Spinal manipulation compared with back school and with individually delivered physiotherapy for the treatment of chronic low back pain: a randomized trial with one-year follow-up

OBJECTIVE

To compare spinal manipulation, back school and individual physiotherapy in the treatment of chronic low back pain.

DESIGN

Randomized trial, 12-month follow-up.

SETTING

Outpatient rehabilitation department.

PARTICIPANTS

210 patients with chronic, non-specific low back pain, 140/210 women, age 59 +/- 14 years.

INTERVENTIONS

Back school and individual physiotherapy scheduled 15 1-hour-sessions for 3 weeks. Back school included: group exercise, education/ ergonomics; individual physiotherapy: exercise, passive mobilization and soft-tissue treatment. Spinal manipulation, given according to Manual Medicine, scheduled 4 to 6 20'-sessions once-a-week.

OUTCOME

Roland Morris Disability Questionnaire (scoring 0-24) and Pain Rating Scale (scoring 0-6) were assessed at baseline, discharge 3, 6, and 12 months.

RESULTS

205 patients completed the study. At discharge, disability score decreased by 3.7 +/- 4.1 for back school, 4.4 +/- 3.7 for individual physiotherapy, 6.7 +/- 3.9 for manipulation; pain score reduction was 0.9 +/- 1.1, 1.1 +/- 1.0, 1.0 +/- 1.1, respectively. At 12 months, disability score reduction was 4.2 +/- 4.8 for back school, 4.0 +/- 5.1 for individual physiotherapy, 5.9 +/- 4.6 for manipulation; pain score reduction was 0.7 +/- 1.2, 0.4 +/- 1.3, and 1.5 +/- 1.1, respectively. Spinal manipulation was associated with higher functional improvement and long-term pain relief than back school or individual physiotherapy, but received more further treatment at follow-ups (P < 0.001); pain recurrences and drug intake were also reduced compared to back school (P < 0.05) or individual physiotherapy (P < 0.001).

CONCLUSIONS

Spinal manipulation provided better short and long-term functional improvement, and more pain relief in the follow-up than either back school or individual physiotherapy.

Effects of a structured physical activity intervention on measures of physical performance in frail elderly patients after cardiac rehabilitation: a pilot study with 1-year follow-up

The objective of this prospective randomized controlled study was to compare the long-term effects of a structured physical activity intervention with those of aerobic exercises alone, in a cohort of elderly patients who had undergone elective cardiac surgery, and who were classified as frail at the end of rehabilitation based on their Short Physical Performance Battery (SPPB) score. At the end of rehabilitation, 140 frail elderly patients were randomly allocated either to the intervention group (IG) or to the control group (CG). CG participants received the usual aerobic exercise prescription, while IG participants were also taught additional exercises for strength, flexibility, balance and coordination. The improvement in SPPB score after 1 year was the outcome of the study. IG showed a significant improvement in SPPB score (9.0 ± 1.1 vs. 7.7 ± 1.4, p < 0.001), while no significant change was found in CG (7.7 ± 1.6 vs. 7.6 ± 1.5, p = 0.252). IG also showed a significantly higher proportion of participants who improved their SPPB score of at least 1 point (70 vs. 37%, p < 0.001). In conclusions, our structured physical activity intervention significantly improves the SPPB score in frail elderly patients who have undergone elective cardiac surgery. An intervention that improves the SPPB score might delay the occurrence of mobility disability.

Predictors of Function, Activity, and Participation of Stroke Patients Undergoing Intensive Rehabilitation: A Multicenter Prospective Observational Study Protocol

Background: The complex nature of stroke sequelae, the heterogeneity in rehabilitation pathways, and the lack of validated prediction models of rehabilitation outcomes challenge stroke rehabilitation quality assessment and clinical research. An integrated care pathway (ICP), defining a reproducible rehabilitation assessment and process, may provide a structured frame within investigated outcomes and individual predictors of response to treatment, including neurophysiological and neurogenetic biomarkers. Predictors may differ for different interventions, suggesting clues to personalize and optimize rehabilitation. To date, a large representative Italian cohort study focusing on individual variability of response to an evidence-based ICP is lacking, and predictors of individual response to rehabilitation are largely unexplored. This paper describes a multicenter study protocol to prospectively investigate outcomes and predictors of response to an evidence-based ICP in a large Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation.

Methods: All patients with diagnosis of ischemic or hemorrhagic stroke confirmed both by clinical and brain imaging evaluation, admitted to four intensive rehabilitation units (adopting the same stroke rehabilitation ICP) within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled (expected sample: 270 patients). Measures will be taken at admission (T0), at discharge (T1), and at follow-up 6 months after a stroke (T2), including clinical data, nutritional, functional, neurological, and neuropsychological measures, electroencephalography and motor evoked potentials, and analysis of neurogenetic biomarkers.

Statistics: In addition to classical multivariate logistic regression analysis, advanced machine learning algorithms will be cross-validated to achieve data-driven prognosis prediction models.

Discussion: By identifying data-driven prognosis prediction models in stroke rehabilitation, this study might contribute to the development of patient-oriented therapy and to optimize rehabilitation outcomes.

Clinical Trial Registration:ClinicalTrials.gov, NCT03968627. https://www.clinicaltrials.gov/ct2/show/NCT03968627?term=Cecchi&cond=Stroke&draw=2&rank=2.

Predictors of short- and long-term outcome in patients with chronic non-specific neck pain undergoing an exercise-based rehabilitation program: a prospective cohort study with 1-year follow-up

The aim of this study was to describe the clinical course of patients with chronic, non-specific neck pain undergoing a public health covered, exercise-based rehabilitation program and to identify predictors of poor outcome. A prospective cohort study was carried out on patients with non-specific neck pain (6 months or longer), referred by their general practitioner to a 6-session program, including education and individually tailored exercise. The primary outcome measure for the course of neck pain was the Northwick neck pain questionnaire (NPQ) administered on baseline, discharge, and 1 year from discharge. Poor outcome was defined as NPQ score improving <30% (minimal clinically important difference-MCID-NPQ). The potential predictors included demographics, general health and psychological factors, neck pain history, and the clinical features described by NPQ. From January 2008 to June 2009, 212 patients were consecutively assessed for eligibility: 178 were enrolled and 162 completed follow-up (mean age = 65.3; 75% women). Baseline NPQ average score (40.7 + 17.1) improved by MCID on discharge (26.1 + 16.3) and at 1 year (28.5 + 17.3%). The poor outcome was reported by 45% patients on discharge and by 56% at follow-up. Pain-related medication intake independently predicted poor short- (OR 4.24; 95% CI 1.83-9.84; p = 0.001) and long-term (OR 2.69; 95% CI 1.19-6.06; p = 0.017) outcome, and catastrophizing (OR 2.91; 95% CI 1.31-6.48; p = 0.009) predicted poor outcome at 1 year. Our cohort of patients with chronic neck pain undergoing an exercise-based rehabilitation program reported improvement by or beyond MICD-NPQ in 55% cases on discharge and in 44% cases at 1 year. Poor outcome was predicted by pain-related medication intake in the short and long term, and by catastrophizing in the long term.

Hemoglobin concentration is associated with self-reported disability and reduced physical performance in a community dwelling population of nonagenarians: the Mugello Study

People aged 90 and older represent a fast-growing population segment who deserve specific attention and research. Aging is associated with a progressive decrease in hemoglobin concentration, which predicts adverse outcome, such as mortality, morbidity, frailty and disability. Whether this association is independent from increased prevalence of comorbidity, causing both anemia and reduced physical function is yet under debate. The aim of this study is to explore the relationship between hemoglobin concentration and self-reported disability and reduced physical performance in a community dwelling population of nonagenarians. Data presented were collected in the framework of the Mugello Study, a clinical epidemiologic survey of nonagenarians living in the Mugello area (Tuscany, Italy). 251 persons (177 women, age 93.2 ± 3.3 years; 74 men, age 92.2 ± 2.5 years) underwent a blood draw. Along with hemoglobin concentration, self-reported disability (basic and instrumental activities of daily living), physical performance (Short Physical Performance Battery), self-reported physical activity and muscular strength (handgrip measurement) were assessed. Covariates, inherent sociodemographic and health indicators and comorbidities were also included in the analysis. This study confirms that anemia is very common in the oldest old, with a significantly higher prevalence in males (50% in men vs 24% in women). Multiple linear regression analysis, including all the comorbid conditions as confounding factors, shows that hemoglobin concentration is independently associated with handgrip strength, self-reported physical activity and disability in dressing, and taking a shower/bath. In conclusion, results from this study confirm that in the oldest old, low hemoglobin concentration is strongly associated with self-reported disability and decline of physical performance independent of comorbidity.

Higher uric acid levels are associated with better functional recovery in elderly patients receiving cardiac rehabilitation

BACKGROUND AND AIMS

Whether uric acid (UA) serves as risk factor for cardiovascular diseases or as antioxidant defense has not yet been completely clarified. In this study we investigated the effects of UA on functional recovery in patients receiving cardiac rehabilitation.

METHODS AND RESULTS

306 patients, 209 men and 97 women, age range 25-87 years (mean 68 ± 11), performed the 6-min walk test (6mWT) before and after the rehabilitation, and the increase in walking distance was considered as the outcome measure of the study. Baseline UA serum levels ranged from 1.0 to 10.9 mg/dL (mean 5.2 ± 1.7). As there was a significant (p = 0.005) age*UA levels interaction, patients were divided into two subgroups, less then 65 years (n. 103, 68 men and 35 women, mean age 56 ± 9) and 65 years or more (n. 203, 141 men and 62 women, mean age 74 ± 5). After adjusting for relevant confounders, higher UA levels remained independent positive predictors of the increase in walking distance in older (p < 0.001) but not in younger patients (p = 0.807).

CONCLUSIONS

Our findings show an independent association of higher UA levels with better functional recovery after cardiac rehabilitation selectively in elderly patients, suggesting that higher UA levels might reflect the decline in antioxidant defenses that occurs with advancing age. Future studies aimed at understanding the several contradictions concerning UA should, probably, address the issue within this perspective.

Factors influencing trunk control recovery after intensive rehabilitation in post-stroke patients: a multicentre prospective study

BACKGROUND

Trunk control plays a crucial role in the stroke rehabilitation, but it is unclear which factors could influence the trunk control after an intensive rehabilitation treatment.

OBJECTIVES

To study which demographic, clinical and functional variables could predict the recovery of trunk control after intensive post-stroke inpatient rehabilitation.

METHODS

Subjects with acute, first-ever stroke were enrolled and clinical and data were collected at admission and discharge. The primary outcome was considered the trunk control measured by the Trunk Control Test (TCT). The data were analyzed by a univariate and multivariate logistic regressions.

RESULTS

Two hundred forty-one post-stroke patients were included. All baseline variables significantly associated to TCT at discharge in the univariate analysis (i.e. gender, NIHSS neglect item at admission, presence of several complexity markers, TCT total score at admission, NIHSS total score, pre-stroke modified Rankin Scale, Fugl-Meyer Assessment motor and sensitivity score) were entered in the multivariate analysis. The multivariate regression showed that age (p = .003), admission NIHSS total score (p = .001), admission TCT total score (p < .001) and presence of depression (p = .027) independently influenced the TCT total score at discharge (R² = 61.2%).

CONCLUSIONS

Age, admission neurological impairment (NIHSS total score), trunk control at the admission (TCT total score), and presence of depression independently influenced the TCT at discharge. These factors should be carefully assessed at the baseline to plan a tailoring rehabilitation treatment achieving the best trunk control performance at discharge.

Development and implementation of a stroke rehabilitation integrated care pathway in an Italian no profit institution: an observational study

BACKGROUND

To standardize assessment and coordinate processes in stroke rehabilitation, an integrated care pathway (ICP) was developed in an Italian Rehabilitation and Research Institution by a knowledge-translation interdisciplinary process, from evidence-based guidelines to rehabilitation practice. The ICP was implemented in two pilot Tuscan rehabilitation Centers.

AIM

The purpose of this study was to describe ICP development and assess the ICP effects on postacute stroke inpatient rehabilitation outcomes.

DESIGN

Prospective observational study, before and after comparison.

SETTING

Two Tuscan inpatient rehabilitation centers.

POPULATION

Patients accessing either centers for intensive rehabilitation after acute stroke.

METHODS

Two cohorts were prospectively recruited before (2015-2017) and after (2018) implementation of the pathway. The primary outcome was change in activities of daily living disability, assessed by the modified Barthel Index (mBI) from admission to discharge. Secondary outcomes included length of stay (LOS), adverse outcomes, and changes in communication ability, trunk control, pain, ambulation, bladder catheter (Y/N), bedsores (Y/N).

RESULTS

In 2015-2017, 443 postacute stroke patients (mean age 77±11 years, 47% women), while in 2018, 84 patients (mean age 76±13 years, 61% women) were admitted to the two facilities. Comparing the 2018 vs. the 2015-17 cohort, the mean mBI increase was not substantially different (26 vs. 24 points), nor were LOS (37±18 vs. 36±16 days), adverse outcomes, discharge destination, and improvement of ambulation, pain, and communication (P>0.05). Instead, a significantly higher improvement of trunk control (trunk control test: 69.6±33.2 vs. 79.0±31.3, P=0.019), and a higher percentage of bedsore resolution (13% vs. 5%, P=0.033), and bladder catheter removal (37% vs. 17% P<0.001) were observed in 2018 vs. 2015-2017.

CONCLUSIONS

Compared to prior practice, ICP was associated to improvement of trunk control recovery, bladder catheter removal, and bedsores resolution. Further ICP implementation on a larger scale is needed to verify improvements of stroke inpatient rehabilitation outcomes.

CLINICAL REHABILITATION IMPACT

An evidence-based stroke rehabilitation ICP was interdisciplinary developed and implemented in two rehabilitation centers of a multicenter Italian health group. ICP implementation as to inpatient intensive postacute stroke rehabilitation was associated to improved trunk control recovery, bladder catheter removal, and bedsore resolution. Further ICP implementation will allow multicenter studies and quality benchmarking.

Intra- and inter-rater reliability of the Italian Fugl-Meyer assessment of upper and lower extremity

PURPOSE

To assess the intra- and inter-rater reliability motor and sensory functioning, balance, joint range of motion and joint pain subscales of the Italian Fugl-Meyer Assessment (FMA) Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE) at the item- subtotal- and total-level in patients with sub-acute stroke.

MATERIALS AND METHODS

The FMA was administered to 60 patients with sub-acute stroke (mean age ± SD = 75.4 ± 10.7 years; 58.3% men) and independently rated by two physiotherapists on two consecutive days. Intra- and inter-reliability was studied by a rank-based statistical method for paired ordinal data to detect any systematic or random disagreement.

RESULTS

The item-level intra- and inter-rater reliability was satisfactory (>70%). Reliability level >70% was achieved at subscale and total score level when one- or two-points difference was considered. Systematic disagreements were reported for five items of the FMA-UE, but not for FMA-LE.

CONCLUSIONS

The Italian version of the FMA showed to be a reliable instrument that can therefore be recommended for clinical and research purposes.Implications for rehabilitationThe FMA is the gold standard for assessing stroke patients' sensorimotor impairment worldwide.The Italian Fugl-Meyer Assessment of Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE) is substantially reliable within and between two raters at the item, subtotal, and total score level in patients with sub-acute stroke.The use of FMA in the Italian context will provide an opportunity for international comparisons and research collaborations.

Pain in patients attending outpatient rehabilitation: results of a pilot study

The aim of the study was to investigate pain occurrence, characteristics and correlations in an outpatient rehabilitation setting. This was an observational pilot study. The setting was an outpatient rehabilitation facility. The subjects included all patients attending physiotherapy in the week 25th to 29th September 2010 and the interventions were made using self-administered questionnaire. Ongoing pain was assessed by a yes-no question, pain intensity by a numeric rating scale (NRS) ranging 0-10. Pain-related medication was investigated, along with pain characteristics, patient treatment expectations, life satisfaction, and catastrophism. Of the 201 patients, 12 were excluded and 189 enrolled (age 63.6 ± 15.6; 70.4% women). Pain (mean NRS = 5.6 ± 2.4) was reported by 60.9% patients (66% orthopedic and 40% neurological). In 87.8% cases, pain was chronic (>6 months). According to patients reporting pain, the main objectives of treatment were both pain relief and functional recovery for 51%; pain relief for 24.9%; functional recovery for 22.8%. Low treatment expectations were reported by 15.3% patients; catastrophism by 40.7%; 28.6% patients were on pain medication: use of drugs was related to age (p = 0.005), pain intensity (p = 0.009) and catastrophism (p = 0.0003). In a multivariate analysis, pain was independently correlated with an orthopedic versus neurological diagnosis (p = 0.000), and with reduced treatment expectations (p = 0.020), while independent of age (p = 0.74) gender (p = 0.22), and catastrophism (0.17). A high prevalence of pain was observed in outpatients undergoing rehabilitation. Pain was chronic in most cases. Pain relief was the most desired treatment outcome by patients reporting pain. Pain complaint was independently correlated to orthopedic vs neurological diagnosis and to reduced treatment expectations.

12-month survival in nonagenarians inside the Mugello study: on the way to live a century

Background

Life expectancy has increased over the last century and a growing number of people is reaching age 90 years and over. However, data on nonagenarians’ health trends are scarce due to difficulties in investigating this specific population. This study aims to identify risk factors for one-year mortality in nonagenarians using data collected within the “Mugello Study”.

Methods

Complete information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 nonagenarians, as well as information about survival after 1 year from the interview.

Results

The sample included 314 women (72.5%) and 119 men (27.5%) with a median age of 92 years (range 90-99 years). The mortality rate was 20.3% (88 deaths). After adjustment for age and sex, a significantly higher risk of dying within 12 months was observed in individuals with more severe cognitive impairment (HR = 5.011, p < 0.001), more severe disability in basic activities of daily living (HR = 4.193, p < 0.001), sedentary lifestyle (HR = 3.367, p < 0.001), higher number of drugs assumed (HR = 1.118, p = 0.031), and kidney dysfunction (HR = 2.609, p = 0.004). When all the variables were included in the analysis, only older age (HR = 1.079, p = 0.048), lower cognitive function (HR = 2.859, p = 0.015), sedentary lifestyle (HR = 2.030, p = 0.026), and kidney dysfunction (HR = 2.322, p = 0.018) remained significantly associated with reduced survival.

Conclusions

Data from the Mugello study support the hypothesis that survival at 12 months in nonagenarians is not a stochastic process and that older age, reduced cognitive function, sedentary lifestyle, and the presence of kidney dysfunction are associated with mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02908-9.

Independent Functioning in Nonagenarians Living in a Rural Italian Community: The Mugello Study

Nonagenarians are a fast-growing population deserving specific research. We explored the prevalence and characteristics of functionally independent nonagenarians from a rural community-dwelling Italian population. Data were collected in the Mugello Study; 475 persons aged ≥90 years (median age, 92) underwent a home-based clinical and functional assessment, including psychosocial, clinical, functional, and lifestyle history and status and physical and instrumental examinations. Sixty-eight (15%) persons reported no need for help in basic and instrumental daily living activities. Among variables significantly associated with independent functionality after age- and gender-adjusted cross-sectional analysis, lower body mass index (BMI; p = .034) and depressive symptoms (p = .028), higher current physical activity (p < .001), better cognitive status (p = .033), and lower medication intake (p = .048) were associated with reporting no disability in the logistic regression analysis. Disability was mainly associated with current lifestyle-related potentially modifiable factors. Thus, lifestyle-oriented multidimensional interventions, should be developed and evaluated for their potential effects on functionality, even in the oldest old.

Italian translation and cross-cultural validation of an assessment tool for participation in stroke survivors: the Frenchay Activities Index

PURPOSE

Participation needs to be assessed objectively, to state accurate rehabilitation objectives. The Frenchay Activities Index (FAI) is a widely used tool to measure participation in stroke patients. To date, no cross-culturally validated Italian version of FAI is available. This study provides a translation and cross-cultural adaptation of FAI into Italian, assessing its validity and reliability in sub-acute stroke patients.

METHODS

According to international guidelines, a multistep translation and cultural adaptation protocol of forward and backward translations was conducted by qualified linguists and independent native English translators and revised by a healthcare committee. Patients admitted to intensive inpatient rehabilitation after stroke were recruited. Structural validity, reliability (internal consistency, inter- and intra-rater reliability and measurement error), and construct validity were studied.

RESULTS

One hundred and seventy-three patients were included in this study. No significant observations in terms of comprehensibility and conceptual equivalence of the FAI Italian version emerged. The exploratory factorial analysis revealed the presence of two subscales (i.e., domestic chores and work/leisure). The internal consistency resulted good for the first and second subscale (α = 0.821 and 0.716, respectively). Intra- and inter-reliability showed an ICC > 0.90 for both subscales. SEM = 5.75% and 2.33% and MDC = 15.85% and 6.48% were found for the first and second subscale, respectively. Construct validity of first subscale was satisfactory, as 100.0% a priori hypotheses were met, while for the second subscale it was moderate, as 66.6% a priori hypotheses were respected.

CONCLUSION

FAI-I provides a tool for professionals to measure participation in Italian stroke patients in health and social care settings.

Design and implementation of a Stroke Rehabilitation Registry for the systematic assessment of processes and outcomes and the development of data-driven prediction models: The STRATEGY study protocol

BACKGROUND

Stroke represents the second preventable cause of death after cardiovascular disease and the third global cause of disability. In countries where national registries of the clinical quality of stroke care have been established, the publication and sharing of the collected data have led to an improvement in the quality of care and survival of patients. However, information on rehabilitation processes and outcomes is often lacking, and predictors of functional outcomes remain poorly explored. This paper describes a multicenter study protocol to implement a Stroke rehabilitation Registry, mainly based on a multidimensional assessment proposed by the Italian Society of Physical and Rehabilitation Medicine (PMIC2020), in a pilot Italian cohort of stroke survivors undergoing post-acute inpatient rehabilitation, to provide a systematic assessment of processes and outcomes and develop data-driven prediction models of functional outcomes.

METHODS

All patients with a diagnosis of ischemic or haemorrhagic stroke confirmed by clinical assessment, admitted to intensive rehabilitation units within 30 days from the acute event, aged 18+, and providing informed consent will be enrolled. Measures will be taken at admission (T0), at discharge (T1), and at follow-up, 3 months (T2) and 6 months (T3) after the stroke. Assessment variables include anamnestic data, clinical and nursing complexity information and measures of body structures and function, activity and participation (PMIC2020), rehabilitation interventions, adverse events and discharge data. The modified Barthel Index will be our primary outcome. In addition to classical biostatistical analysis, learning algorithms will be cross-validated to achieve data-driven prognosis prediction models.

CONCLUSIONS

This study will test the feasibility of a stroke rehabilitation registry in the Italian health context and provide a systematic assessment of processes and outcomes for quality assessment and benchmarking. By the development of data-driven prediction models in stroke rehabilitation, this study will pave the way for the development of decision support tools for patient-oriented therapy planning and rehabilitation outcomes maximization.

CLINICAL TIAL REGISTRATION

The registration on ClinicalTrials.gov is ongoing and under review. The identification number will be provided when the review process will be completed.

The improvement of walking speed after cardiac rehabilitation is associated with the reduction in the metabolic cost of walking in older persons

BACKGROUND

To walk a given distance older persons consume more metabolic energy than younger adults across all speeds. As physical activity interventions improve a variety of physical performance measures in older persons, including walking speed, in this study we hypothesized that the improvement of walking speed might be associated with the reduction of the metabolic cost of walking and we tested our hypothesis in a selected sample of older patients receiving cardiac rehabilitation.

METHODS

In 120 patients (88 men and 32 women, mean age 74.1 years±SD 5.0) we assessed energy expenditure during the 6-min Walk Test (6mWT) before and after the rehabilitation using a portable system for direct calorimetry.

RESULTS

On the 6mWT performed after the rehabilitation patients significantly increased total energy expenditure (28.0 kcal±SD 8.3 vs. 25.7 kcal±SD 7.6, p<0.001), the distance walked (398 m±SD 93 vs. 343 m±SD 95, p<0.001) and, consequently, walking speed (1.11 m/s±SD 0.26 vs. 0.95m/s±SD 0.26, p<0.001) while the metabolic cost of walking, i.e. the amount of energy used to move a body mass of 1 kg for a distance of 1m, was significantly reduced (1.00 cal/kg/m±SD 0.19 vs. 1.11 cal/kg/m±SD 0.32, p<0.001).

CONCLUSIONS

In older patients receiving cardiac rehabilitation the improvement of walking speed is associated with the improvement of walking economy. This might be a contributory factor to the favourable effects of physical activity interventions on physical performance measures.

Predictors of Mortality in 433 Nonagenarians Inside the Mugello Study: A 10 Years Follow-Up Study

OBJECTIVE

to identify the predictors of mortality in a cohort of nonagenarians inside the "Mugello study" after 10 years follow-up.

METHODS

Information on sociodemographic data, cognitive and functional status, lifestyle, medical history, and drug use was collected from 433 non-selected participants aged 90-99 years, living in the Mugello area (Italy). Participants were followed over 10 years and their dates of death were retrieved from the municipal registers. Cox regression analysis was used to determine significant potential prognostic factors.

RESULTS

The mortality rate was 96.5%. Cox proportional hazards analysis showed that a lower cognitive status was significantly associated with higher mortality as well as a poorer functional status, a higher comorbidity, and a higher number of drugs consumption.

DISCUSSION

Impaired cognitive function, loss of functional independence, higher comorbidity, and higher drugs intake were the stronger predictors of mortality.

Critical issue on the extinction and inattention subtest of NIHSS scale: an analysis on post-acute stroke patients attending inpatient rehabilitation

Objectives

This study aims to evaluate the diagnostic performance of NIHSS extinction and inattention item, compared to the results of the Oxford Cognitive Screen (OCS) heart subtest. Additionally, the possible role of the NIHSS visual field subtest on the NIHSS extinction and inattention subtest performance is explored and discussed.

Methods

We analysed scores on NIHSS extinction and inattention subtest, NIHSS visual field subtest, and OCS heart subtest on a sample of 118 post-stroke patients.

Results

Compared to OCS heart subtest, the results on NIHSS extinction and inattention subtest showed an accuracy of 72.9% and a moderate agreement level (Cohen’s kappa = 0.404). Furthermore, a decrease in NIHSS accuracy detecting neglect (61.1%) was observed in patients with pathological scores in NIHSS visual field item.

Conclusions

Extreme caution is recommended for the diagnostic performance of extinction and inattention item of NIHSS. Signs of neglect may not be detected by NIHSS, and may be confused with visual field impairment.

Trial registration

This study refers to an observational study protocol submitted to ClinicalTrials.gov with identifier: NCT03968627. The name of the registry is “Development of a National Protocol for Stroke Rehabilitation in a Multicenter Italian Institution” and the date of the registration is the 30th May 2019.

Trunk Control Test as a Main Predictor of the Modified Barthel Index Score at Discharge From Intensive Post-acute Stroke Rehabilitation: Results From a Multicenter Italian Study

OBJECTIVES

To verify whether trunk control test (TCT) upon admission to intensive inpatient post-stroke rehabilitation, combined with other confounding variables, is independently associated with discharge mBI.

DESIGN

Multicentric retrospective observational cohort study.

SETTING

Two Italian inpatient rehabilitation units.

PARTICIPANTS

A total of 220 post-stroke adult patients, within 30 days from the acute event, were consecutively enrolled.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The outcome measure considered was the modified Barthel Index (mBI), one of the most widely recommended tools for assessing stroke rehabilitation functional outcomes.

RESULTS

All variables collected at admission and significantly associated with mBI at discharge in the univariate analysis (TCT, mBI at admission, pre-stroke modified Rankin Scale [mRS], sex, age, communication ability, time from the event, Cumulative Illness Rating Scale, bladder catheter, and pressure ulcers) entered the multivariate analysis. TCT, mBI at admission, premorbid disability (mRS), communication ability and pressure ulcers (P<.001) independently predicted discharge mBI (adjusted R2=68.5%). Concerning the role of TCT, the model with all covariates and without TCT presented an R2 of 65.1%. On the other side, the model with the TCT only presented an R2 of 53.1%. Finally, with the inclusion of both TCT and all covariates, the model showed an R2 increase up to 68.5%.

CONCLUSIONS

TCT, with other features suggesting functional/clinical complexity, collected upon admission to post-acute intensive inpatient stroke rehabilitation, independently predicted discharge mBI.

Predictors of response to exercise therapy for chronic low back pain: result of a prospective study with one year follow-up

BACKGROUND

Low back pain (LBP) management is a critical public health issue in all developed countries. Most approaches show evidence of effects only in the short term.

AIM

To identify predictors of functional outcome on discharge and at 1 year.

DESIGN

Prospective cohort study.

SETTING

Outpatient rehabilitation department.

POPULATION

Patients aged >18 addressed to exercise therapy for persisting LBP.

METHODS

The individually designed physiotherapy program provided 7 sessions (45'); patients were given advice to stay active and continue exercise program on discharge. Baseline (T0) assessment included: age, sex, time since onset, pain-related drug use, previous treatments, job, physical activity, pain (NRS) and Mental Health (SF36 sub-score); at follow-up (T2), we also enquired to on adherence to exercise prescription, physical activity, drugs. The primary outcome measure was the Roland and Morris Disability Questionnaire (RMDQ) patients scoring improvement >30% (minimal clinical important difference) were classified as respondent.

RESULTS

211 completed follow-up (70% women; age 70.4±11.9). Average RMDQ score was reduced by 35% at T1 and by 31% at T2; NRS by 28% (T1) and 24% (T2); 125 patients (59%) were responders on discharge; 106 (50%) at follow-up. Only higher baseline NRS predicted poor response to treatment at T1 (OR=0.83, 95% CI: 0.71-0.95, P=0.012)). At T2, older age (OR=0.94, 95% CI: 0.91-0.98, P=0.003), drug use (OR=0.18, 95% CI: 0.08-4,69, P<0.001) and previous treatments (OR 0.33, 95% CI: 0.15 to 0.71, P=0.004) were significantly associated with poor response, while, baseline mental health (OR=1.1, 95% CI: 1.01-1.24, P=0.02) and adherence to exercises for LBP (OR=2.10, 95% CI: 1.03-4.42, P=0.04) predicted improved outcome.

CONCLUSIONS

The individually designed exercise therapy program for chronic LBP was associated to clinically significant functional improvement both on discharge and at 1 year. Only severe pain intensity predicted poor treatment response on discharge. At one year, younger age and better mental health predicted improved outcome, while use of drugs and previous LBP treatments were associated with worse response. Adherence to the exercise program almost doubled the probability of a favorable outcome.

CLINICAL REHABILITATION IMPACT

Adherence to an extensive individually designed exercise therapy program improves long term functional outcome of chronic low back pain.

Predicting the functional outcome of intensive inpatient rehabilitation after stroke: results from the RIPS Study

BACKGROUND

The complexity of stroke sequelae, the heterogeneity of outcome measures and rehabilitation pathways, and the lack of extensively validated prediction models represent a challenge in predicting stroke rehabilitation outcomes.

AIM

To prospectively investigate a multidimensional set of variables collected at admission to inpatient post-stroke rehabilitation as potential predictors of the functional level at discharge.

DESIGN

Multicentric prospective observational study.

SETTING

Patients were enrolled in four Intensive Rehabilitation Units (IRUs).

POPULATION

Patients were consecutively recruited in the period December 2019-December 2020 with the following inclusion criteria: aged 18+, with ischemic/haemorrhagic stroke, and undergoing inpatient rehabilitation within 30 days from stroke.

METHODS

This is a multicentric prospective observational study. The rehabilitation pathway was reproducible and evidence-based. The functional outcome was disability in activities of daily living, measured by the modified Barthel Index (mBI) at discharge. Potential multidimensional predictors, assessed at admission, included demographics, event description, clinical assessment, functional and cognitive profile, and psycho-social domains. The variables statistically associated with the outcome in the univariate analysis were fed into a multivariable model using multiple linear regression.

RESULTS

A total of 220 patients were included (median [IQR] age: 80 [15], 112 women, 175 ischemic). Median mBI was 26 (43) at admission and 62.5 (52) at discharge. In the multivariable analysis younger age, along with better functioning, fewer comorbidities, higher cognitive abilities, reduced stroke severity, and higher motor functions at admission, remained independently associated with higher discharge mBI. The final model allowed a reliable prediction of discharge functional outcome (adjusted R2=77.2%).

CONCLUSIONS

The model presented in this study, based on easily collectable, reliable admission variables, could help clinicians and researchers to predict the discharge scores of the global functional outcome for persons enrolled in an evidence-based inpatient stroke rehabilitation program.

CLINICAL REHABILITATION IMPACT

A reliable outcome prediction derived from standardized assessment measures and validated treatment protocols could guide clinicians in the management of patients in the subacute phase of stroke and help improve the planning of the rehabilitation individualized project.

Italian translation and transcultural validation of an assessment tool for community ambulation in stroke survivors: the modified Functional Walking Categories (mFWC)

BACKGROUND

Community ambulation ability is one of the most important functional loss after stroke. The assessment of the level of community walking plays an important role in the multidimensional bio-psycho-social approach, to improve quality of life and social participation of stroke survivors. The modified Functional Walking Categories (mFWC) is a worldwide widely used tool to assess community ambulation in stroke survivors, but no Italian version is yet available.

OBJECTIVE

To cross-culturally adapt the mFWC into Italian and to assess its validity and reliability.

METHODS

According to the international guidelines, a multistep translation and cultural adaptation were conducted and revised by a committee of experts. Patients admitted to intensive inpatient rehabilitation with a sub-acute stroke were recruited. Inter- and intra-rater reliability and construct validity were studied.

RESULTS

Sixty patients with sub-acute stroke were prospectively enrolled in this study. Findings showed almost perfect intra- and inter-rater reliability (k = 1.000 [95% CI 1.000-1.000] and k = 0.984 [95% CI 0.955-1.000], respectively). The construct validity of the scale was satisfactory, as 100.0% a-priori hypotheses were met.

CONCLUSIONS

The Italian mFWC offers a valid tool for measuring community ambulation in stroke patients. Our work provides a validated and a cross-cultural adapted Italian version of the mFWC to accurately measure community ambulation both in clinical and research settings in Italy.

Predictors of functional outcome in patients with chronic low back pain undergoing back school, individual physiotherapy or spinal manipulation

BACKGROUND

Recent studies on chronic low back pain (cLBP) rehabilitation suggest that predictors of treatment outcome may be differ according to the considered conservative treatment.

AIM

To identify predictors of response to back school (BS), individual physiotherapy (IP) or spinal manipulation (SM) for cLBP.

POPULATION

outpatients with cLBP.

SETTING

Outpatient rehabilitation department.

DESIGN

Retrospective analysis from a randomized trial.

METHODS

Two hundred and ten patients with cLBP were randomly assigned to either BS, IP or SM; the Roland Morris Disability Questionnaire (RM) was assessed before and after treatment: those who decreased their RM score <2.5 were considered non-responders. Baseline potential predictors of outcome included demographics, general and cLBP history, life satisfaction.

RESULTS

Of the 205 patients who completed treatment (140/205 women, age 58+14 years), non-responders were 72 (34.2%). SM showed the highest functional improvement and the lowest non-response rate. In a multivariable logistic regression, lower baseline RM score (OR 0.82, 95% CI 0.76-0.89, P<0.001) and received treatment (OR 0.32, 95% CI 0.21-0.50, P<0.001) were independent predictors of non-response. Being in the lowest tertile of baseline RM score (<6) predicted non response to treatment for BS and IP, but not for SM (same risk for all tertiles).

CONCLUSIONS

In our patients with cLBP lower baseline pain-related disability predicted non-response to physiotherapy, but not to spinal manipulation.

CLINICAL REHABILITATION IMPACT

Our results suggest that, independent form other characteristics, patients with cLBP and low pain-related disability should first consider spinal manipulation as a conservative treatment.