Multidisciplinary model for hospital-territory integrated management of patient with bone fragility: primary and secondary prevention of fractures according to severity and complexity

The aim of this study was to promote the construction of a real network and a shared diagnostic and therapeutic management model between hospitals and out-of-hospital healthcare services to capture as many patients with bone fragility as possible. Starting from the analysis of the clinical competences present in the province of Pavia, the bone specialists (BSs) organized some educational events involving both general practitioners (GPs) and hospital specialists. The Fracture Liaison Service (FLS) model, the revision of Note 79, the national plan for chronicity and the health reform of the Lombardy Regional Authority supported the structure of our model, in which the roles of clinicians are well defined and based on the complexity and severity of patients. In our method the GP has a central role as clinical manager, facilitating patient management and communication between the specialists and the BS. In January 2019, the Therapeutic Care Diagnostic Path (PDTA) shared between 2 bone specialists (BSs), 9 GPs, as reference treaters, and a multidisciplinary group of 25 specialists of the Province of Pavia was defined. The strategic directions of the two largest public hospitals in Pavia have supported the PDTA, which was validated by the quality departments of the hospitals themselves. Finally, sixty GPs belonging to the network have joined the PDTA. This model is the first example of integrated management between hospitals and out-of-hospital healthcare services for the primary and secondary prevention of fragility fractures (FF), where the GPs play a pivotal role as managers and supervisors to ensure proper care to chronic patients according to their levels of severity.

Early rehabilitation treatment in newborns with congenital muscular torticollis

BACKGROUND

Congenital Muscular Torticollis (CMT) is the most common form of torticollis in infants; on clinical presentation it is classified into 3 types: 1) postural torticollis, with postural deformity only in the neck; 2) muscular torticollis, where neck deformity is associated with muscle tightness and restricted passive range of motion (ROM); and 3) sternomastoid tumor or pseudotumor, with a fibrotic, sternocleido-mastoid muscle mass and passive ROM limitations.

AIM

The aim of this study was to evaluate the physical therapy outcome of infants with CMT treated either by parents using a home exercise program, or by a physical therapist.

DESIGN

Longitudinal study.

SETTING

Outpatients with CMT at our Department of Physical Medicine and Rehabilitation.

POPULATION

Fifty consecutive newborns with CMT, referred by the primary pediatrician:

METHODS

In our study, 50 infants with CMT were evaluated and treated either by a physical therapist or by parents using a home program.

RESULTS

Sixteen females (32%) and 34 males (68%), aged 10.2 weeks (SD 6.66); 23 of the infants (46%) presented with more severe articular limitations than the others (P=0.002) and were therefore prescribed outpatient treatment by a physical therapist; the remaining 27 less severe cases (54%) were prescribed a home therapy program. 49 infants achieved full resolution after an average of 81.06 days (SD 64.05) of rehabilitation treatment. The group of patients who were treated at home achieved resolution more quickly (72.8 vs. 91.1 days), although statistical significance was not reached.

CONCLUSIONS

Infants with CMT who were treated early, either at home or in the outpatient clinic, completely recovered normal neck movement in a short time. It is important not to discharge patients until they have achieved full resolution of CMT symptoms to exclude the minimal risk of relapse.

CLINICAL REHABILITATION IMPACT

This study demonstrates the importance of early treatment in cases of congenital muscular torticollis.

Quantification of upper limb skills in elderly rehabilitative inpatients: a controlled study

BACKGROUND

Aging has a recognized degenerative effect on the functionality of the hand in terms of strength and dexterity. Despite this, there are few studies in literature that quantify the upper limb skills in the elderly.

AIM

The aim was to present quantitative data regarding upper limb functionality in the elderly and to quantify the effect of aging on them, considering the influence of the comorbidities, of the global level of autonomy, of the cognitive status and of the mood, which are typically compromised in the elderly.

DESIGN

It was a controlled study.

SETTING

It was settled in the Rehabilitation Unit of the "Santa Maria alle Fonti" Medical Center, part of the Don Carlo Gnocchi ONLUS Foundation.

POPULATION

Thirty-five elderly inpatients (aged 78.6±7.5 years) compared to 30 healthy young adults (aged 30±3.9 years).

METHODS

A task consisting in 12 trials of grasping of rulers was administered to each subject and studied with a video analysis software. To assess the comorbidities, the global level of autonomy, the cognitive status and the mood, we respectively used the Cumulative Illness Rating Scale (CIRS), the Functional Independence Measure (FIM™), the Mini Mental State Examination (MMSE) and the Geriatric Depression Scale in the 15-items version (GDS-15). The scores obtained in these scales were correlated to the mean times of trials execution.

RESULTS

The motor performance was significantly worse in the inpatients group compared to the control group in terms of time to complete single tasks (which was on average three times higher in the inpatients group) and of respect of the starting sound stimulus, with more subjects from the inpatients group anticipating the starting signal. This worsening of the motor performance was significantly correlated to the severity of comorbidities and to the global level of autonomy. No significant differences emerged for the correctness of the performance and significant differences were not correlated with depression or cognitive impairment.

CONCLUSION

This study provides quantifiable data regarding upper limb skills in the elderly inpatient, allowing comparisons with other future studies of the rehabilitative environment.

CLINICAL REHABILITATION IMPACT

It suggests the relevance of considering the severity of comorbidities and the global level of autonomy in the assessment of upper limb skills in the elderly.

Affordable, automatic quantitative fall risk assessment based on clinical balance scales and Kinect data

The problem of a correct fall risk assessment is becoming more and more critical with the ageing of the population. In spite of the available approaches allowing a quantitative analysis of the human movement control system's performance, the clinical assessment and diagnostic approach to fall risk assessment still relies mostly on non-quantitative exams, such as clinical scales. This work documents our current effort to develop a novel method to assess balance control abilities through a system implementing an automatic evaluation of exercises drawn from balance assessment scales. Our aim is to overcome the classical limits characterizing these scales i.e. limited granularity and inter-/intra-examiner reliability, to obtain objective scores and more detailed information allowing to predict fall risk. We used Microsoft Kinect to record subjects' movements while performing challenging exercises drawn from clinical balance scales. We then computed a set of parameters quantifying the execution of the exercises and fed them to a supervised classifier to perform a classification based on the clinical score. We obtained a good accuracy (~82%) and especially a high sensitivity (~83%).

Choosing the best rehabilitation treatment for Bell's palsy

BACKGROUND

It is useful to perform neurophysiologic electromyography and electroneurography (EMG/ENG) on patients with peripheral facial palsy during the acute phase of paralysis in order to assess the severity of their nerve lesion and thus plan rehabilitation treatment and evaluate its results.

AIM

To evaluate the motor recovery of patients with Bell's palsy with respect to the severity of their neurological lesion and to compare the results of two different rehabilitation treatments, with electromyographic biofeedback (EMG-BFB) and mirror visual biofeedback (mirror-BFB), in patients with Bell's palsy and neurophysiologic pattern of axonotmesis.

STUDY DESIGN

Cohort study on retrospective clinical records.

POPULATION

102 patients with Bell's facial palsy were clinically assessed according to the House scale both during the acute phase of paralysis and 12 months after onset.

METHODS

All patients underwent EMG/ENG examination 3-4 weeks after the onset of paralysis; 29 patients had an EMG pattern of neurapraxia and were not given rehabilitation treatment; 73 patients who presented with signs of denervation had an EMG pattern of axonotmesis. The group, which was homogenous in terms of lesion severity, was divided into two parts: 38 patients were treated with electromyographic biofeedback (EMG-BFB) and 35 were treated with mirror visual feedback (mirror-BFB).

RESULTS

All 29 patients with neurapraxia made a full spontaneous recovery; Although the 73 patients with axonotmesis received different types of rehabilitation treatment, they obtained similar results regarding quality of recovery, development of synkinesis, rehabilitation timing and resources used.

CONCLUSION AND CLINICAL REHABILITATION IMPACT

Rehabilitation treatment is not necessary for patients with neurapraxia. The two biofeedback methods used to treat patients with axonotmesis resulted in similar rehabilitation outcomes.

Importance of a critical reading of neuropsychological testing

Neuropsychological testing has become an important part of the diagnostic tools available to assess children's functioning. Tests are routinely use to establish diagnosis, measure patient's impairment and drive rehabilitation. The authors present the clinical case of a eight-year-old girl, sent to our Child Neuropsychiatry and Rehabilitation Unit for a suspected Specific Learning Disorder. Peculiar findings regarding attention and reading ability became evident during the initial evaluation; a mistaken diagnosis of dyslexia was avoided by carefully examining her global functioning (in particular sight, as she suffered from hyperopia but more importantly she had an insufficient control of vertical saccadic movements) and the strategies she used during testing. This constitutes a good example of the need to take into consideration the patient as a whole during any assessment, including neuropsychological testing.

Child rehabilitation refusal: why it happens and possible strategies to avoid it

AIM

Despite an obvious need for rehabilitative treatment, some parents deny consent and some others withdraw their children from a previously accepted program. There is limited literature concerning how to prevent this, serving the child's best interest, and the existing is mainly focused on legal implications.

METHODS

This was a naturalistic study, carried out using data obtained during the diagnostic evaluation of 166 children (all those seen in the Child Neuropsychiatry Unit). For 25 children (15.1%), parents refused or interrupted suggested treatment.

RESULTS

Statistical analysis showed that there is a significant difference in terms of impairment in children of parents accepting or refusing the rehabilitative treatment. Treatment discontinuation is related to the diagnosis (higher percentage in severe language disorders or complex developmental disorders), higher reduction in global functioning, higher disability burden, need for integrated treatment, lower age.

CONCLUSIONS

Findings of this study could be useful in order to better plan rehabilitative options and goals. It is possible that an attempt to increase parental involvement in the rehabilitative program could lead to a decrease in treatment discontinuation. Anyway, more research is needed because we are still far from having a good predictive model to anticipate and, if possible, avoid treatment discontinuation.

Instrumental and metabolic evaluation of patients affected by peripheral arterial occlusive disease (PAOD) following surgical revascularization surgery

Experiments were performed on eight subjects affected by peripheral arterial occlusive disease (PAOD) of the lower limbs. Each patient was submitted to Ecodoppler, angiography and the "Treadmill test". Two bioptic muscle of these patients. A sample was used for the spectrophotometric and spectrophotofluorimetric determinations of: glycogen, pyruvate, lactate, citrate, alpha-ketoglutarate, malate, aspartate, glutamate, AMP, ADP, ATP and creatine phosphate (CP). The other bioptic sample was used to determine the following enzyme activities: hexokinase, phosphofructokinase, pyruvate kinase, lactate dehydrogenase, citrate synthase, succinate dehydrogenase, malate dehydrogenase, total NADH cytochrome c reductase, cytochrome oxidase, aspartate aminotransferase and alanine aminotransferase. Patients showed an increase in lactate dehydrogenase, total NADH cytochrome c reductase and succinate dehydrogenase activities, a decrease in glycogen, ATP and CP concentrations. Telethermographic data showed patient muscle thermic emission quantitatively different from control group. The telethermographic test can be used as an additional diagnostic tool to determine and monitor the efficiency of a muscle undergoing metabolic failure.

Power output during knee extension/flexion movement performed in controlled mechanical conditions

In order to investigate how exercise, performed under controlled mechanical conditions, might be influenced by variables such as fatigue and immobilization, a computerized transducer system was specially built. Quadriceps femoris and knee flexors were studied in healthy non-athlete and post-meniscal surgery subjects, by means of an isokinetic extension-flexion protocol. The protocol was applied before and after cycloergometer "fatiguing" effort in the healthy subjects and before and after re-training in the surgical ones. An original software was able to display the time course of dynamic parameters, particularly force, velocity and power output. Results obtained showed a 26.5% significant decrease in power output after the effort, owing to a concomitant decrease in velocity, while force increased, but over a longer time. As to the operated subjects, power output was higher following retraining, as a result of the combination of lower force and higher velocity. The transducer system proved reliable in detecting changes in power output, whatever the cause. The instantaneous control of variables which power is depending upon, such as force and velocity, may give a few hints on the efficacy of training and rehabilitation programs.

[Evaluation of the safety of antitussive agents during respiratory rehabilitation. A clinical study of L-dropropizine]

This study proves that L-dropropizine, a new peripheral antitussive drug, does not hinder the positive and useful effect of cough. This is particularly the case of physiokinesis in chronic obstructive lung disease patients. To quantify results, the respiratory voluntary muscles have been examined by surface electromyography and the peak expiratory flow has been registered by a computer-assisted device. By analysing the curves obtained relating the intensity of muscle contraction to expiratory flow, i.e. the muscle work exerted, no difference has been found after L-dropropizine and placebo. Statistical analysis evidenced increase in maximal peak expiratory flow and decrease in muscle work with both therapies. Both were significant (Student's test for paired data: p less than 0.01) in attaining functional improvement. Levodropropizine does not seem to impair the efficacy of cough elicited as part of respiratory clearance mechanisms.

[Evaluation of force, velocity and power during muscular exercise]

Authors propose an original method for studying muscular hypotrophy considering mechanical output. Tests was performed on femoral quadriceps in order to have standardized parameters about work of normal, pathologic and retrained muscle.

[Fatigue during muscle work at variable traction angles]

Using computerized surface EMG signal analysis, authors point out that muscle fatigue onset depends not only by exercise frequency and external load but also by mechanical arrangement of muscle insertions and this onset is faster if contraction is concentric. Therefore selective muscle training programs must contemplate this phenomenon.

Infantile autism and computerized tomography brain-scan findings: specific versus nonspecific abnormalities

The hypothesis that specific computerized tomography brain-scan findings are associated with infantile autism was tested in 45 cases and 19 controls. The autistic group was subdivided into serious and less-serious language-impaired subgroups. The analysis of Euclidean Distances, a type of cluster analysis, showed that neuroradiological parameters of cases and controls, including ventricular sizes, were on the whole significantly different, but no statistically significant difference appeared between the two autistic subgroups. But the analysis of variance of each neuroradiological parameter did not show any significant difference between autistics and controls. It was concluded that autism is nonspecifically associated with brain-scan abnormalities, and that other nonorganic, as well as organic, factors should be taken into account.

Surface EMG evaluation of quadriceps femoris muscle in hemiplegic patients

The method applied consists of evaluating the power spectra of the electromyographic (EMG) surface signal obtained during maximal isometric effort of the quadriceps femoris muscle. In hemiplegic patients it is possible to observe a particular frequency distribution towards the lowest values of the range considered. This trend might be accounted for by the morphological and enzyme- histochemical studies on the quadriceps femoris showing a selective atrophy of type 2 fibers. During rehabilitation treatment, however, it is imperative to consider parameters such as muscle strength changes and frequency values preferentially activated during the isometric effort (time-course). Observation of the pattern of the power spectra time-course therefore seems to contribute to a better view of the rehabilitation strategies suitable for exploiting the residual motor abilities.