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The study's aim was two-fold: to describe the trend of hip subluxation in the largest sample of Italian nonambulatory cerebral palsy (CP) children ever published; to investigate its determinants. This single-centre retrospective cohort study included patients with spastic or dyskinetic CP, Gross Motor Function Classification System (GMFCS) level IV or V, age 0-18 years, having been referred to our unit before March 2020. The hip subluxation was measured by means of the migration percentage (MP). Other data were gathered such as sex, CP subtype, GMFCS level, presence of drug-resistant epilepsy, age, use of walkers with weight relief or standing devices, previous botulinum injection or hip surgery, oral or intrathecal baclofen and hip pain. Multiple linear stepwise regression was performed and descriptive statistics are provided. Spastic CP had MP maximum increase in early ages, with GMFCS level V values persistently higher than level IV. The dyskinetic subtype showed a slower increase of the MP, with GMFCS level IV presenting similar or higher values, compared to level V. Age, CP severity and spastic subtype are the main determinants. The stepwise multiple regression analysis demonstrated that weight relief walking and standing assistive devices, combined with botulinum contributed to reduce the MP progression. Dyskinetic CP showed overall lower MP values and a more variable behaviour relative to age and GMFCS level, compared to the spastic subtype. Standing and walking assistive devices, with partial or total weight relief, combined with individually targeted botulinum injections, should be considered in the management of bilateral nonambulatory CP patients, to prevent hip subluxation or its recurrence after surgery.

Hip pain is common in cerebral palsy children, particularly at Gross-Motor Function Classification System level IV-V. It is associated to hip displacement and relates to the migration percentage. Recent literature suggested early reconstructive bone surgery, as the best approach to prevent hip luxation, then hip pain. Still, high rates of hip pain are reported.To investigate prevalence and determinants of hip pain in an Italian cerebral palsy sample.Single-center retrospective cohort study.Inpatient and outpatient.Patients with spastic or dyskinetic cerebral palsy, Gross-Motor Function Classification System level IV or V, age 0-18.A chart review was implemented to report hip pain, as a dichotomous variable (pain/no pain), age, sex, cerebral palsy subtype, Gross-Motor Function level, lumbar scoliosis, migration percentage, previous orthopedic surgery, or botulinum injections, oral or intrathecal baclofen, drug-resistant epilepsy, assistive devices for standing or walking. Descriptive statistics and a multivariate logistic stepwise regression were performed.A total of 504 subjects were included: 302 level V, 209 females, 432 spastics. The mean length of follow-up was 6 years. The overall prevalence of hip pain was 8.9% (6.3% were at level V) and of hip dislocation was 19% (15.9% were at level V). Just 39% of dislocated hips were painful. Children at spastic subtype and level V were predominantly affected. Botulinum and soft tissue surgery related to lower rates of hip pain, without statistical significance. Age (OR 1.19, 95%CI 1.14-1.25, P value 0.000), sex (OR 1.72, 95%CI 1.18-2.52, P value 0.005), migration percentage (OR 1.02, 95%CI 1.02-1.03, P value 0.000) and lumbar scoliosis (OR 1.32, 95%CI 0.86-2.01, P value 0.200) resulted significant independent determinants of hip pain.Hip pain relates with the migration percentage, but not all dislocated hips become painful. Hip pain may be transient and requires a targeted and individualized approach. Children at spastic subtype and level V were predominantly affected. Age and sex are confirmed as determinants. Specific validated measures are to be implemented to assess hip pain.Considering severe non-ambulatory cerebral palsy patients, pain and quality of life should be considered as outcomes, in the management of hip luxation.

The assessment of patients with severe Acquired Brain Injury (sABI) is mandatory in every phase and setting of care, and requires a multidimensional and interdisciplinary approach, to develop the individual rehabilitation project, and monitor long-term functional outcomes. In 2001 the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal assessment protocol for traumatic sABI, providing a comprehensive, standardized functional assessment based on the International Classification of Functioning, Disability and Health (ICF), 2001. In 2007, a new protocol was published, extended to all sABI patients (PMGCA). In 2019, the SIMFER appointed a working group to provide a revised, updated version: the PMGCA2020.The purpose of this study was to describe the minimal assessment protocol to be applied at every stage and setting of the care process of patients with sABI.The working group, including one neurologist and 11 physiatrists experts in sABI rehabilitation, performed a review of the international recommendations for sABI assessment focusing on the following key words: "sABI assessment," "sABI rehabilitation," "sABI prognostic factors," "sABI rehabilitation assessment," "sABI outcome," in MEDLINE. Revision and integration proposals by each member were written and motivated, discussed and voted.The PMGCA2020 is addressed to sABI adult patients. It investigates the main clinical problems of sABI at any time of the rehabilitation pathway. It includes a demographic/anamnestic section, a clinical/functional assessment section and an outcome measures section following the ICF model of functioning and the model of the construction of the rehabilitation project.The PMGCA2020 provides an updated tool for the multidimensional rehabilitation assessment of sABI patients, at any stage of the rehabilitation pathway. Further studies will allow the validation of this minimum set of variables paving the way to an assessment standardization of patients with sABI in the rehabilitation settings.This minimum set of variables, defining patient's functioning and clinical status and outcomes, at every stage and setting of the care process to provide a framework for the standardization of the clinical evaluation of patients with sABI in rehabilitation settings.

Sustained involuntary muscle activity (IMA) is a highly disabling and not completely understood phenomenon that occurs after a central nervous system lesion. We tested the feasibility of in-field IMA measuring at an acute rehabilitation ward. We used wearable probes for single differential surface EMG (sEMG), inclusive of a 3D accelerometer, onboard memory and remote control. We collected 429 h of data from the biceps brachii of 10 patients with arm plegia. Data quality was first verified in the time and frequency domains. Next, IMA was automatically identified based on the steady presence of motor unit action potential (MUAP) trains at rest. Feasibility was excellent in terms of prep time and burden to the clinical staff. A total of 350.5 h of data (81.7%) were reliable. IMA was found in 85.9 h (25%). This was often present in the form of exceedingly long-lasting trains of one or a few MUAPs, with differences among patients and variability, both within and between days in terms of IMA duration, root mean square (RMS) and peak-to-peak amplitude. Our results proved the feasibility of using wearable probes for single differential sEMG to identify and quantify IMA in plegic muscles of bedridden acute neurological patients. Our results also suggest the need for long-lasting acquisitions to properly characterize IMA. The possibility of easily assessing IMA in acute inpatients can have a huge impact on the management of their postures, physiotherapy and treatments.

The COVID-19 emergency has imposed distanced education and has interrupted most rehabilitation services. Adolescents with disabilities have been isolated, and the burden on their families has been exacerbated. A cross-sectional survey was administered to adolescents with disability and to parents of disabled children to describe their experience during lockdown and their concerns or expectations about rehabilitation. A sample of 53 adolescents and 239 parents completed the survey. Adolescents were ages 13–18 years old (45.3% female). Most parents were between 35 and 55 years old (84.9% female). While 53.6% of the parents reported no positive effects of the lockdown, 92.5% of the adolescents expressed favorable consequences. The increased time spent with family members was judged positively by 27.2% of parents and by 64.2% of adolescents. Concern for their child’s disability was expressed by 47.3% of parents, while 73.6% of adolescents expressed concerns regarding the ban on meeting friends. In both groups, anxiety symptoms were correlated with the fear of contracting COVID-19 and with financial problems. Parents would have liked even more remote support from school and healthcare professionals, which was available for most participants. Thus, socioeconomic support, assistive technology and telerehabilitation strategies might help families with disabilities during a lockdown.

(1) Background: Falls are a dangerous adverse event in patients discharged from rehabilitation units, with the risk of falling being higher in the first weeks after discharge. In this study, we assessed the predictive performance of the Hendrich Fall Risk Model II tool (HIIFRM) when administered before discharging patients to their home from rehabilitative units in orthopedic (OR), neurologic (NR) and pulmonary (PR) rehabilitation wards. (2) Methods: Over a 6-month period, all adult patients who returned home after discharge were assessed by HIIFRM. At six months from discharge the occurrence of falls was obtained by performing a structured survey. The HIIFRM predictive performance was determined by the area under the ROC curve (AUC), sensitivity (Se) and specificity (Sp) for the whole sample and split by ward. (3) Results: 85 of 141 discharged patients were living at home and agreed to take part in the survey. Of these, 19 subjects fell, 6 suffered fractures or head traumas and 5 were hospitalized. The AUC was 0.809 (95% CI: 0.656–0.963), Se was 0.67 (0.30–0.93) and Sp was 0.79 (0.63–0.90) for OR patients. (4) Conclusions: Our preliminary results support the use of HIIFRM as a tool to be administered to OR patients at discharge and provides data for the design of a large study of predictive ability.

Background Controlling inappropriateness of care, a widespread phenomenon, should be a global target in order to improve the quality of care, save money and ensure system sustainability. Inappropriateness is a relevant issue in public health and in rehabilitation medicine specifically. In fact, admitting a patient to a rehabilitation hospital or unit is a complex decision also due to the absence of shared and objective admission criteria. Aim of this study is to define clinical admission criteria and rules in rehabilitation medicine. Methods A three-round Delphi survey was conducted on a sample of rehabilitation medicine experts skilled in both rehabilitation and healthcare organization. The two initial rounds consisted of an electronic online questionnaire concerning appropriateness of admission to intensive rehabilitation while in the third one a report of the results was provided to the participants. The experts had to score their agreement with each item in the questionnaires, based on either a Likert scale or a dichotomous statement. Consensus between the experts was assessed. Results A total of 53 health professionals completed the Delphi survey. 19 out of 20 Italian regions were represented. The first round consisted of 8 multiple-choice questions questionnaire. The second round was designed thanks to the suggestions provided by the panelists in the previous one and consisted of a twelve items questionnaire. At the end of the survey, eight criteria of appropriateness of admission to rehabilitation were identified and five rules defining an appropriate admission to a rehabilitation facility were elaborated. Conclusions This study represents an attempt to create a worthwhile and reliable tool for a more conscious clinical practice in admission to rehabilitation, based on a set of shared criteria and rules. Key messages Improving appropriateness in healthcare delivery must be a primary goal in public health and in rehabilitation medicine specifically. Delphi method was applied to define shared clinical admission criteria and rules in rehabilitation.

Background Controlling inappropriateness of care is an essential issue, especially in rehabilitation medicine. In fact, admitting a patient to a rehabilitation hospital or unit is a complex decision also due to the absence of shared and objective admission criteria. Aim The aim was to define clinical admission criteria and rules in rehabilitation medicine. Design Survey based on the application of the Delphi method on a sample of rehabilitation medicine experts. Setting Administration of electronic online questionnaires concerning appropriateness of admission to intensive rehabilitation. Population Volunteer sample of 53 experts with the following inclusion criteria: being members of the Italian Society of Physical and Rehabilitation Medicine, having practical experience in the research field, agreeing to the confidentiality of the information and being skilled in both rehabilitation and healthcare organization. Methods A three-round Delphi survey was conducted according to international guidelines. The two initial rounds consisted of an electronic online questionnaire while in the third one a report of the results was provided to the participants. The experts had to score their agreement with each item in the questionnaires, based on either a Likert scale or a dichotomous statement. Consensus between the experts was assessed. Results A total of 53 health professionals completed the Delphi survey. 19 out of 20 Italian regions were represented. The first round consisted of 8 multiple-choice questions. The second round was designed according to the suggestions provided by the panelists in the previous one and consisted of a twelve items questionnaire. At the end of the survey, seven criteria of appropriateness of admission to rehabilitation were identified and five rules defining an appropriate admission to a rehabilitation facility were elaborated. Conclusions This study represents an attempt to create a worthwhile and reliable tool for a more conscious clinical practice in admission to rehabilitation, based on a set of shared criteria and rules. Clinical rehabilitation impact To increase appropriateness of admission to rehabilitation. Improving appropriateness in healthcare delivery must be a primary goal in order to improve healthcare quality, save money and ensure system sustainability.

Patients with acquired brain injuries (ABIs) often need tracheostomy because of dysphagia. However, many of them may recover over time and be eventually decannulated during post-acute rehabilitation. We developed the Decannulation Prediction Tool (DecaPreT) to identify, early in the post-acute course, patients with ABIs who can be safely decannulated.Nonconcurrent cohort study.Patients with ABI, as well as with dysphagia and tracheostomy, were retrospectively selected from the database of a neurorehabilitation unit in Correggio, Reggio Emilia, Italy.Potential bivariate predictors of decannulation were screened from variables collected on admission during clinical examination, conducted by an expert speech therapist. Multivariable prediction was then obtained in 2 separate random subsamples to develop and validate the logistic regression model of the DecaPreT.Of 463 patients with ABI (mean age 52.2 years) selected, 73.0% could be safely decannulated before discharge. After bivariate screening, multivariable predictors of decannulation were identified in the development subsample and confirmed in the validation subsample, each with its odds ratio and 95% confidence interval as follows: age tertile (1.77, 1.08-2.89; P = .024), no saliva aspiration (3.89, 1.73-8.64; P = .001), pathogenesis of ABI (trauma vs other causes vs stroke vs anoxia: 2.23, 1.41-3.54; P = .001), no vegetative status (8.47; 2.91-24.63; P .001), and coughing score (voluntary and reflex vs voluntary vs reflex vs neither voluntary nor reflex cough: 2.62, 1.70-4.05; P .001). In the validation subsample, the predicting equation obtained an area under the receiver operating characteristics curve of 0.836.The DecaPreT predicts safe decannulation in patients with dysphagia and tracheostomy, using simple clinical variables detected early in the post-acute phase of ABI. The tool can help clinicians choose timing and intensity of rehabilitation interventions and plan discharge.

The main goal of this study was to investigate the efficacy of Botulinum Toxin A (BoNT-A), combined with an individualized intensive physiotherapy/orthoses treatment, in improving upper limb activity and competence in daily activity in children with hemiplegia, and to compare its effectiveness with that of non-pharmacological instruments. It was a Randomized Clinical Trial of 27 children with spastic hemiplegic cerebral palsy, outpatients of two high speciality Centres for child rehabilitation. Each child was assigned by simple randomization to experimental group (BoNT-A) or control group (placebo). Assisting Hand Assessment (AHA) was chosen as primary outcome measure; other measures were selected according to ICF dimensions. Participants were assessed at baseline (T0), at T1, T2, T3 (1–3–6 months after injection, respectively). Every patient was given a specific physiotherapeutic treatment, consisting of individualized goal directed exercises, task oriented activities, daily stretching manoeuvres, functional and/or static orthoses. BoNT-A group showed a significant increase of AHA raw scores at T2, compared to control group (T2–T0: p = .025) and functional goals achievement (GAS) was also slightly better in the same group (p = .033). Other measures indicated some improvement in both groups, without significant intergroup differences. Children with intermediate severity of hand function at House scale for upper limb impairment seem to have a better benefit from BoNT-A protocol. BoNT-A was effective in improving manipulation in the activity domain, in association with individualized goal-directed physiotherapy and orthoses; the combined treatment is recommended. The study brings more evidence for the efficacy of a combined treatment botulinum toxin injection-physiotherapy-orthoses, and it gives some suggestions for candidate selection and individualized treatment.

In Italy, at present, a well-known problem is inhomogeneous provision of rehabilitative services, as stressed by MoH, requiring appropriate criteria and parameters to plan rehabilitation actions. According to the Italian National Rehabilitation Plan, Comorbidity, Disability and Clinical Complexity should be assessed to define the patient's real needs. However, to date, clinical complexity is still difficult to measure with shared and validated tools. The study aims to psychometrically validate the Italian Rehabilitation Complexity Scale-Extended v13 (RCS-E v13), in order to meet the guidelines requirements. An observational multicentre prospective cohort study, involving 8 intensive rehabilitation facilities of the Emilia-Romagna Region and 1712 in-patients, [823 male (48%) and 889 female (52%), mean age 68.34 years (95% CI 67.69-69.00 years)] showing neurological, orthopaedic and cardiological problems, was carried out. The construct and concurrent validity of the RCS-E v13 was confirmed through its correlation to Barthel Index (disability) and Cumulative Illness Rating Scale (comorbidity) and appropriate admission criteria (not yet published), respectively. Furthermore, the factor analysis indicated two different components ("Basic Care or Risk-Equipment" and "Medical-Nursing Needs and Therapy Disciplines") of the RCS-E v13. In conclusion, the Italian RCS-E v13 appears to be a useful tool to assess clinical complexity in the Italian rehab scenario case-mix and its psychometric validation may have an important clinical rehabilitation impact allowing the assessment of the rehabilitation needs considering all three dimensions (disability, comorbidity and clinical complexity) as required by the Guidelines and the inhomogeneity could be reduced.

Neurobehavioural sequelae of traumatic brain injuries require an appropriate/effective pharmacological response in that they represent an important cause of disability. In this field, there is no evidence that reaches the level of a standard: there are guidelines on the use of methylphenidate, donepezil and bromocriptine for the treatment of cognitive disturbances, for the non-use of phenytoin and for the use of beta-blockers for controlling aggressiveness. Resolving a single symptom is not relevant in a rehabilitation project if it is not in the context of a more complex picture of neurobehavioural recovery, in which the positive and negative effects of every therapeutic choice are considered. For example, phenytoin could be used for the positive control of epileptic crises but is not advised since it impedes the recovery of cognitive functions in general. Analogous effects not yet identified may concern benzodiazepine, neuroleptics and other sedatives usually prescribed in cases of cranial trauma. Psychotropic drugs are considered to be able to influence the neuronal plasticity processes. Studies on animals have shown that the administration of D-amphetamine combined with sensorial-motor exercise produces the steady acceleration of motor recovery, which acts as a catalyst to the neurological recovery process. On the other hand, alpha1-NA receptor antagonist drugs produce negative effects; these include clonidine (antihypertension) and haloperidol (neuroleptic). Studies need to be carried out to evaluate the effectiveness of particular drugs. These studies need to focus not only on the disappearance of symptoms but also on the positive and negative effects on overall rehabilitation and on the neurobiological recovery of the patient.

Safe removal of tracheal cannula is a major goal in the rehabilitation of tracheostomised patients to achieve progressive independence from mechanical support and reduce the risk of respiratory complications. A tracheal cannula may also cause significant discomfort to the patient, making verbal communication difficult. Particularly when cuffed, tracheal cannula reduces the normal movement of the larynx which can further compromise the basic swallowing defect. A close connection between respiratory, phonating, swallowing and feeding abilities to be recovered, implies a strict integration among different professionals of the rehabilitation team. An appropriate management of tracheostomy cannula is closely connected with assessment and treatment of swallowing disorders in order to limit the development of severe pulmonary and nutritional complications, but at present there are no uniform protocols in the scientific literature. Furthermore, several studies report as an essential criterion for decannulation the presence of good patient consciousness, which is often altered in patients with tracheostomy, but a general agreement is lacking.

To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state.Systematic review of randomized control trials (RCT) and nonrandomized controlled clinical trials (CCT) comparing any type of stimulation programmes with standard rehabilitation in patients in coma or vegetative state. The Injuries Group specialized register, the Cochrane Controlled trial register, EMBASE, MEDLINE, CINAHL, PSYCHLIT from 1966 to January 2002 were searched without language restriction. Reference lists of articles were scanned and experts in the area contacted to find other relevant studies. Abstracts and papers found were initially screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality, resolving disagreement by consensus.Duration of unconsciousness (including coma and vegetative state) defined as the time between trauma and objective recovery of the ability to respond to verbal commands; level of consciousness, as measured by the Glasgow Coma Scale (GCS); level of cognitive functioning (LCF); functional outcomes, as measured by Glasgow Outcome Scale (GOS) or by Disability Rating Scale; negative effects (e.g. increased intracranial pressure).Three studies (one RCT and two CCTs) with 68 traumatic brain-injured patients in total, most of whom were road accident victims, met the inclusion criteria. The overall methodological quality was poor and studies differed widely in terms of study design and conduct. Moreover, due to the diversity in reporting of outcome measures, a quantitative metanalysis was not possible. None of the three studies provided useful and valid results on outcomes of clinical relevance for coma patients.This systematic review indicates that there is no reliable evidence to support the effectiveness of multisensory stimulation programmes in patients in coma or the vegetative state.

Background Coma and vegetative state follow traumatic brain injury in about one out of eight patients, and in patients with non traumatic injury the prognosis is worse. The use of sensory stimulation for coma and vegetative state has gained popularity during the 1980's but beliefs and opinions about its effectiveness vary substantially among health professionals. Objectives To assess the effectiveness of sensory stimulation programmes in patients in coma or vegetative state. Search methods We searched the Injuries Group specialised register, the Cochrane Controlled trials register, EMBASE, MEDLINE, CINAHL and PSYCHLIT from 1966 to January 2002, without language restriction. Reference lists of articles were scanned and we contacted experts in the area to find other relevant studies. Selection criteria Randomised or controlled trials that compared sensory stimulation programmes with standard rehabilitation in patients in coma or vegetative state. Data collection and analysis Abstracts and papers found were screened by one reviewer. Three reviewers independently identified relevant studies, extracted data and assessed study quality resolving disagreement by consensus. Main results Three studies were identified with 68 patients in total. The overall methodological quality was poor and studies differed widely in terms of outcomes measures, study design and conduct. We therefore did not carry out any quantitative synthesis but reviewed results of available studies qualitatively. Authors' conclusions This systematic review indicates that there is no reliable evidence to support, or rule out, the effectiveness of multisensory programmes in patients in coma or vegetative state.

To contribute to the identification of relationships between the return to pre-trauma competitive activities at the final discharge from rehabilitation facilities, and neuroanatomical, neuropsychological and behavioural data collected at different phases of the recovery from a traumatic brain injury (TBI).Thirty-five severe TBI subjects were retrospectively selected from 228 consecutive admissions over a 3-year period, according to pre-morbid, clinical and demographic characteristics matching the established selection criteria, and submitted to comprehensive neurophysiological, intellectual, cognitive and behavioural examinations carried out at different stages of the recovery (acute, subacute and chronic phases).Barthel Activity of Daily Living (BADL) index, Wechsler Adult Intelligence Scale-Revised (WAIS-R), checklists aimed to detect cognitive and behavioural dysfunction.TBI subjects successfully re-employed obtained significantly better scores on length of coma and PTA, intellectual status, cognitive functioning and behavioural competence. Other specific measures of injury severity (CT-scan abnormalities, GCS score level, BADL index) resulted as being unrelated to the resumption of pre-trauma competitive activities.Findings seem to confirm the opinion that a significant relationship exists between the initial TBI severity level, especially as indicated by the duration of coma and PTA, and eventual return to work at the final discharge from facilities.

Objectives (1) To appraise, by the means of Rasch analysis, the internal validity and reliability of the Coma Recovery Scale-Revised (CRS-R) in a sample of patients with disorder of consciousness (DOC); and (2) to provide information about the comparability of CRS-R scores across persons with DOC across different settings and groups, including different etiologies. Design Multicenter observational prospective study. Setting Two rehabilitation wards, 1 intermediate care facility, and 2 nursing homes in Italy. Participants Consecutively admitted patients (N=129) for which assessments at 2 different time points were available, giving a total sample of 258 observations. Interventions Not applicable. Main Outcome Measure CRS-R. Results After controlling for any possible dependency between persons’ measures collected at different time points, and for uniform differential item functioning by etiology showed by the visual subscale, Rasch analysis demonstrated adequate satisfaction of all the model’s requirements, including adequate ordering of scoring categories, unidimensionality, local independence, invariance (χ 2 21 =27.798, P =.146), and absence of differential item functioning across patients’ sex, age, time, and setting. The reliability (person separation index=.896) was adequate for individual person measurement. We devised a practical raw score to measure conversion tables based on the CRS-R calibrations. Conclusions The CRS-R is a psychometrically sound and robust measurement tool. The linear measures of ability derived from the CRS-R total scores do satisfy all the principles of scientific measurement and are sufficiently reliable for high stakes assessments, such as the diagnosis of the level of consciousness in individual patients. Future studies are needed to directly explore the capabilities of the CRS-R measures to reduce the risk of vegetative state misdiagnosis.