Developmental writing disorders: assess to rehabilitate.

BACKGROUND: Writing ability requires to use and control several processes of visual and phonological information processing and an adequate programming and coordination of motor sequences. We studied a writing precursor gesture in children with developmental dysorthography and/or developmental dysgraphia in order to point out anomalies to be treated with specific rehabilitative interventions. METHODS: Twenty-five children affected by developmental dysortography (ICD 9 CM: 315.09; ICD 10: F81.1) and/or developmental dysgraphia (ICD 9 CM: 315.2; ICD 10: F81.8) (mean age 9.1 years [range: 6.3-11.4 years]) ran a maze, project in front of them, using a wireless mouse. Data regarding angular excursions, execution times and gesture accuracy were collected and elaborated using Dartfish 6.0 software and the labyrinth generating program (PRINC), and compared with normative data previously obtained from a sample of 226 healthy children of the same age and grade. RESULTS: The comparison did not evidence significant differences regarding gesture structure (trajectories of arm segments and angular excursions of interested joints). Angular and temporal execution patterns were reached in delay in these children. No correlation was found with general cognitive and visuomotor integration skills; a deficit of visual attention was associated with an abnormal elbow range of motion. CONCLUSIONS: Although these findings need to be confirmed in larger studies, data obtained evidence that children with developmental writing disorders have a time delay in the acquisition of writing motor patterns and not an alteration of gesture structure itself. This has relevant implications for the rehabilitative approach.

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.

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.

Hypoglossal-facial nerve anastomosis and rehabilitation in patients with complete facial palsy: cohort study of 30 patients followed up for three years.

Our study evaluates the grade and timing of recovery in 30 patients with complete facial paralysis (House-Brackmann grade VI) treated with hypoglossal-facial nerve (XII-VII) anastomosis and a long-term rehabilitation program, consisting of exercises in facial muscle activation mediated by tongue movement and synkinesis control with mirror feedback. Reinnervation after XII-VII anastomosis occurred in 29 patients, on average 5.4 months after surgery. Three years after the anastomosis, 23.3% of patients had grade II, 53.3% grade III, 20% grade IV and 3.3% grade VI ratings on the House-Brackmann scale. Time to reinnervation was associated with the final House-Brackmann grade. Our study demonstrates that patients undergoing XIIVII anastomosis and a long-term rehabilitation program display a significant recovery of facial symmetry and movement. The recovery continues for at Hypoglossal-facial nerve anastomosis and rehabilitation in patients with complete facial palsy: cohort study of 30 patients followed up for three years least three years after the anastomosis, meaning that prolonged follow-up of these patients is advisable.

Functional and social limitations after facial palsy: expanded and independent validation of the Italian version of the facial disability index.

BACKGROUND: The Facial Disability Index (FDI) is widely used for self-assessment of functional impairment and quality of life in patients with facial palsy. OBJECTIVE: The study aim was to complete the validation of the FDI by generating an Italian version (IT-FDI) and evaluating its clinimetric properties. DESIGN: This was a longitudinal, observational measurement study. METHODS: The questionnaire was translated, cross-culturally adapted, and administered to 100 consecutive participants (outpatients) with facial palsy. The clinical severity of facial palsy, impairments in physical and social function, and quality of life were evaluated with the Sunnybrook Facial Grading System, IT-FDI, and 12-Item Short-Form Health Survey. RESULTS: The IT-FDI showed excellent test-retest reliability for every item and for total scores (intraclass correlation coefficients of .93 and .84 for physical function subscale and social/well-being function subscale, respectively). The IT-FDI confirmed the high internal consistency of the original version, with theta coefficients of .82 for the physical function subscale and .78 for the social/well-being function subscale. The physical function subscale correlated with the Sunnybrook Facial Grading System composite score (r=.44), and the social/well-being function subscale correlated with the 12-Item Short-Form Health Survey mental component (r=.55). The IT-FDI confirmed the good responsiveness of the original version, as expressed by effect size, standardized response mean, and responsiveness ratio of, respectively, 1, 1.03, and 1.21 for the physical function subscale and 0.75, 0.83, and 1.15 for the social/well-being function subscale. LIMITATIONS: Responsiveness was evaluated with a limited number of participants. CONCLUSIONS: The results demonstrated the test-retest reliability for all items of the FDI and confirmed its internal consistency, construct validity, and responsiveness with an independent and larger clinical subset. This study completes the validation of the FDI and provides the first validated questionnaire in Italian for assessment of disability and quality of life specifically in patients with facial palsy.

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.

Easy quantitative methodology to assess visual-motor skills.

INTRODUCTION: Visual-motor skills are the basis for a great number of daily activities. To define a correct rehabilitation program for neurological patients who have impairment in these skills, there is a need for simple and cost-effective tools to determine which of the visual-motor system levels of organization are compromised by neurological lesions. In their 1995 book, The Visual Brain in Action (Oxford: Oxford University Press), AD Milner and MA Goodale proposed the existence of two pathways for the processing of visual information, the "ventral stream" and "dorsal stream," that interact in movement planning and programming. Beginning with this model, our study aimed to validate a method to quantify the role of the ventral and dorsal streams in perceptual and visual-motor skills. SUBJECTS AND METHODS: Nineteen right-handed healthy subjects (mean age 22.8 years ± 3.18) with normal or corrected-to-normal vision were recruited. We proposed that a delayed pointing task, a distance reproduction task, and a delayed anti-pointing task could be used to assess the ventral stream, while the dorsal stream could be evaluated with a grasping task and an immediate pointing task. Performance was recorded and processed with the video-analysis software Dartfish ProSuite. RESULTS: Results showed the expected pattern of predominance of attention for the superior left visual field, predominance of the flexor tone in proximal peri-personal space arm movements, tendency toward overestimation of short distances, and underestimation of long distances. CONCLUSION: We believe that our method is advantageous as it is simple and easily transported, but needs further testing in neurologically compromised patients.

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.

Nutraceuticals in psychiatric practice.

Nutraceuticals can be defined as food components or active principles present in aliments which have positive effects for health and quality of life, including preventing or treating disorders. Herbal and "natural" food supplements are increasingly used to treat different psychiatric disorders, often as "self-prescribed" therapies. With factors such as chronic illness, poor health, emotional distress, and quality of life influencing the desire for complementary medicine, patients with comorbid medical and psychiatric problems seem likely to turn to this approach. We reviewed the most commonly used herbal and dietary supplements for which a certain efficacy on psychiatric symptoms or disorders has been claimed, checking current Pubmed-indexed literature (the most important being St. John's wort, Omega-3 fatty acids, valerian, Kava, Ginkgo, folate, B vitamins, S-Adenosylmethionine, inositol, alfa-lactoalbumin and passionflower). There is evidence of efficacy for some of these herbs an supplements, proved also by Cochrane's meta-analysis. However many different areas (including efficacy, tolerability, optimal dosing, adequate shelf life, drug and non-pharmacological interactions) need to be thoroughly studied; moreover political decisions need to be scientifically guided in order to best serve psychiatric patients' interests and to prevent using of expensive and sometimes un-useful therapies. This implies that a scientific strategy is needed to rule out any third-part economical interest which could in any way influence therapeutic choices. The article presents some promising patents on nutraceuticals in psychiatric practice.

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.

Gilles de la Tourette's syndrome in a patient with 47(XXX) syndrome: a case report.

INTRODUCTION: To the best of our knowledge, this is the first report of a comorbidity between Gilles de la Tourette's syndrome and 47 (XXX) syndrome. The clinical picture of Gilles de la Tourette's Syndrome is well described, while 47 (XXX) syndrome is much more rare and has a broader spectrum of possible phenotypic presentations. CASE PRESENTATION: An Italian Caucasian girl was referred at the age of 11 to our Rehabilitation Center for anxiety and learning difficulties. The girl had already been diagnosed as having 47(XXX) syndrome; she had some rather typical features of the chromosomal abnormality, but she also showed a high level of anxiety and the presence of motor and vocal tics. When an accurate history was taken, a diagnosis of Gilles de la Tourette's Syndrome emerged. CONCLUSIONS: The possible interaction between peculiar features of these two syndromes in terms of neuropsychological and affective functioning is both interesting for the specific case and to hypothesize models of rehabilitation for patients with one or both syndromes. Executive functions are specifically reduced in both syndromes, therefore it might be hard to discriminate the contribution of each one to the general impairment; the same applies to anxiety. Moreover, mental retardation (with a significantly lower verbal cognitive functioning) poses relevant problems when suggesting cognitive behavioral or psychoeducational rehabilitative approaches.

Corpus callosum agenesis and rehabilitative treatment.

Corpus callosum agenesis is a relatively common brain malformation. It can be isolated or included in a complex alteration of brain (or sometimes even whole body) morphology. It has been associated with a number of neuropsychiatric disorders, from subtle neuropsychological deficits to Pervasive Developmental Disorders.Etiology and pathogenetic mechanisms have been better understood in recent years, due to the availability of more adequate animal models and the relevant progresses in developmental neurosciences. These recent findings are reviewed (through a MedLine search including papers published in the last 5 years and most relevant previously published papers) in view of the potential impact on children's global functioning and on the possible rehabilitative treatment, with an emphasis on the possibility to exploit brain plasticity and on the use of the ICF-CY framework.

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.

Scientifically based nurture and nature: alternative but non exclusive hypotheses on attention development.

Attention is an important neuropsychological function in child development. A lot of literature has been devoted to trying to separate the role of nature (i.e. mainly the genetic basis) from that of nurture (i.e. parenting and life events). The case of preterm born children is an opportunity to try and further study this relationship. We hypothesize that children born preterm might have a reduced attention due to an interaction of factors, to be conceptualized both as nature (mainly the genetic background and the specific consequences of preterm birth and of its complications) and nurture (therapeutic techniques used, alteration in parents-child relationship and so on). The contribution of each of these factors needs to be disembodied from the raw finding of a reduced attention: this is especially important because experience-dependent learning, in which individualized experiences have neural effects, can go on throughout life and this opens interesting rehabilitative possibilities. Different research lines which could be useful to entangle the specific contributions of the above mentioned factors are discussed: the results could in turn inform clinical practice with this highly at risk and increasing in number population, with a view largely corresponding to the one founding the OMS International Classification of Disability, Functioning and Health.

Autism and classification systems: a study of 84 children.

BACKGROUND: A number of studies have shown that current classification systems (ICD 10, DSM IV TR) have limitation when applied to autistic children and the category PDD NOS (DSM IV TR) has in particular been criticized. To check the possible usefulness of other classification systems to better describe patient's functioning, we retrospectively studied 84 patients, seen consecutively in our Child Neurology and Psychiatry Department (excluding only those presenting for another disease even if with clinical signs of a PDD). METHODS: We tried to classify them according to ICD 10, DSM IV TR, CFTMEA-R, "operational classification" (Manzano and Palacio) and de Ajuriaguerra's classification. RESULTS: We found a good correspondence between DSM IV TR and ICD 10 and the use of psychodynamic classification systems (in particular CFTMEA-R) was useful to differentiate clinical subtypes collected under the PDD NOS etiquette according to DSM IV TR. CONCLUSIONS: To rationalize research efforts and find better tailored therapies, we need to improve PDD classification systems, using contributions coming from every field of child psychiatry and neurology: it's possible that 0-3 Classification could help this.

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.

Herbals and natural dietary supplements in psychiatric practice.

There is some evidence that links the increase of mental disorders' prevalence with a deterioration of Western countries' nutritional habits and it is found that the use of herbal and "natural" food supplements to treat different disorders is increasing. With factors such as chronic illness, poor health, emotional distress, and quality of life influencing the desire for complementary medicine, patients with comorbid medical and psychiatric problems seem likely to turn to this approach. We reviewed the most commonly used herbal and dietary supplements for which a certain efficacy on psychiatric symptoms or disorders has been claimed, checking current Pubmed-indexed literature (the most important being St. John's wort, Omega-3 fatty acids, valerian, Kava, Ginkgo, folate, B vitamins, SAMe, Inositol). There is an evidence of efficacy for some of these herbs an supplements, but current studies are often insufficient to reach a final conclusion; still patents are being requested and registered. Many different areas (including efficacy, tolerability, optimal dosing, adequate shelf life, drug and non-pharmacological interactions) need to be thoroughly studied; moreover political decisions need to be scientifically guided in order to best serve psychiatric patients' interests and to prevent the usage of expensive and sometimes un-useful therapies. This implies that a scientific strategy has to be used to rule out any third-part economical interest which could in any way influence therapeutic choices.