Delphi-based assessment of fall-related risk factors in acute rehabilitation settings according to the International Classification of Functioning, Disability and Health.

OBJECTIVE: To apply the International Classification of Functioning, Disability and Health (ICF) model to fall prevention by developing an ICF core set for fall risks in acute rehabilitation settings. DESIGN: Fall risk factors were identified based on a systematic review of the literature and linked to ICF categories. A consensus process was conducted using a Delphi-based evaluation technique. SETTING: University-based hospital. PARTICIPANTS: Multidisciplinary participants (N=20) from different institutions. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: A 5-point Likert-type scale was used to weigh the importance of each risk category. The level of agreement for each consensus was assessed based on Spearman rho and semi-interquartile range indices. Categories with a mean score ≥4 in the third round of evaluation were included in this ICF core set. RESULTS: The core set comprised 34 fall risk categories that were distributed as follows: 18 categories on body functions, 2 on body structures, 8 on activities and participation, 4 on environmental factors, and 2 categories on personal factors. CONCLUSIONS: An ICF core set for falls in acute rehabilitation settings was developed in this study. Further validation is required.

Implementing disability evaluation and welfare services based on the framework of the International Classification of Functioning, Disability and Health: experiences in Taiwan.

BACKGROUND: Before 2007, the disability evaluation was based on the medical model in Taiwan. According to the People with Disabilities Rights Protection Act, from 2012 the assessment of a person's eligibility for disability benefits has to be determined based on the International Classification of Functioning, Disability, and Health (ICF) framework nationwide. The purposes of this study were to: 1) design the evaluation tools for disability eligibility system based on the ICF/ICF-Children and Youth; 2) compare the differences of grades of disability between the old and new evaluation systems; 3) analyse the outcome of the new disability evaluation system. METHODS: To develop evaluation tools and procedure for disability determination, we formed an implementation taskforce, including 199 professional experts, and conducted a small-scale field trial to examine the feasibility of evaluation tools in Phase I. To refine the evaluation tools and process and to compare the difference of the grades of disability between new and old systems, 7,329 persons with disabilities were randomly recruited in a national population-based study in Phase II. To implement the new system smoothly and understand the impact of the new system, the collaboration mechanism was established and data of 168,052 persons who applied for the disability benefits was extracted from the information system and analysed in Phase III. RESULTS: The measures of the 43 categories for body function/structure components, the Functioning Scale of Disability Evaluation System for activities/participation components, and the needs assessment have been developed and used in the field after several revisions. In Phase II, there was 49.7% agreement of disability grades between the old and new systems. In Phase III, 110,667 persons with a disability received their welfare services through the new system. Among them, 77% received basic social welfare support, 89% financial support, 24% allowance for assistive technology, 7% caregiver support, 8% nursing care and rehabilitation services at home, and 47% were issued parking permits for persons with disability. CONCLUSION: This study demonstrated that disability evaluation system based on the ICF could provide a common language between disability assessment, needs assessment and welfare services. However, the proposed assessment protocol and tools require additional testing and validation.

Evolution of system for disability assessment based on the International Classification of Functioning, Disability, and Health: A Taiwanese study.

BACKGROUND/PURPOSE: The criteria for disability were mainly based on the medical model, and the candidates for disability benefits were identified by physicians mainly depending on their degree of bodily impairment, but without sufficient evaluation of their activity, participation, and environment in Taiwan. According to the People with Disabilities Rights Protection Act, the assessment of a person's eligibility for disability benefits was required to be based on the International Classification of Functioning, Disability, and Health (ICF) framework since July 11, 2012. This study investigated a proposed system to assess patients' eligibility for disability in Taiwan, based on the ICF. METHODS: We have initiated a national decision-making process involving members of Taiwan's ICF Team. We facilitated 16 group discussions on the ICF coding system, in which 199 professionals participated. In each group, one member led the group discussion until a consensus was reached. RESULTS: We have developed a process to determine the eligibility of people with disabilities. This study set up the standards, tools, and practice manuals for each category. We have also developed a core set for disability assessment. CONCLUSION: We implemented a new system to assess patients' eligibility for disability. The proposed assessment protocol and tools require further validation.

Factors associated with quality of life among people with spinal cord injury: application of the International Classification of Functioning, Disability and Health model.

OBJECTIVE: To identify the factors that influence an individual's quality of life (QOL) after spinal cord injury (SCI) based on the International Classification of Functioning, Disability and Health (ICF) framework. DESIGN: Cross-sectional exploratory study. SETTING: Taiwan community. PARTICIPANTS: Community-dwelling adults (N=341) who had suffered an SCI at least 1 year previously and were between the ages of 18 and 60 years. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): A combination of self-report questionnaire and interview. The dependent variable, QOL, was measured by the abbreviated version of the World Health Organization Quality of Life, while the independent variables-participation, activity, impairment, and contextual factors-were measured using the Frenchay Activity Index, Barthel Index, and a demographic form. RESULTS: Multivariate analysis results indicated that participation, activity, and marital status are significant factors in the QOL outcome. Results also indicated that among the various factors that affect each domain of QOL (physical health, psychological health, social relationships, and environment), participation was the strongest determinant. CONCLUSIONS: The ICF provided an excellent framework with which to explore the factors influencing QOL after SCI. The results demonstrated that marital status, participation, and activity exert the strongest influence on QOL, while impairment and other variables do not directly influence QOL.

Effect of functional status on survival in patients with stroke: is independent ambulation a key determinant?

OBJECTIVE: To investigate the effect of functional status, measured using the Modified Rankin Scale (MRS), at 3 months after stroke on survival in patients with stroke. DESIGN: Cohort study. SETTING: Referral medical center. PARTICIPANTS: Patients with stroke (N=1032). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Survival after stroke. RESULTS: The Kaplan-Meier survival curves stratified by the 3-month MRS score showed 2 clear groups of patients with 3-month MRS scores of 0 to 3 (able to walk without assistance) and 4 or 5 (unable to walk without assistance). Accordingly, we grouped the patients into a high function (HF) group (3-month MRS≦3) and a low function (LF) group (3-month MRS≧4). Multiple Cox regression analysis showed that the LF group had significantly poorer survival (adjusted hazard ratio=4.69; 95% confidence interval [CI], 2.89-7.60; P<.001) than the HF group. Other significant risk factors of higher mortality were older age, history of diabetes mellitus, and heart disease. CONCLUSIONS: This study showed a significant influence of the 3-month MRS score on stroke survival. Moreover, independent ambulation may be a major determinant of a favorable survival prognosis. This finding suggests a potential role of rehabilitation in promoting stroke survival by maximizing ambulation function.

Pulsed wave Doppler ultrasound is useful to assess vasomotor response in patients with multiple system atrophy and well correlated with tilt table study.

The study aim was to assess sympathetic vasomotor response (SVR) by using pulsed wave Doppler (PWD) ultrasound in patients with multiple system atrophy (MSA) and correlate with the tilt table study. We recruited 18 male patients and 10 healthy men as controls. The SVR of the radial artery was evaluated by PWD, using inspiratory cough as a provocative maneuver. The response to head-up tilt was studied by a tilt table with simultaneous heart rate and blood pressure recording. The hemodynamic variables were compared between groups, and were examined by correlation analysis. Regarding SVR, MSA patients exhibited a prolonged latency and less heart rate acceleration following inspiratory cough. Compared with the tilt table test, the elevation of heart rate upon SVR was positively correlated to the increase of heart rate after head-up tilt. The correlation analysis indicated that the magnitude of blood pressure drop from supine to upright was positively associated with the SVR latency but negatively correlated with the heart rate changes upon SVR. The present study demonstrated that blunted heart rate response might explain MSA's vulnerability to postural challenge. PWD may be used to predict cardiovascular response to orthostatic stress upon head-up tilt in MSA patients.

Wheelchair-related accidents: relationship with wheelchair-using behavior in active community wheelchair users.

OBJECTIVE: To report the prevalence, mechanisms, self-perceived causes, consequences, and wheelchair-using behaviors associated with wheelchair-related accidents. DESIGN: A case-control study. SETTING: Community. PARTICIPANTS: A sample of experienced, community-dwelling, active manual and powered wheelchair users (N=95) recruited from a hospital assistive technology service center. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Wheelchair-using behaviors, wheelchair-related accidents over a 3-year period, and the mechanisms and consequences of the accidents. RESULTS: Among the 95 participants, 52 (54.7%) reported at least 1 accident and 16 (16.8%) reported 2 or more accidents during the 3 years prior to the interview. A total of 74 accidents, were categorized into tips and falls (87.8%), accidental contact (6.8%), and dangerous operations (5.4%). A logistic regression found individuals who failed to maintain their wheelchairs regularly (odds ratio [OR]=11.28; 95% confidence interval [CI], 2.62-48.61) and used a wheelchair not prescribed by professionals (OR=4.31; 95% CI, 1.10-16.82) had significantly greater risks of accidents. In addition to the risk factor, lack of regular wheelchair maintenance, the Poisson regression corroborated the other risk factor, seat belts not used (incident rate ratio=2.14; 95% CI, 1.08-4.14), for wheelchair-related accidents. CONCLUSIONS: Wheelchair-related accidents are closely related to their wheelchair-using behaviors. Services including professional evaluation, repair, maintenance, and an educational program on proper wheelchair use may decrease the risks of wheelchair accidents.

Development of a set of functional hierarchical balance short forms for patients with stroke.

OBJECTIVE: To develop a set of 3 hierarchical balance short forms (HBSF; containing sitting, standing, and stepping forms) to measure balance function in patients with stroke. DESIGN: First, we developed the HBSF, based on a previous data set, with each short form containing 6 items. Second, we examined the psychometric properties and efficiency of the HBSF. SETTING: Six teaching hospitals. PARTICIPANTS: Patients with stroke (n=764) for the first part of this study; inpatients and outpatients (n=85) for the second part of this study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We used the item bank (9 sitting-related, 14 standing-related, and 13 stepping-related items) from the Balance Computerized Adaptive Test to develop the HBSF. Both the HBSF and the Berg Balance Scale (BBS) were administered to patients, to determine the concurrent validity and time needed for administration of both measures. Each patient was assessed by 1 of the 3 short forms selected by a rater. RESULTS: The reliability of the HBSF was relatively high (reliability coefficients, .94-.95). The scores of the HBSF were highly correlated with those of the BBS (Spearman ρ=.80-.91), supporting the concurrent validity of the HBSF. The average time needed to administer the HBSF was 122 seconds (ie, about 40% of that for the BBS). CONCLUSIONS: Our results provide sufficient evidence that the HBSF is an efficient, reliable, valid, and practical way to measure balance function in patients with stroke.

Dose-response relation between neuromuscular electrical stimulation and upper-extremity function in patients with stroke.

BACKGROUND AND PURPOSE: The purpose of our study was to investigate the effects of different doses of neuromuscular electrical stimulation (NMES) on upper-extremity function in acute stroke patients with severe motor deficit. METHODS: Sixty-six acute stroke patients were randomized to 3 groups: high NMES, low NMES, or control. The low-NMES group received 30 minutes of stimulation per day, and the high-NMES group received 60 minutes per day, for 4 weeks. The Fugl-Meyer Motor Assessment Scale, Action Research Arm Test, and Motor Activity Log were used to assess the patients at baseline, 4 weeks, and 12 weeks post baseline (follow-up). RESULTS: Both NMES groups showed significant improvement on Fugl-Meyer Motor Assessment and Action Research Arm Test scales compared with the control group at week 4 and follow-up. The high-NMES group showed treatment effects similar to those of the low-NMES group. CONCLUSIONS: Higher and lower doses of NMES led to similar improvements in motor function. A minimum of 10 hours of NMES in combination with regular rehabilitation may improve recovery of arm function in stroke patients during the acute stage.

Early and intensive rehabilitation predicts good functional outcomes in patients admitted to the stroke intensive care unit.

PURPOSE: Earlier and more intense rehabilitation benefit stroke patients. Yet, studies have caution intensive therapy during acute brain injury. This study examined the rehabilitation commencement time and intensity as predictors of functional outcomes in acute stroke patients admitted to the stroke intensive care unit (ICU). METHOD: Sociodemographic, medical, rehabilitative and functional data were collected on 154 acute stroke patients. Regression analyses were used to identify predictors for the basic activities of daily living (Barthel Index, BI) and the walking ability at discharge. RESULT: Rehabilitation commencement time and intensity significantly predicted the BI score at discharge after adjusting for initial severity (National Institute of Health Stroke Scale, NIHSS) and age (p < 0.05). For the walking function at discharge, only the rehabilitation intensity was a significant predictor after adjusting for initial severity and age (p < 0.05). Furthermore, with increasing rehabilitation intensity, patients with severe stroke benefited more than those with moderate stroke. CONCLUSION: Rehabilitation commencement time and intensity, after adjusting for admission functional status and severity of stroke, remained to be important predictors of stroke functional outcomes. This study supported the recommendation to commence rehabilitation early and intensively and provided evidence that this claim can be extended to acute stroke patients admitted to an ICU.

Low dose HIV-1 Tat improves the defective nuclear factor (NF)-kappaB activity of dendritic cells from persons with spinal cord injury.

Deficits of immune function may be involved in the infections associated with spinal cord injury (SCI). Previous report showed that the impaired maturation potential of dendritic cells (DCs) contributes to immune defect in persons with SCI, especially in those with tetraplegia. To evaluate the roles of cell signaling in the impaired maturation potential of DCs, we assessed the phenotypic and functional maturation potential of DCs in 20 subjects with trauma-induced stable SCI and their neurologically intact healthy control in the presence of DC stimulators, including HIV-1 Tat protein (Tat). Our results showed the tetraplegic subjects had an impaired maturation potential of DCs. The impairment could be attributed to insufficient nuclear factor (NF)-kappaB activity. The maturation potentials and NF-kappaB activity of DCs in response to stimulators could be improved by pretreatment with Tat, although Tat did not increase DC maturation. The improvement by Tat pretreatment was inhibited by a specific NF-kappaB blocker. We concluded that HIV-1 Tat could improve the maturation potentials of DCs from tetraplegic subjects, through Tat-induced enhancement of NF-kappaB activity. These data suggest a potential therapeutic role of HIV-1 Tat in improving immune function in tetraplegic persons.

Circulating levels of markers of inflammation and endothelial activation are increased in men with chronic spinal cord injury.

BACKGROUND/PURPOSE: Accelerated atherogenesis is often seen in individuals with chronic spinal cord injury (SCI). However, the mechanisms contributing to this phenomenon remain unclear. This study aimed to evaluate whether SCI per se is associated with a low-grade chronic inflammatory state and endothelial activation, both of which are well-documented prerequisites for atherogenesis. METHODS: Serum levels of markers of inflammation (C-reactive protein [CRP], interleukin-6, and soluble CD40 ligand) and endothelial activation (endothelin-1, soluble intercellular adhesion molecule-1, and soluble vascular cell adhesion molecule-1 [sVCAM-1]) were measured in SCI patients with CRP levels < 10 mg/L and with no evidence of active infection. Sixty-two men with traumatic neurologically complete SCI (20 tetraplegics and 42 paraplegics) and 29 age-matched male controls were enrolled. RESULTS: Compared with able-bodied controls, subjects with SCI had a significantly lower body mass index (BMI) (-7%) and significantly lower serum levels of albumin (-10%), creatinine (-20%), low-density lipoprotein cholesterol (-10%), and high-density lipoprotein (HDL) cholesterol (-25%), and showed a trend toward higher fasting insulin levels. Irrespective of injury level and duration, subjects with SCI had significantly higher serum levels, compared to able-bodied controls, of CRP (mean, 4.0 +/- 2.7 mg/L vs. 1.4 +/- 1.1 mg/L), interleukin-6 (median, 2.5 pg/mL vs. 0.4 pg/mL; range, 1.5-3.6 pg/mL vs. 0.2-0.5 pg/mL), endothelin-1 (mean, 1.3 +/- 0.4 pg/mL vs. 0.9 +/- 0.3 pg/mL), and sVCAM-1 (mean, 1170 +/- 318 ng/mL vs. 542 +/- 318 ng/mL). The serum levels of all four factors correlated negatively with levels of serum albumin, creatinine and HDL cholesterol, but not with BMI or fasting insulin levels. In multivariate analyses, SCI was the only factor that was independently associated with increased serum levels of CRP, interleukin-6, endothelin-1 and sVCAM-1 after adjustment for confounding factors such as serum albumin and creatinine levels and parameters of dyslipidemia and insulin resistance. CONCLUSION: In this study, we have, for the first time, demonstrated that SCI per se is associated with a low-grade chronic inflammatory state and endothelial activation, which may partly explain the increased atherogenic risk in patients with long-standing SCI.

The predictive factors for length of stay for stroke patients in Taiwan using the path model.

The aim of this study was to examine the predictive factors, and their relative strengths, for predicting length of rehabilitation stay using the path model. One hundred and seventeen stroke patients were recruited from two rehabilitation units in university-affiliated hospitals in northern Taiwan. The Taiwanese Rehabilitation Database System was used to collect the patient's relevant information. Path analysis was used to explore the relative strengths of each predictive factor. The results showed that the ability to engage in self-care activities was the only direct predictor, whereas subjective well-being and cognitive social skills had an indirect effect on the length of rehabilitation stay, mediating through cognitive-social skills and ability to engage in activities of daily living, respectively. The effect of subjective well-being, mediating through cognitive-social skills, on the length of stay was about 1.5 times that of the effects of ability to engage in self-care activities on length of stay. The results of the study confirmed that the ability of stroke patients to engage in self-care activities consistently had a major impact on the length of stay. The effect of subjective well-being of the patients on the rehabilitation outcome raised the issue of psychosocial rehabilitation as an important part of successful rehabilitation services.

Predicting recovery of voluntary upper extremity movement in subacute stroke patients with severe upper extremity paresis.

BACKGROUND AND OBJECTIVE: Prediction of voluntary upper extremity (UE) movement recovery is largely unknown in patients with little voluntary UE movement at admission. The present study aimed to investigate (1) the extent and variation of voluntary UE movement recovery, and (2) the best predictive model of the recovery of voluntary UE movement by clinical variables in patients with severe UE paresis. DESIGN: Prospective cohort study. METHODS: 140 (out of 590) stroke patients with severe UE paresis completed all assessments. Voluntary UE movement was assessed using the UE subscale of the Stroke Rehabilitation Assessment of Movement (STREAM-UE). Two outcome measures, STREAM-UE scores at discharge (DC(STREAM-UE)) and changes between admission and discharge (Δ(STREAM-UE)), were investigated to represent the final states and improvement of the recovery of voluntary UE movement. Stepwise regression analyses were used to investigate 19 clinical variables and to find the best predictive models of the two outcome measures. RESULTS: The participants showed wide variation in both DC(STREAM-UE) and Δ(STREAM-UE). 3.6% of the participants almost fully recovered at discharge (DC(STREAM-UE) > 15). A large improvement (Δ(STREAM-UE) >= 10) occurred in 16.4% of the participants, while 32.9% of the participants did not have any improvement. The four predictors for the DC(STREAM-UE) (R(2) = 35.0%) were 'baseline STREAM-UE score', 'hemorrhagic stroke', 'baseline National Institutes of Health Stroke Scale (NIHSS) score', and 'cortical lesion excluding primary motor cortex'. The three predictors for the Δ(STREAM-UE) (R(2) = 22.0%) were 'hemorrhagic stroke', 'baseline NIHSS score', and 'cortical lesion excluding primary motor cortex'. CONCLUSIONS: Recovery of voluntary UE movement varied widely in patients with severe UE paresis after stroke. The predictive power of clinical variables was poor. Both results indicate the complex nature of voluntary UE movement recovery in patients with severe UE paresis after stroke.

Developing an ICF core set for sub-acute stages of spinal cord injury in Taiwan: a preliminary study.

PURPOSE: The objective of this study was to develop an ICF core set describing sub-acute spinal cord injury (SCI) specifically for Taiwanese patients. METHODS: A consensus process using three rounds of Delphi technique was conducted. Twenty multidisciplinary participants from various institutions were recruited. The questionnaire used in this study comprised 118 ICF second-level categories relevant to the sub-acute stage of SCI. A five-point Likert scale was used, and participants were asked to assign weights to the effect of each category on activities of daily life after SCI. The consensus among ratings was assessed using Spearman's rho and semi-interquartile range (SIQR) indices. The core set for post-acute SCI was developed from categories that attained a mean score of ≥3.8 in the third round of the Delphi exercise. RESULTS: The core set for sub-acute SCI contained 58 categories. Of these, 24 comprised the component of body functions (b), 5 comprised body structures (s), 21 comprised activities and participation (d), and 8 comprised environmental factors (e). CONCLUSION: The preliminary core set for sub-acute SCI offers a comprehensive system of disability assessment and verification after people have sustained an SCI. Further validation is required. Implication for Rehabilitation The preliminary core set for sub-acute SCI offers a comprehensive system for disability assessment related to SCI among Taiwanese patients. This core set reflected problems commonly encountered by patients with SCI. This core set reflects appropriate cultural and geographic perspectives in adjustment to SCI.

A causal model of rehabilitation resource use for subjects with spinal cord injury in Taiwan.

OBJECTIVE: The aim of this study was to construct an adequate causal model of rehabilitation resource use based on a Taiwanese rehabilitation database system. DESIGN: Cross-sectional analysis of data from a Taiwanese rehabilitation database system. SUBJECTS: Records from 68 patients (51 men, 17 women; mean age 43 years) with spinal cord injuries were used in the study. METHODS: Path analysis was used to identify a better-fitted model for patients with spinal cord injuries. RESULTS AND CONCLUSION: The results showed that the final causal model fits the data well. The findings also reveal that activities of daily living have the largest total effect on length of stay, whereas subjective well-being and gender have indirect effects on length of stay, mediating through activities of daily living and subjective well-being, respectively. The impact of subjective well-being on the length of stay in hospital for patients with spinal cord injuries deserves special attention, as the quality of life issue plays a vital role in rehabilitation of these patients. The influence of subjective well-being on activities of daily living suggests that therapy targeted at improving patients' subjective well-being is necessary. Additionally, the impact of sexual dysfunction of patients with spinal cord injuries should be investigated further.

Increased risk of ischemic heart disease in young patients with newly diagnosed ankylosing spondylitis--a population-based longitudinal follow-up study.

BACKGROUND: Prospective data is sparse on the association between ischemic heart disease (IHD) and ankylosing spondylitis (AS) in the young. The purpose of this population-based, age- and sex-matched follow-up study was to investigate the risk of IHD in young patients with newly diagnosed AS. METHODS: A total of 4794 persons aged 18 to 45 years with at least two ambulatory visits in 2001 with the principal diagnosis of AS were enrolled in the AS group. The non-AS group consisted of 23970 age- and sex-matched, randomly sampled subjects without AS. The three-year IHD-free survival rate and cumulative incidence of IHD were calculated using the Kaplan-Meier method. The Cox proportional hazards regression model was used to estimate the hazard ratio of IHD after controlling for demographic and cardiovascular co-morbidities. RESULTS: During follow-up, 70 patients in the AS group and 253 subjects in the non-AS group developed IHD. The cumulative incidence rate of IHD over time was higher in the AS group than the non-AS group. The crude hazard ratio of IHD for the AS group was 1.47 (95% CI, 1.13 to 1.92; p = 0.0043) and the adjusted hazard ratio after controlling for demographic characteristics and comorbid medical disorders was 1.47 (95% CI, 1.13 to 1.92; p = 0.0045). CONCLUSIONS: This study showed an increased risk of developing IHD in young patients with newly diagnosed AS.

Individual-level responsiveness of the original and short-form postural assessment scale for stroke patients.

BACKGROUND: The group-level responsiveness of the Postural Assessment Scale for Stroke Patients (PASS) is similar to that of the short-form PASS (SFPASS). This result is counterintuitive because the PASS has more items (12) and response levels (4) than does the SFPASS (5 items and 3 response levels). OBJECTIVE: The purpose of this study was to compare individual-level responsiveness between both measures to determine whether the SFPASS can detect change with as much sensitivity as the PASS. STUDY DESIGN AND SETTING: Two hundred fifty-one patients were assessed using the PASS at 14 and 30 days after stroke onset in a medical center. METHODS: The SFPASS scores were calculated from the patients' responses on the PASS. Individual-level responsiveness was calculated on the basis of the value of minimal detectable change (MDC). If a patient's change score was greater than the MDC of the PASS or SFPASS, his or her improvement was considered significant. The difference in the number of patients scoring greater than the MDC and the units of MDC (the MDC ratio) improved by the patients on both measures was examined. RESULTS: Fifty-three percent of the patients scored greater than the MDC of the PASS, whereas 43.0% of the patients scored greater than the MDC of the SFPASS. The difference was significant. The mean (±SD) MDC ratio of the PASS (1.8±1.7) was significantly higher than that of the SFPASS (1.2±1.3). LIMITATIONS: The scores of the SFPASS were retrieved from those of the PASS, which limits the generalization of our findings. CONCLUSIONS: The PASS has better individual-level responsiveness than does the SFPASS. To comprehensively report effects of clinical trials, future studies using the PASS should report the individual-level effect (eg, number of patients scoring greater than the MDC).

Does adhesive capsulitis of the shoulder increase the risk of stroke? A population-based propensity score-matched follow-up study.

OBJECTIVES: A previous population-based study reported an increased risk of stroke after the occurrence of adhesive capsulitis of the shoulder (ACS), but there were substantial imbalances in the distribution of age and pre-existing vascular risk factors between subjects with ACS and without ACS, which might lead to a confounded association between ACS and stroke. The purpose of the present large-scale propensity score-matched population-based follow-up study was to clarify whether there is an increased stroke risk after ACS. METHODS: We used a logistic regression model that includes age, sex, pre-existing comorbidities and socioeconomic status as covariates to compute the propensity score. A total of 22025 subjects with at least two ambulatory visits with the principal diagnosis of ACS in 2001 was enrolled in the ACS group. The non-ACS group consisted of 22025, propensity score-matched subjects without ACS. The stroke-free survival curves for these 2 groups were compared using the Kaplan-Meier method. Stratified Cox proportional hazard regression with patients matched on propensity score was used to estimate the effect of ACS on the occurrence of stroke. RESULTS: During the two-year follow-up period, 657 subjects in the ACS group (2.98%) and 687 in the non-ACS group (3.12%) developed stroke. The hazard ratio (HR) of stroke for the ACS group was 0.93 compared to the non-ACS group (95% confidence interval [CI], 0.83-1.04, P = 0.1778). There was no statistically significant difference in stroke subtype distribution between the two groups (P = 0.2114). CONCLUSIONS: These findings indicate that ACS itself is not associated with an increased risk of subsequent stroke.

Correction: Wogonin Improves Histological and Functional Outcomes, and Reduces Activation of TLR4/NF-κB Signaling after Experimental Traumatic Brain Injury.

[This corrects the article DOI: 10.1371/journal.pone.0030294.].