Arm trajectories and writing strategy in healthy children.

BACKGROUND: Evaluation of elementary writing skills in children is usually obtained with high resolution (and high cost) techniques or with low resolution pen-and-paper tests. In this observational study we tested a quantitative method to obtain normative data to describe arm movement during a writing precursor gesture. METHODS: We recruited 226 healthy children (mean age 9,1 years [range: 6.3 - 11.4 years]), attending primary schools belonging to the "Istituto Comprensivo" of Rivanazzano Terme (Pavia). We asked to drive a cursor through a polygonal path (labyrinth) projected in front of them using a wireless mouse. Dartfish™ video analysis software was used to elaborate images and Excel™, MedCalc™ and Statistica 7™ to analyze values of shoulder, elbow and wrist ranges of motion, arm trajectories, execution times and gesture accuracy. RESULTS: Differences seen in motor strategies, when divided according to attended class, suggest a proximal-distal maturation of motor control. Obtained values were not significantly correlated with variables such as gender, ethnicity or cognitive functioning. CONCLUSIONS: This type of approach to a study of arm movement during childhood represents a valid alternative to other tests, considering that it can differentiate children who perform similarly in the VMI test and is non-invasive, low-cost and easily reproducible.

Identification of risk factors for fatigue and pain when performing surgical interventions.

OBJECTIVE: Evaluation of fatigue and pain following surgical activities. METHODS: Cross-sectional study. We distributed a self-evaluation questionnaire to 180 surgeons to investigate working postures and fatigue and/or pain following working activities. RESULTS: 100 surgeons replied (74 male), mean age 40.1 (SD 10.85; 26-65). Multivariate analysis suggests that the highest risk factor for developing muscle fatigue whilst performing surgical operations is standing compared to sitting (OR: 4.92; 95% CI: 1.32-18.33),followed by the ability to alternate between the two postures (OR: 3.46: 95% CI: 1.26-9.52). Surgeons who complain of intense fatigue when standing have 16 times the risk of developing musculoskeletal pain than surgeons who complain of light fatigue when standing (OR: 15.77; 95% CI: 1.51-164.37). The ability to adjust the height of the operating table before each operation reduces the risk of developing musculoskeletal pain by 83% (OR: 017; 95% CI: 0.03-0.87); 90.9% of surgeons who rest their forearms for less than half the duration of an operation reported pain. CONCLUSIONS: Fatigue and pain associated with performing surgical interventions could be managed more effectively by: controlling the working posture, being able to rest forearms, being able to regulate the height of the operating table, and possibly by applying the ergonomic guidelines.

Objective integrated assessment of functional outcomes in reduction mammaplasty.

BACKGROUND: The aim of our study was an objective integrated assessment of the functional outcomes of reduction mammaplasty. METHODS: The study involved 17 women undergoing reduction mammaplasty from March 2009 to June 2011. Each patient was assessed before surgery and 2 months postoperatively with the original association of 4 subjective and objective assessment methods: a physiatric clinical examination, the Roland Morris Disability Questionnaire, the Berg Balance Scale, and a static force platform analysis. RESULTS: All of the tests proved multiple statistically significant associated outcomes demonstrating a significant improvement in the functional status following reduction mammaplasty. Surgical correction of breast hypertrophy could achieve both spinal pain relief and recovery of performance status in everyday life tasks, owing to a muscular postural functional rearrangement with a consistent antigravity muscle activity sparing. Pain reduction in turn could reduce the antalgic stiffness and improved the spinal range of motion. In our sample, the improvement of the spinal range of motion in flexion matched a similar improvement in extension. Recovery of a more favorable postural pattern with reduction of the anterior imbalance was demonstrated by the static force stabilometry. Therefore, postoperatively, all of our patients narrowed the gap between the actual body barycenter and the ideal one. The static force platform assessment also consistently confirmed the effectiveness of an accurate clinical examination of functional impairment from breast hypertrophy. CONCLUSIONS: The static force platform assessment might help the clinician to support the diagnosis of functional impairment from a breast hypertrophy with objectively based data.

Quantitative measurement of evolution of postparetic ocular synkinesis treated with botulinum toxin type A.

BACKGROUND: The Sunnybrook Facial Grading System is considered one of the best scales available to grade facial motility and postparetic synkinesis. To measure facial landmarks and movement excursion, a new software, the Facial Assessment by Computer Evaluation, has been proposed. The aim of this study was to quantify eye synkinesis improvement after botulinum toxin type A injections using the new software and to compare this method with the Sunnybrook grading system. METHODS: The study included 40 injection sessions on 29 Caucasian outpatients with facial synkinesis. Before and 2 weeks after the injection, patients were evaluated using the Italian version of the Sunnybrook system. Eyelid fissure size at rest, during lip puckering, and while smiling was measured with the new software. RESULTS: After botulinum infiltration, the Sunnybrook grading system showed a global facial improvement with reduction of synkinesis and increase of static and dynamic symmetry. The Facial Assessment software detected an increase of ocular fissure measure at rest, during lip puckering, and especially during smiling, and the improvement was positively correlated with initial asymmetry. A single point of the Sunnybrook system synkinesis score corresponded to a mean difference of 0.77 mm during smiling and 1.0 mm during lip puckering. CONCLUSIONS: The Facial Assessment by Computer Evaluation measure allowed the authors to quantify the improvement of eye synkinesis after botulinum toxin type A injection. The Sunnybrook Facial Grading System provided an immediate instrument with which to monitor treatment in routine clinical practice, whereas the Facial Assessment system gave a more accurate quantitative assessment. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Inpatient rehabilitation outcome: a matter of diagnosis?

BACKGROUND: Patients with comorbidities are becoming more and more common in Italian rehabilitative wards. These comorbidities are considered a major problem for inpatient rehabilitation, due to the fact that they cause longer lengths of stay, higher costs, and lower functional results. METHODS: To investigate the possible relationships between comorbidity, functional impairment, age, and type of discharge in patients hospitalized in postacute rehabilitation facilities, we planned an observational study. A total of 178 consecutive inpatients (average age: 78 years [range: 39-99]) from postacute rehabilitation facilities were recruited. Primary diagnosis, comorbidity rating (Cumulative Illness Rating Scale - Geriatric version, CIRS-G) and functional impairment score (Functional Independence Measure, FIM™) were evaluated at admission. The FIM™ rating was also assessed at hospital discharge. RESULTS: A total of 178 of the 199 enrolled patients completed the rehabilitation treatment (89.4%). The average length of stay was 46 ± 24 days. CIRS-G showed an average comorbidity score for each patient of 4.45 ± 1.69. The average FIM™ rating was 79 ± 24.88 at admission, and 91.9 ± 25.7 at discharge. Diagnosis at admission (grouped according to the International Classification of Diseases 9-CM) seemed to correlate with functional results, since lower rehabilitative efficiency was obtained for patients who had a history of stroke. CONCLUSION: The number and type of comorbidities (CIRS-G) in rehabilitation inpatients do not seem to affect functional outcomes of treatment. The determining factor for a lower level of functional recovery seems to be the diagnosis at admission.

Evaluation and treatment of synkinesis with botulinum toxin following facial nerve palsy.

PURPOSE: To assess the effect and efficacy of botulinum toxin type A (BTX-A) in reducing synkinesis in aberrant facial nerve regeneration (following facial paralysis). METHOD: A total of 55 sessions of BTX-A (Botox) infiltration were performed on 30 patients (23 female) with synkinesis after facial palsy. Each subject was injected with 2.5 units of BTX-A in each injection site (the sites were chosen on a case-by-case basis). The synkinetic muscles targeted include: orbicularis oculi, zygomaticus major, depressor labii inferioris, platysma, healthy frontalis and healthy corrugator supercilii. The patients were examined using the Sunnybrook Facial Grading System, both before the BTX-A treatment and after an average of 35 days. RESULTS: All 30 patients experienced improvement to the synkinesis after treatment. Total scores: median pre-BTX-A: 40; post 53 p = 0.004. Resting symmetry scores: mean pre-BTX-A -7.1; post: -3.5; median pre -5 [interquartile range (IQR) -10 to -5]; post: -5 (IQR -5 to 0); p = 0.0001. Symmetry of voluntary movement median pre-BTX-A: 56 post 60 p = 0.10. Synkinesis scores: median pre-BTX-A: -9 post -3 p < 0.0001. Mean duration of improvement was 4 months. CONCLUSIONS: BTX-A injection treatment was effective in reducing facial synkinesis, thus improving facial expression symmetry both at rest and in voluntary movements.