BALANCE BETWEEN MEASURES, BUT ON THE SLIDEBAR THERE IS TINETTI SCALE

Introduction

Balance is a term frequently used by health professionals working in a wide variety of clinical specialties. Nowadays there is not an universally definition of human balance. From a physic point of view, balance is the state of an object, when the resultant load actions (forces or moments) acting upon it are zero. If the line of gravity of an object falls within the base of support, then the object is balanced. This principle can be applicable to the balance of humans, in fact the human body is balanced when muscle forces counteract the force of gravity, and the line of gravity falls inside the base of support. Measuring static and dynamic balance means giving autonomy to the patient and it represents a good way to prevent falls.

Methods

To measure balance, we proposed the following scales to 45 patients, admitted to the department of physical medicine and rehabilitation at the Polyclinic of Messina:

• Berg Balance Scale
• Time Up And Go Test (TUG)
• The 30-Second Chair Stand Test
• Tinetti Scale, it is used to measure balance ability, including fall risk and ambulation. It is composed by 16 items, divided into two different sections (balance and walking), that assess balance and walking performance through the observation of motor skills of great relevance in daily life. Each item is given a score ranging from 0 to 2, (0= inability, 1= ability with aid or adaptation, 2= full ability). The balance functions consists of 9 tests that examine static balance skills in different positions and the execution of position changes. The second section, on the other hand, assesses walking functions through gait characteristics such as symmetry, length, and stride continuity. The maximum score is 28

Results

Through the administration of these scales, we saw a significant improvement in patients’ balance and in the perception of their body

Discussion and Conclusion

Thanks to these scales, we noticed that balance needs to be assessed, measured, and warned. From the data collected, it emerged that, thanks to physiotherapy, patients are able to improve their balance, preventing falls and injuries. For the physiotherapist Tinetti scale is more appropriate because its items give value to the observational aspects of movement.

REFERENCES

Pollock AS, Durward BR, Rowe PJ, Paul JP. What is balance? Clin Rehabil. 2000 Aug;14(4):402-6. doi: 10.1191/0269215500cr342oa. PMID: 10945424.

Proposal of two percentage indices to measure overall joint mobility and segmental mobility useful for managerial purposes

Introduction

Outcome measures used in physiotherapy are typically intended and validated for a particular disease, joint or setting [ 1 ]. For clinical purposes, this is the correct approach. However, functional recovery cannot be compared between different anatomical districts or among different diseases. Such a comparison would be extremely useful at the management level to monitor the overall effectiveness of the physiotherapy interventions.

To address this issue, we developed and tested two indices of joint mobility and segmental mobility that can be used for all joints and with a 0-100 scoring system. Joint mobility depends on the anatomical structural constraints of the joint. Segmental mobility is also affected by other non-anatomical variables, such as pain and muscle strength.

Methods

The joint mobility index (JMI) was computed for each joint as follows: 1) the ROM measurement methodology was standardized according to available literature [ 2 ]; 2) joint maximum excursion in each direction was measured and expressed as a percentage of its normative reference value [ 2 ], leading to a 0-100 grading; and 3) the mean value among all possible joint movements (e.g., flexion, extension, abduction, etc.) was computed. JMI was computed for the following joints: shoulder, elbow, wrist, hip, knee, and ankle (non-axial joints).

With the same approach, the segmental mobility index (SMI) was also computed. This is a multi-dimensional index that takes into account JMI (as computed above), pain at rest, pain during movement, and strength. Pain was assessed using the verbal numeric rating scale [ 3 ]. Muscle strength was measured with the appropriate Manual Muscle Test. Variables were expressed as a percentage of the corresponding normative value and averaged to produce SMI.

Results

A form for JMI computation has been created and added to the electronic medical record of our institution. (Figure 1a). It allows for JMI computation for both the affected and contralateral side (when needed), during active and passive movements, and in subsequent assessment (e.g., admission, hospital stay, discharge). An example of its use is presented for the shoulder joint in Figure 1b, where the increase in SMI (last column) can be seen. An example of the use of SMI is presented in Figure 1c. The increase in both numerical values and plot area is clearly visible.

Discussion and Conclusion

We developed two indices that can be used to follow the recovery in joint mobility and segmental mobility in patients with different diseases and in different settings. Their feasibility and usefulness are currently under test at our institution.

ROM measurements and clinical scales remain key in clinical practice and at the single-patient level. The two proposed indices, one unidimensional and one multidimensional, could be useful at the organizational and managerial level thus providing a broad overview of patients’ recovery following physiotherapy interventions in a ward, a unit, or a hospital.

Further improvements can be added to the current indices, such as the use of age- and gender-matched normative values and the inclusion of other disorders that could hinder segmental mobility (e.g., lymphedema, scar tissue complications, etc.).

REFERENCES

1. Haigh R, Tennant A, Biering-Sørensen F, Grimby G, Marincek C, Phillips S, Ring H, Tesio L, Thonnard JL. The use of outcome measures in physical medicine and rehabilitation within Europe. J Rehabil Med. Novembre 2001; 33(6):273-8.
2. Clarkson HM, Gilewich GB. Valutazione cinesiologica. Esame della mobilità articolare e della forza muscolare. 2° Ed. Milano: Edi.Ermes; 2002. 432 p.

RIDING SCHOOL AND SEWING: MEASURES AND HORSES

Introduction

Autism is a neurodevelopmental disorder that primarily involves language, communication and social interaction. It is characterised  by restricted and stereotyped interests and repetitive behaviors. Due to the range of symptoms present in each patient, autism is now called Autism Spectrum Disorder (or ASD). In fact, the disorder covers a broad spectrum of symptoms, ability levels and disabilities, which may or may not affect the activities of daily living (ADL) and the independence.  Hippotherapy is a therapy that uses the natural gait and movement of a horse to provide motor and sensory input. It aims to improve neurological functions and sensory processes and it is used for patients with physical and mental disorders, including ASD children. The aim is to study, deepen and synthesise research evidence with respect to the role of Hippotherapy as an additional and supportive activity within the rehabilitation project of children with ASD.

Methods

To evaluate the reaching of this objective, we proposed the following scales to 7 children with ASD:

– Time Up and Go Test (TUG), it consists of measuring the time a patient gets up from a chair, he walks 3 meters, he turns around and he walks back to the chair sitting down again. If the patient normally walks with an aid it should be used during the test. A time greater than or equal to 12 seconds indicates that the patient has a compromise balance and he is at risk of future falls.

– Five Times Sit to Stand Test, it is used to asses functional lower extremity strength, transitional movements and balance. Its score is is based on the amount of time a patient is able to transfer from a seated to a standing position and back to sitting five times. The patient sits on the chair by resting his back and he folds his arms across the chest. The lower is the time to complete the test the better is the outcome.

The hippotherapy activity has been proposed every week for twice.

Results

After 10 sessions of hippotherapy, there was an improvement in both balance and walking.

Discussion and Conclusion

: These scales are useful to evaluate balance and motor coordination. We noticed that throught these two scales we added many observations linked to the execution of the task. This dimension corresponds to behavioural difficulties of these children and we think that these observations should be traslated in measurable values

REFERENCES

The work is unfunded

COGNITIVE THERAPEUTIC EXERCSES PROPOSAL IN A FINGER INJURY

Introduction

Alba is a 50 year-old woman with a chronic bone lesion of the second phalanx of the left hand. After the surgical reconstruction and after a period of 6 weeks with the brace, she begins a rehabilitation program based on the Cognitive Therapeutic Exercise (CTE), in order to recover the mobility of the finger. To the first evaluation the patient presents: semiflexion of the proximal inter-phalangeal (10°-15°) with the impossibility of reaching passively the extension; a minimum flexion of the distal inter-phalangeal (2°-3°) with a possible passive realignment and little movement of active extension.

Our aim is to describe the importance and the effectiveness of the Cognitive Therapeutic Exercise in a chronic bone lesion management.

Methods

The treatment initially involved stretching and soft tissue massage in order to prepare the hand and the finger to CTE exercises.

These exercises performed by the patient under the supervision of the therapist were:

Slingbar: the patient is seated with her forearm leaning on the table. Her index finger is located on one end of the slingbar, while on the other end the therapist places four different weights (with an increasing weight). The aim of this exercise is to recognize the different weights with closed eyes.

Crescent: the patient is seated with her forearm leaning on the table. The four fingers (except the thumb) are placed on a crescent-shaped platform, that is balanced on a tip. The therapist places a weight on one of the previously defined positions. The aim of this exercise is to recognize, with closed eyes, in which position the weight is placed, while keeping the platform in balance.

Results

With stretching and soft tissue massage, the therapist was able to detach the scar adhesion of the areas injured by the trauma, improving the ROM of the finger and the drainage of the area.

With the CTE exercises the patient acquired the management, the control and the consciousness of the volar and dorsal  activities of the hand in the space. At the end of the therapeutic program Alba showed an improvement of active and passive ROM of the distal inter-phalangeal (AROM T0: 7°- 10°; T2: 0°-50°. PROM T0:0°-10°;T2: 0°-60°) and an improvement of active and passive ROM of the proximal inter-phalangeal (AROM T0:10°-80°; T2:0°-80°. PROM T0:5°-85°;T2:0°-90°).

Discussion and Conclusion

In conclusion, we can say that, even if in literature there are few evidences about CTE method, these exercises were be able to improve the passive and active ROM of the finger and the patient independence in ADL.

With this work, we want to highlight the cognitive aspect of every exercise performed by the patient. Although the scar treatment and kinesitherapy are suitable to functional recovery, they do not implicate the same cognitive involvement and sensitive stimulation of CTE exercises.

REFERENCES

The work is unfunded

What measurement tool for “Attentional Fatigue”?

Introduction

Attentional fatigue is experienced as a decreased ability to concentrate, engage in purposeful activity, and maintain social relationships when there are competing demands on attention. According to William James there are two types of attention: involuntary attention, which is effortlessly drawn to nature, things that affect survival, and things that fascinate us; and voluntary attention, which requires effort to direct when there are competing stimuli. Voluntary attention is necessary for concentration, purposeful action, and monitoring one’s behavior in social interactions. Nowadays there is no measuring scale for attentional fatigue that describes its characteristics such as dimensional size, measuring range, principle of operation.

Methods

To measure attentional fatigue we created a scale based on the IPDDAI scale (Identificazione Precoce del Disturbo da Deficit di Attenzione e Iperattività). It is an observational questionnaire composed by 10 items (as a reference of the 17 items of the IPDDAI) whose assessment is based on a 4-point Likert scale (0 = not at all/never, 1 = a little/most of the time, 2 = quite a lot/most of the time, 3 = a lot/always). The first 3 items are aimed at the subject’s behavior, item 4 investigates inattention, the next 4 analyze the impulsivity dimension, and the last two are related to self-esteem and relational aspects that could create interference with attention. The physiotherapist proposed this scale to neurologic patients who did not specifically manifest disorders that impaired the ability to pay attention and concentrate.

Results

Through the administration of this scale, we saw a significant improvement in patients’ consciousness about their attentional fatigue.

Discussion and Conclusion

Although there is no validated scale to measure attentional fatigue, thanks to the scale described before we realized that attentional fatigue is an important dimension that must be monitored. The exercises proposed by the physiotherapist are always calibrated to the person’s attention span. In this exercises, the patient is encouraged to stay focused, in order to develop progressively different components of attentional skill, such as focus, sustained attention, selectivity, divisibility and alternation.

REFERENCES

James, W. The Principles of Psychology. Cambridge, MA: Harvard University Press; 1890/1983;

Marcotto, E., Paltenghi, B., & Cornoldi, C. (2002). La scala IPDDAI: contributo per la costruzione di uno strumento per l’identificazione precoce del disturbo da deficit di attenzione e/o iperattività. Difficoltà di apprendimento, 8 (2), 153-172

Lumbar interbody arthrodesis: acute effects of perception and Core activation exercises on balance and spine alignment. Pilot study.

Introduction

Lumbar spondylolisthesis is a pathological condition of the spine characterized by the slipping of one vertebra compared with the underlying one. According to Meyer, severity is classified considering the degree of slip. For low-grades, the first line of treatment is conservative therapy, including: activity modification, bracing, back muscles strengthening exercises, and back brace. If these treatments fail, next treatment option is lumbar interbody fusion surgery (LIF). Following LIF, trunk proprioception, essential for static and dynamic balance, may decrease favoring sensorimotor and movement control alterations. Thus, providing information to the somatosensory system through guided exercises is important. The aim of the study was to evaluate the acute effects of perception and core activation exercises on balance and spine alignment in people undergoing LIF.

Methods

From 20^th June to 30^th September 2022, 20 patients candidates for LIF, were recruited. After signing an informed consent they were randomly assigned to one of the two study groups: Guided Core Activation and Perception Exercises (GE), or Autonomous Self-Correction (GC). Both interventions lasted 10 minutes and were carried out in front of a squared up mirror. Three evaluations were made: before LIF (PRE) and on third day after LIF, before (P1) and after (P2) the intervention assigned to the group. In PRE and P1 participants were asked to assume the most comfortable position. In P2 they were asked to assume the most correct posture possible, using the information learned. Spine alignment (RMS) was evaluated with Spine 3D (Sensormedica, Guidonia, Rome), a non-invasive, three-dimensional optoelectronic detection system that uses Light Detection and Ranging technology, while balance with a stabilometric platform (FreeMed, sensormedica).

Results

Data were processed with Jamovi for Mac version 1.6. Quantitative variables are expressed as mean and standard deviation. Normality of data was calculated with Shapiro Wilk’s test. The difference between the variables over time in the two groups was calculated with ANOVA for repeated measures. The significance was set at p<0.05. In P1, compared to PRE, all investigated parameters worsen, non-significantly, in both groups. In P2, compared to P1, all balance parameters worsen significantly in both groups, some more in GE than in GC. Ellipse Area: GE (158.71±120.08; 83.44±102.2), GC (175.11±133.92; 158.54±139.46) p 0.001. Ellipse Eccentricity: GE (0.64±0.33; 0.48±0.29), GC (0.54±0.15; 0.44±0.2) p 0.018. Delta X: GE (11.37±4.23; 9.73±4.88), GC (18.82±10.85; 15.74±9.77) p 0.001. Delta Y: GE (11.18±6.52; 7.46±4.29), GC (16.97±8.52; 13.41±9.36) p 0.001. RMS improves in GE (3.1±1.85; 4.4±2.41) while it worsens in GC (4.9±0.99; 3.8±1.75); both values are not significant.

Discussion and Conclusion

Comparing PRE and P1, the worsening of balance parameters is referable to the postoperative sequelae of LIF. It is known that immediately after surgery the perceptual-motor adaptation mechanisms are reduced or absent. In P2 compared to P1, the slight improvement in RMS of GE compared to the worsening of GC is probably due to the exercises performed with the Physiotherapist. Likewise, the greater deterioration of the balance of GE compared to GC is in agreement with the literature. This highlights how, in acute phase, a postural correction greater than the usual one, leads a difficulty of the somato-sensory system to adapt to the new position. Limitations of the study are the small number of the sample and the single session of exercises, justified by the reduced post-LIF hospitalization time. Further studies, with a significant sample size and over time, are needed.

REFERENCES

1) Hebert, J. J., Fritz, J. M., Thackeray, A., Koppenhaver, S. L., &amp; Teyhen, D. (2015). Early
multimodal rehabilitation following lumbar disc surgery: a randomised clinical trial comparing
the effects of two exercise programmes on clinical outcome and lumbar multifidus muscle
function. British journal of sports medicine, 49(2), 100–106.
2) Gilmore, S. J., Hahne, A. J., Davidson, M., &amp; McClelland, J. A. (2020). Physical activity
patterns of patients immediately after lumbar surgery. Disability and rehabilitation, 42(26),
3793–3799.
3) Janssens, L., Brumagne, S., Claeys, K., Pijnenburg, M., Goossens, N., Rummens, S., &amp;
Depreitere, B. (2016). Proprioceptive use and sit-to-stand-to-sit after lumbar microdiscectomy:
The effect of surgical approach and early physiotherapy. Clinical biomechanics (Bristol,
Avon), 32, 40–48.

TAILORED REHABILITATION IN A HIRSCHSPRUNG DISEASE: A CASE REPORT

Introduction

La malattia di Hirschsprung è caratterizzata dell’assenza del plesso sottomucoso e mioenterico in un tratto del canale alimentare e causa una sintomatologia ostruttiva. Diverse tecniche chirurgiche sono efficaci, tuttavia, a prescindere dalla tecnica, più del 60% dei pazienti lamenta prolungati disturbi, tra cui incontinenza fecale e stipsi, a volte associati a distensione addominale, vomito ed enterocolite. Spesso nell’adolescenza i sintomi non si risolvono fino alla continenza completa con conseguenti effetti negativi sulla vita del paziente e della sua famiglia. L’obiettivo primario di questo case-report è stato valutare l’efficacia di un trattamento riabilitativo personalizzato intensivo sulla sintomatologia e sulla qualità di vita percepita, attraverso scale di valutazione e questionari specifici. L’obiettivo secondario è stato individuare un protocollo di scale e questionari che valutasse in modo completo e ripetibile la disabilità legata alla patologia.

Methods

Paziente femmina. Alla nascita ricoverata presso Terapia Intensiva Neonatale per vomito e difficoltà nell’evacuazione e alimentazione.Dopo diagnosi di Hirschsprung è stata sottoposta ad intervento chirurgico. Gennaio 2021 all’età di 7 anni ha eseguito valutazione riabilitativa per persistenza di incontinenza fecale ed urinaria. Alla valutazione del pavimento pelvico tramite palpazione del nucleo fibroso centrale emergeva una scarsa capacità di contrazione selettiva ed utilizzo di compensi addominali e adduttori, sensibilità conservata. Emergevano difficoltà di gestione di encopresi ed enuresi. Impostato un programma personalizzato di 8 settimane con sedute della durata di 1,30 h, una volta a settimana. Il programma prevedeva la compilazione di bowel diary, diario alimentare ed esercizi per miglioramento della presa di coscienza ed endurance del pavimento pelvico,sotto forma di gioco. E’stato impostato un programma di home-training quotidiano

Results

E’ stata valutata la QoL attraverso PEDsQL (Pediatric Quality of Life Inventory), la sintomatologia intestinale attraverso le scale Rintala, Wexner incontinenza e Bristol for children, l’incontinenza urinaria con ICIQ-CLUTS (International Consultation on Incontinence Questionnaire-Pediatric Lower Urinary Tract Symptoms). Il CBCL (Child Behaviour CheckList) è stato somministrato ai genitori per l’inquadramento comportamentale; lo stato socio-economico è stato valutato con l’Indice di Hollinshead. La scale e i questionari sono stati somministrati all’inizio (T0), al termine del trattamento (T1) ed al follow-up ad 1 mese (T2). Al termine del trattamento riabilitativo (T1) è stato osservato un miglioramento in tutti i domini indagati che si è mantenuto anche al follow-up (T2), sia per il bambino che per il genitore. Questo ha avuto un effetto positivo sulla QoL, come evidenziato al PEDsQL con correlati miglioramenti del quadro comportamentale evidente al CBCL

Discussion and Conclusion

Il trattamento riabilitativo personalizzato, in esiti di chirurgia per M. di Hirschsprung in età pediatrica sembra essere efficace per migliorare la QoL del paziente e della famiglia, in linea con la letteratura. Il protocollo di valutazione proposto prevede questionari e scale già validati in letteratura e di facile reperibilità, è completo poiché indaga tutti i domini interessati dalla patologia, risulta di facile esecuzione e comprensione per il paziente pediatrico e per la sua famiglia, inoltre è facilmente riproducibile.

REFERENCES

• Ying Dai et al, Long-term outcomes and quality of life of patients with Hirschsprung disease: a systematic review and meta-analysis, BMC Gastroenterol, 2020
• Bocchini, Chiaroni et al. Pelvic floor rehabilitation for defecation disorders, Tech Coloproctol, 2019
• Espeso et al, Persistent Soiling Affects Quality of Life in Children With Hirschsprung’s Disease, J Pediatr Gastroenterol Nutr, 2020
• Trapanotto et al, The Italian version of the PedsQL in children with rheumatic diseases, Clin Exp Rheumatol,2009
• De gennaro et al. Validity of the International Consultation on Incontinence Questionnaire-Pediatric Lower Urinary Tracy Symptoms: a screening questionnaire for children, J Urol,2010
• Collins et al, Quality of life outcomes in children with Hirschsprung disease, J Pediatr Surg, 2017
• Loganathan et al, Assessment of quality of life and functional outcomes of operated cases of Hirschsprung disease in a developing country, Pediatr Gastroenterol Hepatol Nutr, 2017