Quantification and prospective evaluation of serum NfL and GFAP as blood-derived biomarkers of outcome in acute ischemic stroke patients.

Identification of reliable and accessible biomarkers to characterize ischemic stroke patients' prognosis remains a clinical challenge. Neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP) are markers of brain injury, detectable in blood by high-sensitive technologies. Our aim was to measure serum NfL and GFAP after stroke, and to evaluate their correlation with functional outcome and the scores in rehabilitation scales at 3-month follow-up. Stroke patients were prospectively enrolled in a longitudinal observational study within 24 hours from symptom onset (D1) and monitored after 7 (D7), 30 ± 3 (M1) and 90 ± 5 (M3) days. At each time-point serum NfL and GFAP levels were measured by Single Molecule Array and correlated with National Institute of Health Stroke Scale (NIHSS), modified Rankin scale (mRS), Trunk Control Test (TCT), Functional Ambulation Classification (FAC) and Functional Independence Measure (FIM) scores. Serum NfL and GFAP showed different temporal profiles: NfL increased after stroke with a peak value at D7; GFAP showed an earlier peak at D1. NfL and GFAP concentrations correlated with clinical/rehabilitation outcomes both longitudinally and prospectively. Multivariate analysis revealed that NfL-D7 and GFAP-D1 were independent predictors of 3-month NIHSS, TCT, FAC and FIM scores, with NfL being the biomarker with the best predictive performance.

[Remote functional evaluation after reconstruction of the anterior cruciate ligament in amateur sportsmen with sedentary work]. / Valutazione funzionale a distanza dopo ricostruzione del LCA in sportivi amatoriali con lavoro sedentario.

SUMMARY: The anterior cruciate ligament (ACL) is the most commonly injured knee ligament. Currently there are two commonly used surgical procedures: middle third patellar tendon grafts (bone-patellar tendon-bone: BTB) and semitendinosus autografts or semitendinosus combined with gracilis tendon autografts (ST/G). Purpose. The aim of this study is to compare the rehabilitation results over time of amateur sportsmen who have undergone anterior cruciate ligament (ACL) reconstruction surgery by means of one of the two most commonly used procedures: middle third patellar tendon grafts (bone-patellar tendon-bone: BTB) and semitendinosus and gracilis tendon autografts (ST/G). Method. 30 subjects divided into two groups, (15 BTB and 15 ST / G), were evaluated during rehabilitation and at three follow-up periods (16 weeks, 24 weeks, 2 years). Evaluation involved clinical examination, isokinetic tests, and functional rating scales: Lysholm and IKDC. Results. The clinical evaluation resulted in the following mean values: the value of the Lysholm score was 78 in both group at 16 weeks, 91 in group A and 94 in group B at 24 weeks, 98 in group A and 99 in group B at 2 years; the value of the IKDC score was 14 in group A and 15 in group B at 16 weeks, 12 in group A and 14 in group B at 24 weeks, 14 in group A and 15 in group B at 2 years. No major complications occurred during rehabilatation Conclusions. Subjects in both groups showed good neoligament stability up to the 24-week follow up. At the 2-year follow-up the subjects of group B showed poor neoligament stability that prevented the return to the previous level of sporting activity; all the subjects with high intensity sports activity needed a greater muscle strengthening. No statistically significant differences between the two groups are seen.

Functional assessment and rehabilitation protocol in acute patients affected by SARS-CoV-2 infection hospitalized in the Intensive Care Unit and in the Medical Care Unit.

BACKGROUND: Coronavirus disease (COVID-19) is characterized by different clinical pictures that may require prolonged hospitalization and produce disabilities challenging the recovery of previous independence. AIM: The aim is to evaluate the impact of an early assisted rehabilitation program on the functional status of an acutely hospitalized population affected by COVID-19. DESIGN: Single-institution retrospective longitudinal study. SETTING: Inpatient intensive care units (ICU) and medical care units (MCU). POPULATION: Acute COVID-19 patients. METHODS: General information was collected; age-adjusted Charlson Comorbidity Index was used for comorbidities. Duration of hospital stay, the length of stay in ICU and/or MCU, the length of the rehabilitative treatment, and the destination at the discharge were collected. Evaluation was performed when patients were clinically stable (T0), and at hospital discharge (T1); for subjects enrolled in ICU functional status was assessed at the time of transfer to the MCU. Muscle strength of the four limbs was measured with the Medical Research Council (MRC) sum-score. Functional status was assessed using the 3-item Barthel Index (BI-3) and the General Physical Mobility Score (GPMS). Early assisted-tailored rehabilitation protocol was applied in ICU and in MCU: the aims were the maintenance (or recovery) of the range of motion and of the strength and the recovery of sitting/standing position and gait. RESULTS: We evaluated 116 patients (mean age 65, SD 11) (65% male), 68 in ICU (mean age 60, SD 10), 48 in MCU (mean age 73, SD 9). At discharge, BI-3 and GPMS significantly improved in both ICU (P<0.001) and MCU (P<0.001) subgroups of patients. MRC sum-score significantly improved in ICU patients (P<0.001). Patients hospitalized in ICU had a significantly longer hospital stay. At discharge, patients admitted to the ICU reach a functional state that is close to that of patients admitted to the MCU. CONCLUSIONS: The results suggest that an early assisted rehabilitation program may be helpful in improving the short-term functional status of an acutely hospitalized population affected by COVID-19, with discharge at home of 48% CLINICAL REHABILITATION IMPACT: this study focuses on a functional assessment method to be used to identify the rehabilitation needs and verify the results of an early rehabilitation protocol applied to the acute COVID-19 patient admitted to ICU and MCU.

[Evaluation of quality of life and arthropathy in the adult haemophilic patient]. / La valutazione della qualità della vita e dell'artropatia nel paziente emofilico adulto.

SUMMARY: Haemophilia in its most severe clinical form can lead to alterations in the physical and psychosocial state with important repercussions on the quality of life. Purpose. A retrospective study was conducted to highlight the impact of haemophilic arthropathy on quality of life. Materials. We considered 25 patients, with a mean age of 42 years (min 17 - max 71) with haemophilia A, 18 had the severe clinical form (72%). The WFH Physical Examination Score, specific for haemophilia, was used for joint function; the joints examined were: knee, ankle, hip and elbow. To assess the quality of life, two generic self-filling questionnaires were used, SF-36 and the EQ 5D. Results. Significant statistical values have shown that arthropathy affects the SF-36 domain of general health and the subjective well-being EQ-VAS. Conclusions. In the treatment of haemophilic arthropathy, prevention is essential, understood both as a prophylactic medical therapy and as a physiotherapeutic treatment in order to maintain or improve joint function and at the same time play a fundamental role in improving the quality of life of patients.

Postural analysis in a pediatric cohort of patients with Ehlers-Danlos Syndrome: a pilot study.

BACKGROUND: The Ehlers-Danlos Syndrome (EDS) is a rare disorder affecting the connective tissue. EDS patients may suffer of proprioception and balance impairment but all the studies dealing with such symptoms have been addressed to adult subjects. The Study of such impairment in younger patients may lead to a better awareness of own motor abilities and to a focused rehabilitative intervention. Therefore, our work aims to assess the occurrence of these alterations in a pediatric cohort of EDS patients. METHODS: The Research was designed as a cross-sectional study with a matching control group and performed on a pediatric cohort of 12 subjects with Ehlers-Danlos Syndrome (Classic and Hypermobility type) and on 12 healthy controls, during a follow-up visit at the Department of Pediatrics and at the Rehabilitation Unit of the Foundation IRCCS Policlinico San Matteo, in Pavia from April 2015 to October 2015. A square forceplatform was used to obtain the CoP (center of pressure) displacement during quiet standing during an open and a closed eyes trials. The comparisons between EDS and control group were performed using a t-test for independent data. P<0.05 was considered statistically significant. All tests were two-sided. RESULTS: All the postural parameters considered raised at closed eyes, no significant modifications without vision were found only for the standard deviation along the antero-posterior (AP) axis for the two groups. Both at open eyes and at closed eyes, Patients with EDS showed the postural parameters significantly greater than controls (P≤0.05) and this observation was most notably for the Sway. CONCLUSIONS: According to our results, a planned monitoring of age-related changes in postural parameters of patients with EDS could be really interesting to provide a perspective of the development of postural control in these patients. In fact, considering our results, it could be interesting to apply rehabilitative strategies to enhance motor coordination and postural reflexes so improving their postural control as soon as possible. Further studies about the postural control in EDS children and adolescents are required to confirm our results.

Significance of serum Myostatin in hemodialysis patients.

BACKGROUND: Malnutrition and muscle wasting are common in haemodialysis (HD) patients. Their pathogenesis is complex and involves many molecules including Myostatin (Mstn), which acts as a negative regulator of skeletal muscle. The characterisation of Mstn as a biomarker of malnutrition could be useful in the prevention and management of this condition. Previous studies have reported no conclusive results on the actual relationship between serum Mstn and wasting and malnutrition. So, in this study, we evaluated Mstn profile in a cohort of regular HD patients. METHODS: We performed a cross-sectional study, enrolling 37 patients undergoing bicarbonate-HD (BHD) or haemodiafiltration (HDF) at least for six months. 20 sex-matched healthy subjects comprised the control group. Mstn serum levels were evaluated by ELISA before and after HD. We collected clinical and biochemical data, evaluated insulin resistance, body composition, malnutrition [by Malnutrition Inflammation Score (MIS)] and tested muscle function (by hand-grip strength, six-minute walking test and a questionnaire on fatigue). RESULTS: Mstn levels were not significantly different between HD patients and controls (4.7 ± 2.8 vs 4.5 ± 1.3 ng/ml). In addition, while a decrease in Mstn was observed after HD treatment, there were no differences between BHD and HDF. In whole group of HD patients Mstn was positively correlated with muscle mass (r = 0.82, p < 0.001) and inversely correlated with age (r = - 0.63, p < 0.01) and MIS (r = - 0.39, p = 0.01). No correlations were found between Mstn and insulin resistance, such as between Mstn levels and parameters of muscle strength and fatigue. In multivariate analysis, Mstn resulted inversely correlated with fat body content (ß = - 1.055, p = 0.002). CONCLUSIONS: Circulating Mstn is related to muscle mass and nutritional status in HD patients, suggesting that it may have a role in the regulation of skeletal muscle and metabolic processes. However, also considering the lack of difference of serum Mstn between healthy controls and HD patients and the absence of correlations with muscle function tests, our findings do not support the use of circulating Mstn as a biomarker of muscle wasting and malnutrition in HD.

Focused extracorporeal shock wave therapy for greater trochanteric pain syndrome with gluteal tendinopathy: a randomized controlled trial.

OBJECTIVES:: To investigate if focused extracorporeal shock wave therapy (f-ESWT) is an effective treatment in a population affected by greater trochanteric pain syndrome (GTPS). DESIGN:: Randomized controlled trial, with blind outcome assessors. SETTING:: Outpatients, University Hospital. SUBJECTS:: A total of 50 patients affected by GTPS with gluteal tendinopathy. INTERVENTIONS:: The study group was assigned to receive f-ESWT, the control group received ultrasound therapy (UST). MAIN MEASURES:: We assessed hip pain and lower limb function by means of a numeric rating scale (p-NRS) and the Lower Extremity Functional Scale (LEFS scale), respectively. The first follow-up evaluation (2M-FUP) was performed two months after the first treatment session, the second (6M-FUP) was carried out six months later. RESULTS:: The mean age of the population was 61.24 (9.26) years. A marked prevalence of the female sex was recorded (44 subjects, 86%). The statistical analysis showed a significant pain reduction over time for the study group and the control group, the f-ESWT proving to be significantly more effective than UST ( P < 0.05) at the 2M-FUP (2.08 vs 3.36) and at the 6M-FUP (0.79 vs 2.03). A marked improvement of the LEFS total score was observed in both groups as well, but we found no statistical differences in the comparisons between groups. CONCLUSION:: Our findings support the hypothesis that f-ESWT is effective in reducing pain, both in the short-term and in the mid-term perspective. We also observed a functional improvement in the affected lower limb, but, in this case, f-ESWT showed not to be superior to UST.

Treatment of knee osteoarthritis: platelet-derived growth factors vs. hyaluronic acid. A randomized controlled trial.

OBJECTIVE: Aim of this trial was to compare efficacy of activated platelet-rich plasma against hyaluronic acid as intra-articular injections to people with osteoarthritis of the knee. DESIGN: Phase-2 randomized controlled trial, with blind patients and outcome assessors. SETTING: Outpatient rehabilitation service; years 2011-2013. SUBJECTS: Patients with knee osteoarthritis grades 2-3 at magnetic resonance imaging (MRI) were included after consent and randomized. Target sample size was 25 patients per group. INTERVENTIONS: Patients received three activated platelet-rich plasma (intervention group) or hyaluronic acid (controls) intra-articular injections at 4-week intervals. MAIN MEASURES: Main outcome measure was proportion of patients with >1 grade improvement at six months from last injection, as assessed by a radiologist blind to study group. Patients were evaluated over time clinically and with functional scales (Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lysholm, Tegner, American Knee Society Score (AKSS), Lequesne, visual analogue scale (VAS) for pain). RESULTS: Overall, 30 patients were randomized to intervention and 28 to control group. For primary outcome, 28 patients (29 knees) in the intervention and 22 (25 knees) in the control group were available. Patients with at least 1 grade improvement at repeat MRI were 14 (48.3%) in the intervention and 2 (8%) in the control group ( P < 0.003). Improvement in symptoms and functional scales was consistently higher in the intervention group. No side-effects were observed in either group. CONCLUSION: Activated platelet-rich plasma reduces articular damage as evident at MRI, as soon as six months after treatment; it reduces pain and improves patient's function and overall quality of life.

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.

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.

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.

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.

Monitoring iliopsoas muscle contraction in idiopathic lumbar scoliosis patients.

BACKGROUND: Curve evolution in idiopathic scoliosis frequently occurs in lumbar and thoracic-lumbar spine. The spinal and iliopsoas muscles play a major role in maintaining the static and dynamic stability of the spine. OBJECTIVE: To monitor by video recording, the degree to which asymmetric isometric contractions of the iliopsoas muscle improve the lumbar curve. DESIGN: 10 subjects (9 female, 1 male), mean age of 14.1 years (11-18), who were undergoing rehabilitation for idiopathic scoliosis. 8 subjects wore a brace, 6 had a single lumbar curve, 4 had a thoracic curve; 9 curves were convex to the left and 1 convex to the right. The mean Cobb angle was 20.1 degrees ±8.2523) with a mean degree of rotation of 1.2 (±0.4216). METHOD: The scoliotic curves were monitored on video whilst the patients performed muscle contraction exercises. Adhesive markers were applied to the skin to be used as reference points of the curve on video. Subjects performed the exercises in a sitting position, facing away from the video camera, with their knees bent at an angle of 90 degrees. The complete exercise procedure was as follows: initial lengthening of the spine and postural control, concentric activation of the iliopsoas, isometric activation for about 3 seconds, then final release. Differences in curvature angle detected on the video recording were analysed and processed using the computer software Dartfish Pro Suite 5.0_Dartfish LTD_Switzerland. RESULTS: The mean angle of correction through exercise was 6.9 degrees (±3.6) during concentric activation and 4.9 degrees (±3.5) during isometric activation of the iliopsoas. CONCLUSIONS: Data show the corrective effect that iliopsoas muscle contraction produces on the scoliotic curve.

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.