The management of knee osteoarthritis in elderly: results from a national survey compared to ESCEO guidelines.

OBJECTIVE: Knee osteoarthritis (KOA) is a degenerative and inflammatory disease with a rising incidence and prevalence worldwide. Various therapeutic strategies have been proposed over time, depending on the degrees of severity and usually based on individual clinical practice. However, several European and international scientific societies published guidelines, to provide practical clinical stepwise guidance and to facilitate individualized therapeutic decisions regarding the management of KOA. The aim of this prospective multicentre observational study was to describe the real outpatient territorial management of patients with knee osteoarthritis and to compare it with the ESCEO guidelines, in order to identify operational strategies for delivering patient-centric care. MATERIALS AND METHODS: The educational project was divided in three modules: the first and the last through webinar; the second held in daily practice. The participants had to register structured observations. RESULTS: The project has been joined by 155 discussants, and the 2,656 observations collected allowed the understanding of the most common therapeutic approaches for knee osteoarthritis on the Italian territory. CONCLUSIONS: The educational project proved to be useful for updating on the state of the art of therapeutic management of knee osteoarthritis, and to increase expertise in detecting prevention and treatment strategies according to ESCEO guidelines to apply in the Real-Life context.

Staphylococcus Aureus Panton-Valentine Leukocidin causing hip osteomyelitis, thrombophlebitis and necrotizing pneumonia in an immuocompetent child.

Panton-Valentine leukocidin (PVL) represents an important virulence factor for many strains of Staphylococcus aureus. PVL is an esotoxin causing leucocyte destruction and tissue necrosis. We report on a case of osteomyelitis involving the hip joint with thromblophlebitis complicated by necrotizing pneumonia and life-threatening septic shock. The child required advance respiratory support for 14 days with circulatory support for 7 days in ICU (intensive care unit), surgical draninage via arthrotomy of hip joint and second-line antibiotic treatment for 1 month. Among a wide literature, in Europe over half of Panton-Valentine St. Aureus (PVL-SA) is MSSA. Investigations for PVL are not always available determining an under-recognition of the episodes. Data on prevalence of PVL-SA in Italy are scarce. With this clinical report, we emphasize the recognition of clinical features that must lead to suspect PVL-SA osteomyelitis in children, providing their adequate management.

The effectiveness of telerehabilitation after hip or knee arthroplasty: a narrative review.

Telerehabilitation is defined as a set of tools, procedures, and protocols to deliver rehabilitation programs remotely. It involves the use of various communication technologies to efficiently provide rehabilitation services distantly or via some other remote environment. After an orthopedic procedure, physical rehabilitation is essential to restore joint's function, to improve quality of life as well as to relieve pain, to recovery independence. The effectiveness of telerehabilitation has been studied in literature. The aim of this narrative review is to update the current evidence, evaluate the efficacy of telerehabilitation after hip, and knee prosthesis surgery for end stage arthrosis. Results show that it is useful to integrate traditional interventions with telerehabilitation to accelerate efficiency in existing healthcare delivery systems. Future high-methodological-quality studies should be conducted to evaluate the long-term efficacy and safety of innovative technologies.

Development of a patient-centered questionnaire for post-stroke spasticity assessment: a reliability study.

In the emerging scenario of patient-centered medicine, it is becoming increasingly important to involve patients in the management of chronic diseases. The rehabilitation field currently has no assessment tool for evaluating the functional impact of post-stroke spasticity on activities of daily living. The aim of this study was to identify a tool to fill this gap. The "Spasticity Questionnaire in Real Life" (SPQR) was administered, twice, to 39 patients with poststroke spasticity. Statistical analysis showed internal consistency and reliability of the questionnaire, with values greater than 0.96 and 0.76, respectively. These results show that the SPQR is a promising tool for evaluating the functional impact of post-stroke spasticity.

Multicentre registry of brain-injured patients with disorder of consciousness: rationale and preliminary data.

Diagnostic accuracy and reliable estimation of clinical evolution are challenging issues in the management of patients with disorders of consciousness (DoC). Longitudinal systematic investigations conducted in large cohorts of patients with DoC could make it possible to identify reliable diagnostic and prognostic markers. On the basis of this consideration, we devised a multicentre prospective registry for patients with DoC admitted to ten intensive rehabilitation units. The registry collects homogeneous and detailed data on patients' demographic and clinical features, neurophysiological and neuroimaging findings, and medical and surgical complications. Here we present the rationale and the design of the registry and the preliminary results obtained in 53 patients with DoC (vegetative state or minimally conscious state) enrolled during the first seven months of the study. Data at 6-month post-injury follow-up were available for 46 of them. This registry could be an important tool for collecting high-quality data through the application of rigorous methods, and it could be used in the routine management of patients with DoC admitted to rehabilitation settings.

Effects of focal muscle vibration on physical functioning in patients with knee osteoarthritis: a randomized controlled trial.

BACKGROUND: Knee osteoarthritis (OA) is a chronic condition characterized by pain, stiffness and functional limitations. According to the OsteoArthritis Research Society International (OARSI) recommendations, patients with knee OA should undertake regular quadriceps muscle strengthening exercises. Whole body vibration (WBV) proved its effectiveness in strengthening of the quadriceps muscles and improving balance in chronic knee OA patients. To date, there are no published studies that investigated the effects of focal muscle vibration (FMV) in these patients. AIM: The aim of the present study was to evaluate the effects of FMV on physical functioning in patients with symptomatic knee OA. DESIGN: Randomized controlled trial. SETTING: Outpatient clinic, University Hospital. POPULATION: Men and women aged 60 years or older with radiographic diagnosis of mild to moderate monolateral knee OA (Kellgren-Lawrence grade II or III) and chronic knee pain. METHODS: Patients were randomized in two groups (treatment group and placebo control group). The treatment group received FMV treatment, according to the "repeated muscle vibration" protocol. The control group received a sham treatment. The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcome measures were the Short Physical Performance Battery (SPPB) and the Performance-Oriented Mobility Assessment (POMA). Follow up evaluations were done at 3 and 6 months. RESULTS: Fifty patients were recruited and randomly assigned to either the study or control group. There was a statistical significant difference between the two groups both for primary (WOMAC) and secondary (SPPB and POMA) outcomes. CONCLUSIONS: In this study, FMV therapy has proven to be effective and safe in improving functioning of patients affected by mild to moderate chronic knee OA. CLINICAL REHABILITATION IMPACT: The use of FMV therapy might be an additional and safe tool in the conservative management of knee OA.

Animal assisted interventions in neurorehabilitation: a review of the most recent literature.

INTRODUCTION: While conventional wisdom has always affirmed the value of animals in promoting human health and well-being, only recently has their therapeutic role in medicine become a topic for dedicated research. Animal assisted interventions (AAI) can be classified as animal-assisted activities, animal-assisted therapy, and service animal programs. OBJECTIVE: The aim of this review is to analyse original papers addressing AAI and neurological diseases and published in the most influential medical journals between 2001 and 2012, and discuss their findings in the light of what may be of interest in the field of neurology. DISCUSSION: We selected a total of 23 articles on neurorehabilitation in cerebral palsy, pervasive developmental disorders, multiple sclerosis, spinal cord injury, stroke, and mental disorders. The main therapeutic results were improvement on the Gross Motor Function Classification Scale and in upper limb dexterity (cerebral palsy); improvement in social functioning and interaction; reductions in stress, anxiety, and loneliness (pervasive developmental disorders and mental disorders); and decreased spasticity with improved balance (multiple sclerosis, spinal cord injury, stroke). CONCLUSION: These interventions, performed with highly specialised animals in very specific neurological populations, deliver an increasing body of scientific evidence suggesting that they are an effective complement to other existing therapies. In these diseases, further high-quality studies are warranted in order to define the most appropriate programmes for therapy.

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.

Animal-assisted interventions in internal and rehabilitation medicine: a review of the recent literature.

While conventional wisdom has always affirmed the value of animals in promoting human well-being, only recently has their therapeutic role in medicine become the focus of dedicated research. Therapeutic modalities that use animals as a tool for improving the physical, emotional, cognitive and/or social functioning of humans are called animal-assisted interventions (AAI), and are classified into: animal-assisted activities (AAA); animal-assisted therapy (AAT); and service animal programs (SAP). The aim of this review is to analyze the papers published between 2001 and 2010 in the most influential medical journals dealing with AAI, and discuss their findings in the light of what may be of interest for internal medicine and rehabilitation. A total of 35 articles met the strict inclusion criteria for this review: 18 papers dealing with AAA, 8 with AAT, and 9 with SAP. The therapeutic outcomes associated with AAA are: enhancement of socialization; reduction of stress, anxiety and loneliness; improvement in mood and general well-being; and development of leisure/recreation skills. Regarding AAT, horses are often used as a complementary strategy to facilitate the normalization of muscle tone and improve motor skills in children with cerebral palsy and persons with lower limb spasticity. Finally, most SAP utilize dogs, that assist people with various disabilities in performing everyday activities, thus reducing their dependence on other persons. Further studies are needed to better define the fields and programs for the therapeutic use of animals and to increase their utilization in medicine, as a promising, complementary and natural means to improve both functional autonomy and quality of life.

[Sincerity of effort: isokinetic evaluation of knee extension]. / Sincerità dello sforzo: valutazione isocinetica nell'estensione del ginocchio.

The aim of this study was to find a reliable method to evaluate the sincerity of the muscular maximal effort performed in a dynamometric isokinetic test of knee flexion-extension. The coefficient of variation of the peak torque (CV) and 3 new indices were analysed: (1) the average coefficient of variation calculated on the complete peak torque curve (CVM); (2) the slope of the regression line in an endurance test (PRR); (3) the correlation coefficient of the peak torques in the same endurance test (CCR). Twenty healthy subjects underwent assessment in two different trials, maximal (MX) and 50% submaximal (SMX), with 20 minutes of rest between trials. Each trial consisted of 4 tests, each of 3 repetitions, at angular speed of 30, 180, 30, and 180 degrees/s, respectively, and 1 test of 15 repetitions at 240 degrees/s. Our findings confirmed the ability of CV to detect a high percentage of sincere efforts: at 30 degrees/s Sensibility (Sns)=100% and Specificity (Spc)=70%; at 180 degrees/s Sns=75%, Spc=95%. The 3 new indices here proposed showed high characteristics of Sns and Spc, generally better than those of CV. CVM showed at 180 degrees/s Sns=90% and Spc=100%, while at 30 degrees/s Sns=90%, Spc=75%. PRR was the best index identifying all the efforts, except one (Sns=100%, Spc=95%). The CCR coefficient showed Sns and Spc values both of 90%.

Rasch psychometric validation of the Impact on Participation and Autonomy questionnaire in people with Parkinson's disease.

AIM: The aim of this study was to assess the psychometric properties of the Impact on Participation and Autonomy (IPA) questionnaire, in its two scales: IPA-I, perceived limitations in participation and autonomy; IPA-II, perceived problems in participation. METHODS: The IPA data underwent Rasch analysis for rating scale diagnostics and a reliability and validity study. The work and education domain was left out of the analysis due to its low applicability to our subjects. A convenience sample of 100 patients with Parkinson's disease (PD) (41 male, 59 female; mean age 72+/-7 years) were consecutively observed at our Rehabilitation Clinic. RESULTS: According to Rasch analysis, two response categories of IPA-I were collapsed into one and 1 item (''intimate relationship'') was deleted. The remaining 24 items fitted the unidimensional construct that the scale was intended to measure. IPA-I demonstrated good reliability (person separation = 0.93, item separation = 0.97) and internal construct validity. All six IPA-II items proved to belong to the same construct. For IPA-II, item separation = 0.97, person separation = 0.71. The targeting and spread of item difficulty and the quite low person separation reliability of IPA-II made it possible only to differentiate people with low vs high level of problems in participation. Both scales showed the expected correlation with PD-specific clinical and quality of life measures. CONCLUSIONS: IPA-I shows promise as a tool for measuring participation in people with PD. IPA-II has acceptable psychometric characteristics for measuring perceived problems in participation. Additional steps to improve their metric properties and further studies in people with different kinds of health conditions need to be carried out.

The influence of comorbidities and complications on discharge function in stroke rehabilitation inpatients.

AIM: The aims of this prospective study were: 1) to assess the frequency, type and severity of comorbidities (COMs) and complications (COMPLs) in acute stroke patients, according to the weighted comorbidity index (w-CI) of Liu et al. and 2 new indices, respectively COM severity index (COM-SI) and COMPL severity index (COMPL-SI); 2) to separately analyse the interference of COMs and COMPLs with functional status and recovery during stroke rehabilitation treatment; 3) to compare the ability of COM-SI and COMPL-SI to predict functional independence at discharge with that of w-CI. METHODS: Eighty-five stroke rehabilitation inpatients participated in the study. The type, incidence and severity of COM at admission and of COMPL during the whole hospital stay were studied prospectively. The Functional Independence Measure (FIM) scale was administered at both admission and discharge. RESULTS: About 1/3 suffered from some significant COM and another 1/3 developed COMPLs needing specific medical treatment and/or clinical monitoring. The most frequent COMs and COMPLs were cardiovascular and psychiatric/psychological diseases. The odds of having a high efficiency in the daily functional gain (FIM score) were greater for patients without any COM (3.5) and/or COMPL (4.6). Similarly, the odds of having a high FIM score at discharge were greater (3.5) for patients without COM or COMPL. The COM-SI demonstrated a higher predictive capacity of the FIM score at discharge (5%) than w-CI (4%), and COMPL-SI (1%). CONCLUSIONS: COM-SI resulted as the most interesting predictive index of functional outcome at discharge, after accounting for the functional status at admission.

Measuring long-term outcome in people with lower limb amputation: cross-validation of the Italian versions of the Prosthetic Profile of the Amputee and Prosthesis Evaluation Questionnaire.

AIM: Recently 2 questionnaires have been developed for people with lower limb amputation to determine, in follow-up studies, the level of function and extent of prosthetic use, to measure major life domains connected with prosthesis function, and to study the factors potentially related to prosthetic use the Prosthetic Profile of the Amputee (PPA) and the Prosthesis Evaluation Questionnaire (PEQ). The purpose of the present study was: a) to produce Italian versions of both PPA (PPA-it) and PEQ (PEQ-it), using a validated procedure of cross-cultural translation; b) to analyse and discuss the internal consistency and construct validity of the main sections of the 2 questionnaires, in an Italian population. METHODS: The PPA questionnaire consists of 44 questions arranged in 6 sections. The PEQ is composed of 82 questions subdivided into 9 scales related to 4 sectors. In order to produce the Italian versions of the PPA and PEQ the forward/backward translation method was used. The final versions of the questionnaires were mailed to 110 patients and 95 of them returned the questionarries. RESULTS: The Cronbach's alpha of Locomotor Capabilities Index (LCI/5), part of the PPA, was 0.97, and those of the 9 PEQ-it scales ranged from 0.64 (appearance) to 0.95 (mobility, MO). The LCI/5 and MO correlated highly with each other (rs=0.81) and with the variables related to prosthesis use. There was a significant correlation among the PEQ-it domains concerning MO, prosthesis function, psycho-social aspects and well-being. CONCLUSION: Unfortunately, the acceptability and feasibility of both questionnaires (rather low completion rate, visual analogue scale format of PEQ, demanding scoring procedures) were sub-optimal, and their structure (item selection, response format, scaling properties, etc.) would need some refinement and simplification in order to facilitate a broader clinical use. On the other hand, findings for the LCI/5 (PPA) and MO (PEQ) are encouraging (particularly regarding the first scale) and confirm their sound practical and psychometric features.

Balance and fear of falling in Parkinson's disease.

To assess internal consistency and validity of measures of balance (Berg balance scale, BBS), postural changes (postural changes scale, PCS) and fear of falling (fear of fall measure, FFM) in 70 ambulant Parkinson's disease (PD) persons, these instruments were matched with performance-based balance and mobility tests, and other clinical, functional and quality of life PD-specific measures. The BBS, PCS and FFM showed a good internal consistency, moderate to good inter-correlation, and a significant correlation with measures of both disability (UPDRS-ADL, Schwab and England scale) and--to a lesser extent--impairment/severity of symptoms (UPDRS-ME, Hoehn and Yahr Scale). Tandem Romberg, Single-Limb Stance, Functional Reach, and the Timed Up & Go test correlated slightly better with BBS than with PCS and FFM. This study shows that problems of balance and postural control in PD patients result from complex interactions between motor impairment, functional abilities and fear of falling.

[Work-related musculoskeletal diseases in dental professionals. 1. Prevalence and risk factors]. / Disturbi muscolo-scheletrici di natura lavorativa negli operatori sanitari dentali. 1--Prevalenza e fattori di rischio.

The past two decades have witnessed a sharp rise in the incidence of work-related musculoskeletal disorders (WMSD). All occupations are involved; in dental professionals (dentists, dental hygienists and dental auxiliaries) this problem occurs in 54-93% of subjects, with higher risk in elderly subjects and women. Spine, shoulder, elbow and hand are mostly involved. Prevention of WMSD is becoming crucial and requires the identification and modification of risk factors. Individual characteristics of the worker--such as gender, age, stature, physical condition, strength, etc.--may contribute to the occurrence of these musculoskeletal disorders. Moreover, the specific occupation and work organisation may be the source of ergonomic hazards. Awkward postures, prolonged repetitive movements, intense work schedules or fast work pace represent important risk factors for WMSD. Sometimes the dentist's workstation is not suited to the specific professional characteristics and an ergonomic improvement is needed. Finally, factors connected with professional equipment (such as vibrations, or sharp and hard surfaces causing pressure points) may also contribute to generating WMSD in dental professionals.