A multicentre study of intentional behavioural responses measured using the Coma Recovery Scale-Revised in patients with minimally conscious state.

OBJECTIVE: To investigate which conscious behaviour is most frequently detected using the Coma Recovery Scale-Revised in patients with minimally conscious state. DESIGN: Multicentre, cross-sectional study. SETTING: One intensive care unit, 8 post-acute rehabilitation centres and 2 long-term facilities. SUBJECTS: Fifty-two patients with established diagnosis of minimally conscious state of different aetiology. MAIN MEASURES: All patients were assessed by the Coma Recovery Scale-Revised. RESULTS: In most patients (34/52) non-reflexive responses were identified by two or more subscales of the Coma Recovery Scale-Revised, whereas in 14 patients only the visual subscale could identify cortically-mediated behaviours, and in the remaining 4 patients only the motor subscale did so.The clinical signs of intentional behaviour were most often detected by the visual subscale (43/52 patients) and by the motor subscale (31/52), and least frequently by the oromotor/verbal subscale (3/52) of the Coma Recovery Scale-Revised. This clinical pattern was observed independently from time post-onset and aetiology. CONCLUSIONS: Non-reflexive visual behaviour, identified by the visual subscale of Coma Recovery Scale-Revised, is the most frequently detected intentional sign consistent with the diagnosis of minimally conscious state, independently from aetiology and time post-onset.

Redefining a minimal rehabilitation assessment protocol for severe acquired brain injuries.

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

Redefining a minimal assessment protocol for stroke rehabilitation: the new "Protocollo di Minima per l'ICtus" (PMIC2020).

The use of standardized assessment protocols is strongly recommended to identify patient's needs, outcomes, and predictors of response to specific interventions in Stroke rehabilitation. In 2008, the Italian Society of Physical and Rehabilitation Medicine (SIMFER) published the minimal protocol for the person with stroke ("Protocollo di Minima per l'ICtus" [PMIC]), in reference to the International classification of Functioning, Disability and Health. In 2019, the SIMFER appointed a working group to provide a revised, updated version in line with the most recent literature and suitable for all rehabilitation settings: the PMIC2020. Descriptive study based on the consensus of a panel of experts. The study setting includes all the rehabilitation settings. The population included is represented by stroke survivors with disability. The coordinator of the SIMFER National Stroke Section appointed the working group, including the 8 Stroke Section board members, and 4 more experts (3 physiatrists; 1 neurologist). An extensive revision of the international literature on stroke assessment recommendations was performed; each proposed change from PMIC was written and motivated, discussed and voted. The PMIC2020 is a single form, to be administered at any time of the rehabilitation pathway, including a minimum set of variables, consisting of a demographic/anamnestic section, and a clinical/functional assessment section. Newly introduced tools included measures of malnutrition (BMI<18.5); pain in verbal and non-verbal patients (Numeric Rating Scale-pain, Pain Assessment in Advanced Dementia Scale); neurological impairment (National Institute of Health-Stroke Scale); activity (Modified Barthel Index, Short Physical Performance Battery); and participation (Frenchay Activity Index). The PMIC2020 provides an updated tool for the multidimensional rehabilitation assessment of the stroke patient, at any stage of the rehabilitation pathway, aiming at a shared minimum set of variables defining patient's needs and at defined outcomes across different rehabilitation facilities and settings. The PMIC2020 identifies patient's needs, outcomes, and predictors of response to specific interventions in Stroke rehabilitation and provide ground for a highly needed Stroke Registry.

The Italian version of the Coma Recovery Scale-Revised (CRS-R).

We present, in the appendix, the Italian version of the Coma Recovery Scale-Revised (CRS-R), a reliable tool that can distinguish patients in the minimally conscious state from those in a vegetative state. The CRS-R consists of 29 hierarchically organised items divided into 6 subscales addressing auditory, visual, motor, oromotor, communication, and arousal processes. The translation procedure, designed to ensure the development of an Italian version of the CRS-R that mirrors the structure and content of the original, was the following: three translations of the scale were concurrently completed by authors from the groups involved in the study; a selected version underwent back translation to detect errors in translation and to ensure that there was no misinterpretation of administration and scoring guidelines; a consensus meeting was held to agree on a fully comprehensible and accurate Italian translation that was consistent with the original English text; the authors of the original version were consulted for additional assistance with translation when consensus could not be reached; a final back translation was done based on the agreed Italian version. The Italian version of the scale is now available for use in clinical practice and in studies designed to investigate its psychometric properties; this will help in the coordination of multicentre studies to assess its reliability.

An Italian survey of traumatic spinal cord injury. The Gruppo Italiano Studio Epidemiologico Mielolesioni study.

OBJECTIVE: To describe the etiology, clinical presentation, complications, outcome indicators, and links between emergency and acute intervention and rehabilitation of patients with traumatic spinal cord injury (SCI). DESIGN: Multicenter prospective study involving patients with SCI discharged, after rehabilitative care, between February 1, 1997, and January 31, 1999. SETTING: Thirty-two Italian hospitals involved in SCI rehabilitation. PARTICIPANTS: Six hundred eighty-four patients with traumatic SCI on their first admission to a rehabilitation center. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Neurologic improvement (NI), bladder autonomy, feelings of dependency, and destination were evaluated on discharge. Pressure ulcers on admission, time from injury to admission, and length of stay (LOS) were considered as indirect measures of the effectiveness of the health system. RESULTS: Traumatic etiology had a male-to-female ratio of 4:1 (548:136). Collision on the road was the main cause of traumatic injury (53.8%). Mean time from injury to admission was 36.8 days; 126 patients (18%) were admitted within the first week after injury. Mean LOS was 135.5 days. In 184 patients (26.9%), a pressure ulcer was present on admission. On discharge, NI was recorded in 179 patients (26.2%), whereas 446 (65%) and 418 (61%) had bladder and bowel autonomy, respectively, and 560 (81.9%) returned home. In the multivariate analysis, independent variables predicting poor outcome (NI, feelings of dependency, sphincter autonomy, discharge to home, LOS) were related both to the lesion (completeness, cervical involvement) and to the indicators of health service organization (time from injury to admission, complications on admission and during stay). CONCLUSIONS: Our focus on the etiology of traumatic SCI showed that efforts should be made to prevent collisions on the road. Our study also highlights problems in the comprehensive management of patients with SCI in Italy. Better organization could help reduce the time from injury to admission, the number of complications on admission, and LOS, and it could help improve rehabilitation outcome.