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.

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.

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.

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.

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.

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.

Validation of the Italian version of the Sunnybrook Facial Grading System.

The Sunnybrook Facial Grading System (SFGS) is one of the most employed scales to assess the severity of facial palsy. The aim of our study was to produce an Italian version of the SFGS and of its explanatory criteria, and to test their measurement properties when employed by Italian physicians. A multidisciplinary committee translated and adapted the scale and its criteria into Italian. Six native Italian physicians, four of whom experienced in facial palsy and two novices, rated independently 29 videos of facial palsy patients twice. Internal consistency, agreement and repeatability were evaluated. The Italian version of the SFGS showed a high degree of internal consistency with a Cronbach's α of 0.91. The test-retest reliability was high for both inter-rater and intra-rater measures with an ICC of 0.96 and 0.98, respectively. The scores given by the novice physicians were comparable with the scores given by the expert physicians. Our study suggests that the Italian version of the SFGS has excellent internal consistency and reproducibility, comparable to the original scale. Our study confirms in an independent case record the high measurement properties of SFGS and provides the first validated Italian scale for the assessment of facial palsy.

The Italian Society of Physical and Rehabilitation Medicine (SIMFER) recommendations for neck pain.

The paper represents the Italian Society of Physical " and Rehabilitation Medicine (SIMFER) recommendations to Neck Pain. We searched the principal scientific databases for papers concerning the main approaches to NP, including international guidelines, clinical trials of high methodological value and systematic reviews without any temporal limits. The recommendations were graded on the basis of the National Plan for Guidelines of the Italian Istituto Superiore di Sanità, which includes the level of evidence and strength of the recommendation. The principal sections of the recommendations deal with the Evaluation and Therapy for Neck Pain. The first describes the main evidence concerning the evaluation of patients with NP with or without limb involvement and/or headache: medical history, physical examination, neurological examination, laboratory tests, electrodiagnostics, diagnostic imaging and self-administered questionnaires. The second describes the best evidence synthesis concernig the therapy for Neck Pain: education, exercise, medical therapy, manual therapy, traction, physical therapy, acupuncture, orthoses, multimodal treatment, behavioural treatment.

Early rehabilitative treatment in aortocoronary bypass surgery.

AIM: The objective of this retrospective study is to analyze functional recovery and response to rehabilitation treatment during the immediate postoperative phase of aortocoronary bypass (ACB) surgery. METHODS: We studied 319 patients, who had undergone ACB surgery and who needed post-acute rehabilitation. RESULTS: All patients presented post-operative respiratory dysfunction, 300 cases presented inability in position changes and needed neuromotor exercises in addition to chest physiotherapy. Rehabilitation treatment began at a mean number of 1.79 +/-1.37 days after surgery and continued for 5.78 +/- 3.59 days. At the discharge, at mean 5.47 +/- 2.25 days after surgery, most of patients (65.61%) walked independently. CONCLUSIONS: Our study described a protocol of early rehabilitative treatment that appeared to be suitable in promoting patients'functional recovery after aortocoronary bypass surgery.

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.

Child visuomotor skills: preliminary findings using a new low-cost movement analysis method.

Visuomotor skills are obviously important in activities of daily living. In school-aged children they are particularly important in writing and reading processes. The assessment of these skills is usually performed through neuropsychological or complex neurophysiological tests. We present our preliminary findings in 21 healthy children in whom visuomotor assessment was performed using a new, non-invasive method, based on quantitative video analysis of arm movement during a maze task. This low-cost method seems promising because it is easier to perform than other neurophysiological techniques, does not involve the fixing of markers on the child's body and allows accurate evaluation of joint angles. The major drawbacks are the single plane used for the video recording and the need for a well lit environment.

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.

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.

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.

Return to work after thoracic organ transplantation in a clinically-stable population.

PURPOSE: To evaluate the rate of return to work after transplantation and its determinants in a clinically-stable population of patients transplanted and followed-up at a single institution in Italy. METHODS: 151 thoracic organ transplant recipients (72 lung, 79 heart) were examined. Patients were asked about daily activities, level of education, employment and clinical condition. A six-minute walking test was performed with measurement of dyspnoea using the Borg scale. Quality of Life was evaluated with the SF-36 and GHQ questionnaires. RESULTS: Before transplantation 131 patients (87%), (70 heart and 61 lung) worked. After transplantation, 51 patients (39%) went back to work and 3 more started working. We found that younger age, a better quality of life (mainly in the mental domain), having had an occupation previously (particularly as an entrepreneur/freelancer), and having been off work for less than 24 months, were independent predictors of return to work. CONCLUSIONS: Considering their good, objective and subjective, functional status, some patients who could have returned to work, chose not to. Identifying factors which affect return to work might help health professionals to adopt the best course of treatment and psychological support in order to fulfil this goal; however, return to work should not be considered as the only expression of a patient's real psychophysical condition.

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.

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.

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.

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.