were found in any of the postural sway parameters for the static test. CONCLUSIONS:Young soccer players at national level are characterized by better balance performance in terms of faster and more efficient stabilization after a forward jump, while one-leg static standing tests appear not challenging enough to reveal differences in balance abilities associated with the combination of superior technical and physical features.

BACKGROUND:In people with multiple sclerosis (pwMS), disability is generally assessed on the basis of ambulation abilities, whereas upper limb motor dysfunctions are less frequently considered. Nevertheless, they can severely affect the quality of life of pwMS. To date, it remains mostly unknown whether a relationship exists between upper and lower limb impairments. AIM/OBJECTIVE:To investigate the existence of a relationship between upper and lower limb impairments in pwMS based on two fundamental motor tasks, namely walking and hand-to-mouth (HTM) movement. METHODS:Twenty-eight pwMS with Expanded Disability Status Scale (EDSS) scores in the range of 1-6, and 21 healthy controls (HC) underwent a kinematic analysis of gait and HTM movement performed with a motion capture system. The spatiotemporal parameters for the two tasks were calculated and correlated using Spearman's rank correlation coefficients. RESULTS:< 0.05). CONCLUSIONS:Both upper and lower limb motor abilities in pwMS worsen as disability increases. Nevertheless, their relationship is only moderate. This finding emphasizes the need for specific tests to quantify disability considering the overall motor function in pwMS.