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Progressive multifocal leukoencephalopathy is a demyelinating disease of the central nervous system, characterized by aggressive deterioration of white matter pathways throughout the subcortical brain parenchyma. This disease leads the patient to a total dependence in all activities of daily (ADLs) living in few months. The literature on rehabilitation of progressive multifocal leukoencephalopathy is scanty and, at present, it is unknown whether rehabilitation may modify the course of disability in this disease. This paper describes the functional course of a patients with progressive multifocal leukoencephalopathy who incurred in a severe functional impairment of ADLs after an unintentional fall and prolonged bed rest. The multidisciplinary in-hospital rehabilitation program and integrated homecare approach allowed the patient to improve her functional capacities and go on with living at home.

Very few studies have investigated activities of daily living (ADLs) post hip-surgery as a possible determinant of functional outcome after hip fracture.This prospective, observational study aimed to correlate hip-fracture patients' ADLs on admission to in-hospital rehabilitation with their functional outcome post-rehabilitation.Of 216 consecutive hip-fracture patients admitted to our Rehabilitation Unit, 204 patients were eligible for the final analyses. All patients underwent the usual rehabilitation. At admission, basic ADLs were assessed by the Functional Independence Measure (FIM) scale. Discharge scores, efficiency and effectiveness in motor-FIM, and discharge destination were outcome measures. Backward stepwise regressions were performed to identify determinants of outcome measures. Age, sex, education, number of relatives, orthopedic treatment, onset to admission interval, Mini Mental State Examination (MMSE), Cumulative Illness Rating Scale, Neuropsychiatric Inventory, ROM, Muscle Strength, and FIM scores at admission were independent variables.There was functional gain in all ADLs post-rehabilitation, walking being the FIM-item with the highest efficiency and effectiveness (respectively, 0.14±0.0 and 64.2±21). Multivariate analyses showed that MMSE was a determinant of final score, efficiency, and effectiveness in motor-FIM. Bladder control was a determinant of final score and effectiveness in motor-FIM, while eating and bathing were determinants of final motor-FIM score. Bowel management was the only determinant of discharge destination.Basic ADLs, in particular eating, bathing, bladder and bowel management, are important determinants of outcome in hip fracture.The results of this study suggest that, in designing studies on outcome prediction in hip fracture, researchers should include tests assessing performance of basic ADLs as independent variables, as this could allow to identify new prognostic indicators that may be helpful for physicians in managing hip fracture patients post-rehabilitation.

This study reports the case of a 47-year old female with low back pain radiating to groin and anterior regions of the left thigh and leg. At symptoms onset, electromyography showed left L3-L4 radiculopathy, and nuclear magnetic resonance revealed disc protrusion at the same level with impingement of the spinal nerve root. The clinical symptoms were ascribed to lumbar disco-radicular conflict. The patient underwent steroidal anti-inflammatory treatment with epidural steroid injections, chiropractic spinal manipulations and rehabilitation program, with no relief. Thirteen months after the onset of pain, a computed tomography of sacroiliac joints showed osteolytic lesion in the iliac bone of left joint, and a bone scintigraphy highlighted foci of intense uptake at left iliac bone and left proximal extremity of the femur. The bone biopsy and pathological examinations showed findings consistent with large B-cell non-Hodgkin lymphoma. This case report highlights the fact that in making differential diagnosis of low back pain radiating to the leg we have to consider the rare possibility that pain can be due to non-Hodgkin lymphoma that involves simultaneously the iliac bone and proximal extremity of the femur.

Duration of rehabilitation is an important rehabilitation clinical outcome both from a clinical and administrative point of view. Very few studies have looked at predictors oftreatment duration in out-patient rehabilitation setting especially in patients with orthopedic-traumatologic conditions.We undertook a prospective study to assess treatment duration and identify variables predicting this outcome measure (primary outcome) and efficiency in range of motion and activities of daily living (secondary outcome).Prospective and observational study.Out-patient Service for Rehabilitation.Two hundred and ten patients admitted to Out-patient Service for Rehabilitation of orthopedic disorders were enrolled: 94 patients had limb fracture (35 wrist fracture, 28 ankle fracture, 27 shoulder fracture), and 120 and undergone elective orthopedic surgery (27 cruciate reconstruction, 93 rotator cuff repair).Univariate Regression analysis was applied to analyze relationships among variables and length of rehabilitation while backward stepwise regression analysis was used to predict treatment duration. The independent variables were age, gender, work, type of physical therapy, comorbidity, pain, onset to admission interval, initial disability, initial range of motion percentage (ROM), and diagnosis group.Mean treatment duration was 29.7±15 days. Treatment duration following rotator cuff repair was significantly longer than that of cruciate reconstruction (P=0.005), wrist fracture (P0.001), and ankle fracture (P=0.002). Treatment duration was related to working status, admission disability, onset to admission interval, diagnosis group, admission pain, and admission range of motion. In multivariate regression analysis, admission range of motion and onset to admission interval were the only independent predictors of treatment duration and efficiency in range of motion, while admission range of motion and admission Health Assessment Questionnaire were predictors of efficiency in Health Assessment Questionnaire score.The study highlights that rehabilitative treatment duration has strong relationship with admission range of motion and onset admission interval. CLINICAL REHABILITATION IMPACT. These findings should be useful for physicians for planning therapeutic measures in patients with orthopedic-traumatologic conditions and for managing the usual activities of an Out-patient Rehabilitative Service.

Very few studies have investigated the influence of single activities of daily living (ADL) at admission as possible predictors of functional outcome after rehabilitation.The aim of the current study was to investigate admission functional status and performance of basic ADLs as assessed by Functional Independence Measure (FIM) scale as possible predictors of motor and functional outcome after stroke during inpatient rehabilitation.This is a prospective and observational study.Inpatients of our Department of Physical Medicine and Rehabilitation.Two hundred sixty consecutive patients with primary diagnosis of stroke were enrolled and 241 patients were used in the final analyses.Two backward stepwise regression analyses were applied to predict outcome. The first backward stepwise regression had age, gender, stroke type, stroke-lesion size, aphasia, neglect, onset to admission interval, Cumulative Illness Rating Scale, National Institute of Health Stroke Scale (NIHSS), Fugl-Meyer Scale, Trunk Control Test, and FIM (total, motor and cognitive scores) as independent variables. The second analyses included the above variables plus FIM items as an independent variable. The dependent variables were the discharge scores and effectiveness in total and motor-FIM, and discharge destination.The first multivariate analysis showed that admission Fugl-Meyer, neglect, total, motor and cognitive FIM scores were the most important predictors of FIM outcomes, while admission NIHSS score was the only predictor of discharge destination. Conversely, when admission single FIM items were included in the statistical model, admission Fugl-Meyer, neglect, grooming, dressing upper body, and social interaction scores were the most important predictors of FIM outcomes, while admission memory and bowel control scores were the only predictors of discharge destination.Our study indicates that performances of basic ADLs are important stroke outcome predictors and among which social interaction, grooming, upper body dressing, and bowel control are the most important.The results of this study suggests that, when designing other studies on stroke outcome predictions, researchers should also include tests which assess performances of basic ADLs as independent variables, because this may allow identification of new prognostic indicators that can be helpful for the physician for managing stroke patients at the end of the rehabilitation period.

The study evaluates the possible relations between cognitive impairment, persisting anosognosia for hemiplegia and peripersonal neglect. Thirty eight chronic right hemisphere stroke patients were divided in three age- and education-matched groups: A (n = 13) patients with left hemiparesis, peripersonal neglect, and anosognosia for hemiplegia; B (n = 12) patients with left hemiparesis and peripersonal neglect, and C (n = 13) patients with left hemiparesis only. We used MMSE and WAIS Verbal IQ and verbal subtests to assess cognitive impairment in patients, in order to avoid a bias due to visuospatial deficit, which is common in patients with neglect. VIQ, Information, Digit Span and Vocabulary WAIS subtests as well as MMSE were found to be significantly lower in group A versus group B. No difference was found in any test between groups B and C, indicating a general worse cognition in patients compared to those without anosognosia for hemiplegia. Patients with anosognosia for hemiplegia also showed larger brain lesions and, more frequently, frontal, parietal, temporal and basal ganglia involvement, particularly if they had low verbal IQ, indicating a relationship between cognitive impairment, persisting anosognosia for hemiplegia and large right hemisphere lesions.

General intelligence of patients with neglect has been poorly investigated and data at present are contrasting. Moreover it is not yet defined whether the presence of anosognosia for hemiplegia is associated with intellectual impairment in patients with neglect.In this prospective study the authors evaluated the verbal intelligence quotient in neglect patients. This study was carried out on 33 patients with left hemiparesis: 11 patients had neglect (group N), 11 had neglect + anosognosia (group N+A) and 11 had neither neglect nor anosognosia (control group).Patients of group neglect + anosognosia had significantly lower verbal IQ (VIQ) and mini-mental state examination (MMSE) scores than those of neglect (respectively: P=0.004 and P=0.000) and control groups (respectively: P=0.041 and P=0.000). No significant differences were detected between neglect and control groups for VIQ and MMSE. In N+A group VIQ score was lower than 90 in 81.8% and MMSE score was lower than 24 in 100% of patients. Moreover, 18.2% of N+A patients had VIQ score lower than 80 and 45.4% had MMSE score lower than 18/30. Also 9.1% of neglect group had VIQ score lower than 90 and 36.4% MMSE scores less than 24/30, but none of these patients had VIQ and MMSE scores respectively lower than 80 and 18/30. Similar data were present in control group.This study focuses on mental impairment in neglect + anosognosia patients and indicates that A for hemiplegia is a condition that more often occurs when severe mental impairment is present.

The aim of the study was to evaluate the disability of patients with tear of the rotator cuff (TRC) in order to propose an occupational therapy program.We studied 54 patients with TRC. All patients were women (average age 75.4 +/- 5.6 years). X-ray and Ultrasonography were performed on all patients, while Magnetic Resonance Imaging only on 8. The assessment was made using the Constant Scale, the Groningen Activity Restriction Scale, the Health Assessment Questionnaire (HAQ), and shoulder range of motion.According to HAQ, disability was severe in 33.4% of patients, moderate in 51.9%, slight in 12.9% and absent in 1.8%. Active motion of shoulder played a relevant role in determining disability (beta = -0.57, p = 0.000, R2 = 0.54), and the active flexion was the most powerful prognostic factor positively associated with disability (beta = 0.50, p = 0.000, R2 = 0.37). Disability was higher in patients with severe deficit of active flexion (z = -3.401, p = 0.000). In patients with bilateral TRC disability was higher than that of patients with right TRC (p = 0.008). Disability did not differ between left and bilateral TRC and between right and left TRC. In patient with bilateral TRC disability was severe in 46.7% of cases and moderate in 53.3%.Our data show that the TRC causes moderate-severe disability and that disability is related to active flexion. In the light of these data we proposed an occupational therapy program. The main points of this program are the gestural compensation, the use of substitutive mechanical aids and the adjustment of the patient's dwelling.

Few data exist about walking and motility after infratentorial stroke (IS). The aim of this study was to objectively quantify pre-rehabilitation and post-rehabilitation walking and mobility in a group of IS patients admitted for inpatient rehabilitation and to determine factors influencing functional outcomes.Seventy-two patients with IS were selected on the basis of clinical criteria and computer tomography (CT) images. Mean age was 76.5 +/- 10 (31 men and 41 women). The stroke was ischemic in 55 patients and hemorrhagic in 17 Walking (Lindmark scale), mobility (Rivermead Mobility Index) (RMI) and stroke severity (National Institute of Health Stroke Scale) (NIH) were evaluated in all patients at admission to study and at discharge.Before rehabilitation 1.4% of patients were independent in walking and 23.7% were over 75th percentile in RMI. After rehabilitation, 80.5% of the patients were able to walk independently and 84.7% were over 75th percentile of mobility. Age, onset to admission interval, and extent of the stroke did non correlate with Lindmark and RIM. Lindmark and RMI were correlated only with NIH. Patients with higher NIH score (NIH+) had significantly worse walking capacity and mobility than patients with lower NIH score (NIH-) before and after rehabilitation. Moreover, in patients NIH+ length of rehabilitation therapy was significantly longer compared to patients NIH-. In addition, patients NIH+ had efficiency in walking and in mobility significantly lower than patients NIH-.The study shows that: (1) IS patients have a significant functional recovery in walking and mobility after rehabilitation, (2) stroke severity is related with walking and mobility.

Aim of this study is to verify if the presence of extracerebellar stroke lesions negatively affects walking and functional capacities recovery of patients with cerebellar stroke.This study was carried out on 43 patients. Patients' selection was made through CT and MRI scans. Neuroimaging data were used to divide patients into 2 groups: 1) a group composed of 20 patients with isolated cerebellar involvement (group C); (2) a group composed of 23 patients with cerebellar plus extracerebellar involvement (group C+E). Patients were assessed through trunk control test (TCT), Lindmark scale and Rankin scale at admission and at discharge. Before rehabilitation, there were no significant differences in disability, TCT and Lindmark scores between the 2 groups of patients.After rehabilitation, Lindmark scale (P=0.022) and TCT (P=0.015) scores of group C were statistically higher than those of group C+E. Disability was greater in group C+E (P=0.036). In these patients disability was absent in 17.4% of subjects, moderate-slight in 47.8% and severe in 34.8%. In group C disability was absent in 40% of subjects, slight-moderate in 55% and severe in 5%. Effectiveness in walking was 79.1% in group C and 57% in group C+E. Efficiency in walking was 0.13 in C group and 0.07 in C+E subjects. Effectiveness (P=0.008) and efficiency (P=0.008) of group C were significantly greater than of group C+E.The study shows that the rehabilitation prognosis of cerebellar stroke is affected by the presence of extracerebellar stroke lesions.

Global aphasia and neglect are considered to be the neuropsychological disorders mostly affecting the hemiplegia outcome. The aim of this study is to examine which of the two disorders is making worse the recovery from hemiplegia.The study was conduced on 45 patients suffering from hemiplegia: 15 subject with global aphasia, 15 with neglect and 15 without neuropsychological disorders (control group). All patients were subject to rehabilitation treatment. Before and after rehabilitation, the assessment of patients was made using neuropsychological tests, Fugl-Meyer scale and Functional Independence Measure (FIM). At admission, all patients were not self-sufficient.At the end of the rehabilitation period the recovery of motor function was poor in both groups. The damage on limbs motion was severe in 93.4% and marked in 6.6% of both patients with global aphasia and neglect. At discharge, the FIM motor score of patients with global aphasia (44.6 +/- 13) was higher than in those with neglect (37.2 +/- 10) and was not statistically different from control group (51.2 +/- 18) (p = 0.493). The FIM motor score of patients with neglect was significantly lower than control group (p = 0.036). In patients with global aphasia effectiveness was 35.5% and efficiency 0.40 while in patients with neglect effectiveness was 18% and efficiency 0.22. The final disability was lower in patients subject to global aphasia than neglect.The study showed that neglect limits the recovery from stroke more than global aphasia.e.

The aim of the this study is to evaluate the work capacity of housewives with full thickness tear of the rotatory cuff (FTTRC).Twenty-five subjects have been studied. The FTTRC was located un the right shoulder in 16 cases, in the left shoulder in 5 cases and was bilateral in 4 patients. All patients were female; the average age was 72.4 +/- 4 (range 62-81). The Assessments were made using the Constant Scale, the Groningen Activity Restriction Scale and the Simon's Test.The result of this study confirmed that none of the housewives was able to carry out the houseworks quite independently and with no effort. 16% of the patients did the houseworks with great effort while 84% was helped in making some activities. Help is necessary for the usual housework and heavy domestic works (washing glasses, using vacuum cleaner to clean the floor). Patient's relatives provided help in 76.2% of cases while 23.8% were assisted by maid. Help was occasional in 33.3% of cases, continuous in 52.3% and full in 14.4% of patients. Disability resulting from FTTRC is heavier in subjects where electrical household appliances are not used (p0.05) and in subjects who feel deep pain (p0.05). The active movements of shoulder, local shoulder pain and level of use of upper limbs do not affect domestic works.These study showed that FTTRC reduces work capacity of house wives. These disease is more preventing heavy domestic works.

The influence of global aphasia on the outcome rehabilitation of hemiplegia has been considered in very few case studies. Aim of this study is to evaluate motor function and functional capacities of patients whit hemiplegia and global aphasia after rehabilitation.A consecutive sample of 54 first-stroke patients was assessed. The mean age of the patients was 64.9. Assessments were made using the Barthel Index, Fugl-Meyer Scale and Standard Language Examination of Basso.At admission 98.1% of the patients showed a complete paresis of the upper limb, while 72.2% provided a complete paresis of the lower limb. After rehabilitation 90.7% of the cases showed a complete paresis of the upper limb while 29.6% maintained the paresis of the lower limb. The lower limb had motriciy in flexor- and extensor synergies, while the upper limb only in flexor-synergies. At admission all patients showed severe or very severe disability. After rehabilitation disability was very severe in 9.2% of the patients, severe in 16.7%, moderate in 38.9% and light in 35.2%. At discharge 33.3% of the patients had a Berthel Index score above 70 while the mean score was 59.2/100. The higher self-sufficiency was detected in the personal hygiene (83% self-sufficient) and walking (61.1%); a lower degree of self-sufficiency was observed in eating, dressing and toileting (100% of the patients needed assistance). The patients aged less than 65 years showed a recovery in the functional capacities better than the level detected in patients older than 65 (p0.001).These results demonstrate that patients whit hemiplegia and global aphasia recovery better functional capacities than motor function after rehabilitation.

The aims of this study were: 1) to evaluate the degree of walking of patients with Parkinson s syndrome after hip fracture surgically treated; 2) to reexamine the evidence for internal fixation versus endoprosthesis.Forty-one patients with Parkinson s syndrome after hip fracture surgically treated have been studied. Twenty-four fractures (20 femoral neck, 4 subcapital) were treated by endoprosthesis, and 17 by internal fixation (pertrochanteric fractures). The average age of the patients was 76+/-7 years (7 male, 34 female); 97,5% patients could walk without any help before the fracture.At the end of the rehabilitation period, 21.9% patients were unable to walk; 2.4% walked with assistance of two persons, 24.4% with assistance of one person, 19.4% with two canes, 17.1% with one cane, 14.8% without assistance and without cane. At discharge, 87.5% of patients went directly back home, while the remaining 12.5% were admitted to Geriatric hospitals. The degree of walking was higher in fractures treated by endoprosthesis (p0.05). At the end of treatment, 62.5% fractures treated by endoprosthesis and 35.2% treated by internal fixation could walk without any help.1) Parkinson s disease influences the recovery of walking after hip fracture; 2) At the end of rehabilitation, the parkinsonian patients with hip fractures treated by endoprosthesis showed better results than those treated by internal fixation.

The aims of this study were: 1) to evaluated the degree of walking of hemiplegic patients after femur fracture, 2) to evaluate if the neurological damage interferes with the recovery of walking. We studied 51 hemiplegic patients with femur fracture. All patients could walk without any help before the fracture. At the end of the rehabilitation period we had the following results: 5.8% of patients regained full walking independence; 37.2% walked with a cane; 43.1% with a quadripod; 9.8% walked with assistance; 3.9% remained unable to walk. 50.9% of them regained their prefracture functions. 96.1% returned directly to their own home, the remaining 3.9% were admitted to Geriatric hospitals. To address the second aim, we divided the same patients into two groups of 20 patients each (A = mild impairment; B = severe impairment) according to Mathew's scale. At the end of treatment, 95% of group A and 75% of group B regained full walking independence.1) the femur fracture did not influence the recovery of walking in stroke patients, 2) patients with mild neurological impairment had enhanced recovery of walking.

The aim of this study was to determine whether rehabilitation treatment has a real effect on the functional capacity of patients with pseudobulbar syndrome (SP), and whether there is any difference in efficacy between rehabilitation treatment initiated as early as possible following stroke, compared to treatment initiated some months after the last occurrence. We studied 50 SP patients divided into three groups according to time passed since the last stroke: group 1, 20 patients, less than 180 days after stroke; group 2, 30 patients, more than 180 days after stroke, At the end of the rehabilitation treatment, there was an improvement in motility (p0.005), functional capacity (p0.001) and reduction in disability (p0.001) only in group 1. We attribute this result to the specific pathological substrate of the syndrome and its chronic-progressive course, which would seem to hinder the action of compensatory mechanisms involved in late recovery.

One hundred and twenty-seven patients with femour fractures were studied with the aim of verifying the possible influence of Parkinson's disease and hemiplegia on ambulation recovery. Participating in this study were 31 patients with Parkinson's disease, 36 patients with hemiplegia and 60 patients without any neurological damage. After rehabilitation, 61.1% of hemiplegic, 40% patients without neurological damage and 29% of parkinson disease patients reached the same ambulation capacity level present before the fracture. Patients suffering from Parkinson disease showed an important loss of ambulation which was statistically significant compared to the control group. The loss of deambulatory capacity was not statistically significant in hemiplegic group. According to the authors' opinion, this result depends on correlated damages or on poor collaboration typically present in patients with Parkinson disease.

Motor behaviour of 18 complete aphasic-hemiplegic patients have been studied. Among these patients an attitude of motor inhibition has been noticed, prevalently characterized by motor slowing and stopping. It has also been noticed an attitude of motor disinhibition, characterized by motor restlessness and ineffective bustle.