Clinical Instability as a Predictorof Negative Outcomes AmongElderly Patients Admitted to aRehabilitation Ward

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DOI:1

ORIG

Fabio Guerini, MD, Giovanni B. Frisoni, MD, Sara Morghen, PsyD, Salvatore Speciale, MD, Giuseppe Bellelli, MD,and Marco Trabucchi, MD

Objectives: To assess the impact of clinical instability(CI) and delirium on admission to a rehabilitationunit on clinical and functional outcomes (death,transfer to acute care, poor functional recovery) atdischarge, in a population of elderly patients.

Design: Observational study.

Setting: Rehabilitation and Aged Care Unit (RACU).

Participants: Participants were 583 consecutively andfirstly admitted elderly patients.

Measurements: On admission, all patients underwenta comprehensive geriatric assessment including socio-demographics, cognitive and depressive symptoms,nutritional status, physical health, and functional sta-tus. CI was recorded for all patients on admission, as-sessing 5 vital signs (temperature, heart rate, systolicblood pressure, respiratory rate, and oxygen satura-tion). Delirium was assessed daily with the ConfusionAssessment Method.

Results: Patients were on average old (mean age: 77.8� 9.8), predominantly female (68.6%), with mild

ilitation and Aged Care Unit ‘‘Ancelle della Carita’’ Hospital, 26100,ona, Italy; Geriatric Research Group, Brescia, ITALY; LENITEM - Labora-f Epidemiology Neuroimaging & Telemedicine, IRCCS San Giovanni di

BF, Brescia, Italy; ‘‘Tor Vergata’’ University, Rome, Italy.

uthors have no conflicts of interest.

ss correspondence to Giuseppe Bellelli, MD, Rehabilitation and AgedUnit, ‘‘Ancelle della Carita’’ Hospital. 26100, Cremona, Italy. E-mail:li-giuseppe@ancelle.it

ight �2010 American Medical Directors Association

0.1016/j.jamda.2009.10.005

INAL STUDIES

cognitive deterioration (MMSE: 22.1 � 6.3) and de-pressive symptoms (GDS: 5.9 � 3.5). They had moder-ate comorbidity (means CIRS: 3.1 � 1.9), andfunctional impairment both before (Barthel Indexpre-admission: 84.5� 19.2; IADL: 3.3� 3.0) and on ad-mission (Barthel Index: 55.8 � 27.5). On admission,136 (23.3%) patients were classified as clinically un-stable: 76 (13%) had either CI or delirium, and 60(10.3%) had CI associated to delirium. At discharge,26 patients were transferred to acute care hospitals,and 14 died. Transfer to acute care occurred in morethan 10% of patients with almost one altered condi-tion (CI or delirium), and in one fifth of patients withthe association of CI and delirium. In-RACU death wasobserved only in this latter group. Functional recov-ery at discharge was significantly higher in stable pa-tients than in patients with CI and/or delirium.

Conclusions: CI and delirium are useful prognosticmarkers of adverse clinical and functional outcomesin a population of elderly subjects admitted to a reha-bilitative unit. (J Am Med Dir Assoc 2010; 11: 443–448)

Keywords: Clinical instability; delirium; outcomes;rehabilitation

There is a general agreement that in order to benefit frominpatient rehabilitation, patients must be medically stable, sothat ongoing medical problems do not interfere with partici-pation in therapy.1 However, the number of patients dis-

charged from acute care hospitals to postacute care facilitieswith unstable clinical conditions have significantly grownin the recent years, after the implementation of diagnosis-re-lated group-based prospective payment system.2,3

A recent retrospective cohort study on patients completinginpatient rehabilitation from 1994 through 2001 showedthat, despite patients’ similar functional status during thestudy period, mortality at follow-up increased,2 indirectly sug-gesting that medical stability of the patients admitted overthis time may have changed.

Other studies carried out on hospital-based populationshave shown that the proportion of patients discharged fromacute wards with clinical instability (CI) ranges from 16.8%in hip-fractured subjects to 19% in those with pneumonia,4,5

and that the presence of CI at discharge predicted a 5-fold

Guerini et al 443

greater risk of death or hospital readmission 60 days after dis-charge.4 Moreover, it has also been shown that delirium per-sists on admission to postacute care facilities in a proportionof patients ranging from 14% to 30%,6,7 and that this condi-tion is associated with adverse rehabilitative outcomes at dis-charge.8

The aim of this study was to assess the prognostic implica-tion of CI and delirium, alone or in combination, on clinicaland functional outcomes at discharge from rehabilitation.Furthermore, this study also aimed to highlight the need formore clinically oriented assessment in elderly patients under-going rehabilitative training for acute disabling conditions.

METHODS

Setting

The Rehabilitation and Aged Care Unit (RACU) is an 80-bed ward devoted to the rehabilitation of postacute andchronic disabilities of elderly patients. The most frequent rea-sons for RACU admission are postsurgical interventions (hipfracture surgical repair; hip or knee arthroplasty; abdominal,cardiac, or thoracic surgery), stroke (recent or chronic), pe-ripheral vascular diseases, subacute and chronic heart failure,subacute and chronic obstructive pulmonary diseases, Parkin-son diseases and parkinsonisms, or gait and balance disordersowing to a single or mixed etiology, including hypokineticsyndrome.9

Subjects

The study population was selected among all patients aged65 years and older (n 5 583) firstly and consecutively admit-ted from acute care hospitals to our RACU from January 1 toDecember 31, 2008.

The Ethic Committee of Gerontological Sciences of theGeriatric Research Group, Italy, approved all data collectionand the investigators, on RACU admission, obtained an in-formed consent from all patients. A proxy consent was ob-tained for those with moderate to severe dementia or delirium.

Comprehensive Geriatric Assessment

On admission, all patients underwent a comprehensive as-sessment including sociodemographics (age, gender), nutri-tional status (serum albumin and cholesterol, body massindex [BMI], Mini-Nutritional Assessment [MNA]),10–12

physical health (Cumulative Illness Rating Score [CIRS],number of drugs),13 cognitive status (Mini-Mental State Ex-amination [MMSE]),14 and depressive symptoms (15-itemGeriatric Depression Scale [GDS]).15 The CIRS is a screeningtool for comorbidity, assessing the chronic medical illnessburden while taking into account the severity of chronic dis-eases; the score for each of the 14 items can range from 1 (ab-sence of pathology) to 5 (maximum level of severity of thedisease). The Index of Disease Severity is the result of the av-erage score of the first 13 items, whereas the Comorbidity In-dex total score represents the number of items with a scoregreater than or equal to 3/5. Functional status was assessed re-ferring to the month before admission (Instrumental Activi-ties of Daily Living [IADL], Barthel Index [BI]),16,17 onadmission (BI), and then at discharge.

444 Guerini et al

Classification of Clinical Instability

Patients underwent a clinical examination by trained ger-iatricians (F.G., G.B.), to evaluate the presence of CI and/ordelirium on admission. CI was recorded for all patients refer-ring to 5 vital signs, according to previous studies of Halm andcolleagues4,18: temperature higher or equal to 37.8�C; heartrate higher or equal to 100/min; systolic blood pressure lowerthan 90 mm Hg; respiratory rate higher or equal to 24/min;oxygen saturation rate lower than 90% in patients not receiv-ing mechanical ventilation or supplemental oxygen by facemask. Patients were considered clinically unstable if at leastone vital sign was altered in the 24 hours following RACUadmission. Partially differing from Halm et al’s study,4,18 wedid not consider the inability to eat as a measure of CI becauseof the high prevalence of this condition in disabled patientsbefore admission.

The presence of delirium (evaluated with the ConfusionAssessment Method [CAM])19 was also recorded. TheCAM diagnostic algorithm involves 4 criteria: (1) an acutechange in mental status with a fluctuating course, (2) inatten-tion, (3) disorganized thinking, and (4) an altered levelof consciousness. Delirium was considered present if CAMcriteria 1 and 2 were present, along with either criterion3 or 4.

Outcomes at Discharge

Outcomes at discharge included the following:

- transfer to acute care hospital wards: we recorded every un-planned patient’s transfer from the RACU to an acute caremedical or surgical ward;

- deaths: we recorded only in-RACU deaths and notthose that occurred after a transfer to acute care hospitalwards;

- poor functional recovery (PFR): according to previous stud-ies,20,21 we assessed this outcome using the Relative Func-tional Gain (RFG) of the BI. The BI was assessed throughcaregivers’ reports referring to patients’ functional status 1month before admission (BIpread), on admission (BIad),and at discharge (BIdis). The basis for calculating theRFG is the patient’s specific potential for improvement(functional loss before admission). Because most of our pa-tients already presented a certain degree of chronic disabil-ity before RACU admission, we considered their pre-admission functional status as the highest functional statuspotentially achievable through rehabilitation. RFG wasthen computed according to equation (1):

100 � ðBIdis � BIadmÞ = ðBIpreadm � BIadmÞ (1)

PFR was defined as an RFG lower than 100% (ie, patientswho do not achieve their pre-admission functional status).

Data Management and Statistical Methods

All analyses were performed using the SPSS (StatisticalPackage for Social Sciences SPSS Inc., Chicago, IL) softwaretool, version 11.5. Significance between variables waschecked using 1-way analysis of variance (ANOVA). Where

JAMDA – July 2010

Table 1. Demographic, Clinical, and Functional Characteristics of 583 Patients Admitted to a Rehabilitation and Aged Care Unit, Stratified by ClinicalInstability and Delirium

Clinical Stability(n 5 447, 76.7%)

Clinical InstabilityOR Delirium(n 5 76, 13.0%)

Clinical InstabilityAND Delirium(n 5 60, 10.3%)

P

Mean ± SD or n (%) Mean ± SD or n (%) Mean ± SD or n (%)

DemographicsAge, y 76.4 � 9.9b,c 81.3 � 6.4a 83.7 � 6.7a .000Gender female 297 (66.4%) 58 (76.3%) 45 (75.0%) .122

Cognitive and affective statusMini Mental State Examination (0–30) 23.5 � 5.3b,c 18.6 � 6.7 a,c 15.4 � 7.6 a,b .000Geriatric Depression Scale (0–15) 5.6 � 3.3 7.0 � 3.8 6.9 � 4.0 .187

Health StatusIndex of Disease Severity* (CIRS) 1.7 � 0.3b,c 1.9 � 0.3a 2.0 � 0.3a .000Comorbidity Index* (CIRS) 2.8 � 1.4b 3.2 � 1.5a 3.2 � 1.4 .015Drugs on admission 5.1 � 3.4c 5.9 � 1.9 6.4 � 3.0a .001Serum albumin levels (g/dL) 3.3 � 0.4 2.9 � 0.4 2.9 � 0.6 .115

Malnutrition (computed with MNA) 20 (5.2%)b,c 16 (25.8%)a,c 19 (43.2%)a,b .000Functional Status

IADL (functions lost) 2.0 � 1.8b,c 3.2 � 1.8a 3.8 � 1.4a .001Barthel Index Pre-Admission (0–100) 86.4 � 18.1b,c 77.7 � 22.7 a 78.9 � 19.6 a .004Barthel Index Admission (0–100) 63.5 � 24.3b,c 32.4 � 22.3 a 28.3 � 21.3 a .000Barthel Index Discharge (0–100) 83.3 � 20.6b,c 60.9 � 28.4 a,c 40.5 � 31.8 a,b .000

Length of Stay, days 26.1 � 11.0b 31.4 � 11.3 a 26.9 � 16.2 .000

MNA, Mini Nutritional Assessment; IADL, Instrumental Activities of Daily Living.* Index of Disease Severity denotes the average score of the first 13 items at the Cumulative Illnesses Rating Scale (CIRS); Comorbidity Index

denotes the number of items at the CIRS with a score greater or equal to 3/5. P denotes significance between variables using 1-way analysis ofvariance (ANOVA). Where significant group effects were detected, Bonferroni test indicated significant post hoc differences between individ-ual groups, as follows:

a significant difference to the group with clinical stability.b significant difference to the group with clinical instability OR delirium.c significant difference to the group with clinical in stability AND delirium.

significant group effects were detected, Bonferroni test indi-cated significant post hoc differences between individualgroups.

RESULTS

Patient Characteristics

Patients (n 5 583) were on average old (mean age: 77.8 �9.8), predominantly female (68.6%), with mild cognitive de-terioration (MMSE: 22.1 � 6.3) and depressive symptoms(GDS: 5.9 � 3.5). They had a moderate comorbidity (meanCIRS-comorbidity score: 3.1 � 1.9), and functional impair-ment both before (BI pre-admission: 84.5 � 19.2; IADL:3.3 � 3.0) and on admission (BI: 55.8 � 27.5). The meanlength of RACU stay was 26.9 � 11.8 days.

On admission, 136 (23.3%) patients were classified as clin-ically unstable: 76 had either CI or delirium (13.0%) and 60had CI associated with delirium (10.3%). Reasons for CI weretemperature (4.3%), respiratory rate (8.7%), heart rate(7.0%), systolic blood pressure (5.8%), and oxygen saturation(7.7%). On RACU admission, 19.2% of all subjects were pos-itive on delirium screening.

Table 1 shows clinical and functional characteristics of allpatients stratified in 3 groups according to the absence or thepresence of CI and/or delirium. As expected, patients with CIand/or delirium were older, had lower cognitive performanceand more depressive symptoms, worse nutritional status (asexpressed by serum albumin levels and MNA scores), andhigher severity of illnesses in comparison with stable patients.

ORIGINAL STUDIES

Furthermore, patients with CI were generally more function-ally dependent before RACU admission, had worse func-tional recovery, and were more disabled at dischargecompared with stable patients. All clinical and functionalconditions were significantly worse for patients in the groupwith CI and delirium. As expected, stable patients had theshortest length of stay (LOS). However, although not statis-tically significant, LOS of patients with CI and delirium wasshorter than LOS of patients with CI or delirium (26.9� 16.2vs 31.4� 11.8 days, respectively), probably because of the fre-quent transfer to acute care hospitals of patients in the firstgroup.

Outcomes

During RACU stay, 26 patients (4.6%) were transferred toacute care hospitals, and 14 (1.7%) died; at discharge, 236(40.5%) patients did not obtain a complete recovery of thepre-admission functional status. Figure 1 shows that transferto acute care hospital occurred in 11.8% of patients with atleast 1 altered condition (CI or delirium), and in 18.3% of pa-tients with both CI and delirium. In the RACU, deaths wereobserved only in patients of the latter group (CI and delirium,23.3%). Additionally, patients with CI and delirium had thehighest rate of PFR (88.2%), followed by the patients with CIor delirium (79.5%), then the stable patients (38.2%), in a de-creasing order.

The risk of death predicted by the presence of CI and de-lirium is striking (no deaths were observed in the other

Guerini et al 445

2 0

38,2

11,8

0

79,5

18,3 23,3

88,2

0

10

20

30

40

50

60

70

80

90

100

Transfer to Acute CareHospital (P=.000)

Death During RACU Staying(P=.000)

Poor Functional Recovery(P=.000)

%

Clinical stability Clinical Instability OR Delirium Clinical instability AND Delirium

Fig. 1. Adverse outcomes in a population of 583 patients consecu-tively admitted to a Rehabilitation and Aged Care Unit stratified byclinical instability.Transfer to acute-care hospital was defined as every unplanned pa-tient’s transfer from the RACU to an acute care medical or surgicalward. Poor Functional Recovery was defined as a Relative Func-tional Gain lower than 100% (i.e. patients that do not achieve theirpre-admission functional status).

groups), thus not requiring further analysis to assess prognos-tic implications. The unadjusted and adjusted regressionmodels assessing the power of CI and delirium (stratified in3 dummy variables, with stable patients as the referencegroup) and other covariates to predict adverse outcomes(transfer to acute care hospital and poor functional recovery)are shown in Table 2. It could be observed that the combina-tion of CI and delirium was associated with the highest risk ofadverse outcomes, whereas the presence of only one condi-tion (CI or delirium) to a lower although significant risk. Inparticular, the presence of CI or delirium predicted a 6-foldrisk of transfer to acute care hospital, whereas the associationof CI and delirium predicted a 10-fold risk. Interestingly, theonly other factor associated with transfer to acute care hospi-tal was comorbidity (expressed as the CIRS severity score),whereas malnutrition was the only other variable significantlyassociated with poor functional recovery.

DISCUSSION

Our study shows that more than one fifth of elderly patientsconsecutively admitted to a RACU had CI and/or deliriumon admission, and that these conditions are associated withnegative outcomes at discharge (deaths, transfer to acutecare hospitals, poor functional recovery). It may be also usefulfrom a practical standpoint because problems such as CI anddelirium are often associated with elderly patients dischargedfrom acute care hospitals.4,7 In this framework, the ability todiscriminate patients with mainly clinical needs from thosewith predominantly physiotherapeutic needs is crucial. Forthis purpose, we carried out this study demonstrating that rec-ognition of 5 basic parameters and/or delirium is useful on ad-mission to stratify the prognosis of elderly patients inpostacute care.

Several tools aimed to predict adverse clinical outcomeshave been validated in heath care settings; however, mosthave been used in acute and only a few in postacute care.

446 Guerini et al

The APACHE II (Acute Physiology and Chronic HealthEvaluation II)22 score is a severity of disease classification sys-tem, measuring 12 parameters (blood pressure, body temper-ature, heart rate, respiratory rate, arterial oxygenation andpH, serum sodium and potassium, serum creatinine, hemato-crit in percent, white blood cells count, Glasgow coma score)during the first 24 hours after admission, and collecting infor-mation about previous health status and individual variables(age, chronic diseases, and so forth). The global score rangesfrom 0 to 71, with higher values indicating more severe clin-ical conditions. Several studies have shown that the globalAPACHE score is a good prognostic tool for short-term clin-ical outcomes, including mortality.23,24 However, a limit ofthis tool is that the measurement of some parameters (suchas biochemical and blood gases examinations) necessarily de-pends on the availability of laboratory equipment, so that allrequired information might not be easily gathered in everysetting.

Other tools such as CURB 65,25,26 the Toronto RiskScore,27 and the Serious Cardiac Adverse Events score(SCAEs)28 have been validated for predicting mortalityonly in patients with a single predominant clinical condition(ie, pneumonia, cardiac surgery, and ischemic stroke), thuslimiting the transferability of their prognostic power in a post-acute care setting where patients have usually high comorbid-ity and multiple potential causes of CI.

In postacute clinical settings, Bernardini and colleagues29

were the first to assess the impact of active clinical issues onnegative outcomes. In a multicenter study on 4 Italian geriat-ric rehabilitation facilities, the authors evaluated the clinicalcharts of 106 patients admitted to rehabilitation after hipfracture surgical repair, finding that patients with adverseclinical events had worse functional recovery and highernursing home placement rate. However, the study was retro-spective and authors classified adverse clinical events by thenecessity of clinical monitoring and therapeutic interven-tion, without a direct evaluation of symptoms and signs un-derlying the development of adverse clinical events.Furthermore, the selection criteria of a single typology of pa-tients (hip fractured) could have excluded a wide group ofother comorbid patients (respiratory, cardiologic, neurologic,and so forth) frequently admitted to rehabilitation settingswith CI.

Recently, the MDS-Changes in Health, End-stage diseaseand Symptoms and Signs (MDS-CHESS) score has been pur-posed to predict clinical outcomes in long-term care facili-ties.30 This instrument has been demonstrated to havea good predictive power on 3-year mortality and possible im-plications as a measure for instability in health amongchronic disabled patients. However, the analyses were retro-spective in this study also and the main outcome measure (ie,3-year mortality) is not as useful as a routine practical tool inrehabilitation settings with shorter length of stays, such asRACU and Intensive Rehabilitation Facilities.9 Further-more, health instability has been measured with parameters(such as dehydration, leaving 25% of food uneaten, deteriora-tion in MDS cognition and activities of daily living, presenceof end-stage disease) dependant on subjective clinical

JAMDA – July 2010

Tab

le2.

Pre

dict

ive

Pow

erof

Clin

ical

Inst

abili

tyan

dD

elir

ium

onT

ran

sfer

toA

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-Car

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nd

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rF

un

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nal

Rec

over

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58

3P

atie

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atD

isch

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from

aR

ehab

ilita

tion

Un

itin

Biv

aria

tean

d

Mu

ltiv

aria

teM

ultip

leL

ogis

tic

Reg

ress

ion

Mod

els

Tran

sfer

Acu

teC

are

Ho

spit

al

Po

or

Fun

ctio

nal

Reco

very

Un

ad

just

ed

Ad

just

ed

Un

ad

just

ed

Ad

just

ed

OR

95%

CI

PV

alu

eO

R95%

CI

PV

alu

eO

R95%

CI

PV

alu

eO

R95%

CI

PV

alu

e

Cli

nic

al

stab

ilit

yR

ef

——

Ref

——

Ref

——

Ref

——

Cli

nic

al

inst

ab

ilit

yO

RD

eli

riu

m6.5

2.5

to17.0

.000

7.5

2.2

to25.4

.001

6.2

3.3

to11.1

.000

4.5

2.2

to9.2

.560

Cli

nic

al

inst

ab

ilit

yA

ND

Deli

riu

m10.9

4.3

to27.4

.000

15.2

4.0

to55.9

.000

12.1

3.2

to44.8

.000

10.0

3.3

to29.9

.033

Ind

ex

of

Dis

ease

Severi

ty(C

IRS)*

——

—5.4

1.6

to18.3

.007

——

——

—n

.s.

Maln

utr

itio

n(M

NA

)—

——

——

n.s

.—

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2.3

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Bart

hel

Ind

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mis

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n—

——

——

n.s

.—

——

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.

OR

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95%

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.:n

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:no

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as

aR

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100%

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valu

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(CIR

S).

ORIGINAL STUDIES

judgment rather than objective and rater-independent mea-surements. On the contrary, our study had a prospective de-sign and the assessment of both clinical parameters andnegative outcomes have been provided with objective mea-surements.

Interestingly, we observed a dose-effect relationship be-tween presence of CI and/or delirium and the risk of negativeoutcome at discharge. In fact, people with either one alteredvital parameter or delirium had intermediate rates of preva-lence in unplanned transfers to acute care hospital and poorfunctional recovery, whereas the group with both CI and de-lirium had the highest rate of prevalence in all negative out-comes. Moreover, in-RACU deaths occurred only in thislatter group.

Taken together, these data suggest that CI and delirium arebasic elements of the geriatric rehabilitative assessment andmay represent a possible target for intervention. From a prac-tical perspective, the basal assessment of these conditionsmay help to promptly recognize critical patients, to plan ap-propriate interventions, and therefore to tailor the use of re-sources. For example, it could be useful to select patientseligible for high-intensity rehabilitation training from thosewho require an increased level of clinical and nursing assis-tance. From a policy maker’s health care perspective, the as-sessment of CI and delirium could be used as a criterion toallocate patients in dedicated areas, with an intermediatelevel of care between the intensive care units and the typicalrehabilitation facilities. Could we hypothesize the develop-ment of ‘‘clinical instability rooms’’ in line with the exampleof ‘‘delirium rooms’’?31

The finding that malnutrition and comorbidity are inde-pendent predictors of negative outcomes in geriatric rehabil-itation patients has already been stated in the literature.Donini et al,32 for example, found that poor nutritional statusindependently predicted not only the incidence of adverseclinical events, assessed according to the definition of Bernar-dini et al,29 but also of in-hospital mortality. In line withthese data, other studies found that serum albumin, a biologi-cal marker of poor nutritional status, was the strongest predic-tor of 2-year mortality,33 and that hypoalbuminemiaassociated with hypocholesterolemia (another marker of mal-nutrition) further increases the risk of disability and short-term mortality.34 With regard to comorbidity, Bellelli et al9

found that it predicted the 12-month risk of negative out-comes, including institutionalization, rehospitalization, anddeath and Patrick et al35 showed that it also affects rehabili-tation efficiency. Whether the intensive treatment of poornutritional status and comorbidity may improve clinical out-comes will be assessed in future studies. In the meanwhile, weare inclined to promote the creation of specific protocols fornutritional supplementation and for the treatment of comor-bid conditions in clinically unstable patients.

We must highlight some limitations of this study. First, ithas been carried out at a single site, and therefore its resultsare not immediately transferable to other similar settings.Other studies are needed to better clarify the importance ofCI and delirium evaluation in rehabilitative settings. An-other limit is that we did not measure whether more intensive

Guerini et al 447

clinical care of patients with CI and/or delirium could havechanged the findings.

In conclusion, this study suggests that the routine observa-tion of 5 basal parameters and delirium in a population of el-derly subjects admitted to rehabilitative settings may bea useful prognostic tool to predict negative outcomes at dis-charge. In light of the prevalence of these conditions, we sug-gest incorporating the assessment of CI and delirium in theroutine everyday practice of rehabilitative settings.

ACKNOWLEDGMENTS

Sincere appreciation is due to Elena Lucchi, AlessandraMarre, Eleonora Ricci, Valeria Tirelli, Tiziana Torpilliesiand Renato Turco for their support in collecting data, tothe team of physical therapists for their support in rehabilita-tion activities, and to Christian Pezzin for reviewing theEnglish version of this document.

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