Guidelines: basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation.

INTRODUCTION: We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020. DEVELOPMENT: We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research. CONCLUSIONS: All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45-60minutes of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.

Efficacy of Armeo® Spring during the chronic phase of stroke. Study in mild to moderate cases of hemiparesis.

OBJECTIVE: To evaluate the efficacy of a gravity-supported, computer-enhanced device (Armeo® Spring) for upper limb rehabilitation in chronic stroke patients. MATERIAL AND METHODS: We included 23 chronic hemiparetic patients (chronicity: 328 ± 90.8 days; distribution: 17 men and 6 women) aged 54.6 ± 9.5 years, who had sustained ischaemic stroke (n=12) or haemorrhagic stroke (n=11). All patients completed 36 one-hour sessions using the Armeo® Spring system. Arm movement was assessed at the beginning and end of the treatment programme and once more 4 months later. Main outcome measurements covered structure, activity, and function, as per the International Classification of Functioning, Disability and Health: Modified Ashworth Scale, Motricity Index (MI), Fugl-Meyer Assessment Scale (FM), Motor Assessment Scale (MAS), Manual Function Test (MFT), and Wolf Motor Function Test (WMFT). RESULTS: Repeated measures ANOVA showed significant improvement (time effect) for all function scales (P<.01 for FM and MI) and activity scales (P<.01 for MAS, MFT and WMFT-ability, and P<.05 WMFT-time) without significant changes in muscle tone. The post-hoc analysis (Bonferroni) showed different evolutionary patterns for function and activity measurements, and clear benefits related to Armeo® Spring training, especially on activity scales. CONCLUSIONS: Armeo® Spring is an effective tool for rehabilitating the affected arm in patients with hemiparesis secondary to ictus, even in the chronic stage.

Interacting humans use forces in specific frequencies to exchange information by touch.

Object-mediated joint action is believed to be enabled by implicit information exchange between interacting individuals using subtle haptic signals within their interaction forces. The characteristics of these haptic signals have, however, remained unclear. Here we analyzed the interaction forces during an empirical dyadic interaction task using Granger-Geweke causality analysis, which allowed us to quantify the causal influence of each individual's forces on their partner's. We observed that the inter-partner influence was not the same at every frequency. Specifically, in the frequency band of [2.15-7] Hz, we observed inter-partner differences of causal influence that were invariant of the movement frequencies in the task and present only when information exchange was indispensable for task performance. Moreover, the inter-partner difference in this frequency band was observed to be correlated with the task performance by the dyad. Our results suggest that forces in the [2.15-7] Hz band constitute task related information exchange between individuals during physical interactions.

[Effectiveness, adherence and usability of a teleneurorehabilitation programme to ensure continuity of care for patients with acquired brain injury during the COVID-19 pandemic]. / Efectividad, adhesión y usabilidad de un programa de teleneurorrehabilitación para garantizar la continuidad de cuidados en pacientes con daño cerebral adquirido durante la pandemia originada por la COVID-19.

INTRODUCTION: The health pandemic brought about by SARS-CoV-2 (COVID-19) has limited access to neurorehabilitation programmes for many patients who have suffered stroke, traumatic brain injury or acquired brain damage due to some other cause. As telerehabilitation allows for the provision of care in situations of social distancing, it may mitigate the negative effects of confinement. The aim of this study was to determine the efficacy, adherence and usability of a teleneurorehabilitation intervention for patients with acquired brain injury. PATIENTS AND METHODS: All patients included in a face-to-face neurorehabilitation programme at the time of the declaration of the state of alarm in Spain due to COVID-19 and who agreed to participate in the study were included in a teleneurorehabilitation programme. The effectiveness of the programme, understood as an improvement in independence, was quantified with the Barthel index. Adherence to the programme and usability of the tool were explored through questionnaires. RESULTS: Altogether, 46 patients, accounting for 70.6% of the total, participated in the study. Participants significantly improved their independence and showed an improvement in the Barthel index between the start (77.3 ± 28.6) and the end of the programme (82.3 ± 26). Adherence to the intervention was very high (8.1 ± 2.2 out of 10) and the online sessions were the most highly rated content. The tool used showed a high usability (50.1 ± 9.9 out of 60) and could be used without assistance by more than half the participants. CONCLUSION: The teleneurorehabilitation intervention was found to be effective in improving patients' independence, and promoted a high degree of adherence and usability.

TITLE: Efectividad, adhesión y usabilidad de un programa de teleneurorrehabilitación para garantizar la continuidad de cuidados en pacientes con daño cerebral adquirido durante la pandemia originada por la COVID-19.Introducción. La pandemia sanitaria originada por el SARS-CoV-2 (COVID-19) ha limitado el acceso a programas de neurorrehabilitación de muchos pacientes que han sufrido ictus, traumatismos craneoencefálicos o un daño cerebral adquirido por otra causa. Dado que la telerrehabilitación permite la provisión de cuidados en situaciones de distanciamiento social, podría atenuar los efectos negativos del confinamiento. El objetivo de este estudio fue determinar la eficacia, la adhesión y la usabilidad de una intervención de teleneurorrehabilitación dirigida a pacientes con daño cerebral adquirido. Pacientes y métodos. Todos los pacientes incluidos en un programa de neurorrehabilitación presencial en el momento de la declaración del estado de alarma en España con motivo de la COVID-19 y que aceptaron participar en el estudio fueron incluidos en un programa de teleneurorrehabilitación. La eficacia del programa, entendida como una mejora en la independencia, se cuantificó con el índice de Barthel. La adhesión al programa y la usabilidad de la herramienta se investigaron mediante cuestionarios. Resultados. Un total de 146 pacientes, el 70,6% del total, participó en el estudio. Los participantes mejoraron significativamente su independencia y mostraron una mejoría en el índice de Barthel entre el inicio (77,3 ± 28,6) y el fin del programa (82,3 ± 26). La intervención tuvo una gran adhesión (8,1 ± 2,2 sobre 10) y las sesiones en línea fueron el contenido mejor valorado. La herramienta utilizada mostró una elevada usabilidad (50,1 ± 9,9 sobre 60) y pudo ser utilizada sin ayuda por más de la mitad de los participantes. Conclusión. La intervención de teleneurorrehabilitación resultó ser eficaz para mejorar la independencia de los pacientes, y promovió una elevada adhesión y usabilidad.

Priorities for cancer control in Spain.

Spanish cancer strategy is being developed in the context of a decentralised health care system. The advantages and challenges posed by this system are reviewed, particularly vis-à-vis the need to build consensus among regional health services as regards priorities in cancer control. Analysis of the impact of cancer in Spain enables smoking prevention and obesity reduction to be highlighted, especially among adolescents, as targets for primary prevention. Two-yearly colorectal cancer screening using the faecal occult blood test and targeting persons aged 50-69 years is a new goal that should be pursued countrywide, as should population-based breast cancer screening. Insofar as health care is concerned, the focus is on promoting and consolidating multidisciplinary cancer care based on evidence-based clinical guidelines, and on ensuring that cancer patients enjoy prompt access to diagnosis and therapy. Psychosocial support, with experience gained in several health services, should be expanded. Palliative care must be consolidated as a necessary therapy for patients who require it. Finally, the important boost to cancer research witnessed in recent years should be sustained. The approach adopted is based on building a co-operative strategy among all of Spain's autonomous regions (Comunidades Autónomas), which must then apply the interventions in their respective health services. A shared understanding of the main priorities for cancer control, through a review of the evidence and a consensus embracing all stakeholders, including scientific societies and patients' associations, is an essential step in the implementation of cancer strategy in Spain.

APOE genotype and verbal memory recovery during and after emergence from post-traumatic amnesia.

OBJECTIVE: To determine if APOE genotype is linked to memory function after moderate-severe traumatic brain injury (TBI). METHODS: Eighty-two patients in post-traumatic amnesia (PTA) and 107 patients who had emerged from PTA were selected from 239 consecutive patients admitted to the facility. Verbal memory assessments, including the Spanish version of the California Verbal Learning Test and the Working-Memory Index of the WAIS-III, were conducted immediately after PTA resolution or during the first week after admission for patients who were out of PTA. Both groups were reassessed 6 months after inclusion in a multidisciplinary rehabilitation programme. RESULTS: Patients with the APOE-epsilon 4 allele (n = 17 in the PTA group and n = 9 in the out of PTA group) entered rehabilitation at a more impaired level, but made remarkable progress during follow-up. Fifty-five patients from the initial sample emerged from PTA during the follow-up period. Age, GOAT at admission and chronicity, but not APOE genotype or initial trauma severity, were significant predictors of emergence from PTA. CONCLUSIONS: APOE genotype seems to be associated with the trajectory of cognitive recovery after TBI, but does not play a determinant role in the efficacy of memory rehabilitation in this population.

eBaViR, easy balance virtual rehabilitation system: a study with patients.

eBaViR is a virtual rehabilitation system, which has been developed for balance rehabilitation for patients suffering from acquired brain injury. It is a game-based system that uses a low-cost interface, the Nintendo Wii Balance Board. The games have been specifically designed with the help of experts in the rehabilitation of balance disorders and can be adapted to patients according to their needs. We present an experimental study that has been carried out using the system. The aim of the study is to determine whether this setup could be applied as a Virtual Rehabilitation System for balance rehabilitation in Acquired Brain Injury. We randomly divided patients into two groups: a trial group and a control group. The trial group used eBaViR system during the rehabilitation sessions, and the control group followed traditional rehabilitation sessions. We obtained encouraging results.

Current validity of diagnosis of permanent vegetative state: A longitudinal study in a sample of patients with altered states of consciousness. / Validez actual del diagnóstico de «estado vegetativo permanente¼: estudio longitudinal en una muestra clínica de pacientes en estados alterados de conciencia.

INTRODUCTION: Altered states of consciousness have traditionally been associated with poor prognosis. At present, clinical differences between these entities are beginning to be established. METHOD: Our study included 37 patients diagnosed with vegetative state/unresponsive wakefulness syndrome (UWS) and 43 in a minimally conscious state (MCS) according to the Coma Recovery Scale-Revised (CRS-R). All patients were followed up each month for at least 6 months using the CRS-R. We recorded the time points when vegetative state progressed from 'persistent' to 'permanent' based on the cut-off points established by the Multi-Society-Task-Force: 12 months in patients with traumatic injury and 3 months in those with non-traumatic injury. A logistic regression model was used to determine the factors potentially predicting which patients will emerge from MCS. RESULTS: In the UWS group, 23 patients emerged from UWS but only 9 emerged from MCS. Of the 43 patients in the MCS group, 26 patients emerged from that state during follow-up. Eight of the 23 patients (34.7%) who emerged from UWS and 17 of the 35 (48.6%) who emerged from MCS recovered after the time points proposed by the Multi-Society-Task-Force. According to the multivariate regression analysis, aetiology (P<.01), chronicity (P=.01), and CRS-R scores at admission (P<.001) correctly predicted emergence from MCS in 77.5% of the cases. CONCLUSIONS: UWS and MCS are different clinical entities in terms of diagnosis and outcomes. Some of the factors traditionally associated with poor prognosis, such as time from injury and likelihood of recovery, should be revaluated.

Health promotion research: dilemmas and challenges.

OBJECTIVE: To analyse dilemmas and challenges in health promotion research, and to generate ideas for future development. METHOD: The analysis is based on authors' experiences in working in the field of research and action in health promotion and on experiences of others as found in literature. RESULTS: The assumptions underlying scientific research as based in the biomedical design are difficult to meet in community-based health promotion research. Dilemmas are identified in relation to the possibility of defining the independent and dependent variables beforehand and the intermingling of these variables (the intervention and outcome dilemma), the difficulty in quantifying the desired outcomes (the number dilemma), and the problem of diffusion of the programme to the control group (the control group dilemma). CONCLUSION: Research in health promotion has specific reasons to reconsider the approach towards research, the selection of outcome variables, and research techniques. Strategies and methods to make activities and their outcomes clear are discussed and criteria to judge confidence and applicability of research findings are presented.

Research on lifestyles and health: searching for meaning.

This paper is based on an alternative approach to standard quantitative analyses in research on behavior and health. Theory and methods focused on the elaboration of complex situational and behavioral influences on health are used in secondary analyses of data from a population health survey in Spain. Findings showing fundamental differences in the relationships among the behavioral and health variables within various age, gender and social groups illustrate the importance of studying interacting influences in relevant subgroups of the population. Quite meaningful findings can be hidden in behavioral research limited to identifying global statistical correlations in cross-sectional and longitudinal data. The impact that statistical methods can have on the findings from analyses that are not guided by theory and logic based on substantive questions derived from the research literature is discussed. The results point to the need to study patterns of behavior in their contexts of occurrence in research on lifestyles and health.

[Health inequalities in Barcelona and Valencia]. / Desigualdades en salud en Barcelona y Valencia.

BACKGROUND: Inequalities in health have been internationally recognized as an important public health problem with a reduction of 25% being the first target of WHO--Europe for the year 2000. It is, therefore, important to describe and monitor the same. METHODS: An ecological study was performed using secondary data from the statistics of mortality (years 1985-1988) and the municipal censuses from the year 1986 to describe and compare inequalities in health in the cities of Valencia and Barcelona with neighborhoods being the unit of observation and analysis. RESULTS: Although the rates of mortality in Barcelona city are slightly inferior and those of Valencia slightly higher to those of Spain, both cities demonstrate important inequalities in regard to mortality in their neighborhoods with respect to standardized mortality which ranged from 78 to 182 in Barcelona and from 63 to 147 in Valencia. The privileged zones in Barcelona are those of Pedralbes and Sant Gervasi and in Valencia in the neighborhoods of Sant Pau and Jaume Roig with the most unfavorable neighborhoods being District I in Barcelona (Gothic Quarter, City Park, Barceloneta and Raval) and the Na Rovella and Fuensanta neighborhoods of Valencia. The level of inequality in both cities is very similar. Statistically significant associations have been found in both cities between the state of health and the level of poverty in the neighborhoods according to an approximation to the Townsend et al indexes. CONCLUSIONS: The description of important inequalities in two large Spanish cities suggests the possibility of its existence in other cities and established the urgent need for a study using comparable methodologies. With the use of routine and presently available data sources it is possible to describe and posteriorly monitor the level of inequality in large cities in Spain. The development of policies to diminish the inequalities in the large cities would provide considerable gains in terms of human lives. The present results support the hypothesis that material conditions in everyday life play an important role as a condition for public health inequality.

[Spanish language adaptation and validation of the Pfeiffer's questionnaire (SPMSQ) to detect cognitive deterioration in people over 65 years of age]. / Adaptación y validación al castellano del cuestionario de Pfeiffer (SPMSQ) para detectar la existencia de deterioro cognitivo en personas mayores de 65 años.

BACKGROUND: Our aims were to develop a Spanish version of the short portable mental status questionnaire (SPMSQ) (Pfeiffer's test) and to validate the resultant Spanish version of the test among a general population aged 65 years or older. PATIENTS, MATERIAL AND METHODS: First, we developed the Spanish version of the SPMSQ by means of a cross-cultural adaptation methodology. Patients were the assessed by independent teams in two sessions the same day. The first team (two trained psychiatrists and one trained family physician) carried out a standardised neuropsychological assessment to diagnose cognitive impairment/dementia according to ICD-10 criteria which was regarded as the reference "gold standard" to calculate validity parameters (sensitivity and specificity). The second team (family physicians/nurses) assessed the presence of cognitive impairment with the Spanish version of the SPMSQ. RESULTS: 255 subjects (66.7%, females) underwent the assessment. Mean age was 74.5 years and 65.5% of them were illiterate. The inter-rater reliability and test-retest reliability of the SPMSQ Spanish version were 0.738 (p < 0.001), and 0.925 (p < 0.001), respectively,with a convergent validity of 0.74 (p < 0.001) and a discriminant validity of 0.230 (p < 0.001). The internal consistency was high with an *value of 0.82. The area under the ROC curve was 0.89. Sensitivity and specificity were 85.7 and 79.3, respectively (cut-off of 3 or more). CONCLUSIONS: The Spanish version of the SPMSQ test has a good reliability and validity. For clinical use, a cut-off of 3 appears to be most useful. When illiterate patients are assessed, the it is recommended to employ a cut-off of 4 or more.

[Health indicators in urban areas. Variations in function of social coherence of the geographic areas used]. / Indicadores de salud en el medio urbano. Variaciones en función de la coherencia social de las áreas geográficas utilizadas.

The detection of health inequalities in the urban environment and their magnitude depends to a great extent on the internal social coherence of the geographical division used. Using an existing social map of Alicante which divides the city into Basic Units for Social Intervention (BUSI), we have compared the distribution of an indicator with wellknown relationship with the socio-economic level such as Low Birth Weight, using both the BUSI and the municipal districts as analysis units. The data of the newborn were obtained from the records of the Hospital of Alicante corresponding to the years 1985, 1986 and 1987, analysing the 177 Low Birth Weights of the 7,728 born within the period. Using the BUSI we found a dose-response relationship between the socio-economic level and the LBW frequency with a range varying from 86.3 to 123.2. Using the municipal districts, the range varied from 62.5 to 159.6. We conclude that, although the geographical divisions with internal social coherence are better to detect health inequalities, municipal districts can be an analysis unit of easy access and useful for describing inequalities in the cities.

[Induced abortions among Spanish women in England and Wales (1974-1988)]. / Abortos inducidos en mujeres españolas en Inglaterra y Gales (1974-1988).

To assess the importance of travelling for abortion in Spanish women from 1974 to 1988, a descriptive epidemiologic study was undertaken, based on information from the United Kingdom Office for Population Censuses and Surveys. Additionally, the effect of the democratic restitution in Spain (1978) and of the passing of the Spanish abortion law in Spain is explored. During the study period, close to 200,000 Spanish women travelled to England and Wales to have an abortion. The annual figures range from 2,978 in 1974 to 22,002 in 1983. In 1988, in spite of the partial decriminalization of abortion in Spain, still 3,188 travelled to the UK for an abortion. In average, 1 out 35 Spanish women in fertile ages travelled to England and Wales for this reason in the study period. The likelihood was higher for the cohort of women born between 1955 and 1959, for which the risk was 4.5%. The proportional distribution by age shows that teenagers increased their relative importance from 9.3% in 1974 to 17% in 1988, suggesting less benefits for this age group than for older women from the democratization of the country and the abortion law.

[The importance of the gender perspective in health interview surveys]. / La importancia de la perspectiva de género en las encuestas de salud.

The identification and measurement of the population health needs should be the first step in health planning. In order to guarantee equity criteria, to know the situation of the whole population, and therefore also that of women, is a key issue. Health interview surveys are a good tool for pinpointing the needs of the population, but mainly they are usually focused on health risk factors that explain men's health status such as health behaviours and paid job. These factors often fail to capture aspects that are relevant for women's health, such as household work. The main objective of this paper is to emphasise the importance of a gender perspective in the design and analysis of health interview surveys, and to propose variables that should be included in health surveys in order to better know gender health inequalities. Likewise, this article deals with the gender concept and its importance as a health inequality factor. Gender is an analytical construct based on the social organisation of the sexes that can be used to better understand the conditions and factors influencing women's and men's health beginning by the social roles that each culture and society assigns to people based on their sex. Health is a complex process determined by a wide range of factors: biological, social, environmental and health services related factors. Gender, because of its close relation to all of them, plays a key role. The gender approach is characterised by the analysis of the social relation between men and women, taking into account that sex is a determinant of social inequalities. This paper presents the variables that health interview surveys should include from a gender approach point of view: reproductive work, productive work, social class, social support, self-perceived health status, quality of life, mental health and chronic conditions. In addition, issues related to the wording of questions, data collection and analysis are discussed.