Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine

There is confusion in the rehabilitation literature about case-control studies because terms such as "cases" and "controls", used to refer to the subjects in the study, are confused with the design of the study. The aim of this study was to estimate the extent to which the label "case-control study" is misused in the rehabilitation literature and in the literature of other health disciplines. A structured review revealed 7 rehabilitation journals, which, during the period 2000-2006, published 86 research articles in which the key word "case-control" or "case control" appeared in the title or abstract. For comparison purposes, other English language journals whose titles began with "Archives of" were also searched. The proportion of mislabeled case-control studies in rehabilitation journals was 97% (83 of 86 studies were mislabeled). In contrast, 34% (76 of 221) of case-control studies published in the sample of non-rehabilitation journals were found to be mislabeled. The most frequent type of rehabilitation study misclassified as case-control was a cross-sectional study (56/86) followed by intervention studies (13/86). The extent of mislabeling indicates that the case-control design is poorly understood by the rehabilitation community. This is not solely an issue of semantics; mislabeling led to misinterpretation of findings. In rehabilitation, the research questions answered by case-control studies, regarding the etiology of health events, are rarely posed. Rehabilitation researchers must be attentive to issues of design and report correctly on design in publications.

Rehabilitation professionals rarely ask questions about the etiology of health events or outcomes and may not have formal training or relevant experience in the design of studies whose intent is to identify causal factors. The case-control study, which is one design used to answer questions about etiology, is particularly difficult to understand and research has shown that this study design label is often used incorrectly. This paper outlines the main features of case-control studies, with a particular focus on sampling strategies. The goal is to educate clinical rehabilitation colleagues about the fundamental principles of this powerful epidemiologic design. Examples illustrate how the parameters of cumulative incidence, incidence-density, and prevalence are estimated and the effect of sampling strategy on these parameters. Also shown is how sampling strategy affects conclusions drawn about the effects of an exposure on outcome. Even when used appropriately, case-control studies are methodologically complex to design and analyze to ensure an unbiased answer to the research question. The hypothetical and real-life examples given here could be used as course material to educate rehabilitation researchers.

To investigate, in patients with mild traumatic brain injury, serum concentrations of S-100B and neurone-specific enolase in acute phase and post-concussion symptoms, disabilities and life satisfaction 1 year after the trauma. Prospective study. Eighty-eight patients (age range 18-87 years). Blood samples were taken on admission and about 7 hours later. At follow-up 15 +/- 4 months later, the patients filled in questionnaires about symptoms (Rivermead Post Concussion Symptoms), disability (Rivermead Head Injury Follow-up) and life satisfaction (LiSat-11). Concentrations of S-100B and neurone-specific enolase were regularly increased in the first blood sample. Of the 69 patients participating in the follow-up, 45% reported post-concussion symptom, 48% exhibited disability and 55% were satisfied with "life as a whole". In comparison with the "sick-leave" situation on admission to hospital, 3 patients were on sick-leave at the time of follow-up because of the head trauma. Stepwise forward logistic regression analysis revealed a statistically significant association (p<0.05) between disability and S-100B and dizziness. In spite of frequent persistent symptoms, disabilities and low levels of life satisfaction, the sick-leave frequency was low at follow-up. The association between S-100B and disability supports the notion that long-term consequences of a mild brain injury may partly be a result of brain tissue injury.

To evaluate validity and reproducibility of hand-held dynamometry in 11 different muscle groups in children. Maximum isometric muscle strength was measured with a calibrated hand-held dynamometer in 61 patients aged 4-11 years who had been referred to our specialist centre in the past 3 years because of suspected myopathy. All the patients had had muscle biopsy. Validity was assessed by the power to discriminate between patients with and without myopathy, using logistic regression analysis and receiver operating characteristic analysis and sensitivity and specificity at a specifically chosen cut-off point. Reproducibility was evaluated by test-retest reliability in a stratified random sample of 40 patients who returned for re-measurements, using the intraclass correlation coefficient and the standard error of measurement. In the patients, areas under the receiver operating characteristic curve ranged from 0.66 to 0.88. At a specifically chosen cut-off point, sensitivity varied from 73% to 87%, while specificity varied from 54% to 80%. Intraclass correlation coefficients ranged from 0.73 to 0.91. The standard error of measurement ranged from 3.3 N to 12.2 N. Performance of hand-held dynamometry varied widely in the 11 muscle groups. Highest performance was observed in the elbow flexors. Test-retest reliability of the mean value of 2 efforts was generally higher than the maximum value.

To examine the association between socioeconomic position and coping strategies in musculoskeletal pain. Cross-sectional study of a random sample of 40- and 50-year-old Danes, participation rate 69%, n=7,125. The study included 1,287 persons who reported functional limitations due to musculoskeletal pain. Data was collected by postal questionnaires and scales were developed on problem-solving coping and avoidant coping, based on a range of preliminary studies. Multivariate logistic regression analyses was used to study the correlation with socioeconomic position, measured by occupational social class. Among women, there was no correlation between social class and avoidant coping, but a significant decrease in the use of problem-solving coping by decreasing social class, adjusted odds ratio (OR) = 2.64 (95% confidence interval (CI) 1.31-5.32) in social class V vs social classes I + II. Among men, there was no correlation between social class and problem-solving coping, but a significant increase in the use of avoidant coping with decreasing social class, adjusted OR = 3.31 (95% CI 1.75-6.25) in V vs I + II. It is important for clinicians who advise and support patients in their response to musculoskeletal pain to be aware of socioeconomic differences in coping strategies. Gender differences in the association between socioeconomic factors and coping should be further investigated.

To examine rehabilitation interventions and resulting physical activity patterns of patients managed in acute stroke units to help inform development of a randomized controlled trial of very early rehabilitation. An open observational study of patient activity and therapist report of patient interventions. A survey of stroke unit resources. Patients less than 14 days post-stroke from 5 metropolitan stroke units were observed over 2 consecutive weekdays at 10-minute intervals between 08.00 h and 17.00 h. Physical activity, location and person(s) present were ascertained at each observation. Therapists completed treatment records. Senior staff completed stroke unit surveys. Patients after stroke (n=58) were with therapists 5.2% of the observed day. Few patients (17.1%) received daily therapy by more than one therapist. When patients received therapy, average session times were 24 minutes of physiotherapy, 23 minutes of occupational therapy and 33 minutes of speech pathology. The more time that family members were present, the longer the treatment time. Four to 11 min of upper-limb therapy was provided. Muscle weakness and left hemiparesis were associated with less upper-limb activity. These acute stroke care units were resourced according to recommended staff-patient ratios. Patients received little therapy and had low levels of physical activity.

To demonstrate how the International Classification of Functioning, Disability and Health (ICF) can be used to create coded functional status indicators specific for stroke from a simple stroke-specific functional index, the Stroke Impact Scale-16 (SIS-16). Nineteen professionals for the mapping portion and 8 persons with stroke for the cognitive debriefing portion. Participants were asked to identify appropriate codes for the corresponding items of the SIS-16 following a structured protocol for mapping measures to the ICF. A Delphi technique was used in order to reach consensus for as many items as possible. In addition, cognitive debriefing was conducted with persons with stroke. A total of 13 items had Functional Status Indicators endorsed (8 items at the 4 digit level and 5 items at the 3 digit level). There were 3 items that did not reach consensus. The cognitive debriefing sessions demonstrated the differences in interpretation from the persons with stroke and the intentions by the developers. This study has shown how the ICF can capture most items from functional status measures, such as the SIS-16. Furthermore, the items can be used to map onto a standard coding framework, illustrating the potential for increased use of Functional Status Indicators.

To evaluate the activity and participation levels of adults with spastic diplegia 17-26 years after selective dorsal rhizotomy; to investigate relationships between subjects' functioning and age, socio-economic-status, level of satisfaction and their perceptions of the post-operative outcomes. Observational follow-up study. Thirty-one subjects with spastic diplegia, age range 21-44 years, who underwent selective dorsal rhizotomy between 1981 and 1991. A semi-structured interview was used to gather data on patients' characteristics and long-term experiences after the operation. The Functional Mobility Scale and Life-Habit questionnaire were completed. Based on the Functional Mobility Scale 84% of subjects were reported as independent for a distance of 5 m, and 61% for 50 and 500 m. Eighty percent were independent in accomplishing all life habits, with most problems found for Mobility and Recreation. This was in agreement with the subjects' perception, with strong correlations between Life-Habit questionnaire accomplishment and satisfaction levels. No significant associations were found between functioning and age at selective dorsal rhizotomy, current age and socio-economic status. More than 15 years after selective dorsal rhizotomy, adults with spastic diplegia showed high levels of functioning, and similar levels of satisfaction with life habits. The majority had positive feelings about the neurosurgical procedure, although there is a need for better follow-up after subjects leave school.

The aim of this study is to relate different sociodemographic, health and physical activity parameters to levels of satisfaction with life as a whole and with 10 specific domains of life. Data on socio-demographic items were sampled, using strictly structured interviews, while a checklist (LiSat-11) was used for self-reported levels of life satisfaction. A nationally representative Swedish sample of 1207 women and 1326 men aged 18-64 years. Univariately most of these socio-demographic variables were associated with several of the LiSat-11 items. Using logistic regression, perceived good health and not being a first generation immigrant were the most prominent positive predictors of satisfaction with life as a whole and of most of the domains. Also educational level impacted predictively on satisfaction with many LiSat-11 items. Furthermore, those who were vocationally active, perceived their financial situation as better than or similar to most people's and had a steady partner relationship were particularly likely to be satisfied with life as a whole and with two or more of the domains. These results indicate that a multitude of aspects must be taken into account when assessing life satisfaction.

Objective: To describe changes in health-related quality of life in people with lower limb amputation, from time of amputation to 18 months, taking into consideration the influence of age and walking distance. In addition, quality of life for people with amputation is compared with the Dutch population norm values. Design: Multicentre, longitudinal study. Subjects: All people undergoing first amputation: 106 were referred, of whom 82 were included, mean age 67.8 years (standard deviation; SD 13.0), 67% men. A total of 35 remained in the study at 18 months. Methods: Dutch language RAND-36 questionnaire (Research and Development Corporation measure of Quality of Life) was completed at time of amputation, 6 and 18 months after amputation. Results: Over time, a significant improvement was seen in physical function, social function, pain, vitality, and perceived change in health (all p < 0.001). Subjects over 65 years of age had a poorer outcome compared with people <65 years for physical function only (p < 0.001). Walking distance was associated with improved scores in social function (p = 0.047). Conclusion: Quality of life improved significantly in 5 of 7 domains investigated; most change occurred in the first 6 months. Physical function remained well below population norm values. Different domains may be affected in different ways for older and younger age groups, but this requires further research.

Satisfaction with life as a whole and with 10 domains of life was assessed in a nationally representative Swedish sample of 1207 women and 1326 men aged between 18 and 64 years, using a generic self-report checklist (LiSat-11), with levels of satisfaction ranging along a six-grade ordinal scale from 1 (very dissatisfied) to 6 (very satisfied). The main findings are that, with marginal exceptions, life satisfaction is gender independent, while age is systematically and positively associated with vocational and financial situations. Having no partner and being a first-generation immigrant implies for most LiSat-11 items a relatively low level of satisfaction. Factor analysis of the domain-specific items yields a gender-independent four-factor structure, which is robustly independent of different scaling reductions. Gross levels of satisfaction (dichotomized scales 1-4 vs 5-6) of seven domains were significant classifiers (odds ratio 1.7-3.9) of gross level of satisfaction with life as a whole. This investigation provides reference values for LiSat-11, which, with its ease of administration may be an adequate instrument for analysing, in terms of subjects' cognitive appraisal of emotions, aspirations-achievement gaps.

The "learned non-use phenomenon" described by Taub, one of the most original recent contributions to rehabilitation medicine probably corresponds to what Henry Meige (1866-1940), who studied under J.-M. Charcot, described in hemiplegics in 1904 using the expression "functional motor amnesia". He specified in 1914 at the time of the Babinski description of anosognosia, that: "Even with educated subjects who are still relatively young we are sometimes confronted with strange incapacities that are not due to impotence, negligence, or lack of confidence in the results. [...] With the transitory halting of the motility all memory of the function appears to have disappeared". Meige describes motor disorders that are: (i) distinct from lesional paralyses; (ii) secondary to the absence of activity; (iii) linked to a learning process; (iv) linked to a phenomenon of functional memory loss; (v) reversible; and (vi) motor re-education focusing on extended and repeated practice of the lost function: the same characteristics as the "phenomenon of learned non-use" described by Taub in monkeys then in man.

To evaluate the incidence and causes of mild traumatic brain injury in Sweden. Retrospective, population-based incidence cohort study. All persons presenting to hospitals in Sweden between 1987 and 2000 with a discharge diagnosis of ICD-9 code 850 and ICD-10 code S0.60. Data source was the Hospital Discharge Register at the National Board of Health and Welfare (Sweden). Incidence rates are stratified by age, gender, mechanism of injury and length of hospital stay. Men had a mean of 209 mild traumatic brain injuries per 100,000 inhabitants and women averaged 148 per 100,000. Men had more mild traumatic brain injury than women at all ages. There were 2 incidence peaks, in the age strata 16-20 years and those over 65 years. Falls were the most common cause of mild traumatic brain injury overall and occurred commonly under the age of 10 years and over the age of 65 years. Motor vehicle and bicycle injuries were the second and third most common causes of mild traumatic brain injury, and had their peak incidence in those aged 16-35 years. Preventative strategies for mild traumatic brain injury should be age and gender specific.

To evaluate upper limb functioning, restrictions on participation and the independent contribution of upper and lower limb disability to participation in hereditary motor and sensory neuropathy 1a. Descriptive cross-sectional study. Forty-nine patients with hereditary motor and sensory neuropathy 1a. Perceived upper limb functioning was evaluated using the Michigan Hand Outcomes Questionnaire and participation restrictions with the Impact on Participation and Autonomy Questionnaire. Upper and lower limb domains of Guy's Neurological Disability Scale were used to determine their impact on participation restrictions. Limitations in upper limb functioning were perceived by 98% of the patients. Median scores ranged between 70 points for overall hand function and 100 points for aesthetics (scale 0-100). Patients were least satisfied with dominant hand performance. Most patients (46-78%) reported their participation to be sufficient. Restrictions were reported in the domains work, family roles, and autonomy outdoors. Minor problems with restricted participation were indicated by 22-55%, severe problems by 2-12%. Upper limb functioning correlated significantly with all participation subscales. Upper limb disability was independently associated with participation restrictions, whereas lower limb disability was not. Limitations in upper limb functioning were perceived by the majority of patients with hereditary motor and sensory neuropathy 1a and strongly related to restricted participation.

To assess the prevalence and significance of impaired manual dexterity in hereditary motor and sensory neuropathy type 1a (HMSN 1a), with the Sollerman hand function and the Functional Dexterity test, and compare the reliability and agreement of the tests. Descriptive cross-sectional study. Forty-nine subjects with HMSN 1a. Forty-six (94%) subjects had an abnormal Sollerman sum score (< 80) for the dominant hand. The most difficult subtests required finger grips such as pulp, tripod and lateral pinches. Dexterity scores of both hands were categorized as "moderately functional". Test-retest reliability was excellent for the Sollerman test, with intraclass correlation coefficients between 0.98 and 0.99 (95% confidence interval (CI) 0.97-0.99), and good for Functional Dexterity test scores with correlation coefficients between 0.83 and 0.95 (95% CI. 71-0.97). The 95% limits of agreement between Sollerman tests showed that differences greater than 3 points can be interpreted as a change in dexterity. The Functional Dexterity test limits were wide. Impaired manual dexterity is common among subjects with HMSN 1a, stressing that the evaluation of dexterity is an essential element of the functional assessment. Both tests are able to detect impaired manual performance in HMSN 1a. For monitoring of disease progression and the effects of treatment programmes the Sollerman test is most suitable.

Objective: To evaluate the measurement properties of the Wheelchair Use Confidence Scale for manual wheelchair users version 2.1 (WheelCon-M 2.1). Design: Cohort study. Participants: Volunteer sample of 83 community-dwelling, experienced manual wheelchair users. Methods: Participants completed the WheelCon-M 2.1 twice to assess retest reliability. Validity was assessed by evaluating hypothesized relationships between the WheelCon-M 2.1 and relevant variables. Responsiveness was assessed using the standard error of measurement (SEM) and smallest real difference (SRD). Results: The median (interquartile range) WheelCon-M 2.1 score was 84.6 (71.3-92.0) of a possible 0-100. The one-week retest intraclass correlation coefficient was 0.84 with 95% bias-corrected and accelerated confidence intervals of 0.77-0.90. Cronbach's alpha was 0.92. Correlations ranging from rs = -0.19 (p = 0.780) to rs = 0.58 (p < 0.001) were found between the WheelCon-M 2.1 and other relevant outcome measures with all correlations being statistically significant except for age (p = 0.780) and social support (p = 0.057). A statistically significant difference was not found between the sexes (p = 0.140). The SEM and SRM were 5.9 and 16.4, respectively. Conclusions: WheelCon-M 2.1 has high internal consistency, strong retest reliability, and support for concurrent validity, construct validity and responsiveness. This new test holds promise as a clinical and research tool.

Objective: To establish trends in whiplash-related health service use and cost in Victoria, Australia. Design: Administrative data analysis. Subjects: Whiplash patients claiming Transport Accident Commission (TAC) compensation for accidents dating between 1 January 2000 and 31 December 2009 (n = 51,263). Methods: Injury-related health service use during one year following the accident was determined from claim payment records. The incidence of whiplash claims in Victoria was calculated, as were inflation-adjusted health care costs. Results: In 2000-2009, the incidence of compensable whiplash decreased from 1.56 to 1.14 per 1,000 person-years. Physiotherapy, pharmaceuticals, general practitioner, chiro-practic, radiology and osteopathy sessions were the most commonly claimed services. General practitioner, allied health and radiology services decreased, but analgesic use increased. Per person-years in the population, whiplash-related medical expenses were 71% greater for women than men. Overall, population burden decreased by 38%; the decline was most pronounced in persons aged 18-24 (54% decrease) and least pronounced in those aged ≥ 55 (23% decrease). Conclusion: The population-based health service cost of whiplash decreased between 2000 and 2009. The overall reduction was related to a decrease in incidence and a reduction in service use per whiplash claim.

Objective: To analyse the 9-year trend in oral intake ability 3 months after onset in acute stroke patients, with a view to indirect clarification of advances in acute stroke treatment and swallowing rehabilitation. Methods: A database of patients admitted to our hospital (Saiseikai Kumamoto Hospital, Kumamoto) with acute ischaemic stroke between 2003 and 2011 was analysed. Exclusion criteria were: patients with premorbid modified Rankin Scale score ≥ 1; those who died during hospital stay; and those whose outcomes after 3 months were not recorded. Mode of nutritional intake was investigated with a questionnaire posted to the patient 3 months after stroke onset. Patients were divided into 2 groups according to mode of nutritional intake: an oral intake group and a non-oral intake group. Whether the date or year of admission were related to the proportion of patients with oral intake, independent of other factors, was investigated using a logistic regression model. Results: Of a total of 2,913 patients, 2,677 (91.9%) were included in the oral intake group. The proportion of patients with oral intake 3 months after stroke increased significantly over the period of analysis (p = 0.034 by Cochran-Armitage test). On logistic regression analysis, the trend was significant after adjustment for age, sex, vascular risk factors, stroke subtype, and stroke severity on admission (odds ratio 1.098, 95% confidence interval 1.029-1.173; per 1 year). Conclusion: The proportion of ischaemic stroke patients in the institution studied who were capable of oral intake at 3 months post-stroke increased significantly over the past decade, independent of other patient characteristics.

To explore construct(s) (ability, capability, actual performance, and/or perceived difficulty) of activities of daily living measures that have been used in randomized controlled trials. Three databases (Medline, CINAHL, and OTSeeker) were searched. A questionnaire was sent to the author of each eligible study requesting information about the activities of daily living construct(s) that were adopted in his/her study. A total of 106 studies, which altogether used 17 different activities of daily living measures, were found. Among these, only 12 studies specified in the paper the activities of daily living construct assessed; 7 studies assessed "ability" and 5 assessed "actual performance". Only 20% of the randomized controlled trials authors reported the mode of administration in the paper. Authors of 34 studies replied to our questionnaire. The most commonly used activities of daily living measures (i.e. the Barthel Index (either the 0-20 or 0-100 scoring version) and the Functional Independence Measure) were employed for assessing various constructs of activities of daily living, with inconsistency between the studies. In stroke randomized controlled trials that measured activities of daily living as an outcome, the measures were used for assessing various construct(s) of activities of daily living (including ability, capability, actual performance, and/or perceived difficulty). This could hamper data interpretation, meta-analysis, and the translation of evidence into clinical practice.

Whilst prognostic factors for recovery from whiplash associated disorders have been documented, factors related to high physiotherapy use are not well recognized. This study profiles predictors for high use of physiotherapy services from a large dataset from an Australian state insurer for motor vehicle accidents. A dataset of Motor Accident Commission claims in South Australia for whiplash associated disorders (2006-2009) was interrogated. The median number of physiotherapy services per claimant was 15 (range: 1-194). The typical high user of physiotherapy was female, aged 25-59 years, living in a high socio-economic area, with legal representation, who delayed obtaining physiotherapy for at least 28 days after the accident. The largest mean number of days between treatments (5.4 days) in the first 5 treatments related to the lowest subsequent use of physiotherapy services. This represents the first review of physio-therapy service use based on an insurance dataset. A range of factors were related to high use of physiotherapy services. It is hoped that identifying the mean number and spread of physiotherapy interventions for whiplash associated disorders, and the profile of high users of physiotherapy will help gauge the success of strategies to maximize the efficacy of physiotherapy management of whiplash associated disorders.

Objective: To investigate the functional status of fracture victims 4 years after the 2008 Wenchuan earthquake. Methods: A total of 374 fracture victims who were admitted to the rehabilitation department of 5 municipal hospitals in the hardest hit areas in 2008 were interviewed face to face in 2012. Functional assessments, including muscle strength, range of motion, pain, activities of daily living and working status, were conducted. Results: Approximately one-third (33.2%) of the fracture victims had decreased muscle strength and 29.4% had limited range of motion. Among the 55.3% of subjects who still experienced pain, the proportions of mild, moderate and severe pain were 65.7%, 28.5% and 5.8%, respectively. The majority (83.4%) of fracture victims were independent in caring for themselves. However, 1.6% of subjects were highly dependent or totally dependent. Single-fracture victims had better muscle strength, range of motion, pain and independence than those with multiple fractures. The degrees of pain, muscle strength and dependency were worse in the older age group, and better in those with a higher level of education. In addition 17.1% were jobless and 22.2% received economic support mainly from family members. The mean unemployment rate was significantly higher and the annual household income (USD 3,086 (standard deviation 1,985) was lower than in the general population in rural Sichuan province. Conclusion: The prevalence of functional disorders, including pain, limited range of motion, decreased muscle strength and dependency in activities of daily living, remained high among fracture victims 4 years after the Wenchuan earthquake. Unemployment rate was high and annual household income was low in this population.

To examine the development and determinants of long-term outcomes for earthquake victims with amputations, including physical function, pain, quality of life and life satisfaction. Prospective cohort study with 2-3 measurement points. A total of 72 people who underwent amputations following the 2008 Sichuan Earthquake and resided in Mianzhu County, Sichuan Province, China were enrolled in the study. Of these, 27 people were lost to follow-up. Data on pain (visual analogue scale) and physical function (Barthel Index) were collected at 3 measurement points (2009, 2010 and 2012), and data on quality of life (Medical Outcomes Short-Form 36) and life satisfaction (Life Satisfaction Questionnaire-11) were collected at 2 measurement points (2010 and 2012). Data were analysed with mixed effects regression. Pain severity declined significantly and physical function increased by 2012. Quality of life and life satisfaction remained relatively stable between 2010 and 2012, while quality of life was significantly lower than reference values from the general population. Illiteracy and lower extremity amputations were associated with lower quality of life and life satisfaction in several domains. While amputees' functioning and pain were improved over time, quality of life and life satisfaction did not change. Illiterate earthquake survivors and those with lower extremity amputations are at particular risk of low quality of life and life satisfaction, and may require additional attention in future earthquake rehabilitation programs.

To investigate the efficacy and safety of repeated treatment with incobotulinum toxin A (botulinum neurotoxin type A free from complexing proteins; NT 201) in post-stroke upper limb spasticity. After completing a double-blind, placebo- controlled, multicentre study (up to 20 weeks), 145 patients received up to 5 additional sets of NT 201 injections for an open-label extension period of up to 69 weeks. Upper limb muscle groups were treated as clinically indicated; injection intervals were ≥ 12 weeks. Outcome was assessed 4 weeks after each injection session and at the end of the study. Muscle tone (flexors of wrist, elbow, finger, and thumb, and forearm pronators) improved throughout the study (response rate: up to 80.6%, p < 0.0001, Ashworth Scale). Continuous and significant improvements were also observed in disability (p < 0.05, Disability Assessment Scale). The majority of investigators, patients and caregivers rated NT 201 efficacy as very good or good (56-84%). Adverse events considered treatment-related occurred in 11% of patients. Formation of neutralizing antibodies was not observed in any patient after repeated treatments. Treatment with NT 201 showed sustained improvements in muscle tone and functionality (median dose 400 units) over a study duration of up to 89 weeks, and was well tolerated during repeated treatments for post-stroke upper limb spasticity.

The aim of this pilot study was to describe problems in functioning and associated rehabilitation needs in persons with spinal cord injury after the 2010 earthquake in Haiti by applying a newly developed tool based on the International Classification of Functioning, Disability and Health (ICF). Pilot study. Eighteen persons with spinal cord injury (11 women, 7 men) participated in the needs assessment. Eleven patients had complete lesions (American Spinal Injury Association Impairment Scale; AIS A), one patient had tetraplegia. Data collection included information from the International Spinal Cord Injury Core Data Set and a newly developed needs assessment tool based on ICF Core Sets. This tool assesses the level of functioning, the corresponding rehabilitation need, and required health professional. Data were summarized using descriptive statistics. In body functions and body structures, patients showed typical problems following spinal cord injury. Nearly all patients showed limitations and restrictions in their activities and participation related to mobility, self-care and aspects of social integration. Several environmental factors presented barriers to these limitations and restrictions. However, the availability of products and social support were identified as facilitators. Rehabilitation needs were identified in nearly all aspects of functioning. To address these needs, a multidisciplinary approach would be needed. This ICF-based needs assessment provided useful information for rehabilitation planning in the context of natural disaster. Future studies are required to test and, if necessary, adapt the assessment.

To examine whether the incidences of neck and low-back symptoms were elevated during the severe floods that occurred in Bangkok, Thailand in 2011, and to explore flood-related risk factors for neck and low-back symptoms. Prospective cohort design. Severe flooding occurred in Bangkok and surrounding neighbourhoods between October and December, 2011. After the flood had subsided (January 2012), 377 healthy office workers, who were already taking part in a study on musculoskeletal symptoms, were asked about their contact with floodwater. Data were gathered from subjects, who had reported no neck and low-back symptoms at the end of September 2011 and who were affected by the flood. Two regression models for the outcomes of 3-month incidence of neck and low-back symptoms, respectively, were performed. Eighty-two percent of the subjects were affected by the flood. No flood-related factor was found to associate significantly with either neck or low-back symptoms. However, neck symptoms may be associated with commuting frequently through flooded areas, and low-back symptoms may be associated with the subjects' homes or workplaces being flooded. These findings indicate that more attention needs to be paid to the problem of musculoskeletal symptoms during flooding in urban areas, and that preventive measures are required.

Abstract is missing (Guest Editorial).

To study the incidence and claim closure of traffic-related mild traumatic brain injury and the effect of insurance factors. Population-based, cohort study of mild traumatic brain injury caused by traffic collisions in Saskatchewan, Canada, between July 1, 1994 and December 31, 1995. On January 1, 1995 the insurance law changed from tort to no fault. 657 adults, 18 years or older, who hit their head and indicated loss of consciousness or uncertain loss of consciousness and were not hospitalized for more than 2 days. Subjects entered the cohort on the injury date and exited on the day the insurance claim closed, or on November 1, 1997, when remaining open claims were censored. All 657 subjects answered a baseline questionnaire, and 479 who did not reopen their claim were included in the follow-up. The relationship between claim closure and health was studied in 225 (47%) of these claimants. The 6-month incidence dropped from 36/100,000 to 27/100,000 after the insurance change. The median time-to-claim closure dropped from 408 days to 233 days. Prolonged claim closure was associated with both injury and insurance-related factors. Claim closure occurred faster when claimants' health improved. Mild traumatic brain injury incidence and claim closure is affected by both health and insurance-related factors.

Objective: To determine the psychometric properties of the 23-item version of the Roland Morris Disability Questionnaire (RMDQ-23) and to quantify their stability across 2 cultures/languages and 2 types of care-settings. Methods: Rasch analysis of data from 1,000 patients with low back pain from primary care (UK and Denmark) and secondary care (Denmark). Results: The RMDQ-23 is unidimensional if local item dependency issues are accommodated, but contains several misfitting or overdiscriminating items, some poor targeting of items, and the scoring of 4-5 items is differentially affected by common clinical characteristics (such as age, gender, pain intensity, pain duration and care setting), depending on the country. Conclusion: As similar results have been found for the RMDQ-24, we believe it is timely to reconsider whether: (i) the RMDQ should be reconstructed using an item-response theory-based approach that includes consideration of new items and response options; or (ii) the use of alternative questionnaires should be recommended, such as the Oswestry Disability Index, that have shown evidence of fitting the Rasch model; or (iii) a completely new condition-specific questionnaire should be developed, perhaps utilizing a computerized adaptive testing platform.

Objective: To explore the dose equivalence ratio and treatment costs for abobotulinumtoxinA and incobotulinumtoxinA for patients with focal dystonias. Design: Patient chart review. Subjects/patients: Adult patients with blepharospasm (n = 19), cervical dystonia (n = 122), hemifacial spasm (n = 91) or segmental/generalized dystonia (n = 19) at a neurology outpatient clinic. Methods: Patients were switched from established abobotulinumtoxinA therapy to incobotulinumtoxinA at a ~4:1 unit ratio. Dose requirements, injection intervals, treatment efficacy, and adverse events were evaluated for a period of ≥ 1 year. Results: Patients were switched from abobotulinumtoxinA to incobotulinumtoxinA with a mean dose ratio of 4.07 (standard deviation (SD) 0.50). After switching, incobotulinumtoxinA dose requirements remained stable; the mean (SD) dose ratio at the end of the review period (52-219 weeks after switching) was 3.89 (SD 0.58). Injection intervals also remained stable after switching. Adverse events were injection site pain (n = 45) and bruising (n = 4). Five patients (2.0%) discontinued incobotulinumtoxinA treatment: 4 stopped receiving injections, and 1 reverted to abobotulinumtoxinA. Switching to incobotulinumtoxinA reduced the mean toxin expenditure to 76.7% of the cost of abobotulinumtoxinA. Conclusion: For patients with conditions commonly treated in dystonia clinics, switching from abobotulinumtoxinA to incobotulinumtoxinA, given at equivalent doses (~4:1 unit ratio) at similar intervals, was effective, well tolerated and achieved cost savings.

To evaluate functional outcomes, health-related quality of life and life satisfaction in fracture victims 27 months after the 2008 Sichuan earthquake. A total of 390 earthquake survivors from 3 earthquake areas who sustained fractures were divided into early intervention, late intervention and control groups. Functional outcomes assessed included activities of daily living using the Modified Barthel Index and pain level with a visual analogue scale. Health-related quality of life was evaluated with the Medical Outcomes Study Short-Form 36 and life satisfaction using the Life Satisfaction Questionnaire. Activities of daily living and life satisfaction in the intervention groups were significantly improved compared with the control group. Health-related quality of life was higher in early intervention subjects compared with controls. Group differences in pain level were not significant. In addition, the early and late intervention groups did not differ significantly in any of the measured outcomes. Good performance of activities of daily living and widowed marital status predicted high health-related quality of life, while pain level was associated with worsened outcomes. Rehabilitation therapy, remunerative employment and female gender were predictors of improved life satisfaction. Clinical effectiveness of physical rehabilitation intervention was demonstrated in fracture earthquake victims.

Analysis of the impact of an individualized comprehensive focal spasticity management on health-related quality of life. Prospective observational and interventional 12-week trial in a single-centre rehabilitation outpatient clinic. Forty-one adult patients with upper motor neurone lesions (23 men), mean age 52 (standard deviation 13) years; 27 stroke, 7 cerebral palsy and 7 miscellaneous diagnoses. Patients were assessed using the Short Form 36 (SF-36) Questionnaire before and after intramuscular injections of botulinum toxin type A combined with physical interventions. Spasticity was assessed with the Ashworth Scale (0-4). A verbal scale for patients' self-report of therapy effect was also used. Significant improvement was found in 3 of 8 SF-36 health scales: social (p = 0.008) and physical functioning (p = 0.026), and role physical (p = 0.048). Spasticity improved significantly (mean 1.1, p < 0.001). Improvement according to the verbal scale was observed for 57 (86%) indications (overall improvement in 36 patients, 88%). Comprehensive focal spasticity management with botulinum toxin type A intramuscular injections and physical interventions can improve patients' perceived health-related quality of life in addition to objectively and subjectively measured motor functions.

The aim of this study was to investigate unidimensionality and differential item functioning of the SF-36 physical functioning scale (PF10) in patients with various neurological disorders. Patients: Patients post-stroke (n = 198), with multiple sclerosis (n = 151) and amyotrophic lateral sclerosis (n = 193) participated. Unidimensionality of the PF10 within the patient groups was investigated by performing a separate Rasch analysis for each group. Differential item functioning was investigated in a pooled Rasch analysis of the 3 groups. Within each group, all items fitted the Rasch model, except the "bathing/dressing" item in the amyotrophic lateral sclerosis group. The pooled analysis showed inadequate fit to the Rasch model for one item ("walking several hundred metres"). Of the other 9 fitting items, 5 showed differential item functioning for stroke vs multiple sclerosis and amyotrophic lateral sclerosis, while no differential item functioning was found between multiple sclerosis and amyotrophic lateral sclerosis. All items of the PF10, except one for the amyotrophic lateral sclerosis group, form a unidimensional scale, supporting the use of a sum score as a measure of physical functioning within these diagnostic groups. When comparing the data of patients after stroke, with that of patients with multiple sclerosis and/or amyotrophic lateral sclerosis patients, adjustments for differential item functioning are required.

Few studies have evaluated the scale assumptions of the Medical Outcomes Study 36-item Short-Form (SF-36) with stroke survivors. The aims of this study were to evaluate the scale assumptions of SF-36 using Swedish patients after stroke and to compare patients' quality of life with that of a healthy population. Cross-sectional study. SF-36 was tested in 188 patients (mean age 74 years) with acute stroke consecutively enrolled from a stroke unit in southern Sweden during 2003-05. Data were collected by interview during a home visit 2-3 weeks after discharge. Psychometric analyses were conducted, and stroke survivors' quality of life was compared with a Swedish normal population. The internal consistency reliability was >0.70 for all scales. There were notable floor and/or ceiling effects for 3 scales. For 7 scales, there was the expected association with the 2 summary scales. Compared with a normal Swedish population, stroke has a negative effect on health-related quality of life, especially for patients aged 45-54 years. SF-36 functions well as a measure of health-related quality of life in Swedish patients after stroke, but the 2 summary scales have shortcomings. Our findings support good divergent validity of SF-36 for discriminating health-related quality of life of stroke groups and normal populations.

Objective: To investigate whether an interdisciplinary rehabilitation for chronic musculoskeletal disorders is associated with changes in the purchase of prescribed pain medication. Design: Prospective register-based study. Subjects: Employees in the public sector (n = 4,365) who participated in the rehabilitation programme between 1996 and 2009. Methods: The changes in annual purchases of prescribed pain medication were measured for a 9-year exposure window, starting from 4 years before the start date of rehabilitation and ending 5 years after this date. Results: Purchases of prescribed pain medication increased throughout the follow-up in all medication groups. The steepest increase was observed for analgesics, antidepressants, and hypnotics and sedatives. The growth rate of annual purchase, however, slowed significantly following the year of the start of rehabilitation for analgesics (annual growth rate (rate ratio) before and after rehabilitation 1.27 and 1.04, respectively, difference in trend p < 0.001); antidepressants (rate ratio 1.17 and 1.09, p = 0.005); and muscle relaxants (rate ratio 1.31 and 1.01, p < 0.001). For anxiolytics, and hypnotics and sedatives, no differences were observed in the trends of annual purchase before and after rehabilitation. Conclusion: Rehabilitation was associated with a slowing increase in purchases of prescribed pain medication amongst rehabilitants. This may be a reflection of the positive effect that rehabilitation has on the need for pain medication.

The aim of this study was to examine the self-reported health status of road traffic accident victims and the predictors of self-assessed recovery 1 year after major trauma in a French population. A follow-up study. The cohort comprised 276 seriously injured victims of road traffic accidents, aged > 16 years from the Rhône administrative department, France. Victim characteristics at the time of the crash and self-reported health status 1 year after trauma were collected. Predictive factors for self--assessed recovery were examined using a Poisson regression approach. The majority of victims were male (76%); most had severe injuries (76%), involving mainly the lower limbs and the head (68% and 55%, respectively). At 1-year follow-up, 80% reported being not fully recovered. Self-reported health status was not significantly associated with age, gender, being in employment, type of road user, or health status during the year preceding the accident, but rather with low socio-economic status, high injury severity, and presence of lower limb injury. Care for subjects who are at high risk of not fully recovering (manual workers, the very seriously injured, and those with lower limb injury) needs to be extended and improved. Longer follow-up studies on the risk factors for not fully recovering are needed in order to reduce harmful consequences for victims.

Objective: To examine sexual function at least 10 years after traumatic spinal cord injury. Study design: Cross-sectional questionnaire plus retrospective and prospective data from medical files. Subjects: A total of 279 individuals with traumatic spinal cord injury. Results: For spinal cord injured women: 94% had no problems with impaired vaginal lubrication; 22% had given birth after the injury; and 69% reported being satisfied with their sexual life. The women who were satisfied with their sexual life were younger than those who were not, and were younger at the time of injury. For spinal cord injured men: 75% could achieve erection, and they were younger than those who could not achieve erection; 35% used aid(s) for erection; 78-94% had positive reported effect of penile vibration, drugs and intracavernous injection for erection; 44% could achieve ejaculation, and they were younger than those who could not; 56% used aid(s) for ejaculation; 19% had made a woman pregnant, and a higher frequency of these men could achieve erection and ejaculation; 54% reported being satisfied with their sexual life; and significantly more men who had made a woman pregnant were satisfied with their sexual life. For both genders problems regarding bladder and bowel management, pressure ulcers, spasticity or pain correlated with lower satisfaction with sexual life.

To establish the prevalence and patterns of self-reported musculoskeletal symptoms in community-dwelling stroke survivors and their impact on common activities of daily living. Analysis of data from two consecutive postal surveys in northern England. Data on overall joint pain, swelling or stiffness and difficulties with daily living tasks were obtained from 16,222 individuals aged ≥ 55 years (a response rate of 86%). Information on stroke-specific impairments was obtained from the 415 individuals who reported a stroke. Forty-seven percent of stroke survivors reported musculoskeletal symptoms. There was a greater prevalence of reported symptoms in the smaller peripheral joints: 23.4% of stroke survivors reported symptoms in the ankle joint compared with 12.3% in the general population aged ≥ 55 years. Although both stroke-specific impairments and musculoskeletal pain contributed to difficulty in functional tasks, the effect of both was more than additive (for example, left hip symptoms increased the risk of having difficulty with standing and walking by 10.3 times (95% confidence interval 1.0, 106.3); stroke affecting the right leg increased the odds by 4.8 times (95% confidence interval 2.5, 9.2). Having both impairments increased the odds by 49.1 times (95% confidence interval 10.7, 225.4)). Musculoskeletal symptoms are common in people with stroke and can have a significant additional effect on disability.

To assess to what extent individual physical therapy treatment goals for children with cerebral palsy are reflected in 2 standardized measures: the GMFM-88 and the PEDI. A total of 36 paediatric physical therapists working in primary healthcare with children with cerebral palsy in their caseload. The International Classification of Functioning, Disability and Health was used as a measure to link individual treatment goals to the GMFM-88 and the PEDI. Sixty percent of the treatment goals were covered by the 2 measures. Twenty-seven percent and 21% of the goals were reflected in the GMFM-88 and the PEDI, respectively; 12% of the goals were reflected in both instruments. Another 26% of the treatment goals appeared to be partly covered (21% in PEDI and 5% in GMFM-88). Fourteen percent of the goals were not covered by the 2 measures. Individual goals set in a physical therapy practice for children with cerebral palsy can be linked, to a large extent, to items and activities of 2 standardized measures.

Objective: To use transcranial magnetic stimulation and electromyography to assess the potential for preserved function in the abdominal muscles in individuals classified with motor-complete spinal cord injury above T6. Subjects: Five individuals with spinal cord injury (C5-T3) and 5 able-bodied individuals. Methods: Transcranial magnetic stimulation was delivered over the abdominal region of primary motor cortex during resting and sub-maximal (or attempted) contractions. Surface electromyography was used to record motor-evoked potentials as well as maximal voluntary (or attempted) contractions in the abdominal muscles and the diaphragm. Results: Responses to transcranial magnetic stimulation in the abdominal muscles occurred in all spinal cord injury subjects. Latencies of muscle response onsets were similar in both groups; however, peak-to-peak amplitudes were smaller in the spinal cord injury group. During maximal voluntary (or attempted) contractions all spinal cord injury subjects were able to elicit electromyography activity above resting levels in more than one abdominal muscle across tasks. Conclusion: Individuals with motor-complete spinal cord injury above T6 were able to activate abdominal muscles in response to transcranial magnetic stimulation and during maximal voluntary (or attempted) contractions. The activation was induced directly through corticospinal pathways, and not indirectly by stretch reflex activations of the diaphragm. Transcranial magnetic stimulation and electromyography measurements provide a useful method to assess motor preservation of abdominal muscles in persons with spinal cord injury.

Objective: To evaluate hip abductor strength-training for patients with unilateral transfemoral amputation. Design: Single-blind, cross-over (AB/BA) trial with randomization. Subjects: Seventeen patients with transfemoral amputation. Methods: Subjects completed 8-week programs of twice weekly hip abductor strength training or arm ergometry. Subjects were randomly assigned to receive either the experimental or active control intervention first. A physiotherapist blinded to group assignment conducted baseline and post-intervention assessments. The Timed Up and Go (TUG) test was selected as the primary outcome measure; secondary measures included the 2 Minute Walk (2MW), hip abductor strength, Activities Specific Balance Confidence Scale (ABC) and prosthetic use. A two-way cross-over ANOVA was used for baseline and post-intervention treatment comparisons. Results: There were no baseline differences between treatments for TUG, 2MW, ABC, Houghton scale, sitting or side-lying abductor strength (p ≥ 0.05 for all), though supine strength was greater for the experimental treatment (p < 0.05). After 8-weeks of hip abductor strength training, there were significant treatment effects for TUG, ABC (p < 0.01 for both), 2MW (p < 0.05), sitting and side-lying abductor strength (p = 0.05 for both), but not for supine strength, prosthetic use, nor thigh girth measures (p ≥ 0.05 for all). Conclusions: This study suggests that patients with unilateral transfemoral amputation can improve functional performance and balance confidence following intense hip abductor strength training.