[Function recovery in patients with knee arthroplasty: role of proprioceptive rehabilitation]. / Il recupero funzionale del ginocchio artroprotesizzato: ruolo dell'allenamento propriocettivo.

This study evaluates the outcome of proprioceptive rehabilitation in 18 patients who underwent knee joint prosthetic replacement using the dynamic electronic plate Pro-kin_machine. The proprioceptive performance was determined by having the patients trace a set of three outlines (horizontal, vertical and circular) using the foot of the operated limb. The measures of outcome parameters were: 1) time taken to do the test; 2) score of accuracy of the test measured in percentage. Tests were performed on admission, half way through rehabilitation and on discharge. Each patient had 15 sittings of physiotherapy. Our results demonstrate a significant improvement of both parameters at the end of the treatment. After prosthetic knee joint replacement, not only is it important to re-establish mechanical stability but also dynamic stability. The latter can be achieved through active virtual taping by the stabilizer muscles. Prompt management of instability of the joint in the rehabilitation phase is extremely important in the re-activating of the control mechanisms that are compromised by the surgical operation.

[Assessment of function recovery in patients with total knee prosthesis]. / Valutazione della ripresa funzionale nei pazienti sottoposti ad intervento di protesi totale di ginocchio.

The aim of this study was to analyse the evolution of motor performance in a group of patients who underwent surgical knee replacement. We also assessed patient satisfaction at 3 and 9 months after the operation. Sixty-two patients (40 women, 22 men, mean age 72.4 years) underwent isokinetic evaluation associated with surface EMG. All the patients had undergone a total prosthetic knee joint replacement for arthrosis, and had followed a standardised 30-day rehabilitation program at our centre for recovery of knee joint function, strengthening of the flexor-extensor muscles and restoration of ambulation as best as possible. Each of these patients underwent isokinetic evaluations 3 months and 9-10 months after their operation. The isokinetic test consisted of carrying out 5 flexion-extensions of the knee at an angular velocity of 60 degrees/second, followed by an endurance test of 30 repetitions of flexion-extension of the knee at 120 degrees/second. This isokinetic test provided data on extensor strength and flexor strength; furthermore, specifically designed software allowed simultaneous visualisation of the surface EMG tracing, torque and joint excursion. The first analysis showed a macroscopic decrease in the strength of the flexor-extensor muscles of the knee. This muscle weakness was clearly evident 3 months after the operation and was particularly pronounced for the extensor muscles of the operated limb compared with the muscles of contralateral, unoperated limb. Muscle weakness was still present 9 months after the operation although there had been a considerable improvement compared with 6 months previously; the imbalance in the flexor/extensor ratio, which differed from that in the contralateral, unoperated limb, was noted to be still present. The surface EMG demonstrated persistent myoelectrical activity in the flexors even when the extensor activity was predominant: this is an expression of imbalance between agonists-antagonists. A questionnaire administered to the patients about their satisfaction with the operation revealed that 9 months after the surgery 23 patients still complained of continuous joint pain with increased loads, 27 complained of frequent pain with load-bearing and only 12 no longer complained of any disturbance, manifesting full satisfaction with the operation. Total knee replacement is thus a valid treatment in those cases in which degenerative joint disease necessitates a radical solution. Nevertheless, dissatisfaction with the operation is common, and may be due to persistence of joint pain and incomplete joint recovery of joint function or muscle strength. In our series of patients, we found that although there was progressive recovery of strength of both the flexor and extensor muscles, a considerable imbalance remained between the operated and unoperated limbs; this finding was also confirmed by the surface EMG investigation.

Weakness of respiratory and skeletal muscles after a short course of steroids in patients with acute lung rejection.

There have been occasional reports of acute respiratory and skeletal muscle weakness in intensive care unit patients treated with massive doses of corticosteroids. However, in this setting the concomitant use of other drugs may have influenced the finding. In this study the effects of 5 days of treatment with high doses of steroids in consecutive patients with acute lung rejection after transplantation were systematically evaluated. Maximal inspiratory pressure during phrenic nerve stimulation and peak torque of isokinetic contraction of the quadriceps and hamstring muscles were measured objectively. Compared to the pretreatment condition, approximately 45% of patients showed acute generalised muscle weakness that recovered after approximately 2 months. This demonstrates muscle weakness induced by steroids within patients.

[Correlation between computed tomography and isokinesis in patients with reconstructive surgery of anterior cruciate ligament of the knee]. / Correlazione fra tomografia computerizzata e isocinesi in pazienti operati diricostruzione di ricostruzione di legamento crociato anteriore di ginocchio.

AIM: The aim of this study was to correlate the length (measured by computed tomography) of the anterior cruciate neoligament following knee surgery with the time required by the flexors-extensors of the knee to reach isokinesis (measured using an isokinetic method). MATERIAL AND METHODS: Twenty-five patients (all males, median age 25.4 years), who had undergone surgical repair of the anterior cruciate ligament (ACL), were assessed by computed axial tomography (CT) and isokinetic tests a mean of 6.3 months after their operation. The following isokinetic parameters were calculated: time to reach isokinesis in flexion, time to reach isokinesis in extension, flexion strength, and extension strength. Mean values were calculated from all the values recorded during the test cycles performed. The CT examinations, after lateral scanograms, were carried out with 1 mm contiguous axial scans parallel to the tibial plate. It was possible to assess the integrity of the neoligament which was measured from a section of the tibial plate above the tibial cartilage to its insertion in the intercondylar furrow. RESULTS: As expected, all the values recorded from the healthy knee were significantly different from those recorded on the operated side. As far as concerns analysis of any correlations, there were good correlations between the time to reach isokinesis in extension and the length of the ACL both on the operated side (r=.62) and the healthy side (r=.69), whereas the correlations between the length of the ACL and all other measurements were moderate or very weak (from 0.44 to 0.03). DISCUSSION AND CONCLUSIONS: That the isokinetic measurements show an increased time for the extensor muscles of the operated knee to reach isokinesis is related to altered biomechanics of the passage of the tibia from a posterior translaction position to one of an anterior translaction that is, to anterior displacement of the tibia during extension of the knee, which leads to the prolonged time. The correlation between this time and the length of the ACL, as measured by CT, offers the possibility of being able to monitor the outcome of cruciate ligament repair periodically during various phases of rehabilitation treatment and of only using control CT examinations if there are any complications and/or problems.

[Isokinetic assessment and mid-term work reincorporation of patients surgically treated with the shoulder Latarjet technique]. / Valutazione isocinetica e reinserimento lavorativo a medio termine di pazienti operati di plastica secondo Latarjet alla spalla.

We studied a group of 12 subjects with chronic posttraumatic scapulo-humeral instability who underwent arthroscopic coracoid transposition using Latarjet's technique. All patients were followed-up after the operation for a mean of 1.7 years (minimum 1 year, maximum 3 years). The follow-ups consisted of a clinico-functional evaluation with a apprehension test and isokinetic studies of strength and joint movements during internal and external rotation of the abducted shoulder, both on the healthy side and on the operated side. The isokinetic evaluation consisted of 5 repetitions of internal-external rotation at ana angular velocity of 60 degrees/sec. The results showed that the operated shoulder was slightly weaker than the healthy one, but that the difference was not statistically significant according to Student's t test for paired data. The profile of the trace did not show macroscopic differences between the two sides. At clinical assessment 11 of 12 patients reported a good-excellent outcome of the operation with complete recovery of shoulder function and return to previously performed sporting activities. In conclusion, this technique is shown to have a good medium-term outcome. Although there have been no complications in our series, a longer follow-up to evaluate possible complications would be advisable.

Heart failure-related myopathy. Clinical and pathophysiological insights.

AIMS: To evaluate the relationship of skeletal and respiratory muscular dysfunction with the degree of clinical severity, cardiac impairment and exercise intolerance in patients with chronic heart failure. METHODS AND RESULTS: Ninety-one patients (age 52.7+/-8 years) on standard therapy and in a stable clinical condition with normal nutritional status underwent evaluation of (1) clinical severity and metabolic status (NYHA class, weight, albuminaemia, natraemia, cortisol, insulin, neurohormones), (2) cardiac function (Echo, right heart catheterization), (3) exercise tolerance (peak VO(2)), (4) dynamic isokinetic forces of the quadriceps and hamstring (Cybex method), and respiratory muscle strength (maximal inspiratory and expiratory pressures). Fifty patients had a peak VO(2)<14 ml x kg(-1) x min(-1)(10.6+/-2) and 41 had values >/=14 (18.3+/-4). In the former group, leg and respiratory strength were significantly lower (extensors: 80+/-24 vs 100.9+/-22 Nm; flexors: 48.5+/-24 vs 75.3+/-22, both P<0.001; maximal expiratory pressure: 85.5+/-30 vs 104.8+/-31, P<0.01). Muscular strength was not related to indices of clinical severity, metabolic status, neurohormones or to the degree of systolic/diastolic cardiac function, but it was related to weight and age. Multivariate analysis of the peak VO(2)with clinical, haemodynamic and peripheral indicators showed weight (beta= 0.32, P = 0.007), muscular strength (beta= 0.32, P = 0.01) and NYHA class (beta= 0.31, P = 0.001) as the only independent predictors. The joint adjusted R(2)value was 0.48 (P<0.001). CONCLUSION: Muscular dysfunction is part of the syndrome of heart failure. Together with symptom perception, it predicts nearly half of the variation in exercise tolerance.

[Changes in phospho-calcium metabolic factors in function of the rate of bone turnover. Epidemiologic study of osteoporosis (part 2)]. / Variazioni di fattori del metabolismo fosfo-calcico in funzione della velocità di turnover osseo. Studio epidemiologico sull osteoporosi (parte seconda).

BACKGROUND: The recent development of highly accurate and precise osseous mass quantitative evaluation methodology, permits the conduction, in the sphere of osteoporosis, of epidemiologic investigations no longer limited solely to fracture complications, but also based on the definition of osseous mass. Fractures being only complications, possible but not certain, of the advanced stages of the disease, the studies based on their incidence allow one to underestimate the global entity of prevalence and incidence, besides building only a partially useful reference in view of primary and secondary prevention. METHODS: The main points of our study are the following: 1) evaluation of the incidence of the primary risk factors for osteoporosis as they appear in the literature, on the bone mass values of examined subjects, utilizing static mineralometric data as a reference standard; 2) study of biohumoral data relative to phospho-calcium metabolism and to sexual function, to show the possibility of their use as early identifying markers of subjects at risk; reference values represented by dynamic mineralometric data. The principal conclusions that emerged in the course of the study are the following. RESULTS: In relation to the use of phospho-calcium metabolic biohumoral and hormonal variables, as a predictive function on the variations of bone turnover, the variables; osteocalcin, alkaline phosphatase, alkaline phosphatase bone isoenzyme, hydroxyprolinuria/ creatininuria, have resulted significantly different in the comparison between high and low turnover subjects. The degree of quantitative correlation of such variables with the entity of percentage decrement of bone mass has been modest. The overall value of R-square of the predictive model, besides the variables mentioned the value of bone mass at 1 degree control visit, was 0.38 (osteocalcin: 0.27; osteocalcin+hydroxyprolinuria/ creatininuria: 0.33; preceding variables+bone mass at 1st control: 0.36; preceding variables+alkaline phosphatase: 0.37; preceding variables+alkaline phosphatase bone isoenzyme: 0.38). CONCLUSIONS: The single value osteocalcin may furnish indications on the future variations of bone turnover and consequently on the early identification of the subjects at risk for osteoporosis at high turnover; the addition of the other variables indicated in our predictive model allows an increase of the possibilities of individualizing of these subjects.

[Correlation between risk factors and bone mass in pre- and postmenopause. Epidemiologic study on osteoporosis (Part one)]. / Correlazioni fra fattori di rischio e massa ossea in periodo pre- e post-menopausale. Studio epidemiologico sull'osteoporosi (Parte prima).

The recent development of highly accurate and precise osseous mass quantitative evaluation methodology, permits the conduction, in the sphere of osteoporosis, of epidemiologic investigations no longer limited solely to fracture complications but also based on the definition of osseous mass. Fractures being only complications, possible but not certain, of the advanced stages of the diseases, the studies based on their incidence allow one to underestimate the global entity of prevalence and incidence, besides building only a partially useful reference in view of primary and secondary prevention. The main points of our study are the following: 1) evaluation of the incidence of the primary risk factors for osteoporosis as they appear in the literature, on the bone mass values of examined subjects, utilizing tatic mineralometric data as a reference standard; 2) study of biohumoral data relative to phospho-calcium metabolism and to sexual function, to show the possibility of their use as early identifying markers of subjects at risk; references values represented by dynamic mineralometric data. The principal conclusions that emerged int he course of the study are the following. In regard to the evaluation of the principal risk factors, they prove to be correlated to the osseous mass values registered at the first control: physical activity (highly positive action). Favorable levels of correlation were also discovered for the variables of increased body weight (positive action) and increased age (negative action). In multivariate analysis, the R-square value (index of the variation fraction of osseous mass values due to the risk factors) has reached a total value of 0.65 (physical) activity: 0.46; physical activity + dietary calcium: 0.55; history + increased age: 0.58; history + smoking: 0.62; history + increased weight: 0.64; history + pre- or post-menopausal: (0.65). Such analysis furnishes useful indications on the modalities to employ in the anamnestic framing of the patients at risk for osteoporosis, and on the importance attributable to single risk factors.

Time course of exercise capacity, skeletal and respiratory muscle performance after heart-lung transplantation.

Recipients of heart-lung transplantation (HLT) show reduced exercise capacity due to several pre- and postsurgical factors. The aim of this study was to evaluate the time course of exercise capacity, and skeletal and respiratory muscle performance in 11 patients (5 females and 6 males; age (mean +/- SD) 38 +/- 13 yrs) undergoing HLT. All of the patients were admitted to our institution for a rehabilitation programme after surgery, and were followed-up for 18 months. On admission, at discharge after an in-patient rehabilitation programme, and every 6 months, patients underwent evaluation of: lung function values; incremental treadmill exercise, 6 min walking distance (6-MWD); maximal inspiratory and expiratory pressures (MIP and MEP, respectively); and peak torque of isokinetic contraction of leg flexor and extensor muscles (IFX and IEX, respectively). On admission, patients had: reduced lung volumes as assessed by vital capacity (VC) (60 +/- 15% of predicted); reduced exercise capacity as assessed by peak oxygen consumption (V'O2,peak) (40 +/- 12% pred); reduced skeletal and respiratory muscle performance as assessed by IEX, IFX (48 +/- 16 and 28 +/- 12 Newton-metres (N x m), respectively) and by MIP and MEP (54 +/- 21 and 58 +/- 19 cmH2O, respectively). Ten patients completed the rehabilitation programme. At discharge, no significant change in dynamic and static lung volumes was observed. However, nonsignificant increases in MIP, MEP, IEX, IFX, 6-MWD and V'O2,peak were recorded. After 6 and 12 months, indices of skeletal and respiratory muscle function and V'O2, peak improved further, but still remained lower than normal values. We conclude that in patients with heart-lung transplantation, skeletal and respiratory muscle function and exercise performance are reduced after surgery, that they may improve with time but are still less than normal after 18 months.

[Chronic chondromalacia of the patella: comparison of morphological (magnetic resonance) and functional findings (isokinetic parameters) after rehabilitation]. / Sofferenze condrali rotulee croniche: confronto fra dati morfologici (Risonanza Magnetica) e funzionali (parametri isocinetici) dopo rieducazione.

The knee is a common site for injuries of the cartilage, capsule and ligament, which calls for the use of noninvasive techniques to assess injury severity properly and to plan adequate rehabilitation. Our study was aimed at comparing MR with isokinetic findings. To this purpose, 40 patients were examined; they were all affected with chondromalacia patellae, grades I-III, previously diagnosed at arthroscopy. Namely, 8 patients had grade I and 32 grades II and III chondromalacia. After MR and isokinetic exams, all patients were submitted to a standardized rehabilitation program. Our results indicate a marked decrease in quadriceps strength, especially in the most severe cases; in less severe cases, recovery was complete at 6 months, while the deficit remained in grades II and III injuries. MR yield was not relevant in 4 of 8 cases, while isokinetic findings were negative in one case. Both methods were positive in the most severe cases. At 6 months, both functional and MR findings were normal in grade I injuries, while some alterations remained in the others.

[Isokinetic evaluation and gait study in patients undergoing arthroplasty of the knee: verification of the efficacy of rehabilitation]. / Valutazione isocinetica e studio del passo in pazienti sottoposti ad artroprotesi di ginocchio: verifica di efficacia riabilitativa.

In this work the Authors have studied the efficacy of a standardized rehabilitative trial in patients with knee arthroplasty using an isokinetic technique and walking evaluation. 20 patients affected by gonarthrosis were evaluated: each of them underwent on one side an isokinetic evaluation before and 60 days after surgery, and on the other side a step evaluation, at the begin of limb charging and 60 days after surgery. The isokinetic parameters (strength, work, power) showed a sharp decrease of absolute values as compared to the preoperative situation, while in the walking evaluation the time reduction still remains in the first impact of the foot.

[Control of muscle reinforcement with the isokinetic endurance test in patients undergoing reconstruction of the anterior cruciate ligament of the knee]. / Controllo del rinforzo muscolare con il test di endurance isocinetico in pazienti sottoposti a ricostruzione di legamento crociato anteriore di ginocchio.

In the present study authors analyzed a group of fifty patients (mean age 24.3 years) affected by a chronic lesion of the anterior cruciate ligament of the knee, who underwent a ACL reconstruction by free patellar tendon in arthroscopy. Each of these patients carried out a standardized rehabilitative training and underwent an isokinetic evaluation immediately before and at 3, 4 and 6 months after ACL reconstruction. The considered parameters were the increasing of both strength and work in the standardized times at the angular speed of 60 and 180 degrees/sec. Our results, compared to the pre surgery, showed a high decrease of both strength and work at the third month after surgery, especially regarding the extensor muscles (-44% and -38% respectively); we observed an increase between the third and the fourth month, even if the parameters of the extensors still remain much lower than the controlateral healthy side.

Motor rehabilitation: evolution of functional markers in trained hemiparetic patients and effectiveness of synchronous techniques.

The authors investigated, by means of isokinetic tests, a group of normotonic hemiparetic patients with the aim of showing the evolution, and in the short and medium term, functional markers of muscle strength and motor patterns. The results showed that the efficacy of the synchronous techniques used was good during the period of use. In the medium term, while the recovery of strength remained constant, the motor patterns deteriorated as co-contraction of antagonistic muscle groups restarted. This did not, however, lead to functional regression in comparison with the short term result (effectiveness).

[Medium- and long-term effects of various treatment schedules with nasal S-calcitonin spray]. / Effetti a medio e lungo termine di diversi schemi di trattamento con S-calcitonina spray nasale.

188 patients with high-turnover type post-menopausal osteoporosis were treated for 18 months with 4 different treatment regimens of S-calcitonin nasal spray. For a total of 18 months group 1 was given 100 IU/day, continuously; group 2, 100 IU/day daily for 30 days every other month ("ciclically"); group 3, 200 IU/day continuously, and group 4, 200 IU/day, ciclically. To monitor the effects of treatment, MOC of L2-L4, as well as serum osteocalcin and urinary hydroxyproline: creatinine levels were measured, on initiation of therapy, then at 9, 12 and 18 months, and finally at 6 and 12 months after completion of therapy. Analysis of the results yields the following major points: (A) The peak increase in bone mass occurs at 9 months the continuous therapy groups, and at 18 months in the cyclic therapy groups. In absolute values, the peak are higher in the continuous groups than in the cyclic groups. (B) The long-term increase in bone mass (measured at one year after completion of therapy) does not differ significantly between cyclic and continuous treatment groups at the same dosage. (C) During treatment, a dose-effect relationship exist when comparing dosages of 100 IU/day and 200 IU/day. However, this disappears by one year after completion of therapy. (D) There seems to be a "rebound effect" on osseous turnover after cessation of S-calcitonin therapy. The magnitude and rapidity of onset of this effect appear to correlate directly with the dosage of S-calcitonin administered.

[A computerized endurance test: efficacy of pelvic floor rehabilitation treatment in patients with stress incontinence]. / Test di endurance computerizzato: efficacia del trattamento riabilitativo del pavimento pelvico in pazienti affette da stress incontinence.

In the present study the authors wanted to transfer rigorous methods of study, already in use in other sectors (sports, medicine, isokinetic work, etc.) of the validity of interventions made and their effectiveness, into an "emerging" field, that of perineal rehabilitation. 15 female patients, aged between 35 and 45, affected by stress incontinence underwent a baseline clinico-instrumental evaluation of the perineal floor including a computerized test of endurance. The patients then embarked upon a standardized rehabilitative perineal training lasting a month and at the end underwent an identical evaluation as that performed at the outset. Statistical analysis of the results obtained showed an objective improvement in the parameters considered (endovaginal pressure and its variations during a series of intermittent static contractions) quantitatively supporting clinical evidence.

[Skeletal and respiratory muscle strength in chronic heart failure]. / Forze dei muscoli scheletrici e respiratori nello scompenso cardiaco cronico.

BACKGROUND: The aim of this study was to investigate limb and respiratory muscle strength in chronic heart failure (CHF). METHODS: Our study population consisted of 45 male CHF patients, 25 in NYHA Class II and 20 in NYHA Class III, and 22 male post-MI patients without left ventricular dysfunction (LVEF > 50%). All patients underwent assessment of respiratory muscle strength by maximal inspiratory (MIP) and expiratory (MEP) pressures, of handgrip force and peak torque developed during isokinetic Knee extension (EX) (quadriceps) and flexion (hamstring) at 120 degrees/sec. RESULTS: CHF patients showed a significant decrease in all limb and respiratory muscle strength compared to control patients. Moreover, NYHA Class III patients showed significantly reduced values of MIP, handgrip, and EX forces, as well as significantly reduced exercise tolerance in terms of METS (2.8 +/- 0.9 vs 4.4 +/- 1.2, p < .05) and anaerobic threshold level (9.4 +/- 3 vs 12.8 +/- 1.7 mlO2/Kg, p < .05), as compared to those patients in NYHA Class II, while no significant differences were observed in LVEF, cardiac index and pulmonary capillary wedge pressures. Weak, but significant (p < .05) were the correlations between limb muscle and respiratory muscle strength. No correlations were found between muscle force and hemodynamic parameters. Significant correlations (from p < .05 to p < .0001) were found among exercise tolerance and limb muscle strength, but not between exercise tolerance and respiratory muscle strength. In summary: 1) respiratory and skeletal muscle strength is impaired in CHF; 2) respiratory and limb muscle strength reductions are partially related to each other; 3) the degree of central hemodynamic impairment is not correlated with muscle force. Deconditioning could be a major determinant of skeletal but not respiratory muscle weakness. Other factors link limb and respiratory weakness in CHF.

[The role of drug therapy in the treatment of nerve root lesions caused by compression. Clinical and electrophysiological study of 30 patients operated on for the removal of herniated disks]. / Ruolo della terapia farmacologica nel trattamento delle lesioni radicolari da compressione. Studio clinico ed elettrofisiologico in 30 pazienti operati di asportazione di ernia discale.

The therapeutic efficacy of two neurotrophic substances (exogenic gangliosides and Vitamin B12) is examined in 30 cases of patients suffering from postoperative radiculopathy after the excision of herniated discs. All patients were subjected to clinical examination as well as electromyography and electroneuronography. Check-ups 10 and 60 days after surgery revealed a much greater improvement among the treated than the untreated patients and that statistically significant clinical and electrophysiological improvement was only found among those treated with exogenic gangliosides.