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Maurizio Bejor,1 Francesca Chiara Ramella,1 Elena Dalla Toffola,1 Mario Comelli,2 Matteo Chiappedi31University of Pavia, Department of Surgical, Resuscitative, Rehabilitative and Transplant Sciences, Pavia, Italy; 2University of Pavia, Department of Brain Sciences, Medical Statistics Section, Pavia, Italy; 3Don Carlo Gnocchi ONLUS Foundation, Milan, ItalyBackground: Patients with comorbidities are becoming more and more common in Italian rehabilitative wards. These comorbidities are considered a major problem for inpatient rehabilitation, due to the fact that they cause longer lengths of stay, higher costs, and lower functional results.Methods: To investigate the possible relationships between comorbidity, functional impairment, age, and type of discharge in patients hospitalized in postacute rehabilitation facilities, we planned an observational study. A total of 178 consecutive inpatients (average age: 78 years [range: 39–99]) from postacute rehabilitation facilities were recruited. Primary diagnosis, comorbidity rating (Cumulative Illness Rating Scale – Geriatric version, CIRS-G) and functional impairment score (Functional Independence Measure, FIM™) were evaluated at admission. The FIM™ rating was also assessed at hospital discharge.Results: A total of 178 of the 199 enrolled patients completed the rehabilitation treatment (89.4%). The average length of stay was 46 ± 24 days. CIRS-G showed an average comorbidity score for each patient of 4.45 ± 1.69. The average FIM™ rating was 79 ± 24.88 at admission, and 91.9 ± 25.7 at discharge. Diagnosis at admission (grouped according to the International Classification of Diseases 9-CM) seemed to correlate with functional results, since lower rehabilitative efficiency was obtained for patients who had a history of stroke.Conclusion: The number and type of comorbidities (CIRS-G) in rehabilitation inpatients do not seem to affect functional outcomes of treatment. The determining factor for a lower level of functional recovery seems to be the diagnosis at admission.Keywords: diagnosis, rehabilitation, inpatients, outcome

Matteo Chiappedi,1 Alessio Toraldo,2 Silvia Mandrini,3 Federica Scarpina,2 Melissa Aquino,2 Francesca Giulia Magnani,2 Maurizio Bejor31Don Carlo Gnocchi ONLUS Foundation, Milan, Italy; 2University of Pavia, Department of Psychology, Pavia, Italy; 3University of Pavia, Department of Surgical, Resuscitative, Rehabilitative and Transplant Sciences, Pavia, ItalyIntroduction: Visual-motor skills are the basis for a great number of daily activities. To define a correct rehabilitation program for neurological patients who have impairment in these skills, there is a need for simple and cost-effective tools to determine which of the visual-motor system levels of organization are compromised by neurological lesions. In their 1995 book, The Visual Brain in Action (Oxford: Oxford University Press), AD Milner and MA Goodale proposed the existence of two pathways for the processing of visual information, the “ventral stream” and “dorsal stream,” that interact in movement planning and programming. Beginning with this model, our study aimed to validate a method to quantify the role of the ventral and dorsal streams in perceptual and visual-motor skills.Subjects and methods: Nineteen right-handed healthy subjects (mean age 22.8 years ± 3.18) with normal or corrected-to-normal vision were recruited. We proposed that a delayed pointing task, a distance reproduction task, and a delayed anti-pointing task could be used to assess the ventral stream, while the dorsal stream could be evaluated with a grasping task and an immediate pointing task. Performance was recorded and processed with the video-analysis software Dartfish ProSuite.Results: Results showed the expected pattern of predominance of attention for the superior left visual field, predominance of the flexor tone in proximal peri-personal space arm movements, tendency toward overestimation of short distances, and underestimation of long distances.Conclusion: We believe that our method is advantageous as it is simple and easily transported, but needs further testing in neurologically compromised patients.Keywords: dorsal stream, ventral stream, visual-motor skills, rehabilitation, neurological disorders

Purpose. To assess the effect and efficacy of botulinum toxin type A (BTX-A) in reducing synkinesis in aberrant facial nerve regeneration (following facial paralysis). Method. A total of 55 sessions of BTX-A (Botox(R)) infiltration were performed on 30 patients (23 female) with synkinesis after facial palsy. Each subject was injected with 2.5 units of BTX-A in each injection site (the sites were chosen on a case-by-case basis). The synkinetic muscles targeted include: orbicularis oculi, zygomaticus major, depressor labii inferioris, platysma, healthy frontalis and healthy corrugator supercilii. The patients were examined using the Sunnybrook Facial Grading System, both before the BTX-A treatment and after an average of 35 days. Results. All 30 patients experienced improvement to the synkinesis after treatment. Total scores: median pre-BTX-A: 40; post 53 p = 0.004. Resting symmetry scores: mean pre-BTX-A -7.1; post: -3.5; median pre -5 [interquartile range (IQR) -10 to -5]; post: -5 (IQR -5 to 0); p = 0.0001. Symmetry of voluntary movement median pre-BTX-A: 56 post 60 p = 0.10. Synkinesis scores: median pre-BTX-A: -9 post -3 p < 0.0001. Mean duration of improvement was 4 months. Conclusions. BTX-A injection treatment was effective in reducing facial synkinesis, thus improving facial expression symmetry both at rest and in voluntary movements. [ABSTRACT FROM AUTHOR]

Abstract Background Evaluation of elementary writing skills in children is usually obtained with high resolution (and high cost) techniques or with low resolution pen-and-paper tests. In this observational study we tested a quantitative method to obtain normative data to describe arm movement during a writing precursor gesture. Methods We recruited 226 healthy children (mean age 9,1 years [range: 6.3 – 11.4 years]), attending primary schools belonging to the “Istituto Comprensivo” of Rivanazzano Terme (Pavia). We asked to drive a cursor through a polygonal path (labyrinth) projected in front of them using a wireless mouse. Dartfish™ video analysis software was used to elaborate images and Excel™, MedCalc™ and Statistica 7™ to analyze values of shoulder, elbow and wrist ranges of motion, arm trajectories, execution times and gesture accuracy. Results Differences seen in motor strategies, when divided according to attended class, suggest a proximal-distal maturation of motor control. Obtained values were not significantly correlated with variables such as gender, ethnicity or cognitive functioning. Conclusions This type of approach to a study of arm movement during childhood represents a valid alternative to other tests, considering that it can differentiate children who perform similarly in the VMI test and is non-invasive, low-cost and easily reproducible.

Abstract Introduction To the best of our knowledge, this is the first report of a comorbidity between Gilles de la Tourette's syndrome and 47 (XXX) syndrome. The clinical picture of Gilles de la Tourette's Syndrome is well described, while 47 (XXX) syndrome is much more rare and has a broader spectrum of possible phenotypic presentations. Case presentation An Italian Caucasian girl was referred at the age of 11 to our Rehabilitation Center for anxiety and learning difficulties. The girl had already been diagnosed as having 47(XXX) syndrome; she had some rather typical features of the chromosomal abnormality, but she also showed a high level of anxiety and the presence of motor and vocal tics. When an accurate history was taken, a diagnosis of Gilles de la Tourette's Syndrome emerged. Conclusions The possible interaction between peculiar features of these two syndromes in terms of neuropsychological and affective functioning is both interesting for the specific case and to hypothesize models of rehabilitation for patients with one or both syndromes. Executive functions are specifically reduced in both syndromes, therefore it might be hard to discriminate the contribution of each one to the general impairment; the same applies to anxiety. Moreover, mental retardation (with a significantly lower verbal cognitive functioning) poses relevant problems when suggesting cognitive behavioral or psychoeducational rehabilitative approaches.

Abstract Corpus callosum agenesis is a relatively common brain malformation. It can be isolated or included in a complex alteration of brain (or sometimes even whole body) morphology. It has been associated with a number of neuropsychiatric disorders, from subtle neuropsychological deficits to Pervasive Developmental Disorders. Etiology and pathogenetic mechanisms have been better understood in recent years, due to the availability of more adequate animal models and the relevant progresses in developmental neurosciences. These recent findings are reviewed (through a MedLine search including papers published in the last 5 years and most relevant previously published papers) in view of the potential impact on children's global functioning and on the possible rehabilitative treatment, with an emphasis on the possibility to exploit brain plasticity and on the use of the ICF-CY framework.

Abstract Background A number of studies have shown that current classification systems (ICD 10, DSM IV TR) have limitation when applied to autistic children and the category PDD NOS (DSM IV TR) has in particular been criticized. To check the possible usefulness of other classification systems to better describe patient's functioning, we retrospectively studied 84 patients, seen consecutively in our Child Neurology and Psychiatry Department (excluding only those presenting for another disease even if with clinical signs of a PDD). Methods We tried to classify them according to ICD 10, DSM IV TR, CFTMEA-R, "operational classification" (Manzano and Palacio) and de Ajuriaguerra's classification. Results We found a good correspondence between DSM IV TR and ICD 10 and the use of psychodynamic classification systems (in particular CFTMEA-R) was useful to differentiate clinical subtypes collected under the PDD NOS etiquette according to DSM IV TR. Conclusions To rationalize research efforts and find better tailored therapies, we need to improve PDD classification systems, using contributions coming from every field of child psychiatry and neurology: it's possible that 0-3 Classification could help this.

Background: Writing ability requires to use and control several processes of visual and phonological information processing and an adequate programming and coordination of motor sequences. We studied a writing precursor gesture in children with developmental dysorthography and/or developmental dysgraphia in order to point out anomalies to be treated with specific rehabilitative interventions., Methods: Twenty-five children affected by developmental dysortography (ICD 9 CM: 315.09; ICD 10: F81.1) and/or developmental dysgraphia (ICD 9 CM: 315.2; ICD 10: F81.8) (mean age 9.1 years [range: 6.3-11.4 years]) ran a maze, project in front of them, using a wireless mouse. Data regarding angular excursions, execution times and gesture accuracy were collected and elaborated using Dartfish 6.0 software and the labyrinth generating program (PRINC), and compared with normative data previously obtained from a sample of 226 healthy children of the same age and grade., Results: The comparison did not evidence significant differences regarding gesture structure (trajectories of arm segments and angular excursions of interested joints). Angular and temporal execution patterns were reached in delay in these children. No correlation was found with general cognitive and visuomotor integration skills; a deficit of visual attention was associated with an abnormal elbow range of motion., Conclusions: Although these findings need to be confirmed in larger studies, data obtained evidence that children with developmental writing disorders have a time delay in the acquisition of writing motor patterns and not an alteration of gesture structure itself. This has relevant implications for the rehabilitative approach.

Background and Aim of the Work: Functional activity may remain limited in patients affected by critical limb ischemia, despite successful infrainguinal lower limb bypass surgery (ILLBS). The aim of the work was to evaluate the impact of a rehabilitative intervention on postoperative ambulatory status and pain., Methods: In an observational study, data were collected on 34 patients undergoing ILLBS for critical limb ischemia or end-stage peripheral arterial disease. All patients underwent a postoperative rehabilitation program aimed at recovering gait autonomy. Information was collected on pre-operative comorbidities, ambulatory status (on admission to and discharge from hospital) and pain in the affected lower limb (on the first physiotherapy session and at discharge)., Results: Before ILLBS, 61.8% of the patients walked independently without aids or assistance. The rehabilitative program started on average 5.7 (SD: 2.1) days after surgery. At discharge, 50% of the patients walked independently, 41.2% walked with aids and/or assistance and 8.8% were not able to walk. Overall, 76.5% of the sample recovered their pre-operative ambulatory status. Although pain tended to decrease, the difference at the first (1.5; SD: 2.6) and at the last treatment session (0.8; SD= 1.3) was not statistically significant., Conclusion: Our exercise protocol resulted to be easy to perform during hospital stay, with an overall favourable outcome for ambulatory status. Our results are in line with those reported in literature about the rates of postoperative dependence in walking, but appear to be slightly better in regards to the percentage of patients who recovered pre-operative ambulatory status.

Background: After masseteric-facial nerve (V-VII) anastomosis, a new neurological circuit oversees the facial muscles and patients should learn to activate the facial movements using the masseteric function., Aim: To monitor the rehabilitative protocol of facial muscles activation through teeth clenching and to assess the clinical evolution after V-VII anastomosis in terms of facial symmetry and functional recovery., Design: Case series., Setting: Outpatients clinic., Population: Eleven patients undergone V-VII anastomosis for complete unilateral facial palsy., Methods: After surgery, patients underwent a needle electromyography (EMG) and a rehabilitative training with mirror feedback to learn how to reach the symmetry at rest and during facial movements through teeth clenching. The rehabilitative protocol at the first clinical evaluation has been monitored through the Italian version of Sunnybrook Facial Grading System (SFGS) and the Software Facial Assessment by Computer Evaluation (FACE). Functional limitations and quality of life have been evaluated using the Italian version of Facial Disability Index (FDI). The clinical evolution at 18 months was evaluated with EMG, SFGS, biting evaluation and FDI., Results: At the first clinical evaluation after reinnervation, through teeth clenching patients displayed an improvement of symmetry at rest, symmetry of voluntary movement, symmetry of smile and composite score of SFGS. Objective measurement of facial structures with FACE system demonstrated an improvement of symmetry at rest and during smile through teeth clenching. At 18 months patients displayed a good reinnervation with a further improvement of SFGS scores and reduction of functional disability. No biting deficit has been observed., Conclusions: After V-VII anastomosis, at the first rehabilitative visit, patients learn to activate the reinnervated facial muscles through teeth clenching. Eighteen months after the anastomosis, patients display a further improvement of voluntary control on facial symmetry and smile and a reduction of disability., Clinical Rehabilitation Impact: Our study illustrates the rehabilitative protocol after V-VII anastomosis and analyzes the clinical evolution after this intervention in terms of recovery of facial symmetry and reduction of disability. This will be instrumental to standardize the rehabilitative protocol among different centers and to choose the best patient-tailored surgical approach for subjects affected by complete facial palsy.

Purpose: To evaluate and compare clinical, functional and quality of life (QOL) outcomes after two types of surgical approach for single level cervical disc herniation: anterior cervical discectomy andfusion (ACDF) with cage and cervical artificial disc replacement (C-ADR)., Method: 119 patients with cervical disc herniation underwent surgery from January 2007 to December 2010; 55 patients were included in the study (27 ACDF, 28 C-ADR). We performed: a pre and postoperative clinical evaluation of cervicobrachial pain, motor and sensory deficit in the upper limbs; a functional and QOL evaluation with self assessment scales (VAS, NPNQ, SF-36); a postoperative instrumental evaluation of cervical ROM and pain. Mean follow-up period was 24 months., Results: After surgery both groups showed clinical, functional and QOL improvement. No pre and postoperative differences were found between the groups. The postoperative instrumental evaluation showed a globally reduced cervical ROM and a decreased pain threshold in comparison with normal values in both groups., Conclusion: Our results demonstrate the clinical equivalence of the two surgical techniques and the satisfaction of the two groups of patients two years after surgery. Although functional changes persist after surgery they do not affect quality of life.

Background: Congenital Muscular Torticollis (CMT) is the most common form of torticollis in infants; on clinical presentation it is classified into 3 types: 1) postural torticollis, with postural deformity only in the neck; 2) muscular torticollis, where neck deformity is associated with muscle tightness and restricted passive range of motion (ROM); and 3) sternomastoid tumor or pseudotumor, with a fibrotic, sternocleido-mastoid muscle mass and passive ROM limitations., Aim: The aim of this study was to evaluate the physical therapy outcome of infants with CMT treated either by parents using a home exercise program, or by a physical therapist., Design: Longitudinal study., Setting: Outpatients with CMT at our Department of Physical Medicine and Rehabilitation., Population: Fifty consecutive newborns with CMT, referred by the primary pediatrician:, Methods: In our study, 50 infants with CMT were evaluated and treated either by a physical therapist or by parents using a home program., Results: Sixteen females (32%) and 34 males (68%), aged 10.2 weeks (SD 6.66); 23 of the infants (46%) presented with more severe articular limitations than the others (P=0.002) and were therefore prescribed outpatient treatment by a physical therapist; the remaining 27 less severe cases (54%) were prescribed a home therapy program. 49 infants achieved full resolution after an average of 81.06 days (SD 64.05) of rehabilitation treatment. The group of patients who were treated at home achieved resolution more quickly (72.8 vs. 91.1 days), although statistical significance was not reached., Conclusions: Infants with CMT who were treated early, either at home or in the outpatient clinic, completely recovered normal neck movement in a short time. It is important not to discharge patients until they have achieved full resolution of CMT symptoms to exclude the minimal risk of relapse., Clinical Rehabilitation Impact: This study demonstrates the importance of early treatment in cases of congenital muscular torticollis.

Background: Aging has a recognized degenerative effect on the functionality of the hand in terms of strength and dexterity. Despite this, there are few studies in literature that quantify the upper limb skills in the elderly., Aim: The aim was to present quantitative data regarding upper limb functionality in the elderly and to quantify the effect of aging on them, considering the influence of the comorbidities, of the global level of autonomy, of the cognitive status and of the mood, which are typically compromised in the elderly., Design: It was a controlled study., Setting: It was settled in the Rehabilitation Unit of the "Santa Maria alle Fonti" Medical Center, part of the Don Carlo Gnocchi ONLUS Foundation., Population: Thirty-five elderly inpatients (aged 78.6±7.5 years) compared to 30 healthy young adults (aged 30±3.9 years)., Methods: A task consisting in 12 trials of grasping of rulers was administered to each subject and studied with a video analysis software. To assess the comorbidities, the global level of autonomy, the cognitive status and the mood, we respectively used the Cumulative Illness Rating Scale (CIRS), the Functional Independence Measure (FIM™), the Mini Mental State Examination (MMSE) and the Geriatric Depression Scale in the 15-items version (GDS-15). The scores obtained in these scales were correlated to the mean times of trials execution., Results: The motor performance was significantly worse in the inpatients group compared to the control group in terms of time to complete single tasks (which was on average three times higher in the inpatients group) and of respect of the starting sound stimulus, with more subjects from the inpatients group anticipating the starting signal. This worsening of the motor performance was significantly correlated to the severity of comorbidities and to the global level of autonomy. No significant differences emerged for the correctness of the performance and significant differences were not correlated with depression or cognitive impairment., Conclusion: This study provides quantifiable data regarding upper limb skills in the elderly inpatient, allowing comparisons with other future studies of the rehabilitative environment., Clinical Rehabilitation Impact: It suggests the relevance of considering the severity of comorbidities and the global level of autonomy in the assessment of upper limb skills in the elderly.

Background: The Facial Disability Index (FDI) is widely used for self-assessment of functional impairment and quality of life in patients with facial palsy., Objective: The study aim was to complete the validation of the FDI by generating an Italian version (IT-FDI) and evaluating its clinimetric properties., Design: This was a longitudinal, observational measurement study., Methods: The questionnaire was translated, cross-culturally adapted, and administered to 100 consecutive participants (outpatients) with facial palsy. The clinical severity of facial palsy, impairments in physical and social function, and quality of life were evaluated with the Sunnybrook Facial Grading System, IT-FDI, and 12-Item Short-Form Health Survey., Results: The IT-FDI showed excellent test-retest reliability for every item and for total scores (intraclass correlation coefficients of .93 and .84 for physical function subscale and social/well-being function subscale, respectively). The IT-FDI confirmed the high internal consistency of the original version, with theta coefficients of .82 for the physical function subscale and .78 for the social/well-being function subscale. The physical function subscale correlated with the Sunnybrook Facial Grading System composite score (r=.44), and the social/well-being function subscale correlated with the 12-Item Short-Form Health Survey mental component (r=.55). The IT-FDI confirmed the good responsiveness of the original version, as expressed by effect size, standardized response mean, and responsiveness ratio of, respectively, 1, 1.03, and 1.21 for the physical function subscale and 0.75, 0.83, and 1.15 for the social/well-being function subscale., Limitations: Responsiveness was evaluated with a limited number of participants., Conclusions: The results demonstrated the test-retest reliability for all items of the FDI and confirmed its internal consistency, construct validity, and responsiveness with an independent and larger clinical subset. This study completes the validation of the FDI and provides the first validated questionnaire in Italian for assessment of disability and quality of life specifically in patients with facial palsy., (© 2014 American Physical Therapy Association.)

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.

The problem of a correct fall risk assessment is becoming more and more critical with the ageing of the population. In spite of the available approaches allowing a quantitative analysis of the human movement control system's performance, the clinical assessment and diagnostic approach to fall risk assessment still relies mostly on non-quantitative exams, such as clinical scales. This work documents our current effort to develop a novel method to assess balance control abilities through a system implementing an automatic evaluation of exercises drawn from balance assessment scales. Our aim is to overcome the classical limits characterizing these scales i.e. limited granularity and inter-/intra-examiner reliability, to obtain objective scores and more detailed information allowing to predict fall risk. We used Microsoft Kinect to record subjects' movements while performing challenging exercises drawn from clinical balance scales. We then computed a set of parameters quantifying the execution of the exercises and fed them to a supervised classifier to perform a classification based on the clinical score. We obtained a good accuracy (~82%) and especially a high sensitivity (~83%).

Background: The Sunnybrook Facial Grading System is considered one of the best scales available to grade facial motility and postparetic synkinesis. To measure facial landmarks and movement excursion, a new software, the Facial Assessment by Computer Evaluation, has been proposed. The aim of this study was to quantify eye synkinesis improvement after botulinum toxin type A injections using the new software and to compare this method with the Sunnybrook grading system., Methods: The study included 40 injection sessions on 29 Caucasian outpatients with facial synkinesis. Before and 2 weeks after the injection, patients were evaluated using the Italian version of the Sunnybrook system. Eyelid fissure size at rest, during lip puckering, and while smiling was measured with the new software., Results: After botulinum infiltration, the Sunnybrook grading system showed a global facial improvement with reduction of synkinesis and increase of static and dynamic symmetry. The Facial Assessment software detected an increase of ocular fissure measure at rest, during lip puckering, and especially during smiling, and the improvement was positively correlated with initial asymmetry. A single point of the Sunnybrook system synkinesis score corresponded to a mean difference of 0.77 mm during smiling and 1.0 mm during lip puckering., Conclusions: The Facial Assessment by Computer Evaluation measure allowed the authors to quantify the improvement of eye synkinesis after botulinum toxin type A injection. The Sunnybrook Facial Grading System provided an immediate instrument with which to monitor treatment in routine clinical practice, whereas the Facial Assessment system gave a more accurate quantitative assessment., Clinical Question/level of Evidence: Diagnostic, II.

Background: It is useful to perform neurophysiologic electromyography and electroneurography (EMG/ENG) on patients with peripheral facial palsy during the acute phase of paralysis in order to assess the severity of their nerve lesion and thus plan rehabilitation treatment and evaluate its results., Aim: To evaluate the motor recovery of patients with Bell's palsy with respect to the severity of their neurological lesion and to compare the results of two different rehabilitation treatments, with electromyographic biofeedback (EMG-BFB) and mirror visual biofeedback (mirror-BFB), in patients with Bell's palsy and neurophysiologic pattern of axonotmesis., Study Design: Cohort study on retrospective clinical records., Population: 102 patients with Bell's facial palsy were clinically assessed according to the House scale both during the acute phase of paralysis and 12 months after onset., Methods: All patients underwent EMG/ENG examination 3-4 weeks after the onset of paralysis; 29 patients had an EMG pattern of neurapraxia and were not given rehabilitation treatment; 73 patients who presented with signs of denervation had an EMG pattern of axonotmesis. The group, which was homogenous in terms of lesion severity, was divided into two parts: 38 patients were treated with electromyographic biofeedback (EMG-BFB) and 35 were treated with mirror visual feedback (mirror-BFB)., Results: All 29 patients with neurapraxia made a full spontaneous recovery; Although the 73 patients with axonotmesis received different types of rehabilitation treatment, they obtained similar results regarding quality of recovery, development of synkinesis, rehabilitation timing and resources used., Conclusion and Clinical Rehabilitation Impact: Rehabilitation treatment is not necessary for patients with neurapraxia. The two biofeedback methods used to treat patients with axonotmesis resulted in similar rehabilitation outcomes.

Objective: Evaluation of fatigue and pain following surgical activities., Methods: Cross-sectional study. We distributed a self-evaluation questionnaire to 180 surgeons to investigate working postures and fatigue and/or pain following working activities., Results: 100 surgeons replied (74 male), mean age 40.1 (SD 10.85; 26-65). Multivariate analysis suggests that the highest risk factor for developing muscle fatigue whilst performing surgical operations is standing compared to sitting (OR: 4.92; 95% CI: 1.32-18.33),followed by the ability to alternate between the two postures (OR: 3.46: 95% CI: 1.26-9.52). Surgeons who complain of intense fatigue when standing have 16 times the risk of developing musculoskeletal pain than surgeons who complain of light fatigue when standing (OR: 15.77; 95% CI: 1.51-164.37). The ability to adjust the height of the operating table before each operation reduces the risk of developing musculoskeletal pain by 83% (OR: 017; 95% CI: 0.03-0.87); 90.9% of surgeons who rest their forearms for less than half the duration of an operation reported pain., Conclusions: Fatigue and pain associated with performing surgical interventions could be managed more effectively by: controlling the working posture, being able to rest forearms, being able to regulate the height of the operating table, and possibly by applying the ergonomic guidelines.

Nutraceuticals can be defined as food components or active principles present in aliments which have positive effects for health and quality of life, including preventing or treating disorders. Herbal and "natural" food supplements are increasingly used to treat different psychiatric disorders, often as "self-prescribed" therapies. With factors such as chronic illness, poor health, emotional distress, and quality of life influencing the desire for complementary medicine, patients with comorbid medical and psychiatric problems seem likely to turn to this approach. We reviewed the most commonly used herbal and dietary supplements for which a certain efficacy on psychiatric symptoms or disorders has been claimed, checking current Pubmed-indexed literature (the most important being St. John's wort, Omega-3 fatty acids, valerian, Kava, Ginkgo, folate, B vitamins, S-Adenosylmethionine, inositol, alfa-lactoalbumin and passionflower). There is evidence of efficacy for some of these herbs an supplements, proved also by Cochrane's meta-analysis. However many different areas (including efficacy, tolerability, optimal dosing, adequate shelf life, drug and non-pharmacological interactions) need to be thoroughly studied; moreover political decisions need to be scientifically guided in order to best serve psychiatric patients' interests and to prevent using of expensive and sometimes un-useful therapies. This implies that a scientific strategy is needed to rule out any third-part economical interest which could in any way influence therapeutic choices. The article presents some promising patents on nutraceuticals in psychiatric practice.

Neuropsychological testing has become an important part of the diagnostic tools available to assess children's functioning. Tests are routinely use to establish diagnosis, measure patient's impairment and drive rehabilitation. The authors present the clinical case of a eight-year-old girl, sent to our Child Neuropsychiatry and Rehabilitation Unit for a suspected Specific Learning Disorder. Peculiar findings regarding attention and reading ability became evident during the initial evaluation; a mistaken diagnosis of dyslexia was avoided by carefully examining her global functioning (in particular sight, as she suffered from hyperopia but more importantly she had an insufficient control of vertical saccadic movements) and the strategies she used during testing. This constitutes a good example of the need to take into consideration the patient as a whole during any assessment, including neuropsychological testing.

Attention is an important neuropsychological function in child development. A lot of literature has been devoted to trying to separate the role of nature (i.e. mainly the genetic basis) from that of nurture (i.e. parenting and life events). The case of preterm born children is an opportunity to try and further study this relationship. We hypothesize that children born preterm might have a reduced attention due to an interaction of factors, to be conceptualized both as nature (mainly the genetic background and the specific consequences of preterm birth and of its complications) and nurture (therapeutic techniques used, alteration in parents-child relationship and so on). The contribution of each of these factors needs to be disembodied from the raw finding of a reduced attention: this is especially important because experience-dependent learning, in which individualized experiences have neural effects, can go on throughout life and this opens interesting rehabilitative possibilities. Different research lines which could be useful to entangle the specific contributions of the above mentioned factors are discussed: the results could in turn inform clinical practice with this highly at risk and increasing in number population, with a view largely corresponding to the one founding the OMS International Classification of Disability, Functioning and Health., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

There is some evidence that links the increase of mental disorders' prevalence with a deterioration of Western countries' nutritional habits and it is found that the use of herbal and "natural" food supplements to treat different disorders is increasing. With factors such as chronic illness, poor health, emotional distress, and quality of life influencing the desire for complementary medicine, patients with comorbid medical and psychiatric problems seem likely to turn to this approach. We reviewed the most commonly used herbal and dietary supplements for which a certain efficacy on psychiatric symptoms or disorders has been claimed, checking current Pubmed-indexed literature (the most important being St. John's wort, Omega-3 fatty acids, valerian, Kava, Ginkgo, folate, B vitamins, SAMe, Inositol). There is an evidence of efficacy for some of these herbs an supplements, but current studies are often insufficient to reach a final conclusion; still patents are being requested and registered. Many different areas (including efficacy, tolerability, optimal dosing, adequate shelf life, drug and non-pharmacological interactions) need to be thoroughly studied; moreover political decisions need to be scientifically guided in order to best serve psychiatric patients' interests and to prevent the usage of expensive and sometimes un-useful therapies. This implies that a scientific strategy has to be used to rule out any third-part economical interest which could in any way influence therapeutic choices.

Visuomotor skills are obviously important in activities of daily living. In school-aged children they are particularly important in writing and reading processes. The assessment of these skills is usually performed through neuropsychological or complex neurophysiological tests. We present our preliminary findings in 21 healthy children in whom visuomotor assessment was performed using a new, non-invasive method, based on quantitative video analysis of arm movement during a maze task. This low-cost method seems promising because it is easier to perform than other neurophysiological techniques, does not involve the fixing of markers on the child's body and allows accurate evaluation of joint angles. The major drawbacks are the single plane used for the video recording and the need for a well lit environment.

Aim: Despite an obvious need for rehabilitative treatment, some parents deny consent and some others withdraw their children from a previously accepted program. There is limited literature concerning how to prevent this, serving the child's best interest, and the existing is mainly focused on legal implications., Methods: This was a naturalistic study, carried out using data obtained during the diagnostic evaluation of 166 children (all those seen in the Child Neuropsychiatry Unit). For 25 children (15.1%), parents refused or interrupted suggested treatment., Results: Statistical analysis showed that there is a significant difference in terms of impairment in children of parents accepting or refusing the rehabilitative treatment. Treatment discontinuation is related to the diagnosis (higher percentage in severe language disorders or complex developmental disorders), higher reduction in global functioning, higher disability burden, need for integrated treatment, lower age., Conclusions: Findings of this study could be useful in order to better plan rehabilitative options and goals. It is possible that an attempt to increase parental involvement in the rehabilitative program could lead to a decrease in treatment discontinuation. Anyway, more research is needed because we are still far from having a good predictive model to anticipate and, if possible, avoid treatment discontinuation.

Synaptosomal-associated protein of 25 KD (SNAP-25) is a protein that participates in synaptic vesicle exocytosis through the formation of a SNARE complex; SNAP-25 also plays a pivotal role in modulating calcium homeostasis through negative regulation of voltage-gated calcium channels. SNAP-25 has been involved in different neuropsychiatric disorders, including attention deficit hyperactivity disorder. There are well known physiological gender differences in many neuropsychological skills, and there are even more striking gender differences in patients with attention deficit hyperactivity disorder and autism spectrum disorders. We hypothesize that these differences are the result of a mechanism involving SNAP-25 polymorphisms and its differential expression in specific brain areas.

Experiments were performed on eight subjects affected by peripheral arterial occlusive disease (PAOD) of the lower limbs. Each patient was submitted to Ecodoppler, angiography and the "Treadmill test". Two bioptic muscle of these patients. A sample was used for the spectrophotometric and spectrophotofluorimetric determinations of: glycogen, pyruvate, lactate, citrate, alpha-ketoglutarate, malate, aspartate, glutamate, AMP, ADP, ATP and creatine phosphate (CP). The other bioptic sample was used to determine the following enzyme activities: hexokinase, phosphofructokinase, pyruvate kinase, lactate dehydrogenase, citrate synthase, succinate dehydrogenase, malate dehydrogenase, total NADH cytochrome c reductase, cytochrome oxidase, aspartate aminotransferase and alanine aminotransferase. Patients showed an increase in lactate dehydrogenase, total NADH cytochrome c reductase and succinate dehydrogenase activities, a decrease in glycogen, ATP and CP concentrations. Telethermographic data showed patient muscle thermic emission quantitatively different from control group. The telethermographic test can be used as an additional diagnostic tool to determine and monitor the efficiency of a muscle undergoing metabolic failure.

In order to investigate how exercise, performed under controlled mechanical conditions, might be influenced by variables such as fatigue and immobilization, a computerized transducer system was specially built. Quadriceps femoris and knee flexors were studied in healthy non-athlete and post-meniscal surgery subjects, by means of an isokinetic extension-flexion protocol. The protocol was applied before and after cycloergometer "fatiguing" effort in the healthy subjects and before and after re-training in the surgical ones. An original software was able to display the time course of dynamic parameters, particularly force, velocity and power output. Results obtained showed a 26.5% significant decrease in power output after the effort, owing to a concomitant decrease in velocity, while force increased, but over a longer time. As to the operated subjects, power output was higher following retraining, as a result of the combination of lower force and higher velocity. The transducer system proved reliable in detecting changes in power output, whatever the cause. The instantaneous control of variables which power is depending upon, such as force and velocity, may give a few hints on the efficacy of training and rehabilitation programs.

The method applied consists of evaluating the power spectra of the electromyographic (EMG) surface signal obtained during maximal isometric effort of the quadriceps femoris muscle. In hemiplegic patients it is possible to observe a particular frequency distribution towards the lowest values of the range considered. This trend might be accounted for by the morphological and enzyme- histochemical studies on the quadriceps femoris showing a selective atrophy of type 2 fibers. During rehabilitation treatment, however, it is imperative to consider parameters such as muscle strength changes and frequency values preferentially activated during the isometric effort (time-course). Observation of the pattern of the power spectra time-course therefore seems to contribute to a better view of the rehabilitation strategies suitable for exploiting the residual motor abilities.

The hypothesis that specific computerized tomography brain-scan findings are associated with infantile autism was tested in 45 cases and 19 controls. The autistic group was subdivided into serious and less-serious language-impaired subgroups. The analysis of Euclidean Distances, a type of cluster analysis, showed that neuroradiological parameters of cases and controls, including ventricular sizes, were on the whole significantly different, but no statistically significant difference appeared between the two autistic subgroups. But the analysis of variance of each neuroradiological parameter did not show any significant difference between autistics and controls. It was concluded that autism is nonspecifically associated with brain-scan abnormalities, and that other nonorganic, as well as organic, factors should be taken into account.