Translation, cross-cultural adaptation, and validation of the Italian version of the Synkinesis Assessment Questionnaire in individuals with peripheral facial palsy.

BACKGROUND: After peripheral facial palsy, the onset of facial synkinesis results in aesthetic disfigurement and local muscle tension or pain, with possible deterioration of patient's well-being and social participation. The availability of valid instruments to evaluate patient-reported severity of facial synkinesis is important to capture the subjective perception of facial impairment. AIM: To generate and validate an Italian version of the Synkinesis Assessment Questionnaire, a patient-reported outcome measure to assess patient-perceived severity of facial synkinesis after peripheral facial palsy. DESIGN: Observational study. SETTING: Outpatient clinic of a Rehabilitation Unit. POPULATION: Seventy-five patients with peripheral facial palsy. METHODS: Through a process of translation and cross-cultural adaptation, we generated the Italian version of the questionnaire (SAQ-IT) and administered it twice to patients with peripheral facial palsy. We evaluated the clinical severity with the Sunnybrook Facial Grading System (SFGS) and the physical and social/well-being function with the two subscales of the Facial Disability Index (FDI-PHY and FDI-SWB, respectively). RESULTS: Cronbach's alpha was 0.87. Item-total correlations ranged from 0.30 to 0.70, while inter-item correlations ranged from 0.15 to 0.82, with an average value of 0.48. Test-retest reliability showed an Intraclass Correlation Coefficient of 0.946 (95% confidence interval: 0.916-0.966). The minimum detectable change (with a 95% confidence level, MDC95) was 13.14 points. The correlation between SAQ-IT and the SFGS synkinesis subscore was rho=0.74, while that with the SFGS composite score was rho=0.25, with the FDI-PHY rho=-0.11 and with the FDI-SWB rho=-0.13. CONCLUSIONS: Our study validates the SAQ-IT in Italian-speaking individuals with peripheral facial palsy, confirming its acceptable psychometric properties, and providing the MDC95. CLINICAL REHABILITATION IMPACT: The availability of a valid instrument for the evaluation of patient-perceived severity of facial synkinesis plays an important role in the definition of tailored rehabilitative interventions after peripheral facial palsy.

Facial Disability Index in Adults With Peripheral Facial Palsy: Rasch Analysis and Suggestions for Refinement.

OBJECTIVE: To investigate the psychometric properties of the validated Italian version of the Facial Disability Index (FDI), a patient-reported outcome measure widely used to assess individuals with peripheral facial palsy. DESIGN: Methodological research on cross-sectional data from a convenience sample. SETTING: Outpatient university rehabilitation clinic. PARTICIPANTS: A total of 168 (N=168) outpatients (66% female; mean age, 44±15 years) with peripheral facial palsy of diverse etiology (48% postsurgical, 31% Bell palsy, 8% posttraumatic, 3% congenital, 11% other medical conditions) and severity at the first visit. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The 2 FDI subscales, physical function (FDI-PHY) and social/well-being function (FDI-SWB), were separately analyzed using classical test theory methods and Rasch analysis. RESULTS: Cronbach α was 0.79 in FDI-PHY and 0.74 in FDI-SWB, while item-rest correlation ranged from 0.36-0.67 in FDI-PHY and from 0.43-0.68 in FDI-SWB. In the FDI-PHY, we deleted 2 underused response categories, rescoring the remaining ones. In the FDI-SWB, some response categories did not function as expected by the Rasch model: their collapse into a 4-level format solved this problem. In each subscale, all items fitted the Rasch model except item 4 (eye tearing/becoming dry) in FDI-PHY that showed an unexpectedly high response variability. The person separation reliability of both subscales indicated that they are useful only for group-level judgments. In both subscales, principal component analysis of the residuals showed unidimensionality and absence of locally dependent items. No significant differential item functioning concerning sex, age, or time from paralysis emerged. CONCLUSIONS: Our study demonstrated overall positive psychometric characteristics of FDI except for the functioning of the response categories. We propose a refined version with 4 response categories only and related conversion graphs that may improve the interpretability, feasibility, and metric performance of this tool.

Activity limitations and participation restrictions in patients with peripheral facial palsy: a cross-sectional study over a six-year period.

BACKGROUND: Peripheral facial palsy is a pathological condition caused by a wide range of etiologies. A damage of VII cranial nerve produces facial disfigurement and limitations in daily life activities, such as drinking, eating and speaking. As a consequence, patients may experience psychological distress and social isolation. To counsel and design a patient-tailored rehabilitation for patients affected by peripheral facial palsy, physical and social limitations should be considered. Moreover, the knowledge of factors associated with disability plays a key role in the early identification and adequate care of patients with higher risk to develop psychological distress and participation restrictions. AIM: To evaluate activity limitations, psychological distress and participation restrictions of patients affected by peripheral facial palsy seeking for rehabilitation and to identify individual and disease-specific factors associated to disability. DESIGN: Cross-sectional study. SETTING: Consultation hour dedicated to facial palsy patients in the outpatient clinic of a Rehabilitation Unit. POPULATION: One hundred eighty-six outpatients with recent or chronic peripheral facial palsy at the first assessment at our Rehabilitation Unit. METHODS: Using multiple linear regression models, we evaluated the association between the two subscales of Facial Disability Index (FDI) and the composite score of Sunnybrook Facial Grading System, as well as the association between the two FDI subscales and other clinical and demographic variables. RESULTS: Activity limitations correlate with the severity of palsy, while psychological distress and participation restrictions do not correlate with the neurological impairment. The correlation between the severity of palsy and both activity limitations and participation restrictions is influenced by palsy etiology. Activity limitations decrease with time from palsy onset, while psychological distress and participation restrictions are more severe in women. CONCLUSIONS: Beyond severity, also etiology, time from onset and gender influence disability after facial palsy. These factors should be considered in counselling and planning a patient-tailored multidisciplinary rehabilitative treatment. CLINICAL REHABILITATION IMPACT: Our study highlights the individual and pathology-associated factors related to activity limitations and participation restrictions in patients with peripheral facial palsy. These elements should be considered in the definition of a patient-tailored rehabilitative plan and in the organization of a multidisciplinary care.

Potentiation of muscle strength by focal vibratory stimulation on quadriceps femoris.

OBJECTIVES: Several studies have investigated the effects of focal vibration on muscle strength. Non-univocal results have been found. The aim of this study was to evaluate the effect of prolonged focal vibratory stimulation on quadriceps muscle strength at two different frequencies (80 and 300 Hz). The evaluation of muscle strength was performed at different intervals of time after the end of the vibratory stimulation in order to quantify the long-term effects and their trends over time. METHODS: Twenty-seven healthy volunteers were divided into three groups, a control group (no treatment) and two groups treated with vibratory stimulation (80 or 300 Hz) of relaxed quadriceps femoris bilaterally, once a day (30 min) for 5 consecutive days. The quadriceps' strength was measured through an isokinetic dynamometer, before and at three time intervals after the treatment, with a follow-up period of 4 weeks. The outcome measure was the Peak Torque (PT, Nm) of the quadriceps femoris produced by extension movement at three defined angular velocities and during isometric contraction. RESULTS: No changes in PT were observed in the control group over time, while PT increased in the treated groups. No significant difference in PT behavior was observed between these two groups. PTs recorded before and after the treatment were markedly different, and the increase in the PT persisted until the follow-up at 4 weeks, for all angular velocities tested. CONCLUSIONS: Prolonged vibratory stimulation of the quadriceps femoris, both at 80 and at 300 Hz, leads to an increase in muscle strength. The vibration effect does not appear to fade at the end of treatment, but persists at the follow up, suggesting a likely underlying plastic process. The results of the current study suggest that 30-min per day, 5 day focal vibratory treatment can be helpful during the clinical practice to regain muscular strength. It does not require patient's effort during the treatment, requires a little time, its effects are long-lasting, and there are no known adverse effects.

Disability after major abdominal surgery: determinants of recovery of walking ability in elderly patients.

BACKGROUND: Increased life expectancy and improved surgical techniques have led to a sharp rise in healthcare resource consumption by older patients. In these patients early recovery of walking ability after abdominal surgery may shorten length of hospital stay and reduce overall healthcare costs, but it is important to understand what factors determine this recovery. AIM: To assess preoperative and postoperative determinants of walking ability recovery after major abdominal surgery in older patients. DESIGN: Prospective observational study. SETTING: General Surgery Unit. POPULATION: The study included 327 consecutive older inpatients who underwent major acute-care abdominal surgery. METHODS: Data on demographic characteristics, diagnosis, comorbidities defined by Charlson Comorbidity Index (CCI), preoperative walking ability, and early postoperative physical deconditioning (PPDS) were gathered. All patients underwent an individually-tailored rehabilitation program. At discharge, pain (by a Visual Analogue Scale, VAS-pain, 0-10), transfers and walking ability were assessed. Number of rehabilitation sessions attended and discharge setting were recorded. RESULTS: Of 320 patients included in the analysis (7 died), 72% had CCI>5, signifying presence of >1 comorbidities. Before hospitalization, 79% of patients were completely independent in walking at home, 12% needed assistive devices or direct assistance from the caregiver, and 9% were unable to walk. Complex postoperative physical deconditioning was detected in 25%. At discharge, most patients (87%) had achieved their rehabilitative goal and returned home. Only PPDS and VAS-pain were able to predict both walking ability and the discharge setting, PPDS alone showing adequate sensitivity (82%) and specificity (70%). CONCLUSIONS: PPDS was the sole early postoperative predictor of recovery of walking ability and the discharge setting. Pain therapy might be a key factor influencing the postoperative functional decline. Age and severity of preoperative comorbidities seem not important determinants of functional decline in older surgical patients. CLINICAL REHABILITATION IMPACT: An early postoperative assessment of physical deconditioning might be able to predict the walking ability at discharge (hence, the discharge setting), in older patients undergoing major surgery.

Focused extracorporeal shock wave therapy combined with supervised eccentric training for supraspinatus calcific tendinopathy.

BACKGROUND: Extracorporeal shockwave therapy (ESWT) is effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy. Eccentric exercise has been introduced as an effective treatment choice for Achilles tendinopathy, but poor evidence exists about its role in the treatment of rotator cuff tendinopathy. AIM: To investigate if adding a supervised eccentric training of the shoulder abductor muscles could improve the outcome of ESWT. DESIGN: Pre-post intervention pilot study with matched control-group. SETTING: Outpatient, University Hospital. POPULATION: Twenty-two subjects affected by painful supraspinatus calcific tendinopathy. METHODS: The study-group was assigned to receive focal ESWT (f-ESWT) plus a supervised eccentric training (SET) of the shoulder abductor muscles. The matched control-group received f-ESWT only. The post-treatment assessment at follow-up (T1) was performed nine weeks after the enrollment (T0). We assessed shoulder pain and function by the means of a numeric rating scale (p-NRS) and a DASH scale. As secondary outcome, we measured the isometric strength of the abductor muscles of the affected shoulder using a handheld dynamometer. RESULTS: At T1, we recorded a significant decrease in pain (P<0.001) and an improvement in upper limb function (P<0.001) in both groups. However, we observed no statistical differences in favor of the study-group, in terms of p-NRS and DASH total score. A mild increase (+13% from baseline) of the maximum isometric abduction strength was noticed in the study group at T1. CONCLUSIONS: Our findings did not support the hypothesis that adding a supervised eccentric training of the shoulder abductor muscles could improve the outcome (pain and function) of shock wave therapy. CLINICAL REHABILITATION IMPACT: Our study confirmed that f-ESWT is effective in reducing shoulder pain and improving function in calcific supraspinatus tendinopathy. Adding a supervised eccentric training, focused on the abductor muscles, was useful to improve maximum isometric abduction strength, but appeared to give no advantage in the short-term outcome of shock wave therapy.

Early rehabilitation after elective total knee arthroplasty.

BACKGROUND AND AIM OF THE WORK: Outcomes after TKA surgery are supposed to be related to the intensity and type of post-operative rehabilitation. Aim of this paper is to describe our early rehabilitation protocol following TKA with mini-invasive surgery in the immediate post-operative period and analyze functional recovery and changes in pain scores in these patients. METHODS: in this observational study, data were collected on 215 total knee arthroplasty patients referred to Orthopedics and Traumatology inpatient ward from July 2012 to January 2014, treated with the same early start rehabilitation protocol. We recorded times to reach functional goals (sitting, standing and assisted ambulation) and pain after the treatment. RESULTS: length of hospital stay in TKA was 4.6±1.8 days, with a rehabilitation treatment lenght of 3.3±1.3 days. The mean time needed to achieve the sitting position was 2.3±0.7 days, to reach the standing position was 2.6±1.0 days to reach the walking functional goal was 2.9±1.0 days.  Pain NRS scores remained below 4 in the first and second post-operative day and below 3 from the third post-operative day. CONCLUSION: Our study confirms that rehabilitation started as soon as 24 hours after surgery with mini-invasive approach, enables early verticalization of patients and early recovery of walking with a good control of pain.

Early rehabilitative treatment after infrainguinal lower limb bypass surgery.

BACKGROUND AND AIM OF THE WORK: Functional activity may remain limited in patients affected by critical limb ischemia, despite successful infrainguinal lower limb bypass surgery (ILLBS). The aim of the work was to evaluate the impact of a rehabilitative intervention on postoperative ambulatory status and pain. METHODS: In an observational study, data were collected on 34 patients undergoing ILLBS for critical limb ischemia or end-stage peripheral arterial disease. All patients underwent a postoperative rehabilitation program aimed at recovering gait autonomy. Information was collected on pre-operative comorbidities, ambulatory status (on admission to and discharge from hospital) and pain in the affected lower limb (on the first physiotherapy session and at discharge). RESULTS: Before ILLBS, 61.8% of the patients walked independently without aids or assistance. The rehabilitative program started on average 5.7 (SD: 2.1) days after surgery. At discharge, 50% of the patients walked independently, 41.2% walked with aids and/or assistance and 8.8% were not able to walk. Overall, 76.5% of the sample recovered their pre-operative ambulatory status. Although pain tended to decrease, the difference at the first (1.5; SD: 2.6) and at the last treatment session (0.8; SD= 1.3) was not statistically significant. CONCLUSION: Our exercise protocol resulted to be easy to perform during hospital stay, with an overall favourable outcome for ambulatory status. Our results are in line with those reported in literature about the rates of postoperative dependence in walking, but appear to be slightly better in regards to the percentage of patients who recovered pre-operative ambulatory status.

Assessment of physical performance and quality of life in kidney-transplanted patients: a cross-sectional study.

BACKGROUND: Information on physical and mental wellness in renal transplantation is limited. Therefore, we performed a cross-sectional study to evaluate and describe the different components of physical performance and quality of life (QoL) in a cohort of kidney-transplanted patients. METHODS: Physical performance and QoL were determined through the administration of validated tests and questionnaires [muscle strength, dynamometer handgrip, tactile sensitivity, visual analogue scale (VAS) for pain, Timed Up and Go (TUG) test, Fatigue Severity Scale (FSS) and the 36-item Short Form Health Survey]. The patients were divided into three groups based on time elapsed since transplantation: early (in the first 6 months), middle (from 7 to 60 months) and late (>60 months). RESULTS: Of 132 enrolled patients, 11 patients (8.3%) presented a severe reduction of muscle strength, 63 patients (47%) had significant bilateral impaired handgrip and tactile sensitivity was altered in 23 patients (17.4%). TUG assessment showed significant mobility limitation in 29 patients (21.9%). The FSS presented a pathological value in 50 patients (37.3%), while the mean VAS was 1.8 ± 2.7. There were no significant differences in physical performance parameters among the three patient groups. There were inverse correlations among different components of physical performance and age, comorbidity and dialysis vintage, and there was a direct correlation with renal function. During the first months after transplantation there were limitations in physical, social and emotional activities. Overall, the self-perceived physical performance was significantly lower in transplanted patients with respect to the normal reference level. CONCLUSION: Kidney-transplanted patients may present different degrees of impairment in physical performance and quality of life. Systematic functional assessment is essential to identify patients needing intensive and personalized rehabilitation programmes.

Postoperative rehabilitation for chronic subdural hematoma in the elderly. An observational study focusing on balance, ambulation and discharge destination.

BACKGROUND: Chronic subdural hematoma (CSDH) can have a negative impact on autonomy of the elderly. Ambulatory and functional status may remain limited despite successful surgical evacuation. AIM: To evaluate the outcome of a postoperative assisted rehabilitation program. DESIGN: Single-institution short-term observational study. SETTING: Inpatient (Neurosurgery Unit of a University Hospital). POPULATION: Thirty-five patients, aged 65 or older, who underwent burr-hole drainage for chronic subdural hematoma. METHODS: Postoperatively all participants underwent a rehabilitation program, described in details, aimed at recovering standing position and gait as soon as possible. The program involved daily 30-minute individual sessions assisted by a physiotherapist, until discharge from hospital. The Markwalder's Grading Scale was used to assess the neurological status preoperatively and at discharge. The Trunk Control Test, the Standing Balance by Bohannon Scale and the Modified Rankin Scale were used to evaluate balance and general function (primary outcome) in the immediate postoperative and at discharge. We also recorded the rate of pre-CSDH walking patients who maintained ambulation at discharge and the discharge destination (secondary outcome). RESULTS: Total scores of Markwalder's Grading Scale, Trunk Control Test, Standing Balance by Bohannon Scale and Modified Rankin Scale improved (P<0.05), indicating a global favorable outcome, especially for balance. Excluding the patients who were dependent pre-CSDH, the others maintained gait function in 74.2% of cases. Only 45.7% of the patients were discharged home, the others being divided between inpatient medical settings and rehabilitation. CONCLUSIONS: The rehabilitation program was well tolerated by the patients. Our study showed a clear improvement in trunk control and standing balance and an overall favorable outcome for neurological and ambulatory status at discharge. Despite an assisted postoperative rehabilitation program, the residual impairment in general function was the main factor that prevents us to discharge more elderly patients home rather than to assisted settings. CLINICAL REHABILITATION IMPACT: The results of this descriptive study suggest that an assisted rehabilitation program may be helpful in improving short-term postoperative balance and ambulatory status (more than functional status), but further studies, with a randomized controlled design, are certainly justified to understand the efficacy of rehabilitation in this context.

Integrating and monitoring hand burn rehabilitative treatment using Virtual Reality.

OBJECTIVES: Hand burn is not a common condition in the clinical practice and needs a long and laboured rehabilitative treatment to restore the lost function. METHODS: This case report illustrates the achievable improvements in mobility and function by using innovative inertial systems for occupational exercise in a Virtual Reality, in addition to a traditional rehabilitative treatment. RESULTS: Through these instruments, we could promote and concurrently assess the recovery of a functional grasp and the ability in the execution of Activities of Daily Living.

Changes in quality of life and functional capacity after lung transplantation: A single-center experience.

Lung transplantation (LT) increases the life expectancy of patients affected by end stage pulmonary disease; specifically, its ultimate aims are to improve survival and health related quality of life (HRQoL). The aim of the present longitudinal study was to determine the HRQoL trajectory and changes in functional capacity from time of entry in the waiting list for LT to 2 year after LT. The study included sixty-nine outpatients enrolled in a single medical center when they entered the waiting list for LT and who subsequently received it. They were then followed up over 2 years after LT. HRQoL was assessed by the physical and mental component summary (PCS and MCS) scores of the 36-item Short Form Health Survey (SF-36) and Saint George's Respiratory Questionnaire (SGRQ). Psychological distress was evaluated with the General Health Questionnaire (GHQ), and functional capacity was investigated using the six-minute walk test (6MWT) and forced expiratory volume (FEV1). Patients showed low SF-36 PCS (30.5±7.8) and SGRQ total (61.8±17.5) scores at entry in the waiting list, but exhibited significant changes over time after LT (p<0.001). Furthermore, patients who showed an increase of at least 50% in SF36 PCS and SGRQ scores at 6 months survived longer. Both FEV1 and 6MWT distance as well as GHQ scores significantly changed over time, with improvements occurring in the first 6 months after LT but no major changes thereafter. Out of the 69 patients enrolled, 32 died over a median follow-up of 51 months. Although mortality tended to be slightly higher for patients with lower HRQoL at the baseline assessment, this difference was not statistically significant. HRQoL evaluations appear critical in the follow-up of LT candidates, in particularly SGRQ, because of its specificity in targeting respiratory symptoms and functional wellbeing.

Effect of Botulinum Toxin on Disabling Neuropathic Pain: A Case Presentation Suggesting a New Therapeutic Strategy.

This case presentation describes a 47-year-old woman who developed complex regional pain syndrome type II with severe neuropathic pain following iatrogenic transection of the tibial nerve at the ankle. The pain and disability progressively worsened over time, markedly impaired ambulation, and were not relieved despite various analgesic treatments. After injection of botulinum toxin (abobotulinumtoxinA, BoNT-A) in the leg muscles the tendons of which pass through the tarsal tunnel (together with the tibial nerve), her pain decreased and her walking capacity improved. This case suggests a new therapeutic role for botulin toxin in treating peripheral neuropathic pain caused by movement-evoked ectopic potentials. LEVEL OF EVIDENCE: V.

Diagnosis and treatment of pain in plexopathy, radiculopathy, peripheral neuropathy and phantom limb pain. Evidence and recommendations from the Italian Consensus Conference on Pain on Neurorehabilitation.

Pain may affect all aspects of social life and reduce the quality of life. Neuropathic pain (NP) is common in patients affected by plexopathy, radiculopathy, mononeuropathy, peripheral neuropathy. Phantom limb pain (PLP) is a painful sensation that is common after amputation, and its pathophysiological mechanisms involve changes in the peripheral and central nervous system. Given the lack of conclusive evidence and specific guidelines on these topics, the aim of the Italian Consensus Conference on Pain on Neurorehabilitation (ICCPN) was to collect evidence and offer recommendations to answer currently open questions on the assessment and treatment of NP associated with the above conditions and PLP. When no evidence was available, recommendations were based on consensus between expert opinions. Current guidelines on the assessment and pharmacological treatment of NP can be applied to plexopathy, radiculopathy, mononeuropathy, peripheral neuropathy, while evidence for invasive treatments and physical therapy is generally poor because of the low quality of studies. Treatment of PLP is still unsatisfactory. Data on the functional outcome and impact of pain on neurorehabilitation outcome in these conditions are lacking. In most cases, a multidisciplinary approach is recommended to offer a better outcome and reduce side effects. High quality studies are requested to address the unmet needs in this field.

Long-term facial improvement after repeated BoNT-A injections and mirror biofeedback exercises for chronic facial synkinesis: a case-series study.

BACKGROUND: Only few studies have considered the effects of the combined treatment with onabotulinumtoxinA (BoNT-A) injections and biofeedback (BFB) rehabilitation in the recovery of postparetic facial synkinesis (PPFS). AIM: To explore the presence of a persistent improvement in facial function out of the pharmacological effect of BoNT-A in subjects with established PPFS, after repeated sessions of BoNT-A injections combined with an educational facial training program using mirror biofeedback (BFB) exercises. Secondary objective was to investigate the trend of the presumed persistent improvement. STUDY DESIGN: Case-series study. SETTING: Outpatient Clinic of Physical Medicine and Rehabilitation Unit. POPULATION: Twenty-seven patients (22 females; mean age 45±16 years) affected by an established peripheral facial palsy, treated with a minimum of three BoNT-A injections in association with mirror BFB rehabilitation. The interval between consecutive BoNT-A injections was at least five months. METHODS: At baseline and before every BoNT-A injection+mirror BFB session (when the effect of the previous BoNT-A injection had vanished), patients were assessed with the Italian version of Sunnybrook Facial Grading System (SB). The statistical analysis considered SB composite and partial scores before each treatment session compared to the baseline scores. RESULTS: A significant improvement of the SB composite and partial scores was observed until the fourth session. Considering the "Symmetry of Voluntary Movement" partial score, the main improvement was observed in the muscles of the lower part of the face. CONCLUSIONS: In a chronic stage of postparetic facial synkinesis, patients may benefit from a combined therapy with repeated BoNT-A injections and an educational facial training program with mirror BFB exercises, gaining an improvement of the facial function up to the fourth session. This improvement reflects the acquired ability to use facial muscle correctly. It doesn't involve the injected muscles but those trained with mirror biofeedback exercises and it persists also when BoNT-A action has vanished. CLINICAL REHABILITATION IMPACT: The combined therapy with repeated BoNT-A injections and an educational facial training program using mirror BFB exercises may be useful in the motor recovery of the muscles of the lower part of the face not injected but trained.

Oxygen saturation and heart rate monitoring during a single session of early rehabilitation after cardiac surgery.

BACKGROUND: Early rehabilitation after cardiac surgery aims to prevent immobilization, to reduce the effects of surgery on the respiratory function and to facilitate the recovery of autonomy in the activities of daily living (ADL), after discharge. Nevertheless the optimal perioperative physical therapy care for patients undergoing cardiac surgery is not well established. Moreover, most of the studies monitored peripheral oxygen saturation (SpO2) and heart rate (HR) during surgery or focused only on their recovery after rehabilitation and not on their pathways during a session of exercises. AIM: To monitor peripheral oxygen saturation and HR before, during and at the end of a single session of early rehabilitation after cardiac surgery, so testing our protocol's safety. DESIGN: A case series. SETTING: Department of Cardiothoracic Surgery, inpatients. POPULATION: Forty-eight consecutive inpatients (35 M), mean age 61 years, with cardiovascular disease (CVD), who underwent cardiac surgery. METHODS: We monitored SpO2%, HR, systemic blood pressure (BP), pain in the thoracic wound (VAS) and rate of perceived exertion (RPE) during the rehabilitation session after weaning from oxygen therapy. RESULTS: During all phases mean SpO2 was 94% (±1.8) and mean HR was 85 bpm (±13.3). Number of desaturation events were 14 in total and mean of % of time with SpO2<90% was 3 (±6.5) during all the rehabilitative session. Moreover, mean BP after reaching the sitting position was 124.7 (±11.9)/78.6 (±8.4) and after ambulation was 131.5 (±11.5)/82.9 (±7.3). CONCLUSION: The monitoring peripheral oxygen saturation and HR during and not only before and at the end of a standardized early rehabilitation session helped us to ensure the safety of our protocol. CLINICAL REHABILITATION IMPACT: Because of its feasibility, safety and reproducibility our rehabilitation treatment has been applied to different types of surgical inpatients in order to limit the negative consequences of immobilization.

Rehabilitation and functional recovery after masseteric-facial nerve anastomosis.

BACKGROUND: After masseteric-facial nerve (V-VII) anastomosis, a new neurological circuit oversees the facial muscles and patients should learn to activate the facial movements using the masseteric function. AIM: To monitor the rehabilitative protocol of facial muscles activation through teeth clenching and to assess the clinical evolution after V-VII anastomosis in terms of facial symmetry and functional recovery. DESIGN: Case series. SETTING: Outpatients clinic. POPULATION: Eleven patients undergone V-VII anastomosis for complete unilateral facial palsy. METHODS: After surgery, patients underwent a needle electromyography (EMG) and a rehabilitative training with mirror feedback to learn how to reach the symmetry at rest and during facial movements through teeth clenching. The rehabilitative protocol at the first clinical evaluation has been monitored through the Italian version of Sunnybrook Facial Grading System (SFGS) and the Software Facial Assessment by Computer Evaluation (FACE). Functional limitations and quality of life have been evaluated using the Italian version of Facial Disability Index (FDI). The clinical evolution at 18 months was evaluated with EMG, SFGS, biting evaluation and FDI. RESULTS: At the first clinical evaluation after reinnervation, through teeth clenching patients displayed an improvement of symmetry at rest, symmetry of voluntary movement, symmetry of smile and composite score of SFGS. Objective measurement of facial structures with FACE system demonstrated an improvement of symmetry at rest and during smile through teeth clenching. At 18 months patients displayed a good reinnervation with a further improvement of SFGS scores and reduction of functional disability. No biting deficit has been observed. CONCLUSIONS: After V-VII anastomosis, at the first rehabilitative visit, patients learn to activate the reinnervated facial muscles through teeth clenching. Eighteen months after the anastomosis, patients display a further improvement of voluntary control on facial symmetry and smile and a reduction of disability. CLINICAL REHABILITATION IMPACT: Our study illustrates the rehabilitative protocol after V-VII anastomosis and analyzes the clinical evolution after this intervention in terms of recovery of facial symmetry and reduction of disability. This will be instrumental to standardize the rehabilitative protocol among different centers and to choose the best patient-tailored surgical approach for subjects affected by complete facial palsy.

Objective Clinical Assessment of Posture Patterns after Implant Breast Augmentation.

BACKGROUND: An increased weight of the breasts causes several spinal postural alterations that reduce the ability to perform dynamic tasks requiring a stable balance. The effects of the increased weight of the breasts on static posture after implant breast augmentation have not been investigated yet. METHODS: Forty volunteer healthy women were asked to wear different sized breast implants (800, 400, and 300 g) inside a dedicated sports bra for 6½ consecutive hours during their everyday life activities, 1 day for every implant size. Posture changes were assessed with the association of a physiatric clinical examination with a static force platform analysis. RESULTS: A significant increase in cervical lordosis after the use of 400-g breast implants and upward was demonstrated. This alteration was stable between the 400-g and 800-g breast implants. The 400-g (per breast) implant might therefore be the load threshold that breaks the cervical postural physiologic balance. A significant increase in lumbar lordosis was demonstrated only after the use of the 800-g breast implants. The static force platform assessment demonstrated a worsening of the balance independent from the visual control with the use of 400-g and 800-g implants. CONCLUSIONS: Heavy breast implants proved to induce reversible alterations in the spinal curve, and 400 g is the cutoff for functional physiologic compensation in the short term. Such a weight might be considered the safety limit for the use of breast implants for cosmetic purposes.

Functional assessment and quality of life before and after pulmonary endoarterectomy.

PURPOSE: The study investigates Quality of Life (QOL) and correlation with functional status of patients affected by Chronic Thromboembolic Pulmonary Hypertension who undergo Pulmonary Endoarterectomy. METHODS: We investigated with an observational design (before surgery, three and twelve months afterwards) the hemodynamic data (NYHA class, mean pulmonary arterial pressure, cardiac output and pulmonary vascular resistance), the functional status (using the 6-Minute Walk Test) and the QOL, using three questionnaires: Medical Outcome Study Short Form-36 (SF-36), Minnesota Living with Heart Failure Questionnaire (MLHFQ), Saint George Respiratory Questionnaire (SGRQ). We report the results of forty-nine patients. RESULTS: After surgery there was an improvement on functional and hemodynamic parameters and on QOL. The physical domain (PCS) of SF-36 was weakly but significantly associated with all functional parameters. There was no association between functional parameters and mental domain (MCS) of SF-36 or SGRQ. The improvement in 6-Minute Walk Distance was associated with an increase in MLHFQ. CONCLUSIONS: Both QOL and submaximal exercise tolerance improve after surgery. However only the physical domains of SF-36 appear to be significantly associated to the functional data.

Functional and quality of life evaluation after single level cervical discectomy and fusion or cervical artificial disc replacement.

PURPOSE: To evaluate and compare clinical, functional and quality of life (QOL) outcomes after two types of surgical approach for single level cervical disc herniation: anterior cervical discectomy andfusion (ACDF) with cage and cervical artificial disc replacement (C-ADR). METHOD: 119 patients with cervical disc herniation underwent surgery from January 2007 to December 2010; 55 patients were included in the study (27 ACDF, 28 C-ADR). We performed: a pre and postoperative clinical evaluation of cervicobrachial pain, motor and sensory deficit in the upper limbs; a functional and QOL evaluation with self assessment scales (VAS, NPNQ, SF-36); a postoperative instrumental evaluation of cervical ROM and pain. Mean follow-up period was 24 months. RESULTS: After surgery both groups showed clinical, functional and QOL improvement. No pre and postoperative differences were found between the groups. The postoperative instrumental evaluation showed a globally reduced cervical ROM and a decreased pain threshold in comparison with normal values in both groups. CONCLUSION: Our results demonstrate the clinical equivalence of the two surgical techniques and the satisfaction of the two groups of patients two years after surgery. Although functional changes persist after surgery they do not affect quality of life.