Prevalence and determinants of hip pain in non-ambulatory cerebral palsy children: a retrospective cohort study.

BACKGROUND: Hip pain is common in cerebral palsy children, particularly at Gross-Motor Function Classification System level IV-V. It is associated to hip displacement and relates to the migration percentage. Recent literature suggested early reconstructive bone surgery, as the best approach to prevent hip luxation, then hip pain. Still, high rates of hip pain are reported. AIM: To investigate prevalence and determinants of hip pain in an Italian cerebral palsy sample. DESIGN: Single-center retrospective cohort study. SETTING: Inpatient and outpatient. POPULATION: Patients with spastic or dyskinetic cerebral palsy, Gross-Motor Function Classification System level IV or V, age 0-18. METHODS: A chart review was implemented to report hip pain, as a dichotomous variable (pain/no pain), age, sex, cerebral palsy subtype, Gross-Motor Function level, lumbar scoliosis, migration percentage, previous orthopedic surgery, or botulinum injections, oral or intrathecal baclofen, drug-resistant epilepsy, assistive devices for standing or walking. Descriptive statistics and a multivariate logistic stepwise regression were performed. RESULTS: A total of 504 subjects were included: 302 level V, 209 females, 432 spastics. The mean length of follow-up was 6 years. The overall prevalence of hip pain was 8.9% (6.3% were at level V) and of hip dislocation was 19% (15.9% were at level V). Just 39% of dislocated hips were painful. Children at spastic subtype and level V were predominantly affected. Botulinum and soft tissue surgery related to lower rates of hip pain, without statistical significance. Age (OR 1.19, 95%CI 1.14-1.25, P value 0.000), sex (OR 1.72, 95%CI 1.18-2.52, P value 0.005), migration percentage (OR 1.02, 95%CI 1.02-1.03, P value 0.000) and lumbar scoliosis (OR 1.32, 95%CI 0.86-2.01, P value 0.200) resulted significant independent determinants of hip pain. CONCLUSIONS: Hip pain relates with the migration percentage, but not all dislocated hips become painful. Hip pain may be transient and requires a targeted and individualized approach. Children at spastic subtype and level V were predominantly affected. Age and sex are confirmed as determinants. Specific validated measures are to be implemented to assess hip pain. CLINICAL REHABILITATION IMPACT: Considering severe non-ambulatory cerebral palsy patients, pain and quality of life should be considered as outcomes, in the management of hip luxation.

Can vitamin D deficiency influence muscle performance in postmenopausal women? A multicenter retrospective study.

BACKGROUND: The presence of the vitamin D receptor (VDR) has been recently demonstrated in human muscle supporting the theory of a role of vitamin D in the proliferation and differentiation of muscle cells. So far only few studies investigated the association between vitamin D and muscle performance in postmenopausal women. AIM: To define the functional impact of vitamin D deficiency. DESIGN: Multicenter retrospective study. SETTING: Five Italian outpatient services of Physical and Rehabilitation Medicine (PRM). POPULATION: Postmenopausal women. METHODS: We divided the population in two groups based on the threshold of 30 ng/mL as cut-off to define sufficient and insufficient serum levels of 25-hydroxyvitamin D3 [25(OH)D3]. Outcome measures were: appendicular lean mass (ALM); ALM-to-BMI ratio (ALMBMI); total fat mass (FM); visceral adipose tissue (VAT); Hand Grip Strength (HGS); Knee Isometric Extension Strength (KES); Short Physical Performance Battery (SPPB); 4-meter gait speed (4MGS). RESULTS: We analyzed the data records of 401 postmenopausal women (mean age 66.93±8.47 years): 203 with hypovitaminosis D (mean age 66.81±8.11 years) and 198 with normal levels of 25(OH)D3 (mean age 67.04±8.84 years). The analysis showed a significant difference between the two groups in terms of: ALMBMI (0.002), FM (P<0.001), VAT mass (0.010), VAT volume (P=0.006), HGS (P<0.001), KES (P<0.001), SPPB score (P<0.001), percentage of people with a 4MGS≤0.8 m/s (P<0.001). Furthermore, there were significant correlations (P<0.001) between serum levels of 25(OH)D3 and HGS (r=0.323), KES (r=0.510), and SPPB sit to stand (r=-0.362) and walking sub-scores (r=-0.312). CONCLUSIONS: This multicenter study demonstrated that postmenopausal women with vitamin D deficiency had a significant reduction of appendicular muscle strength and physical performance. CLINICAL REHABILITATION IMPACT: This study reported the frequency of hypovitaminosis D in postmenopausal women and its influence on the reduction of muscle mass, strength, and physical performance in a typical population referring to the physiatrist for musculoskeletal disorders.

Rehabilitation needs in oncological patients: the On-rehab project results on patients operated for musculoskeletal tumors.

BACKGROUND: Rehabilitation plays an important role in improving functional outcome in patients operated on musculoskeletal tumors. Literature in the field is scarce and the specific needs for rehabilitation of these patients are still unknown. AIM: To analyze the rehabilitation needs of patients with primary malignant musculoskeletal tumors. DESIGN: Observational, longitudinal study on both inpatient and outpatient operated on musculoskeletal tumors. METHODS: Rehabilitation needs of oncological patients were explored by means of questionnaires administered by a physician. Demographic, oncological, psychological domains were also assessed. RESULTS: Twenty-nine patients were evaluated in the immediate post-operative period, 25 patients had a follow up at 6 months, and 11 patients at 12 months. Rehabilitation needs concerned essentially the neuromotor function and the improvement of independence at home/outside home. At first admission, support for occupational rehabilitation was also relevant, while its importance was reduced over the follow-up. Pain control need was greater at first admission (VAS over the follow-up 3.3, 0.52, and 1.09, respectively) and required treatment with painkillers. Quality of life (EORTC) increased over the three assessments (respectively 48.80; 71.42; 82.14). The Psychological Distress Inventory (PDI) scores were 26.23, 21.75, 23.6, and the Caregiver Needs Assessment (CNA) scores were 32.69, 27.95, and 31.7 respectively at the three follow up. CONCLUSIONS: The relevant domains in which rehabilitation needs emerged in up to 1 year follow up were the neuromotor area in order to gain independence at home and outside the home, pain control, particularly after surgery, nursing, psychological support of patients and caregivers, and occupational activities (personal, work, school, social). CLINICAL REHABILITATION IMPACT: The findings of the present study suggest that: short and midterm clinical rehabilitation programs should be made available for patients operated on musculoskeletal tumors. Physical function recovery is only one aspect of rehabilitation, and psychosocial functioning must be taken into account and coordinated by a comprehensive team of specialists. Appropriate assessment tools should be used, and a continuum of care from the hospital to the patient's home should be promoted.

Cross-Cultural and Construct Validity of the Animated Activity Questionnaire.

OBJECTIVE: The Animated Activity Questionnaire (AAQ) assesses activity limitations in patients with hip/knee osteoarthritis and consists of video animations; the patients choose the animation that best matches their own performance. The AAQ has shown good validity and reliability. This study aims to evaluate cross-cultural and construct validity of the AAQ. METHODS: Cross-cultural validity was assessed using ordinal logistic regression analysis to evaluate differential item functioning (DIF) across 7 languages. Construct validity was assessed by testing correlations between the AAQ and a patient-reported outcome measure (PROM) and performance-based tests. RESULTS: Data from 1,239 patients were available. Compared to the Dutch language (n = 279), none of the 17 items showed DIF in English (n = 202) or French (n = 193), 1 item showed uniform DIF in Spanish (n = 99) and Norwegian (n = 62), and 2 items showed uniform DIF in Danish (n = 201). In all these languages, the occurrence of DIF did not influence the total score, which remained comparable with the original Dutch version. For Italian (n = 203) versus Dutch, however, 6 items showed uniform DIF, and 1 item showed nonuniform DIF, indicating some problems with the cross-cultural validity between these countries. With regard to construct validity, the correlations with PROM (0.74) and performance-based tests (0.36-0.68) were partly as expected (>0.60). CONCLUSION: The AAQ, an innovative tool to measure activity limitations that can be placed on the continuum between PROMs and performance-based tests, showed a good overall cross-cultural validity, and seems to have great potential for international use in research and daily clinical practice in many European countries.

Gait analysis: clinical facts.

Gait analysis is a well-established tool for the quantitative assessment of gait disturbances providing functional diagnosis, assessment for treatment planning, and monitoring of disease progress. There is a large volume of literature on the research use of gait analysis, but evidence on its clinical routine use supports a favorable cost-benefit ratio in a limited number of conditions. Initially gait analysis was introduced to clinical practice to improve the management of children with cerebral palsy. However, there is good evidence to extend its use to patients with various upper motor neuron diseases, and to lower limb amputation. Thereby, the methodology for properly conducting and interpreting the exam is of paramount relevance. Appropriateness of gait analysis prescription and reliability of data obtained are required in the clinical environment. This paper provides an overview on guidelines for managing a clinical gait analysis service and on the principal clinical domains of its application: cerebral palsy, stroke, traumatic brain injury and lower limb amputation.

Functional and clinical assessment of two ankle arthrodesis techniques.

Isolated tibiotalar fusion is the preferred choice for isolated end-stage arthritis, joint destruction after infection, talar avascular necrosis, Charcot neuroarthropathy, and joint replacement failure. Combined tibiotalar and subtalar joint fusion with an intramedullary nail can achieve better alignment and save patients from prolonged non-weightbearing. The purpose of the present study was to functionally assess using instrumental gait analysis and clinically assess the effect of these 2 surgical techniques. Twelve patients with a mean follow-up duration of 70 (range 55 to 89) months after successful ankle fusion were analyzed, 6 isolated and 6 combined. The main outcome measure was the functional assessment performed using a stereophotogrammetric system and an established multisegment foot kinematics protocol. Standard clinical, imaging, and score systems were also assessed in the 2 groups, including radiographic-based classification of arthritic degeneration at the neighboring foot joints. No significant differences were found between the 2 groups using the scoring systems. Severe arthritic degeneration was found at the subtalar joint in the isolated fusion group and at the talonavicular and Lisfranc joints in the combined fusion group. From the gait analysis, no differences were found in the time-distance parameters; however, significant differences were observed in several joint rotations and planar angles. Isolated tibiotalar fusion allows for motion, however small, at the subtalar joint but can result in severe degeneration. Good clinical and functional results can also be obtained with combined tibiotalar and subtalar fusion, although this can result in degeneration of the adjacent joints of the foot.

Painful os Acromiale: Conservative Management in a Young Swimmer Athlete.

An os acromiale (OA) arises from a fusion failure of the anterior acromial apophysis. This case report presents the successful management of a painful OA associated to rotator cuff impingement in a competitive swimmer, based on ultrasonographic diagnosis and conservative management. Rest from sport activity, oral anti-inflammatory drugs and previous attempt of treatment of shoulder pain were ineffective. After two months of conservative treatment consisting of avoidance of swimming, local anti-inflammatory, physical therapy with ice, strengthening exercises with elastic bands to strengthen the scapular stabilizing muscles, rotator cuff and lowering humeral head muscles, the patient was pain free and all specific clinical tests for impingement syndrome (Neer, Hawkins, Whipple and Yocum tests) were negative. Digital compression of the OA site was not painful, and the Jobe and Palm-up tests were negative. The athlete returned to swim continuing the rehabilitation exercises, and the successful results were maintained at one year follow up. An unstable and symptomatic OA can be easily diagnosed with ultrasound exam. Rehabilitation for rotator cuff tendinopathies or/and bursitis can be a valid alternative to surgery. Key pointsAn os acromiale (OA) arises from a fusion failure of the anterior acromial apophysis.A correct diagnosis of OA associated to rotator cuff impingement can be performed by ultrasonographic exam.A conservative management of rotator cuff impingement syndrome, associated to OA, can be planned in athletic patients as a valid alternative to surgery.