Functional assessment and rehabilitation protocol in acute patients affected by SARS-CoV-2 infection hospitalized in the Intensive Care Unit and in the Medical Care Unit.

BACKGROUND: Coronavirus disease (COVID-19) is characterized by different clinical pictures that may require prolonged hospitalization and produce disabilities challenging the recovery of previous independence. AIM: The aim is to evaluate the impact of an early assisted rehabilitation program on the functional status of an acutely hospitalized population affected by COVID-19. DESIGN: Single-institution retrospective longitudinal study. SETTING: Inpatient intensive care units (ICU) and medical care units (MCU). POPULATION: Acute COVID-19 patients. METHODS: General information was collected; age-adjusted Charlson Comorbidity Index was used for comorbidities. Duration of hospital stay, the length of stay in ICU and/or MCU, the length of the rehabilitative treatment, and the destination at the discharge were collected. Evaluation was performed when patients were clinically stable (T0), and at hospital discharge (T1); for subjects enrolled in ICU functional status was assessed at the time of transfer to the MCU. Muscle strength of the four limbs was measured with the Medical Research Council (MRC) sum-score. Functional status was assessed using the 3-item Barthel Index (BI-3) and the General Physical Mobility Score (GPMS). Early assisted-tailored rehabilitation protocol was applied in ICU and in MCU: the aims were the maintenance (or recovery) of the range of motion and of the strength and the recovery of sitting/standing position and gait. RESULTS: We evaluated 116 patients (mean age 65, SD 11) (65% male), 68 in ICU (mean age 60, SD 10), 48 in MCU (mean age 73, SD 9). At discharge, BI-3 and GPMS significantly improved in both ICU (P<0.001) and MCU (P<0.001) subgroups of patients. MRC sum-score significantly improved in ICU patients (P<0.001). Patients hospitalized in ICU had a significantly longer hospital stay. At discharge, patients admitted to the ICU reach a functional state that is close to that of patients admitted to the MCU. CONCLUSIONS: The results suggest that an early assisted rehabilitation program may be helpful in improving the short-term functional status of an acutely hospitalized population affected by COVID-19, with discharge at home of 48% CLINICAL REHABILITATION IMPACT: this study focuses on a functional assessment method to be used to identify the rehabilitation needs and verify the results of an early rehabilitation protocol applied to the acute COVID-19 patient admitted to ICU and MCU.

Potentiation of muscle strength by focal vibratory stimulation on quadriceps femoris.

OBJECTIVES: Several studies have investigated the effects of focal vibration on muscle strength. Non-univocal results have been found. The aim of this study was to evaluate the effect of prolonged focal vibratory stimulation on quadriceps muscle strength at two different frequencies (80 and 300 Hz). The evaluation of muscle strength was performed at different intervals of time after the end of the vibratory stimulation in order to quantify the long-term effects and their trends over time. METHODS: Twenty-seven healthy volunteers were divided into three groups, a control group (no treatment) and two groups treated with vibratory stimulation (80 or 300 Hz) of relaxed quadriceps femoris bilaterally, once a day (30 min) for 5 consecutive days. The quadriceps' strength was measured through an isokinetic dynamometer, before and at three time intervals after the treatment, with a follow-up period of 4 weeks. The outcome measure was the Peak Torque (PT, Nm) of the quadriceps femoris produced by extension movement at three defined angular velocities and during isometric contraction. RESULTS: No changes in PT were observed in the control group over time, while PT increased in the treated groups. No significant difference in PT behavior was observed between these two groups. PTs recorded before and after the treatment were markedly different, and the increase in the PT persisted until the follow-up at 4 weeks, for all angular velocities tested. CONCLUSIONS: Prolonged vibratory stimulation of the quadriceps femoris, both at 80 and at 300 Hz, leads to an increase in muscle strength. The vibration effect does not appear to fade at the end of treatment, but persists at the follow up, suggesting a likely underlying plastic process. The results of the current study suggest that 30-min per day, 5 day focal vibratory treatment can be helpful during the clinical practice to regain muscular strength. It does not require patient's effort during the treatment, requires a little time, its effects are long-lasting, and there are no known adverse effects.

Disability after major abdominal surgery: determinants of recovery of walking ability in elderly patients.

BACKGROUND: Increased life expectancy and improved surgical techniques have led to a sharp rise in healthcare resource consumption by older patients. In these patients early recovery of walking ability after abdominal surgery may shorten length of hospital stay and reduce overall healthcare costs, but it is important to understand what factors determine this recovery. AIM: To assess preoperative and postoperative determinants of walking ability recovery after major abdominal surgery in older patients. DESIGN: Prospective observational study. SETTING: General Surgery Unit. POPULATION: The study included 327 consecutive older inpatients who underwent major acute-care abdominal surgery. METHODS: Data on demographic characteristics, diagnosis, comorbidities defined by Charlson Comorbidity Index (CCI), preoperative walking ability, and early postoperative physical deconditioning (PPDS) were gathered. All patients underwent an individually-tailored rehabilitation program. At discharge, pain (by a Visual Analogue Scale, VAS-pain, 0-10), transfers and walking ability were assessed. Number of rehabilitation sessions attended and discharge setting were recorded. RESULTS: Of 320 patients included in the analysis (7 died), 72% had CCI>5, signifying presence of >1 comorbidities. Before hospitalization, 79% of patients were completely independent in walking at home, 12% needed assistive devices or direct assistance from the caregiver, and 9% were unable to walk. Complex postoperative physical deconditioning was detected in 25%. At discharge, most patients (87%) had achieved their rehabilitative goal and returned home. Only PPDS and VAS-pain were able to predict both walking ability and the discharge setting, PPDS alone showing adequate sensitivity (82%) and specificity (70%). CONCLUSIONS: PPDS was the sole early postoperative predictor of recovery of walking ability and the discharge setting. Pain therapy might be a key factor influencing the postoperative functional decline. Age and severity of preoperative comorbidities seem not important determinants of functional decline in older surgical patients. CLINICAL REHABILITATION IMPACT: An early postoperative assessment of physical deconditioning might be able to predict the walking ability at discharge (hence, the discharge setting), in older patients undergoing major surgery.

Neuropsychological outcomes after pulmonary endarterectomy using moderate hypothermia and periodic circulatory arrest.

BACKGROUND: In this prospective, single-center, observational study, we investigated the association between repeated short periods of circulatory arrest with moderate hypothermia during pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and different neuropsychological dimensions. METHODS: We examined 70 patients with CTEPH, >18 to 80 years of age, who had been treated with PEA. Neuropsychological testing was performed. RESULTS: Learning ability and delayed memory remained well within the normal range for patients' age. We found a statistically significant post-surgical improvement in motor speed, which was accompanied by a better quality of life and reduced symptoms of depression and anxiety. CONCLUSION: PEA with repeated short periods of circulatory arrest in CTEPH did not result in any neuropsychological complications and may even lead to post-surgical psychological improvements.

Assessment of physical performance and quality of life in kidney-transplanted patients: a cross-sectional study.

BACKGROUND: Information on physical and mental wellness in renal transplantation is limited. Therefore, we performed a cross-sectional study to evaluate and describe the different components of physical performance and quality of life (QoL) in a cohort of kidney-transplanted patients. METHODS: Physical performance and QoL were determined through the administration of validated tests and questionnaires [muscle strength, dynamometer handgrip, tactile sensitivity, visual analogue scale (VAS) for pain, Timed Up and Go (TUG) test, Fatigue Severity Scale (FSS) and the 36-item Short Form Health Survey]. The patients were divided into three groups based on time elapsed since transplantation: early (in the first 6 months), middle (from 7 to 60 months) and late (>60 months). RESULTS: Of 132 enrolled patients, 11 patients (8.3%) presented a severe reduction of muscle strength, 63 patients (47%) had significant bilateral impaired handgrip and tactile sensitivity was altered in 23 patients (17.4%). TUG assessment showed significant mobility limitation in 29 patients (21.9%). The FSS presented a pathological value in 50 patients (37.3%), while the mean VAS was 1.8 ± 2.7. There were no significant differences in physical performance parameters among the three patient groups. There were inverse correlations among different components of physical performance and age, comorbidity and dialysis vintage, and there was a direct correlation with renal function. During the first months after transplantation there were limitations in physical, social and emotional activities. Overall, the self-perceived physical performance was significantly lower in transplanted patients with respect to the normal reference level. CONCLUSION: Kidney-transplanted patients may present different degrees of impairment in physical performance and quality of life. Systematic functional assessment is essential to identify patients needing intensive and personalized rehabilitation programmes.

Changes in quality of life and functional capacity after lung transplantation: A single-center experience.

Lung transplantation (LT) increases the life expectancy of patients affected by end stage pulmonary disease; specifically, its ultimate aims are to improve survival and health related quality of life (HRQoL). The aim of the present longitudinal study was to determine the HRQoL trajectory and changes in functional capacity from time of entry in the waiting list for LT to 2 year after LT. The study included sixty-nine outpatients enrolled in a single medical center when they entered the waiting list for LT and who subsequently received it. They were then followed up over 2 years after LT. HRQoL was assessed by the physical and mental component summary (PCS and MCS) scores of the 36-item Short Form Health Survey (SF-36) and Saint George's Respiratory Questionnaire (SGRQ). Psychological distress was evaluated with the General Health Questionnaire (GHQ), and functional capacity was investigated using the six-minute walk test (6MWT) and forced expiratory volume (FEV1). Patients showed low SF-36 PCS (30.5±7.8) and SGRQ total (61.8±17.5) scores at entry in the waiting list, but exhibited significant changes over time after LT (p<0.001). Furthermore, patients who showed an increase of at least 50% in SF36 PCS and SGRQ scores at 6 months survived longer. Both FEV1 and 6MWT distance as well as GHQ scores significantly changed over time, with improvements occurring in the first 6 months after LT but no major changes thereafter. Out of the 69 patients enrolled, 32 died over a median follow-up of 51 months. Although mortality tended to be slightly higher for patients with lower HRQoL at the baseline assessment, this difference was not statistically significant. HRQoL evaluations appear critical in the follow-up of LT candidates, in particularly SGRQ, because of its specificity in targeting respiratory symptoms and functional wellbeing.

Oxygen saturation and heart rate monitoring during a single session of early rehabilitation after cardiac surgery.

BACKGROUND: Early rehabilitation after cardiac surgery aims to prevent immobilization, to reduce the effects of surgery on the respiratory function and to facilitate the recovery of autonomy in the activities of daily living (ADL), after discharge. Nevertheless the optimal perioperative physical therapy care for patients undergoing cardiac surgery is not well established. Moreover, most of the studies monitored peripheral oxygen saturation (SpO2) and heart rate (HR) during surgery or focused only on their recovery after rehabilitation and not on their pathways during a session of exercises. AIM: To monitor peripheral oxygen saturation and HR before, during and at the end of a single session of early rehabilitation after cardiac surgery, so testing our protocol's safety. DESIGN: A case series. SETTING: Department of Cardiothoracic Surgery, inpatients. POPULATION: Forty-eight consecutive inpatients (35 M), mean age 61 years, with cardiovascular disease (CVD), who underwent cardiac surgery. METHODS: We monitored SpO2%, HR, systemic blood pressure (BP), pain in the thoracic wound (VAS) and rate of perceived exertion (RPE) during the rehabilitation session after weaning from oxygen therapy. RESULTS: During all phases mean SpO2 was 94% (±1.8) and mean HR was 85 bpm (±13.3). Number of desaturation events were 14 in total and mean of % of time with SpO2<90% was 3 (±6.5) during all the rehabilitative session. Moreover, mean BP after reaching the sitting position was 124.7 (±11.9)/78.6 (±8.4) and after ambulation was 131.5 (±11.5)/82.9 (±7.3). CONCLUSION: The monitoring peripheral oxygen saturation and HR during and not only before and at the end of a standardized early rehabilitation session helped us to ensure the safety of our protocol. CLINICAL REHABILITATION IMPACT: Because of its feasibility, safety and reproducibility our rehabilitation treatment has been applied to different types of surgical inpatients in order to limit the negative consequences of immobilization.

Functional assessment and quality of life before and after pulmonary endoarterectomy.

PURPOSE: The study investigates Quality of Life (QOL) and correlation with functional status of patients affected by Chronic Thromboembolic Pulmonary Hypertension who undergo Pulmonary Endoarterectomy. METHODS: We investigated with an observational design (before surgery, three and twelve months afterwards) the hemodynamic data (NYHA class, mean pulmonary arterial pressure, cardiac output and pulmonary vascular resistance), the functional status (using the 6-Minute Walk Test) and the QOL, using three questionnaires: Medical Outcome Study Short Form-36 (SF-36), Minnesota Living with Heart Failure Questionnaire (MLHFQ), Saint George Respiratory Questionnaire (SGRQ). We report the results of forty-nine patients. RESULTS: After surgery there was an improvement on functional and hemodynamic parameters and on QOL. The physical domain (PCS) of SF-36 was weakly but significantly associated with all functional parameters. There was no association between functional parameters and mental domain (MCS) of SF-36 or SGRQ. The improvement in 6-Minute Walk Distance was associated with an increase in MLHFQ. CONCLUSIONS: Both QOL and submaximal exercise tolerance improve after surgery. However only the physical domains of SF-36 appear to be significantly associated to the functional data.

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.

Early rehabilitative treatment in aortocoronary bypass surgery.

AIM: The objective of this retrospective study is to analyze functional recovery and response to rehabilitation treatment during the immediate postoperative phase of aortocoronary bypass (ACB) surgery. METHODS: We studied 319 patients, who had undergone ACB surgery and who needed post-acute rehabilitation. RESULTS: All patients presented post-operative respiratory dysfunction, 300 cases presented inability in position changes and needed neuromotor exercises in addition to chest physiotherapy. Rehabilitation treatment began at a mean number of 1.79 +/-1.37 days after surgery and continued for 5.78 +/- 3.59 days. At the discharge, at mean 5.47 +/- 2.25 days after surgery, most of patients (65.61%) walked independently. CONCLUSIONS: Our study described a protocol of early rehabilitative treatment that appeared to be suitable in promoting patients'functional recovery after aortocoronary bypass surgery.

Return to work after thoracic organ transplantation in a clinically-stable population.

PURPOSE: To evaluate the rate of return to work after transplantation and its determinants in a clinically-stable population of patients transplanted and followed-up at a single institution in Italy. METHODS: 151 thoracic organ transplant recipients (72 lung, 79 heart) were examined. Patients were asked about daily activities, level of education, employment and clinical condition. A six-minute walking test was performed with measurement of dyspnoea using the Borg scale. Quality of Life was evaluated with the SF-36 and GHQ questionnaires. RESULTS: Before transplantation 131 patients (87%), (70 heart and 61 lung) worked. After transplantation, 51 patients (39%) went back to work and 3 more started working. We found that younger age, a better quality of life (mainly in the mental domain), having had an occupation previously (particularly as an entrepreneur/freelancer), and having been off work for less than 24 months, were independent predictors of return to work. CONCLUSIONS: Considering their good, objective and subjective, functional status, some patients who could have returned to work, chose not to. Identifying factors which affect return to work might help health professionals to adopt the best course of treatment and psychological support in order to fulfil this goal; however, return to work should not be considered as the only expression of a patient's real psychophysical condition.

Usefulness of BFB/EMG in facial palsy rehabilitation.

OBJECTIVE: To analyze and to compare the recovery and the development of synkinesis in patients with idiopathic facial palsy (Bell's palsy) following treatment with two methods of rehabilitation, kinesitherapy (KT) and biofeedback/EMG (BFB/EMG). STUDY DESIGN: Retrospective cases--series review. METHODS: Seventy-four patients with Bell' palsy were clinically evaluated within 1 month from onset of palsy and at 12 months after palsy (House scale and synkinesis evaluation). Electromyography (EMG) and Electroneurography (ENG) were performed about 4 weeks after palsy to better evaluate functional abnormalities due to facial nerve lesion. The patients followed two different protocols for rehabilitation: the first 32 patients were treated with therapeutic exercises performed by therapists (KT group), the latter 42 patients were treated using BFB/EMG methods (BFB group) with inhibition of synkinetic movement as the primary goal. RESULTS: KT and BFB patients were evaluated for clinical and neurophysiological characteristics before rehabilitative treatment. BFB patients showed better clinical recovery and minor synkinesis than KT patients. CONCLUSIONS: BFB/EMG seems to be more useful than KT in Bell's palsy treatment. This could be due to the fact that BFB/EMG gives more accurate information than KT on muscle activation with better modulation in voluntary recruitment of motor unit.