Fabio Giuseppe Masuccio

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Background: Spasticity represents a major symptom of people with multiple sclerosis (MS), frequently causing disability, pain, and abnormal postures. The aim of this study is the evaluation of safety and efficacy of radial extracorporeal shock wave therapy (RESWT) for triceps surae muscle spastic hypertonia in people with MS. Methods: Two centers recruited people 18 years or older with MS and triceps surae muscle hypertonia. People were excluded if they had other neurological conditions; had used anticoagulants; had intrathecal baclofen, botulinum toxin, and/or physiotherapy within the past 8 months; or had oral antispasmodics therapy modification in the past 4 weeks. The participants underwent triceps surae RESWT once a week for 4 weeks. Participants were scored on the Modified Ashworth Scale (MAS), the Numerical Rating Scale for spasticity (NRS-Sp), the Medical Research Council (MRC) scale, the Timed Up and Go (TUG) test, and the Timed 25-Foot Walk (T25-FW) test before RESWT (T0) and immediately after RESWT (T1). Self-perceived effect was evaluated via the Global Perceived Effect (GPE) at T1. Results: Twenty-six people with MS were included (10 women and 16 men; mean age ± SD, 52.46 ± 8.39 years; mean Expanded Disability Status Scale score ± SD, 5.44 ± 1.34; mean disease duration ± SD, 14.88 ± 10.83 years), and 36 triceps surae were treated. MAS and NRS-Sp scores decreased at T1, whereas TUG, T25-FW, and MRC scores were comparable over time. Via the GPE, 73% of participants reported a self-perceived positive effect of RESWT on spasticity. Conclusions: RESWT may be efficacious and safe for treating spasticity in people with MS and does not adversely affect gait, strength, or dynamic balance. Further long-term studies are needed to evaluate the possibility of using RESWT as a treatment for spasticity in people with MS.

Detailed data on post-stroke depression (PSD) in older adults are limited in spite of the high vulnerability of this population to stroke. In fact, PSD prevalence in older adults ranges from 16.0 to 43.9%; however, timing and instruments of evaluation often differ significantly across all available studies. The etiology, genetic and inflammatory factors, as well as structural brain alterations, are claimed as part of a multifaceted mechanism of action in PSD onset. Thus, the aim of this narrative review was to further elaborate on the prevalence, etiology, diagnosis, consequences and treatment of PSD in older adults. The consequences of PSD in older adults may be devastating, including a poor functional outcome after rehabilitation and lower medication adherence. In addition, lower quality of life and reduced social participation, higher risk of new stroke, rehospitalization, and mortality have been reported. In this scenario, treating PSD represents a crucial step to prevent these complications. Both pharmacological and non-pharmacological therapies are currently available. The pharmacological treatment utilizes antidepressant drugs, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TAs) and new multimodal antidepressants (NMAs). Non-pharmacological therapies include psychological interventions and non-invasive brain stimulation techniques, while excluding drug administration. In the general population experiencing PSD, SSRIs (sertraline in particular) are the most prescribed, whereas the combination of antidepressants and psychotherapy is underused. Furthermore, about one-third of patients do not receive treatment for PSD. In regard to older adults with PSD, the possibility of more adverse effects or contraindications to antidepressant prescription due to comorbidities may limit the therapeutic window. Although drugs such as citalopram, escitalopram, sertraline, venlafaxine, and vortioxetine are usually well tolerated by older patients with PSD, the few randomized controlled trials (RCTs) specifically considering older adults with PSD have been conducted with fluoxetine, fluvoxamine, reboxetine, citalopram and nortriptyline, often with very small patient samples. Furthermore, data regarding the results of non-pharmacological therapies are scarce. High-quality RCTs recruiting large samples of older adults are needed in order to better manage PSD in this population. In addition, adequate screening and diagnosis instruments, with reliable timing of evaluation, should be applied.

Introduction Coronavirus disease (COVID-19) was associated with cognitive alterations affecting everyday life activities. These need input integration of both motor and cognitive systems. The study aim is to evaluate cognitive-motor interference phenomenon in previously independent patients with mild-to-moderate COVID-19 (PwMCOVID-19) compared with healthy controls (HC), through dual-task (DT) paradigm. Methods PwMCOVID-19 were included if being independent at home, had no previous referred cognitive impairment, mechanical ventilation or oxygen need. They were assessed at admission and after 6 months with a motor-cognitive DT test (counting backward by twos while walking 2 min). HC were enrolled as control group. Differences between single-task (ST) and DT performance, DT effect (DTE) and task prioritization amongst groups and during time points were analyzed. Results One-hundred PwMCOVID-19 [mean age=67.32(12.08) years; 53 M/47 F] and 39 HC [mean age=63.11(9.90) years; 20 M/19 F] were recruited. Upon T0, PwMCOVID-19 showed lower cognitive and motor DT performances than ST and HC. Mutual interference pattern was predominant in PwMCOVID-19. At T1, 41 PwMCOVID-19 were examined [mean age=64.85(10.75); 22 M/19 F]. They had a worse DT performance compared to ST, although DT improved at T1. A stronger cognitive ST-DT difference was present at T0, compared to ST-DT difference at T1, while motor ST-DT difference was unchanged over time in PwCOVID-19. Conclusion In PwMCOVID-19, there is an impairment of DT counting while walking at baseline and after 6 months from hospitalization, with a more pronounced DT mutual interference pattern at T0. After 6 months, the motor and cognitive ST and DT performances ameliorated, not reaching the HC level.

Aggressive neuromyelitis optica spectrum disorders (NMOSDs) with antibodies (Abs) against aquaporin-4 (AQP4) can be treated by blocking the interleukin 6 (IL6) pathways with tocilizumab. This IL6-inhibitor was employed to treat coronavirus disease 2019 (COVID-19) pneumonia with unconclusive results. We present a 52-year-old woman with AQP4 NMOSD, unresponsive to rituximab, that stabilized on tocilizumab one year after the disease onset. She was bed-bound and progressively recovered her mobility. During intensive rehabilitation, she presented fever and cough for one week with nasopharyngeal swabs positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This mild COVID-19 recovered spontaneously without sequelae, and the monthly tocilizumab infusions were continued for another 10 months. Subsequently, serious and prolonged respiratory and urinary infections caused treatment interruption, and then her disease re-activated. In our case, tocilizumab was effective in preventing NMOSD relapse and was safe to use during SARS-CoV-2 infection.

We read with interest the comment on our recent article regarding the follow-up of C-GBS and NC-GBS in the COVID-19 era. ¹ We fully agree with the reader’s observations, the majority of which were reported in our paper as limitations. In fact, due to the nature of the study (a single-center observation/case series) and for the small number and heterogeneity of the sample, it was not possible to conduct a statistical analysis; a descriptive analysis was performed, and each case was described with its functional follow-up. The high percentage of acute motor axonal neuropathy in our cohort, which is known to have a worse outcome than acute inflammatory demyelinating polyradiculopathy, probably was the most important factor that negatively influenced the recovery of those individuals, in association with the high rate of complications, as stated in our paper. We are aware that a preexisting peripheral nerve involvement or damage could represent a negative factor for the recovery, although none of our patients had documented neuropathy before the acute event.

Objective: COVID-19 has been associated with neurological complications such as Guillain-Barre syndrome (GBS). Several cases have been reported but without functional outcome data after intensive rehabilitation and medium-term follow-up. Methods: In this observational study, patients were admitted in 2019 and 2020 to inpatient rehabilitation for GBS and were examined using the Barthel index, GBS-Disability Scale, and Medical Research Scale-sum score at admission, discharge, and at least 6 months after onset of symptoms. All the participants received personalized, goal-oriented inpatient rehabilitative treatment for the recovery of self-sufficiency in everyday life. Results: Eleven people with GBS—3 cases related to COVID-19—were admitted in 2019 and 2020 to inpatient rehabilitation. Eight patients with GBS not related to COVID-19 experienced a high complication rate during inpatient rehabilitation, with 2 deaths due to sepsis. In this cohort, a higher prevalence than expected of acute motor axonal neuropathy was also detected. The COVID-19–related GBS group did not have any complications. After a mean of 10.11 months (SD = 4.46 months), 55.55% of patients regained autonomous walking. Conclusion: COVID-19–related GBS appeared to have a better clinical outcome than GBS that was not COVID-19 related. A higher than usual prevalence of acute motor axonal neuropathy form was encountered. More follow-up studies are needed to understand whether the recovery of GBS related to COVID-19 might be different from that of GBS unrelated to COVID-19. Impact: No data are currently available on the follow-up of GBS in the COVID-19 era and on the functional outcome of those patients. This study provides important information indicating that GBS related to COVID-19 might have a better clinical outcome than GBS unrelated to COVID-19.