Nutritional status in post SARS-Cov2 rehabilitation patients.

BACKGROUND & AIMS: After prolonged hospitalization, the assessment of nutritional status and the identification of adequate nutritional support is of paramount importance. In this observational study, we aimed at assessing the presence of a malnutrition condition in SARS-Cov2 patients after the acute phase and the effects of a multidisciplinary rehabilitation program on nutritional and functional status. METHODS: We recruited 48 patients (26 males/22 females) admitted to our Rehabilitation Unit after discharge from acute Covid Hospitals in northern Italy with negative swab for SARS-Cov2. We used the Global Leadership Initiative on Malnutrition (GLIM) criteria to identify patients with different degrees of malnutrition. Patients underwent a 3 to 4-week individual multidisciplinary rehabilitation program consisting of nutritional intervention (energy intake 27to30 kcal/die/kg and protein intake 1-1.3 g/die/kg), exercise for total body conditioning and progressive aerobic exercise with cycle- and arm-ergometer (45 min, 5 days/week). At admission and discharge from our Rehabilitation Unit, body composition and phase angle (PhA) (BIA101 Akern), muscle strength (handgrip, HG) and physical performance (Timed-Up-and-Go, TUG) were assessed. RESULTS: At admission in all patients the mean weight loss, as compared to the habitual weight, was -12.1 (7.6)%, mean BMI was 25.9 (7.9) kg/m2, mean Appendicular Skeletal Muscle Index (ASMI) was 6.6 (1.7) kg/m2 for males and 5.4 (1.4) kg/m2 for females, mean phase angle was 2.9 (0.9)°, mean muscle strength (HG) was 21.1 (7.8) kg for males and 16.4 (5.9) kg for females, mean TUG value was 23.7 (19.2) s. Based on GLIM criteria 29 patients (60% of the total) showed a malnutrition condition. 7 out of those 29 patients (24%) presented a mild/moderate grade and 22 patients (76%) a severe grade. After a rehabilitation program of an average duration of 25 days (range 13-46) ASMI increased, with statistically significant differences only in females (p = 0.001) and HG improved only in males (p = 0.0014). In all of the patients, body weight did not change, CRP/albumin (p < 0.05) and TUG (p < 0.001) were reduced and PhA increased (p < 0.01). CONCLUSIONS: We diagnosed a malnutrition condition in 60% of our post SARS-Cov2 patients. An individualized nutritional intervention with adequate energy and protein intake combined with tailored aerobic and strengthening exercise improved nutritional and functional status.

Preliminary evidence of effectiveness of TECAR in lymphedema.

Lymphedema of the lower limbs often contributes to the mobility impairment of morbidly obese patients. Defining novel costeffective protocols is important for reducing treatment costs. The study aimed to assess if Capacitive and Resistive Energy Transfer (TECAR) can reduce edema and the minimum number of sessions needed to observe volume reduction. Forty-eight severely obese subjects (age range: 46-78 years; BMI >40 kg/m2) with bilateral lower limb lymphedema were divided into three groups undergoing either manual lymphatic drainage, pressure therapy, or TECAR, in addition to a multidisciplinary rehabilitation program. They were compared to a control group composed by 12 women (age: 67.4 ± 8.9 years, BMI: 44.6 ± 4.1 Kg/m2) undergoing only the rehabilitation program. A handheld laser scanner 3D system was used for volume measurements. In addition, patients were evaluated with a Timed Up and Go (TUG) test and pain/heaviness of the lower limbs with a Visual Analog Scale (VAS). A significant volume reduction was observed after 6 sessions of TECAR: specifically, in the whole limb (PRE: 9.7+2.8 dm3; POST: 9.4+2.8 dm3; p<0.05) and in the thigh (PRE: 3.5+1.3 dm3; POST: 3.3+1.2 dm3; p<0.05). The TUG and VAS for pain showed a significant improvement in all groups. Our preliminary results suggest that TECAR can provide a relatively early reduction of lower limb edema with improvement of patients' function and pain.

Spinal Cord Stimulation in Failed Back Surgery Syndrome: Effects on Posture and Gait-A Preliminary 3D Biomechanical Study.

We studied 8 patients with spinal cord stimulation (SCS) devices which had been previously implanted to treat neuropathic chronic pain secondary to Failed Back Surgery Syndrome. The aim of our study was to investigate the effects of SCS on posture and gait by means of clinical scales (Short Form Health Survey-36, Visual Analogue Scale for pain, and Hamilton Depression Rating Scale) and instrumented evaluation with 3D Gait Analysis using a stereophotogrammetric system. The latter was performed with the SCS device turned both OFF and ON. We recorded gait and posture using the Davis protocol and also trunk movement during flexion-extension on the sagittal plane, lateral bending on the frontal plane, and rotation on the transversal plane. During and 30 minutes after the stimulation, not only the clinical scales but also spatial-temporal gait parameters and trunk movements improved significantly. Improvement was not shown under stimulation-OFF conditions. Our preliminary data suggest that SCS has the potential to improve posture and gait and to provide a window of pain-free opportunity to optimize rehabilitation interventions.

Effects of muscle composition and architecture on specific strength in obese older women.

NEW FINDINGS: What is the central question of this study? Do obesity-specific factors affect skeletal muscle performance in older individuals? What is the main finding and its importance? Older obese women have a larger quadriceps femoris size but develop lower tension per unit of skeletal muscle than their normal-weight counterparts. Muscle impairment and excess body mass are very common among older people. Given that the effect of obesity on strength production has scarcely been studied in older individuals, we analysed functional and structural characteristics of quadriceps femoris (QF) in obese (OB) and normal-weight (NW) older women with comparable habitual physical activity. In five OB (body mass index 36.8 ± 1.9 kg m(-2), age 72.4 ± 2.3 years) and six NW well-functioning older women (body mass index 24.3 ± 1.8 kg m(-2), age 72.7 ± 1.9 years), peak knee-extension torque (KET) was measured in isometric (90 deg knee flexion) and isokinetic conditions (240, 180, 120 and 60 deg s(-1)). Mid-thigh QF cross-sectional area (CSA) and muscle tissue fat content (MF%) were determined with magnetic resonance imaging (Dixon sequence). Muscle fascicle length and pennation angle (PA) were assessed with ultrasonography for each muscle belly of the QF (vastus lateralis, vastus intermedius, rectus femoris and vastus intermedius). Despite similar values of KET, CSA was 17.0% larger in OB than in NW women (P < 0.05), so that KET/CSA was significantly lower (P < 0.05) in OB women. Compared with NW women, OB women had 28.7% higher MF% (P < 0.05) and 24.9% higher average PA (P < 0.05), while fascicle length was similar. Overall, isometric KET/CSA was negatively affected by both MF% (P < 0.05) and PA (P < 0.05), while isokinetic KET/CSA was negatively affected only by MF% (P < 0.01). Muscle composition and architecture seem to be important determinants of KET/CSA in elderly women. In fact, owing to the effect of obesity overload, OB women have a larger QF size than NW women, but unfavourable muscle composition and architecture. The higher MF% and steeper PA observed in OB women are associated with reduced levels of muscle specific strength.

Gait strategy in genetically obese patients: a 7-year follow up.

The aim of this study was to quantitatively evaluate the change in gait and body weight in the long term in patients with Prader-Willi Syndrome (PWS). Eight adults with PWS were evaluated at baseline and after 7 years. During this period patient participated an in- and out-patient rehabilitation programs including nutritional and adapted physical activity interventions. Two different control groups were included: the first group included 14 non-genetically obese patients (OCG: obese control group) and the second group included 10 age-matched healthy individuals (HCG: healthy control group). All groups were quantitatively assessed during walking with 3D-GA. The results at the 7-year follow-up revealed significant weight loss in the PWS group and spatial-temporal changes in gait parameters (velocity, step length and cadence). With regard to the hip joint, there were significant changes in terms of hip position, which is less flexed. Knee flexion-extension showed a reduction of flexion in swing phase and of its excursion. No changes of the ankle position were evident. As for ankle kinetics, we observed in the second session higher values for the peak of ankle power in terminal stance in comparison to the first session. No changes were found in terms of ankle kinetics. The findings demonstrated improvements associated to long-term weight loss, especially in terms of spatial-temporal parameters and at hip level. Our results back the call for early weight loss interventions during childhood, which would allow the development of motor patterns under normal body weight conditions.

Rationale for hospital-based rehabilitation in obesity with comorbidities.

Severely obese patients affected by two or more chronic conditions which could mutually influence their outcome and disability can be defined as "complex" patients. The presence of multiple comorbidities often represents an obstacle for being admitted to clinical settings for the treatment of metabolic diseases. On the other hand, clinical Units with optimal standards for the treatment of pathological conditions in normal-weight patients are often structurally and technologically inadequate for the care of patients with extreme obesity. The aims of this review paper were to review the intrinsic (anthropometrics, body composition) and extrinsic (comorbidities) determinants of disability in obese patients and to provide an up-to-date definition of hospital-based multidisciplinary rehabilitation programs for severely obese patients with comorbidities. Rehabilitation of such patients require a here-and-now multidimensional, comprehensive approach, where the intensity of rehabilitative treatments depends on the disability level and severity of comorbidities and consists of the simultaneous provision of physiotherapy, diet and nutritional support, psychological counselling, adapted physical activity, specific nursing in hospitals with appropriate organizational and structural competences.

Rehabilitation needs after bariatric surgery.

BACKGROUND: Bariatric surgery has grown from an obscure experimental procedure to one of the most popular operations in the world. Such accelerated progress left many gaps, notably concerning subsequent rehabilitation needs of this population. AIM: In the present study, a brief description of both the patients and the interventions is provided, along with potentially disabling features especially concerning the locomotor system, which has received comparatively little attention . DESIGN: Based on reported protocols and actual experience, major issues are addressed. SETTING: Bariatric patients are initially managed in the hospital, however long-term and even lifetime needs may be recognized, requiring major lifestyle and physical activity changes. These have to be focused in all settings, inside and outside the healthcare institutions. POPULATION: Initially only adults were considered bariatric candidates, however currently also adolescents and the elderly are admitted in many centers. RESULTS: Bariatric weight loss is certainly successful for remission or prevention of metabolic, cardiovascular and cancer comorbidities. Yet benefits for bones, joints and muscles, along with general physical performance are still incompletely established. This should be no reason for denying continued care to such individuals, within the context of well-designed protocols, as available evidence points toward favorable rehabilitation in the realms of physical, social and workplace activities. CONCLUSION: The importance of a physiatric curriculum in medical schools has been emphasized. Even more crucial is the presence of such a specialists in obesity and bariatric teams, a requirement recognized in a few countries but not in others. CLINICAL REHABILITATION IMPACT: The relevance of obesity as a disabling condition is reviewed, along with the positive changes induced by surgical weight loss. Although obesity alleviation is a legitimate end-point it is not a sufficient one. The shortcomings of such result from the point of view of physical normalization are outlined, and recommendations are suggested.

Effectiveness of in-patient rehabilitation in obesity-related orthopedic conditions.

BACKGROUND: The aim of the present paper is to provide initial evidence that in-patient multidisciplinary rehabilitation is effective in minimizing the obesity-related disability and enhancing functional capacities in obese patients with motor disability. SUBJECTS: Four hundred and sixty-four obese patients with orthopedic conditions admitted to our Rehabilitation Unit for multidisciplinary rehabilitation were enrolled in this study. METHODS: At admission and discharge (after 4 weeks), the following outcome measures were computed: body weight (BW) (kg), body mass index (BMI) (kg/m2), Functional Independence Measure (FIM) motor and cognitive, Obesity-related disability test (TSD-OC), Visual Analogue Score (VAS) for functioning, Timed-Up-Go (TUG). Intensive rehabilitation addressed to obese patients with orthopedic conditions and motor difficulties consisted of a 4-week and 3-h daily multidisciplinary program covering nutritional, motor and psychological aspects. RESULTS: All of the outcomes measured, except the FIM cognitive score, improved significantly after in-patient rehabilitation. The obesity-specific disability scale appears sensitive to changes among groups with different grades of disability and the percentage of change does not differ among groups. Younger obese individuals generally showed to benefit more from rehabilitation interventions than the older ones. CONCLUSIONS: In-patient rehabilitation interventions appear effective in reducing both mild and severe disabilities related to obesity with orthopedic co-morbidities. This paper provides initial evidence that in-patient multidisciplinary intensive rehabilitation is effective in minimizing the obesity-related disability and initial support to the indications of the Italian Ministry of Health for such rehabilitation pathway. The disability grading could help the decision making of allocating patients to appropriate rehabilitation settings.

Measuring changes after multidisciplinary rehabilitation of obese individuals.

BACKGROUND: In 2009, the Italian Society of Obesity developed the short-form questionnaire for Obesity-related Disabilities (TSD-OC). AIMS: To stage the degree of disability in obese patients using TSD-OC; to verify its sensitivity to change after rehabilitation. SUBJECTS: Three hundred and fifty-five adult obese individuals [body mass index (BMI) >30 kg/m2] undergoing rehabilitation. Exclusion criteria were severe cardiovascular or respiratory diseases, neurological and psychological conditions. Sensitivity to change of TSD-OC was evaluated in 194 patients out of the initial sample. METHODS: To define the disability levels according to TSD-OC, the method of interquartile range was applied to the initial sample. The 194 in-patients were assessed with Roland-Morris Disability Questionnaire, Functional Independence Measure (FIM), Functional Visual Analogue Scale, and TSD-OC before (S0) and after 4 weeks (S1) of intensive (3 h daily) rehabilitation multidisciplinary program. Individuals were grouped according to age (1: age 30-59 yr; 2: age over 60 yr) and degree of obesity (BMI: A, 30-40 kg/m2; B, 40-50 kg/m2). RESULTS: At S1, BMI and all the clinical scores improved significantly in the whole study sample. The younger individuals with higher level of obesity showed a higher functional improvement (-51.3%). In the older subjects, improvement was not statistically different when varying BMI (A2 -13.7% vs B2 -14.6%). In the whole group, the TSD-OC improvement was statistically greater than the physical FIM gain (-25.9% vs +5.4%, p<0.05). CONCLUSIONS: Our data evidenced that the TSD-OC is a sensitive measure of short-term changes in disability status of obese individuals after rehabilitation.

Instrumental measures of spinal function: is it worth? A state-of-the art from a clinical perspective.

In the last decades, assessment of trunk posture and motion has gained importance in clinical practice, and several instrumental non-invasive techniques have been developed to overcome limitations of manual and radiological methods. Despite the large effort spent in improving the underlying technologies, the actual role of these measures in the clinical setting remains still undefined due to a variety of issues. The main question concerns the provision of parameters providing a significant contribution to the clinical decision making. In this paper, we review the available spine surface measurement techniques from a technical viewpoint, and point out their current and potential applications according to a clinical perspective. Conclusions are drawn on the basis of both the technical features and accessibility in daily clinical practice, as well as of the validity, reliability and clinical value of the provided parameters. A well-defined clinical role is established for surface topography in the follow-up of spine sagittal plane deformities, adulthood scoliosis and spine disorders involving the spino-pelvic alignment. Conversely, further studies are required to identify reliable key parameters for use in the clinical (adolescent scoliosis, back and neck pain), occupational (measurement of spine exposure to mechanical loads) and forensic (assessment of segmental functional impairments) fields.

[Applicability of the test SIO on obesity-related disability (TSD-OC) in occupational medicine for the evaluation of work problems linked to overweight-obesity condition]. / Applicabilità del Test SIO sulla disabilità correlata all'obesità (TSD-OC) in Medicina del Lavoro per la valutazione di problematiche lavorative legate al sovrappeso-obesità.

Obesity is frequently associated with functional changes that may affect work capacity, so we administered to a group of 198 overweight-obese subjects with median BMI of 32.7 and median waist circumference of 101 cm, the test-TSD OC which consists of 7 sections (pain, stiffness, activities of daily life, activities of the house, instrumental activities of daily living, work, social relations) for a total of 36 visual analogical scales. After the identification of 4 workers categories (health, services, administration, commerce/industry), resulted homogeneous for age, BMI, CV, we saw that the work section was more compromised for health and services. The overall disability increases especially in relation to BMI and seems influenced by age and sex.

[Impact of obesity-related disability in different work categories]. / Impatto dello disabilità correlata all'obesità nelle diverse categorie professionali.

Absenteeism and sick leave are often reported in obese workers. To evaluate disability work related we assess 180 overweight-obese subjects [BMI 34,6 + 6,4, range 26,0-59,0) with TSD-OC questionnaire divided into 7 items (pain; stiffness; ADL; housework; IADL; occupational activities; social life) with a total of 36 visual analogue scales. Among the job categories, health-care workers showed the highest TSD-OC total score (26,9 + 22,5%, ANOVA p < 0,05) and BMI (BMI 37,7 + 6,9 kg/m2). Among the items, pain was statistically significant in health-care workers (16,1 + 13,2%), in Services (16,3 + 14,3%), in Education (15,1 + 11,4%) and in Administration (13,3 +11,0%) ( p <0,05). "Occupational activities" item was statistically significant in health-care (11, 6 +10,6%, p <0,05).

[Obesity and Eating Disorders. Indications for the different levels of care. An Italian Expert Consensus Document]. / Documento di Consensus. Obesità e Disturbi dell'Alimentazione Indicazioni per i diversi livelli di trattamento.

This paper is an Italian Expert Consensus Document on multidimensional treatment of obesity and eating disorders. The Document is based on a wide survey of expert opinion. It presents, in particular, considerations regarding how clinicians go about choosing the most appropriate site of treatment for a given patient suffering from obesity and/or eating disorders: outpatient, partial hospitalization, residential rehabilitation centre, inpatient hospitalization. In a majority of instances obesity and eating disorders are long-term diseases and require a multiprofessional team-approach. In determining an initial level of care or a change to a different level of care, it is essential to consider together the overall physical condition, medical complications, disabilities, psychiatric comorbidity, psychology, behaviour, family, social resources, environment, and available services. We first created a review manuscript, a skeleton algorithm and two rating scales, based on the published guidelines and the existing research literature. As the second point we highlighted a number of clinical questions that had to be addressed in the specific context of our National Health Service and available specialized care units. Then we submitted eleven progressive revisions of the Document to the experts up to the final synthesis that was approved by the group. Of course, from point to point, some of the individual experts would differ with the consensus view. The document can be viewed as an expert consultation and the clinical judgement must always be tailored to the particular needs of each clinical situation. We will continue to revise the Document periodically based on new research information and on reassessment of expert opinion to keep it up-to-date. The Document was not financially sponsored.

Balance in patients with anorexia and bulimia nervosa.

AIM: Neuro-muscular adaptations to the loss or increase in body weight may induce postural alterations. The aim of this study was to investigate the effect of body weight alterations on postural stability in patients with anorexia nervosa and bulimia. METHODS: The study enrolled 15 women affected by anorexia nervosa (AN), (mean body mass index [BMI] 15.8+/-1.8 kg/m(2)), 15 women affected by bulimia nervosa (BN), (mean BMI 20.1+/-2.9 kg/m(2)) and 11 healthy matched women (HC), (mean BMI 20.1+/-1 kg/m(2)). Two quiet standing conditions with eyes open (EO) and closed (EC) were analysed with an optoelectronic system (Vicon 460, Viconpeak, Oxford, UK) with passive markers to estimate the centre of mass (CoM) position. RESULTS: BN patients were more unstable than HC, showing statistically significant differences in antero-posterior CoM excursions and path length. AN patients showed non significant differences from HC. Only HC showed differences between EO and EC conditions, with significantly greater excursions in medio-lateral direction in EC condition (P<0.013) as well as an increased sway area (P<0.022). CONCLUSIONS: In BN, musculoskeletal factors seem to play a major role in the diminished postural control, which appear to be linked to body weight fluctuations rather than to BMI absolute values. No clear-cut postural instability was demonstrated in patients with AN as compared to HC. Visual input appears not to affect balance in patients with eating disorders. Possible further causes of postural instability in BN and implications for rehabilitation treatment are discussed.

[Risk reduction in handling obese patients]. / La riduzione del rischio nella movimentazione del paziente obeso.

BACKGROUND: Hospital staff are exposed to significant risk in the manual handling and care of obese patients. OBJECTIVES: to illustrate how risk reduction can be achieved by means of integrated measures, particularly aimed at developing specific know-how among the operators, and the use of safety guidelines and technical aids for transferring obese patients in various situations. METHODS: on the basis of the recent literature, the present article reviews the technological aids and the preventive procedures that ensure safe transfer and health care of obese patients. RESULTS: Many devices are available in the USA for the handling and assisting the obese patient; however, much remains to be done for the development of specific equipment. In Italy, along with knowledge of the devices, specific competence needs to be promoted among the operators dealing with obese patients. Organizational and structural issues arise from this new specialty. CONCLUSIONS: An integrated approach, requiring suitable environments, ergonomic devices, standard procedures and personnel competence needs to be adopted in order to reduce the risk in health-care workers dealing with obese patient.

[Treadmills in rehabilitation medicine: technical characteristics and selection criteria]. / Il treadmill in medicina riabilitativa: caratteristiche tecniche e criteri di selezione.

The treadmill is a commonly used means of testing and training patients with cardiopulmonary diseases. There is growing interest in the use of the treadmill also for rehabilitation of patients with orthopaedic and neurological diseases. Commercially available treadmills show wide differences in terms of structure and function that have a direct impact on the specific rehabilitation protocols. The aims of this paper are: a) to briefly review the physiology and biomechanics of treadmill exercise as compared to overground walking; b) to point out the technical specifications of treadmills suitable for rehabilitation settings; c) to provide guidelines for treadmill selection in the different categories of rehabilitation patients. First, the different physiological and biomechanical characteristics of walking on a treadmill and overground are discussed. Uphill and downhill walking as well as backward walking are also presented together with the spin-offs for rehabilitation practice. Then, the technical features of treadmills (treadbelt, frame, bars, deck, rollers, shock absorption, elevation motor, drive motor, flywheel, display) are described and the specific requisites for the different patient categories undergoing rehabilitation are discussed in detail. Finally, guidelines and a flow-chart for identifying the main technical requisites for appropriate treadmill selection in the different disabilities are provided. A summary table of the technical specifications of the commercially available rehabilitation treadmills is also included.

Kinematics of trunk movements: protocol design and application in obese females.

PURPOSE: Whether kinematic analysis of the trunk can provide useful clinical insight into the relationship between function and various spinal conditions is still under debate. The aim of this study was to develop a clinical protocol and an associated biomechanical model to characterize quantitatively the trunk movements in obese subjects. METHODS: Twenty (10 obese, 10 control) female subjects were evaluated with an optoelectronic system and passive markers attached to the spine during forward flexion, lateral bending, and rotation of the trunk. RESULTS: We found a systematic error due to skin artifacts of less than 5 degrees in both groups. Intra- and inter-subject standard deviation was less than 6 degrees . Obese subjects demonstrated a significantly reduced motion in the thoracic spine associated with an increased pelvic tilt angle as compared to controls. CONCLUSIONS: Our protocol was able to characterize trunk mobility in obese and normal subjects suggesting that kinematics could represent, even in an obese population, a promising method to investigate subclinical spinal disorders and to assess the effectiveness of rehabilitation programs.

[Cycle ergometers in rehabilitation medicine: technical characteristics and selection criteria]. / I cicloergometri in medicina riabilitativa: caratteristiche tecniche e criteri di selezione.

The cycle ergometer is a commonly used means of testing and training patients with energetic disabilities (particularly in the area of cardiopulmonary diseases). Recent evidence suggests that cycle ergometers can also be useful in patients with subacute and chronic stroke, brain injury, chronic degenerative neurological conditions, and in spinal cord injury. Commercially available cycle ergometers show wide differences in terms of structure and function that have a direct impact on the specific rehabilitation protocols. The aims of this review paper are: a) to briefly review the physiology and biomechanics of exercise on a cycle ergometer; b) to review and discuss the technical specifications of the cycle ergometers suited to rehabilitation settings; c) to provide guidelines for selecting appropriate cycle ergometers for the different categories of rehabilitation patients. First, the physiology of exercise on the cycle ergometer and its biomechanical features are discussed, including the patterns of muscular activity during down- and up-stroke. Upright and recumbent ergometers and their specific clinical indications are compared. Finally, the technical characteristics of the cycle ergometers (load, motor, resistance, flywheel, belt, resilience, pedals, frame, display) are described and the specific requisites for the different patient categories undergoing rehabilitation are discussed in detail. Finally, guidelines are offered for identifying the main technical requisites for appropriate cycle ergometer selection in the different disabilities.