Religious and spiritual beliefs in outpatients suffering from Parkinson Disease.

OBJECTIVE: Personality changes are known to occur in idiopathic Parkinson's Disease (PD). The aim of the study was to evaluate whether religious and spiritual beliefs in PD patients are different from age-matched controls. DESIGN: Eighty-three PD participants, 79 hypertensive individuals not affected by PD and 88 healthy subjects participated to a cross-sectional study. The Royal Free Interview (RFI) was used to evaluate participants' beliefs. The Hospital Anxiety and Depression Scale (HADS) was applied to monitor emotional distress. RESULTS: There was no statistical evidence of a difference between PD participants and the two control groups, the only exception being observed between the left PD onset group and the controls, where the total RFI score was about 5 points higher (t-test: p = 0.0273). RFI total score was uncorrelated with age, severity of illness and depression, but was strongly dependent on the type of beliefs. The percentage of PD participants suffering from anxiety and depression was high (right onset: 54.8%; left onset: 68.6%), while only 15.2% of the hypertensive participants, and none of the healthy controls, had a HADS score above 10 points. Total RFI score was higher in women. CONCLUSION: PD participants maintain their Faith in spite of the disease severity. Differences are found between right and left onset of PD. The possible beneficial effect of religious coping is discussed.

Spectral analysis of the voice in Down Syndrome.

The voice quality of individuals with Down Syndrome (DS) is generally described as husky, monotonous and raucous. On the other hand, the voice of DS children is characterized by breathiness, roughness, and nasality and is typically low pitched. However, research on phonation and intonation in these participants is limited. The present study was designed to provide data from the spectral analysis of the human voice in DS people. A cross-sectional, observational design was applied. Thirty DS adults and 48 DS children were enrolled after clinical evaluation. Thirty men, 30 women and 46 children constituted the control group. The participants had to repeat a set of Italian words twice. The Real Time Pitch software manufactured by KayPENTAX recorded the voice. The following spectral descriptors were obtained for each word: Mean Frequency and standard deviation, Energy, Duration, Jitter and Shimmer. Test-retest performance was also checked. The voice of DS adults was characterized by a significantly higher Mean Frequency, particularly in males (p<0.0001), by a smaller variation (p=0.0044 in males and p=0.0046 in females) and by a significantly lower level of Energy (p=0.0037 in males and p=0.0025 females). Furthermore, limited to male adults, a shorter Duration (p=0.0156) and a smaller value of Shimmer (p=0.0014) was observed. The difference between DS children and age-matched controls was limited, reaching significance only for the Coefficient of Variation (CV) (p=0.031). The difference in Mean Frequency between adults and children was more evident in the control males than in all other groups. The lack of marked difference between voice characteristics of children with and without DS is outlined by findings. Pearson's correlation coefficients on repeated productions ranged from 0.23 (Jitter) to 0.86 (Mean Frequency) in children, and from 0.07 (Shimmer) to 0.86 (Mean Frequency) in adults. In the control group, all the coefficients ranged between 0.85 and 0.98. As expected, women had a higher Mean Frequency than men, but the CV was around 0.1 for both. By contrast, children had a significantly higher Mean Frequency and a lower CV. In conclusion, spectral analysis of the human voice is recommended in each laboratory of speech and language rehabilitation to exploit the accuracy of voice descriptors.

Hydrotherapy after total knee arthroplasty. A follow-up study.

The study evaluated the subjective functional outcome following total knee arthroplasty (TKA) in participants who underwent hydrotherapy (HT) six months after discharge from a rehabilitation unit. A total of 70 subjects, 12 of which were lost at follow-up, were randomly assigned to either a conventional gym treatment (N=30) or HT (N=28). A prospective design was performed. Participants were interviewed with Western-Ontario McMasters Universities Osteoarthritis Index (WOMAC) at admission, at discharge and six months later. Kruskal-Wallis and Wilcoxon tests were applied for statistical analysis. Both groups improved. The WOMAC subscales, namely pain, stiffness and function, were all positively affected. Statistical analysis indicates that scores on all subscales were significantly lower for the HT group. The benefits gained by the time of discharge were still found after six months. HT is recommended after TKA in a geriatric population.

Hydrotherapy after total hip arthroplasty: a follow-up study.

The aim of the study was to evaluate the subjective functional outcome of total hip arthroplasty (THA) in patients who underwent hydrotherapy (HT) 6 months after discharge. A prospective randomized study was performed on 70 elderly inpatients with recent THA, who completed a rehabilitation program. After randomization, 33 of them were treated in conventional gyms (no-hydrotherapy group=NHTG) and 31 received HT (hydrotherapy group=HTG). Interviews with the Western-Ontario MacMasters Universities Osteoarthritis Index (WOMAC) were performed at admission, at discharge and 6 months later. Kruskal-Wallis, Mann-Whitney and Wilcoxon tests were applied for statistical analysis. Both groups improved. Pain, stiffness and function were all positively affected. Statistical analysis indicated that WOMAC sub-scales were significantly lower for all patients treated with HT. The benefits at discharge still remained after 6 months. We conclude that HT is recommended after THA in a geriatric population.

Spectral analysis of the human voice: a potentially useful tool in rehabilitation.

AIM: The study was aimed at providing normal data from the spectral analysis of the human voice. This step of the research has a bearing in the field of speech and language retraining. The possibility of providing quantitative data would hasten monitoring of possible improvements along a rehabilitation program. METHODS: A cross-sectional, observational design was applied. Thirty-two men, 30 women and 34 children were the healthy volunteers participating to the study. The adult participants had to repeat the 12 words of the ENPA instrument for Italian language. The children repeated words from the Fanzago test. Real Time Pitch Model 5121 manufactured by Kay PENTAX recorded the voice. The following spectral descriptors were obtained for each word: mean frequency, standard deviation, loudness, duration, jitter and shimmer. Test-retest performance was also checked. RESULTS: As expected, women had a higher mean frequency than men (119+/-3 v. 193+/-5 Hz), but the variation coefficient (CV: SD/mean) was the same, namely 0.1. By contrast, children had a significantly higher mean frequency (245+/-35 Hz) and a lower CV. Under this respect, groups could be statistically divided. Loudness was practically the same among the groups, whereas the children had short time duration in word uttering. Children had also the highest jitter values, whereas shimmer values were higher in men. CONCLUSIONS: Spectral analysis of the human voice is recommended in each laboratory of speech and language rehabilitation. The usual testing is not replaced but can exploit the accurate definition of voice descriptors.

Stability of word comprehension with age. An electrophysiological study.

Behavioural studies have suggested that lexical access is relatively unaffected by normal aging unlike other aspects of semantic processing. This psychophysiological study was designed to gather further evidence on the issue. Using an oddball procedure, an auditory N400 was recorded in both young (mean age 27.7 years) and elderly (mean age 65.1 years) volunteers in normal health. The target was either a high frequency word or a non-word, in two different sessions. The amplitude, onset latency and duration of the N400 did not differ in the two groups of subjects although the peak latency was delayed in the elderly group. The earlier N100-P200 complex had also a longer duration in the elderly group. The results indicate that aging processes affect the various stages of perceptual processing and language comprehension in different ways. Whereas P200, the main index of perceptual processing, was slowed, some measures of lexical access were found to be stable with age.

Breath test for differential diagnosis between small intestinal bacterial overgrowth and irritable bowel disease: an observation on non-absorbable antibiotics.

AIM: To estimate the prevalence of small intestine bacterial overgrowth (SIBO) among patients with an earlier diagnosis of irritable bowel disease (IBS) in our geographical area, and to collect information on the use of locally acting non-absorbable antibiotics in the management of SIBO. METHODS: A non-interventional study was conducted in 73 consecutive patients with a symptom-based diagnosis. RESULTS: When the patients underwent a "breath test", 33 (45.2%) showed the presence of a SIBO. After treatment with rifaximin 1,200 mg/d for seven days in 32 patients, 19 (59.4%) showed a negative "breath test" one week later as well as a significant reduction of symptoms, thus confirming the relationship between SIBO and many of the symptoms claimed by patients. In the other 13 patients, "breath test" remained positive, and a further cycle of treatment with ciprofloxacin 500 mg/d was given for 7 additional days, resulting in a negative "breath test" in one patient only. CONCLUSION: (1) about half of the patients with a symptomatic diagnosis of IBS have actually SIBO, which is responsible for most of the symptoms attributed to IBS; (2) only a "breath test" with lactulose (or with glucose in subjects with an intolerance to lactose) can provide a differential diagnosis between IBS and SIBO, with almost identical symptoms; and (3) the use of non-absorbable antibiotics may be useful to reduce the degree of SIBO and related symptoms; it must be accompanied, however, by the correction of the wrong alimentary habits underlying SIBO.

Return to work in stroke patients.

PURPOSE: To present the current state of knowledge regarding return to work (RTW) following stroke. METHOD: A comprehensive review of the current stroke rehabilitation literature pertaining to prognostic and treatment factors for RTW following stroke. RESULTS: Stroke is a major healthcare problem and one of the most expensive diseases in modern society. Stroke results not only in impairment and limitation in basic daily activities; it also impacts on participation in community activities, such as returning to work. Return to work in post-stroke patients has been reported to range between 19% and 73%. Various studies report on return to work in diverse populations, using different follow-up periods, while utilizing variable definitions of stroke and successful work outcomes. The factors positively related to RTW in stroke patients, as found in the literature, are age less then 65 years, high education level and white-collar employment. The significant negative predictor is the severity of stroke. This is indicated by neurological parameters including functional measures of the presence and extent of motor and cognitive impairment. Significantly, the side of the brain damaged and stroke location were not found to be correlated with RTW. Social and financial factors also significantly influence RTW. CONCLUSIONS: RTW in stroke patients should be considered one of the indicators of a successful rehabilitation as it influences self-image, well-being and life satisfaction. There is still a considerable lack of knowledge regarding effective assessments and interventions in vocational rehabilitation in stroke patients.

Effects of music-based therapy on distress following knee arthroplasty.

Anxiety and depression are frequent after total knee arthroplasty (TKA). Musical intervention can benefit many, including severe patients (agitated older people with dementia and terminal-ill patients) and surgical cases. This pilot study was aimed at verifying whether music therapy is beneficial after TKA. Reducing anxiety and depression is has a positive effect for the wellbeing of patients and is likely to have positive effects on outcome. In their pilot study, the authors found that a positive and specific effect of singing on depression was seen and that music therapy may be recommended after TKA instead of a pharmacological intervention.

The role of P300 in the recovery of post-stroke global aphasia.

Seventeen right-handed patients suffering from global aphasia caused by a recent stroke in the left-hemisphere were studied. Passive P300 auditory event related potential paradigm was applied every months for 6 months. Aachen subtests were used for evaluating comprehension. Only a minority of the patients displayed the P300 at the baseline. Those patients had the best outcome at the Aachen comprehension subtest. Latency and amplitude changed over time in an unpredictable way. The number of patients presenting with the P300 also fluctuated, since some patients could regain the potential, whereas some other patients could lose that from month to month. Passive P300 is a monitor of recovery following global aphasia. A single passive P300 recording is useful for prognostic purposes. Repairing mechanisms in the first 6 months have a non-linear trend.

Early detection of dementia in clinical practice.

Early identification of dementia and possible risk factors is a critical issue. The Basic Italian Cognitive Questionnaire (BICQ) is designed as a routine instrument for screening patients with initial cognitive impairment in daily practice. It is devoted to the general physician who needs a tool for deciding whether a subject deserves further diagnostic investigation in specialised centres. The administration of BICQ is easy, fast and does not require any training, since it is composed of 12 simple and ecologic questions referring to daily life. The discriminant analysis, a predictive model that generates a function based on linear combinations of the predictor variables, provided the best discrimination between controls with respect to the group of deteriorated patients. According to the classification function coefficients, the questionnaire score predicted correctly 100% of normal subjects and 85% of patients with cognitive impairment. Moreover, the receiving operating characteristics (ROC) analysis showed that the highest sensitivity and specificity were obtained at the cut-off value of 10. Thus, a

Do nurses exercise power in rehabilitation wards?

AIM: Nowadays, there is a change in nursing policy. The nurse-centred model is shifting to the patient-centred model. Decision-making is therefore transferred to the customer (Power to the Patient). Data from literature mainly deals with acute care and long-term care facilities. The aim of the study was to evaluate whether: i) a nurse-centred model is still effective in rehabilitation wards; ii) patients' dignity is nevertheless considered; iii) nurses experience role satisfaction in a rehabilitation setting. METHODS: A cross-sectional design was applied. Forty-eight nurses of our rehabilitation centre were invited to compile -in an anonymous way- a questionnaire developed by Finnish researchers from both acute care and geriatric units. More questions dealt with personal data. RESULTS: The sum of variables describing the nurses' exercise of power showed that power was most commonly exercised in obligatory daily activities. Power was less in activities necessitated by obligatory daily activities and in voluntary activities. Nurses' power was due to the necessity of organising the individual rehabilitation programs, which are tailored for each patient and require the observance of time-schedules. Nevertheless, patients had a say in many choices and their dignity was maintained. The nurses also answered that work in rehabilitation wards was more stressful than in both medical or surgical acute care. A third of them felt themselves not involved in the rehabilitation of the patients. CONCLUSIONS: The exercise of power is not a negative phenomenon in situations requiring safety, control, quick decisions, coping with time-contingencies, as it daily happens in rehabilitation wards. However, subject's dignity is compatible with that exercise of power. Rehabilitation staff should be aware of the nurse role, which can be only partially perceived. Better communication between nurses and other components of the rehabilitative staff would improve self-esteem and hasten motivation. Apparently, when the association between the ''experience'' variable and the sum variable was considered, it was found that the group of low clinical experience believed that power was exercised more often.

Determinants of the subjective functional outcome of total joint arthroplasty.

The aim of the study is three-fold: (i) to analyze association between early subjective functional outcome of total joint arthroplasty (TJA) and patient-related risk factors; (ii) to evaluate the six-month subjective functional outcome of TJA as compared with subjective functional status of non-operated outpatients; (iii) to evaluate TJA self-perceived amelioration rates compared to the status of an age-matched sample from a general medical practice. A prospective consecutive study was performed upon 100 elderly inpatients with recent primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) for osteoarthritis. Interviews on preoperative status and short-term outcome were performed at admission and six months after surgical intervention with Western Ontario and MacMasters Universities Osteoarthritis Index (WOMAC). One hundred aged-matched consecutive outpatients were screened for osteoarthritis and interviewed with the same questionnaire in a single session. Differences between baseline and follow-up scores were evident and statistically significant for both TJA groups, although THA patients showed more improvement. The comparison between TJA patients at baseline and age-matched osteoarthritis outpatients highlighted less impairment among outpatients. The situation reversed six months after the intervention. Objective functional outcome of post-operative rehabilitation has not revealed predictive value for the six-month outcome of TJA in terms of self-perceived functional status. Logistic regression analysis indicated that preoperative status was the only significant predictor of higher WOMAC scores six months after TJA. The survey confirms the early benefit of THA or TKA for osteoarthritis, but a less favorable subjective functional outcome is expected at six months when preoperative subjective functional status is severely compromised.

Self-perceived distress and self-perceived functional recovery after recent total hip and knee arthroplasty.

The research was aimed at verifying whether psychological distress and depression are associated to reduced functional improvement following arthroplasty. Thirty-six patients with total knee arthroplasty (TKA) and 36 patients total hip arthroplasty (THA) were enrolled at the beginning of their rehabilitation. The mean age in TKA patients was 71.3+/-7.8 years (S.D.). The mean age in THA patients was 67.9+/-8.4 years. The Western Ontario and MacMasters Universities Osteoarthritis Index (WOMAC) and the Hospital Anxiety and Depression (HAD) were applied. Forty-four percent of THA and 58% of TKA showed over-threshold HAD scores at admission. The proportion was even higher considering HAD-Depression sub-scale, where 55% of THA and 61% of TKA patients had over-threshold scores. Lack of depression prompted better functional outcome in TKA. The effect of depression on TKA functional improvement was still significant after adjusting for age and sex. No association was found for THA patients. In order to maximize rehabilitation benefit it is then suggested that patients with recent TKA intervention are screened for distress and depression at admission and that psychological symptoms are treated if over-threshold.

Recovery mechanisms are stronger than expected.

The study was aimed at identifying recovery possibility in elderly patients suffering from a first ever stroke and admitted to rehabilitation with concomitant high disability. From 1998 to 1999 one hundred elderly patients were entered consecutively into this study. Disability was measured by functional independence measure (FIM). The FIM value at admission had a median value 23, which indicated a very high post-stroke disability. At discharge the FIM median value was 33. After one year 41 patients were at home. Their median FIM value was 62.5. Thirty-one patients had died over the interval. The death was mainly due to a new stroke, cardiac diseases or acute pneumonia. Six patients were in a nursing home and 22 could not be studied at follow-up.

Is the Kennard effect supported by clinical evidence?

The objective of the study was to evaluate the so-called Kennard effect, i.e., the existence of a negative correlation between recovery and age. Thirty-eight elderly patients(median age 71 years, range 60-81) suffering from their first stroke were enrolled. The mean interval since the stroke was 15 days. Patients entered a 60-day rehabilitation pro -gram. Their functional condition was assessed by means of the functional independence measure (FIM). Only FIM values under 36 at admission were considered. Computerized tomographic (CT) or magnetic resonance imaging (MRI) scans were performed in all cases. The type of lesion was ischemic in 24 cases, hemorrhagic in 7 cases and 7 cases had more than one lesion. The patients' families were contacted after one year for a follow-up and all of them gave their consent. The survivors were examined again. The FIM score at discharge and the corresponding values at follow-up were statistically compared by means of Wilcoxon test (two-tailed). The FIM value at admission of the whole population had the median value of 27.5. None of these patients died during their stay at our rehabilitation center and their median FIM value at discharge was 34.5, a value still indicating high disability. After one year, 22 were still alive at home (57.9 %). Their FIM median value was 46. The difference was significant compared to discharge (Z = -3.228, p = 0.001). Three patients scored 85, 87 and 88, respectively, although none of them received rehabilitation treatment. In conclusion, our results indicate that restorative processes are still active in elderly patients, despite previous stroke and existing comorbidities. Some of the elderly patients of our group could approach to independence, although they displayed a very low FIM value at admission.

Comorbidity in post-stroke rehabilitation.

Patients referred to rehabilitation centers often suffer from associated comorbidity, which might negatively influence the effective outcome of the treatment program. The study was aimed at evaluating the impact of comorbidity on functional independence and gain after stroke. Ninety-three patients admitted to rehabilitation were enrolled. The disability was evaluated, both at time of admission and at discharge. The functional independence measure (FIM) was used. Comorbidity was evaluated by means of the Cumulative Illness Rating Scale (CIRS), that generates two indexes, the cumulative index (CI) and the severity index (SI). A logistic model could discriminate patients who were regularly discharged from the others (dead or transferred to acute care) pooled together (P < or = 0.02). The CI and SI were significantly correlated with FIM at admission. The r-values were -0.24 (P < or = 0.02) and -0.32 (P < 0.002). Recovery was not even influenced in the most severe patients. In conclusion, the CIRS appears to be a sensitive tool for the evaluation of comorbidity in stroke patients. The comorbidity is correlated to dependence in stroke patients but does not affect functional gain. However, comorbidity is of actual interest in view of new payment systems in rehabilitation, because it is included among the variables leading to costs.

The aftermath of rehabilitation for patients with severe stroke.

OBJECTIVE: The study evaluates the aftermath of stroke in patients with very severe disability after their first ever stroke and dismissed after rehabilitation. MATERIALS AND METHODS: Sixty-nine inpatients were studied, who were highly disabled at discharge with a Functional Independence Measure (FIM) score in the range of 18-39. Their rehabilitation program had lasted 60 days. The degree of functional independence was measured by means of the FIM at the beginning of treatment, at discharge and at follow-up. The data collected were examined by using parametric and distribution-free statistical methods. The role of age in the process of recovery was also evaluated. RESULTS: All patients were discharged home after 2 months. At 6 month follow-up, 15 patients (21.7%) were lost, 27 (39.1%) had died and 27 (39.1%) lived at home. Among stroke survivors a clear trend toward an improvement was detected during the 6 months observation period. Indeed, the third quartile changed from 33 to 63 and a patient approached to independence (FIM 87). None underwent a rehabilitation program at home beside the relatives' assistance. CONCLUSIONS: Highly disabled stroke patients are probably to undergo unfavourable outcome but unexpected recovery cannot be ruled-out on the basis of cut-off parameters measured after the acute phase of stroke. Multivariate statistical methods can identify factors which can interfere with functional recovery but are error-prone in setting individual prognosis. Moreover the recovery process may develop in a long period of time. Taking into consideration the spontaneous recovery observed during the follow-up period after the dismissal from rehabilitation ward, a suitable rehabilitation at home might be fruitful in these patients, who should not be considered as "lost".

On the outcome in stroke patients one year later: the role of atrial fibrillation.

The post-stroke aftermath of patients suffering from atrial fibrillation (AF) is investigated. A total of 104 consecutive patients (80 with AF and 24 without AF) were referred to a rehabilitation centre and enrolled. They underwent a rehabilitative programme. Disability was assessed by using the Functional Independence Measure (FIM), at the time of admission, discharge and after 1 year. Death was more frequent over the 1-year interval in AF group. Ten patients died (42%), whereas in the non-AF group death occurred in 15 cases (19%). By using chi-square test, the difference was significant (P < 0.02). The logistic regression analysis indicated that the unique variable affecting the FIM at follow-up was the FIM at discharge (P < 0.0001). AF was not a significant variable in the equation. The result can be attributed to subject attrition in the AF group, as the most severe patients died and survivors could benefit from a better functional status.

Dipolar source modeling of the P300 event-related potential after somatosensory stimulation.

The cerebral generators of the P300 potential evoked by somatosensory stimuli were investigated. Event-related potentials elicited by an oddball paradigm were recorded in 15 healthy subjects by 19 scalp electrodes. Nontarget and target electric stimuli were delivered on the anterior surface of the left elbow and of the wrist, respectively. Target traces showed an N140 potential followed by a widely distributed P300 response. Dipolar source modeling of target traces resulted in a six-dipole model. In the earlier latency range (up to 200 ms), one dipole in the contralateral perirolandic region and two dipoles in the parasylvian cortex of both hemispheres were activated. Two dipolar sources located bilaterally in the medial temporal region (MTR) showed their maximal activity at the P300 latency. Finally, a dipole in the contralateral frontal lobe was activated both at the latency of the N140 response and after 200 ms. It was found that two symmetrical MTR sources and a frontal dipole contributed to P300 generation.