Internal structure and validity of the bedside oral examination tool in patients with brain injury at neurorehabilitation setting.

OBJECTIVES: To assess the internal structure and validity of the 'bedside oral examination' (BOE) instrument in individuals with acquired brain injury (ABI). METHODS: Ninety ABI individuals were examined using BOE in their first week of neurorehabilitation. BOE measures oral health within eight categories including: swallow, tongue, odour, teeth, lips, saliva, mucosa and gingiva. To assess the validity of BOE, full-mouth clinical examination (gold standard) was performed. The internal structure of BOE was assessed using exploratory and confirmatory factor analyses. To measure the validity, the BOE scores were dichotomised into excellent oral health and altered oral health. Sensitivity, specificity and area under the receiver operating characteristic (ROC) curve of the six/eight BOE items were compared with their related clinical oral examination tool. RESULTS: Overall, the patients had poor oral health irrespective of the oral examination tool used. Factor analyses indicated two factors within BOE: 'oral hygiene' (teeth, gingiva and mucosa) and 'orofacial health' (lips, swallow and saliva). BOE tongue and odour items loaded in neither factor. BOE items showed low validity since the highest area under the ROC curve was 0.60. Findings on the sensitivity value ranged from 35.0 to 74.2, while specificity from 44.4 to 83.3, depending on the item evaluated. CONCLUSION: Bedside oral examination does not seem to be an ideal 'single' outcome tool in a neurorehabilitation setting as it lacks validity. BOE evaluates oral health as two independent but correlated components and treat them separately indicating precision treatment depending on their oral health dysfunction. It is advisable to use BOE as a screening tool. However, it should be complimented by proper clinical examination before establishing a treatment plan for oral health in patients with ABI.

Periodontitis and orofacial health-related systemic impairment in patients with brain injury: a factor analysis approach.

Aim: To investigate the association of periodontitis to orofacial health-related systemic impairment in patients with acquired brain injury (ABI).Methods: Ninety individuals with ABI were included. Full mouth periodontal examination was performed. Orofacial health-related 'motor' and 'cognitive' scores, dysphagia and feeding status, onset of pneumonia were retrieved from e-journal. Factor analysis dubbed periodontal data as 'moderate' and 'severe' periodontitis while orofacial health-related brain injury scores were dubbed into 'motor' and 'cognitive' domains. Association between periodontal findings and systemic impairments were analyzed using multivariable linear regression models.Results: Higher scores of 'moderate' periodontitis were significantly associated with lower scores of motor impairment (ß = -0.2), feeding tube dependency (ß = 0.2) and dysphagia (ß = 1.21), whereas higher scores of 'severe' periodontitis were associated with lower scores of cognition (ß = -0.2) and reduced dental visits (ß = -0.2). Both periodontal domains were significantly associated with aging (ß = 0.02) and onset of pneumonia (ß = 0.5-0.7).Conclusions: Robust association between 'moderate' periodontitis and motor impairment, feeding problems and dysphagia, reflects an acute clinical condition, demanding cross-disciplinary intervention. Periodontal examination can be an early indicator tool for systemic chronic conditions, as ABI and periodontitis share a common environmental, social and biological background. Periodontitis majorly affects ageing population and are prone to pneumonia, compromising rehabilitation plan.

Changes in oral health related quality of life and its associated factors in individuals with brain injury.

Purpose: To evaluate changes in oral health-related quality of life (OHRQoL) and associated factors in individuals with acquired brain injury (ABI) during hospitalization.Methods: Forty-six individuals with ABI were examined at week 1 and 5 of hospitalization. OHRQoL was recorded through Oral Health Impact Profile-14 (OHIP-14), clinical oral examinations were conducted, while orofacial health-related 'motor' and 'cognitive' scores were retrieved from patients' e-journal. Association between variables were investigated using factor analysis and multilevel regression modeling.Results: There were no significant differences in the OHIP-14 scores between week 1 and 5. Factors analysis revealed two OHIP-14 domains, 'psychosocial' and 'physica'. Individuals who improved their cognitive skills over study period and those with 'severe' periodontitis at baseline had increased scores of OHIP-14 'psychosocial' domain. Individuals who improved orofacial health-related 'motor' skills over study period had decreased 'physical' domain scores. Increased cognition over study period, current smoking and dental calculus were associated with increased 'physical' domain.Conclusions: The OHRQoL was poor both at week 1 and 5. Individual's cognitive and motor skills as well as their oral health status influenced their OHRQoL. Thus, individual's awareness and involvement in addition to oral care seem to be imperative in improving the OHRQoL in neurorehabilitation setting.

Epilepsy after severe traumatic brain injury: frequency and injury severity.

Objective: To estimate national frequency of posttraumatic epilepsy (PTE) after severe traumatic brain injury (TBI) and assess injury severity (Glasgow Coma Scale (GCS) and posttraumatic amnesia (PTA)) as prognostic factors for PTE. METHODS: Data on patients ≥18 years surviving severe TBI 2004-2016 were retrieved from the Danish Head Trauma Database (n = 1010). The cumulative incidence proportion (CIP) was estimated using death as competing event. The association between injury severity and PTE was assessed using multivariable competing risk regressions. RESULTS: CIP of PTE 28 days and one year post-TBI was 6.8% (95% confidence interval (CI) 5.4-8.5) and 18.5% (95% CI 16.1-21.1%), respectively. Injury severity was not associated with PTE within 28 days post-TBI but indicated higher PTE-rates in less severely injured patients. PTA-duration >70 days was associated with PTE 29-365 days post-TBI (Adjusted sub-hazard ratio 4.23 (95% CI 1.79-9.99)). GCS was not associated with PTE 29-365 days post-TBI. CONCLUSION: The PTE frequency was higher compared to previous estimates. Increasing injury severity was associated with PTE 29-365 days post-TBI when measured with PTA, but not with GCS. Though nonsignificant, the increased PTE-risk within 28 days in lower severity suggests an underdiagnosing of PTE.

Oral health: something to worry about in individuals with acquired brain injury?

OBJECTIVES: To investigate the oral health status in patients with acquired brain injury (ABI) admitted at neurorehabilitation setting. METHODS: 132 individuals with ABI were examined within their first week of admission. Individuals' socio-behavioral history, length of stay in acute care etc. were recorded. Comprehensive clinical oral examination consisting of acute conditions [dental plaque, bleeding on probing (BOP)] and chronic conditions [periodontal status, tooth loss] were recorded. RESULTS: The average length of stay in acute care was 41 days before admission at neurorehabilitation. It was observed that 42% and 50% of the patients with ABI had visible plaque and active BOP in >60% of all examined sites respectively. All patients suffered from periodontitis and 74% had severe periodontitis (Stage III), indicating a chronic inflammatory destruction of the supporting tissues. Each participant had at least two decayed teeth, five filled and five extracted teeth. CONCLUSIONS: Presence of dental plaque and BOP, an acute condition, speculates that poor oral health worsened while patients were at acute care setting. Majority of individuals had severe periodontitis indicating chronic poor oral health. Thus, indicating the need of not only planning treatment strategies while hospitalization but also uplifting the prevention of oral diseases much earlier in life.

Reducing redundant testing using the Functional Independence Measure and Early Functional Abilities scale during rehabilitation in patients with brain injury.

PRIMARY OBJECTIVE: Rehabilitation scales following neurological injury can be useful for monitoring patient progress. However, too often, rehabilitation scales are administered unnecessarily placing an extra burden on clinicians and patients. The primary objective was to reduce redundant testing by providing guidelines for the concurrent use of the Functional Independence Measure (FIM) and Early Functional Abilities (EFA) scales during rehabilitation in patients with brain injury. METHODOLOGY: In total, 3289 concurrent FIM and EFA scores from 929 patients were examined. We proposed, using clinically sound and operational criterion, that the FIM should be used throughout rehabilitation, EFA should be used as a supplement when the FIM is ≤36 and FIM should be administered before the EFA on each testing occasion. RESULTS: Around 24% of patients should be measured with the FIM and EFA throughout rehabilitation, 35% of patients should be measured with the EFA and FIM initially but not require EFA measurements when there is an increase in function and 39% of patients should only be measured with the FIM. According to these guidelines, the EFA was administered unnecessarily 53% of the time. CONCLUSIONS AND IMPLICATIONS: These guidelines ensure that the EFA is used when it is sensitive. This will optimize clinician time and minimize redundant testing, without compromising the measurement of clinical progress.

Assessment of primary rehabilitation needs in neurological rehabilitation: translation, adaptation and face validity of the Danish version of Rehabilitation Complexity Scale-Extended.

BACKGROUND: Assessing primary rehabilitation needs in patients with acquired brain injury is a challenge due to case complexity and the heterogeneity of symptoms after brain injury. The Rehabilitation Complexity Scale-Extended (RCS-E) is an instrument used in assessment of rehabilitation complexity in patients with severe brain injury. The aim of the present study was to translate and test the face validity of the RCS-E as a referral tool for primary rehabilitation. Face validity was tested in a sample of patients with acquired brain injury. METHODS: Ten clinicians and records from 299 patients with acquired brain injury were used in the translation, cross-cultural adaptation and face validation study of the RCS-E. RCS-E was translated into Danish by a standardized forward-backward translation by experts in the field. Face validity was assessed by a multi-professional team assessing 299 patients. The team was asked their opinion on whether the RCS-E presents a sufficient description of the patients. RESULTS: The RCS-E was translated according to international guidelines and tested by health professionals; some adaptations were required due to linguistic problems and differences in the national health system structures. The patients in the study had a mean age of 63.9 years (SD 14.7); 61 % were male. We found an excellent face validity with a mean score of 8.2 (SD 0.34) assessed on a 0-10 scale. CONCLUSIONS: The RCS-E demonstrated to be a valid assessment of primary rehabilitation needs in patients with acquired brain injury. Excellent face validity indicates that the RCS-E is feasible for assessing primary rehabilitation needs and the present study suggests its applicability to the Danish health care system.

Analysis of 15 different pelvis marker protocols during sit-to-stand.

Sit-to-stand (STS) is a common transition movement needed to perform daily tasks. Previously, the kinematics of the STS movement has been investigated using optical motion capture. This method uses cameras and reflective markers on the body to capture movements. During STS, these markers can be difficult to measure due to blocked vision from the chair's arm- and backrest. This can result in poor data quality. The aim of this study was to investigate 15 different marker protocols and compare them in terms of visibility and selected outcome measures: hip flexion mean angle and range of motion (ROM). Fourteen healthy subjects completed five successful trials of STS. Marker protocols consisted of three anterior marker protocols and five posterior marker protocols, combined into a total of 15 marker protocols. For visibility, the traditional pelvis marker protocol proved unsuitable for STS tracking. Marker pins or additional markers anteriorly, and sacrum markers posteriorly, proved to be more suitable alternatives. For hip flexion mean angle and ROM, the estimates had similar tendencies. Hence, marker protocols were not outcome measure specific. Anteriorly, marker pins resulted in similar estimates as the traditional pelvis marker protocol. Posteriorly, sacrum markers estimated a smaller hip flexion angle, compared to the traditional pelvis marker protocol. In conclusion, marker pins can be used instead of regular ASIS markers at anterior pelvis. Posteriorly, sacrum markers can be used instead of PSIS markers.

Disability and physical activity in people with chronic disease receiving physiotherapy. A prospective cohort study.

Chronic disease affects patients' disability and participation in activities of daily living. Longitudinal information on disability and physical activity is generally scarce in patients with chronic disease. The current study aimed to investigate if self-reported disability and physical activity changed in patients with chronic disease receiving physiotherapy. Furthermore, the aim was to assess if an improvement in self-reported disability was related to an increase in objectively measured physical activity and if an aggravation in self-reported disability was related to a decrease in physical activity. Seventy patients with either multiple sclerosis, Parkinson's disease, rheumatoid arthritis or stroke receiving free of charge physiotherapy were tested at baseline and 1 year later. Disability was measured with the self-reported modified Ranking Scale-9 Questionnaire and physical activity was objectively measured using tri-axial accelerometry. Neither self-reported disability nor physical activity changed among patients receiving 1 year of free of charge physiotherapy at group level. Furthermore, self-reported change of disability was not expressed with changes in objectively measured physical activity, indicating that the two measures represent two different constructs.

Phase modulation of the short-latency crossed spinal response in the human soleus muscle.

Short-latency spinally mediated interlimb reflex pathways were recently reported between the left and right soleus muscles in the human lower-limb during sitting. The aim of the current study was to establish if these pathways were observed during a functional motor task such as human gait and modulated by the gait cycle phase and/or electrical stimulation intensity. The second aim was to elucidate on the afferents involved. Two interventions were investigated. First was ipsilateral tibial nerve (iTN) stimulation at motor threshold (MT), 35% of the maximal peak-to-peak M-wave(M-Max) and 85% M-Max (85M-Max) with stimuli applied at 60%, 70%, 80%, 90%, and 100%of the gait cycle of the ipsilateral leg. Second was ipsilateral sural nerve (SuN) and medial plantar nerve (MpN) stimulation at 1, 2, and 3X perceptual threshold at 90% of the gait cycle [corrected]. The root mean squared (RMS) of the contralateral soleus (cSOL) responses were analyzed in a time window, 40-55 ms (or 45-60 ms for subjects >50 y/o) following iTN stimulation. The most consistent responses occurred at 90 and 100% of the gait cycle at higher stimulation intensities of the iTN. Significantly inhibitory responses (P = 0.006) were reported at 60 versus 80% (P = 0.03), 90% (P = 0.006), and 100% (P = 0.002) and 70 versus 90% (P = 0.02) and 100% (P = 0.009) of the gait cycle at 85M-Max. The responses became more inhibitory with increasing stimulation intensities at 80% (P = 0.01), 90% (P = 0.001), and 100% (P = 0.004) of the gait cycle. Stimulation of the MpN and SuN at all stimulation intensities demonstrated no short-latency responses. Therefore, it is unlikely that afferents within these nerves contribute to the response. This is the first study to show short-latency spinally mediated responses in the cSOL following iTN stimulation, during walking. It provides evidence for a new spinal pathway contributing to motor control and demonstrates that the response likely has functional relevance.

Crossed spinal soleus muscle communication demonstrated by H-reflex conditioning.

INTRODUCTION: A conditioning volley to the ipsilateral tibial nerve (iTN) inhibits contralateral soleus (cSOL) electromyographic activity at latencies of 37-41 ms. This is evidence for spinal muscular communication in opposing limbs. The aim of our study was to determine whether the cSOL H-reflex would be inhibited in a similar manner. METHODS: Thirteen subjects participated in two experiments: (1) stimuli delivered to the iTN at 85% of the maximal peak-to-peak M-wave (85% M-max) with a pre-contracted cSOL; (2) 510 stimuli delivered at 85% M-max to the iTN with a test volley delivered to the contralateral tibial nerve at interstimulus intervals of -6 to 100 ms. RESULTS: Significant inhibition was observed in the cSOL H-reflex when conditioning stimuli were delivered 3-33 ms before the test H-reflex. CONCLUSIONS: The activity of this spinal pathway can be quantified using H-reflex conditioning to provide a controlled model for further studies of this response.

Reduced effective connectivity between right parietal and inferior frontal cortex during audiospatial perception in neglect patients with a right-hemisphere lesion.

A lesion to the right hemisphere of the brain in humans commonly leads to perceptual neglect of the left side of the sensorium. The clinical observation that lesions to disparate cortical and subcortical areas converge upon similar behavioural symptoms points to neglect as a dysconnection syndrome that may result from the disruption of a distributed network, rather than aberrant computations in any particular brain region. To test this hypothesis, we used Bayesian analysis of effective connectivity based on electroencephalographic recordings in ten patients (6 male, 4 female; age range 41-68) with left-sided neglect following a right-hemisphere lesion. In line with previous research, age-matched healthy controls showed a contralateral increase in connection strength between parietal and frontal cortex with respect to the laterality of audiospatial oddball stimuli. Neglect patients, however, showed a dysconnection between parietal and frontal cortex in the right hemisphere when oddballs appeared on their left side, but preserved connectivity in the left hemisphere when stimuli appeared on their right. This preserved fronto-parietal connectivity was associated with lower neglect severity. Moreover, we saw ipsilateral fronto-temporal connectivity increases for oddballs appearing on the neglected side, which might be a compensatory mechanism for residual left side awareness. No group differences were found in intrinsic (within-region) connectivity. While further validation is required in a bigger sample, our findings are in keeping with the idea that neglect results from the disruption of a distributed network, rather than a lesion to any single brain region. SIGNIFICANCE STATEMENT: Lesions to the right hemisphere of the brain commonly lead to neglect syndrome, characterized by perceptual deficits where patients are unaware of the left side of their body and environment. Using analysis of non-invasive electrophysiological recordings, we provide evidence that patients with left-sided neglect have reduced connectivity between the right parietal and frontal cortex during audiospatial stimuli, but preserved connectivity between regions in the non-lesioned left hemisphere. Moreover, for these intact connections we observed an ipsilateral fronto-temporal increase in connectivity during oddballs appearing on the neglected side, which might be a compensatory mechanism for residual perception. Crucially, we found that patients with more severe neglect symptoms had reduced connectivity between parietal and frontal cortex in the left hemisphere. This suggests that neglect may be caused by the disruption of a distributed network in the brain, rather than a lesion to any particular brain region.

Effectiveness of Standard Oral Care Plan During Hospital Stay in Individuals With Brain Injury.

Objective: To investigate the effectiveness of an existing standard oral care program (SOCP) and factors associated with it during hospitalization in individuals with acquired brain injury (ABI). Material and Methods: A total of 61 individuals underwent a SOCP for 4 weeks in a longitudinal observational study. Rapidly noticeable changes in oral health were evaluated by performing plaque, calculus, bleeding on probing (BOP) and bedside oral examination (BOE) at weeks 1 and 5. Individuals' brushing habits, eating difficulties, and the onset of pneumonia were retrieved from their medical records. Association between oral-health outcomes to systemic variables were investigated through multilevel regression models. Results: Dental plaque (P = 0.01) and total BOE score (P < 0.05) decreased over time but not the proportion of dental calculus (P = 0.30), BOP (P = 0.06), and tooth brushing frequency (P = 0.06). Reduction in plaque and BOE over time were negatively associated with higher periodontitis scores at baseline (coef. -6.8; -1.0), respectively, which in turn were associated with an increased proportion of BOP (coef. ≈ 15.0). An increased proportion of calculus was associated with eating difficulties (coef. 2.3) and the onset of pneumonia (coef. 6.2). Conclusions: Nursing care has been fundamental in improving oral health, especially reducing dental plaque and BOE scores. However, our findings indicate a need for improving the existing SOCP through academic-clinical partnerships. Clinical Relevance: Early introduction of oral care program to brain-injured individuals is beneficial in reducing plaque accumulation and improving oral health.

Externally validated model predicting gait independence after stroke showed fair performance and improved after updating.

OBJECTIVE: To externally validate recent prognostic models that predict independent gait following stroke. STUDY DESIGN AND SETTING: A systematic search identified recent models (<10 years) that predicted independent gait in adult stroke patients, using easily obtainable predictors. Predictors from the original models were assigned proxies when required, and model performance was evaluated in the validation cohort (n = 957). Models were updated to determine if performance could be improved. RESULTS: Three prognostic models met our criteria, all with high Risk of Bias. Validation data was only available for the Australian model. This model used National Institute of Health Stroke Scale (NIHSS) and age to predict independent gait, using Motor Assessment Scale (MAS) walking item. For validation, Scandinavian Stroke Scale (SSS) was a proxy for NIHSS, and Functional Independence Measure (FIM) locomotion item was a proxy for MAS. The Area Under the Curve was 0.77 (0.74-0.80) and had good calibration in the validation dataset. Adjustment of the intercept and regression coefficients slightly improved discrimination. By adding paretic leg strength, the model further improved (AUC 0.82). CONCLUSION: External validation of the Australian model with proxies showed fair discrimination and good calibration. Updating the model by adding paretic leg strength further improved model performance.

Cortical and spinal excitability changes after robotic gait training in healthy participants.

BACKGROUND: Recent studies have proposed a role for robotic gait training in participants with acquired brain injury, but the effects on the excitability of cortical and spinal neurons even in healthy participants are uncertain. OBJECTIVE: To investigate changes in corticospinal excitability in healthy participants after active and passive robotic gait training in a driven gait orthosis (DGO), the Lokomat. METHODS: Thirteen healthy participants took part in 2 experiments. Each participant performed 20 minutes of active and passive gait training in a DGO. Motor evoked potentials (MEP), short-interval intracortical inhibition (SICI), intracortical facilitation (ICF), F-wave frequency, and Mmax were measured in the right tibialis anterior muscle before and after training. RESULTS: Active training led to a decline in MEP amplitude and F-wave frequency. The MEP decline was associated with subjective muscle fatigue. Passive training induced a decrease in SICI lasting for 20 minutes after training. CONCLUSIONS: The decline in MEP after active training is most likely because of central fatigue, whereas the decreased F-wave frequency might represent short-term plastic changes in the spinal cord. The decrease in SICI after passive training probably reflects a decrease in intracortical GABA activity, which could benefit the acquisition of new motor skills.

Three-dimensional kinematics of shoulder function in stroke patients: Inter- and intra-rater reliability.

BACKGROUND: It is important to monitor progress during rehabilitation of stroke patients. To that end, clinical function tests may be supported by three-dimensional kinematic measures. The aim of this study was to evaluate the inter- and intra-rater reliability of three-dimensional kinematic measures of shoulder movements in stroke patients with reduced shoulder function. METHODS: Seventeen patients were tested in three sessions by two trained raters. Three-dimensional motion capture was performed of the more affected upper extremity and the trunk. Measures of movements of the scapula and humerus related to the trunk, the trunk related to the laboratory, the forearm related to the humerus, and temporospatial measures were obtained during two reach tasks from the Wolf Motor Function Test, ReachLow and ReachHigh. Inter- and intra-rater reliability was quantified with intraclass correlation coefficients (ICC). FINDINGS: In general, range of movements of scapula, shoulder, trunk and elbow and movement time and reach length showed high inter-rater reliability (ICC∞ 0.84-0.98) and intra-rater reliability (ICC∞ 0.75-1.00), A minimum of five trials per task were required to achieve reliable ICC estimates. INTERPRETATION: Selected three-dimensional kinematic measures can be used reliably to evaluate specific movements of the shoulder in stroke patients with reduced shoulder function.

Gastrointestinal transit time and heart rate variability in patients with mild acquired brain injury.

BACKGROUND: Constipation is suspected to occur frequently after acquired brain injury (ABI). In patients with ABI, heart rate variability (HRV) is reduced suggesting autonomic dysfunction. Autonomic dysfunction may be associated with prolonged gastrointestinal transit time (GITT). The primary aim of this study was to investigate if GITT is prolonged in patients with ABI. Secondarily, HRV and its correlation with GITT was investigated. METHODS: We included 25 patients with ABI (18 men, median age: 61.3 years, range [30.7-74.5]). GITT was assessed using radio-opaque markers and HRV was calculated from 24-hour electrocardiograms. Medical records were reviewed for important covariates, including primary diagnosis, time since injury, functional independence measure, and use of medication. The GITT assessed in patients was compared to a control group of 25 healthy subjects (18 men, median age: 61.5 years, range [34.0-70.9]). RESULTS: In ABI patients, the mean GITT was significantly longer than in healthy controls (2.68 days, 95% CI [2.16-3.19] versus (1.92 days, 95% CI [1.62-2.22], p = 0.011)). No correlation was found between HRV and GITT. CONCLUSION: Patients with mild to moderate ABI have prolonged GITT unrelated to the HRV.

Decreased contribution from afferent feedback to the soleus muscle during walking in patients with spastic stroke.

We investigated the contribution of afferent feedback to the soleus (SOL) muscle activity during the stance phase of walking in patients with spastic stroke. A total of 24 patients with hemiparetic spastic stroke and age-matched healthy volunteers participated in the study. A robotic actuator attached to the foot and leg was used to apply 3 types of ankle perturbations during treadmill walking. First, fast dorsiflexion perturbations were applied to elicit stretch reflexes in the SOL muscle. The SOL short-latency stretch reflex was facilitated in the patients (1.4 +/- 0.3) compared with the healthy volunteers (1.0 +/- 0.3, P = .05). Second, fast plantar flexion perturbations were applied during the stance phase to unload the plantar flexor muscles, thus, removing the afferent input from these muscles to the SOL motoneurons. These perturbations produced a distinct decrease in SOL activity that was significantly smaller in the patients (-30 +/- 3%) compared with the control subjects (-43 +/- 4%, P = .03). Third, slow-velocity, small-amplitude ankle trajectory modifications mimicking small deviations in the walking surface were applied to evaluate the afferent-mediated amplitude modulation of the locomotor SOL electromyogram (EMG). In the healthy volunteers these perturbations generated gradual increments and decrements on the SOL EMG; however, in the patients the SOL EMG modulation was significantly depressed (P = .04). Moreover, this depression was related to the spasticity level measured by the Ashworth score. These results indicate that although the stretch reflex response is facilitated during spastic gait, the contribution of afferent feedback to the ongoing locomotor SOL activity is depressed in patients with spastic stroke.

Referral decision support in patients with subacute brain injury: evaluation of the Rehabilitation Complexity Scale - Extended.

PURPOSE: To test if the Rehabilitation Complexity Scale Extended (RCS-E) can be used as decision support for patient referral to primary rehabilitation as either complex specialized services (CSS) or district specialist services (DSS). METHOD: Two independent expert teams analyzed medical records on 299 consecutive patients admitted for CSS or DSS rehabilitation. One team provided a golden standard for the patient referrals, and the other team provided RCS-E scores. Models for predicting referrals from RCS-E scores were developed on data for 149 patients and tested on the remaining 150 patients. RESULTS: The optimal RCS-E sum score threshold for referral prediction was 11, predicting the golden standard for patient referral with sensitivity 88%, specificity 78% and correct classification rate 81%. Improved referral prediction performance was achieved by using RCS-E item-wise score thresholds (sensitivity 81%, specificity 89%, correct classification rate 87%). The RCS-E sum score range for patients referred CSS and DSS by the item-wise model was, respectively, 0-12 and 2-22 suggesting strong non-linear interaction of the RCS-E items. CONCLUSIONS: We found excellent referral decision support in the RCS-E and the item specific threshold model, when patients with acquired brain injury are to be referred to CSS or DSS as their primary rehabilitation. Implications for Rehabilitation Efficient rehabilitation after acquired brain injury requires rehabilitation settings that meet patient needs. Validated tools for referral decision support make the process more transparent. Patient rehabilitation complexity can be stratified by the RCS-E with high sensitivity, specificity and predictive value of positive test. RCS-E is an excellent tool for referral decision support.

Cannabis use in persons with traumatic spinal cord injury in Denmark.

OBJECTIVE: To evaluate recreational and medical cannabis use in individuals with traumatic spinal cord injury, including reasons and predictors for use, perceived benefits and negative consequences. DESIGN: Cross-sectional survey in Denmark. METHODS: A 35-item questionnaire was sent to 1,101 patients with spinal cord injury who had been in contact with a rehabilitation centre between 1990 and 2012. RESULTS: A total of 537 participants completed the questionnaire. Of these, 36% had tried cannabis at least once and 9% were current users. Of current users, 79% had started to use cannabis before their spinal cord injury. The main reason for use was pleasure, but 65% used cannabis partly for spinal cord injury-related consequences and 59% reported at least good effect on pain and spasticity. Negative consequences of use were primarily inertia and feeling quiet/subdued. Lower age, living in rural areas/larger cities, tobacco-smoking, high alcohol intake and higher muscle stiffness were significantly associated with cannabis use. Those who had never tried cannabis reported that they would mainly use cannabis to alleviate pain and spasticity if it were legalized. CONCLUSION: Cannabis use is more frequent among individuals with spinal cord injury in Denmark than among the general population. High muscle stiffness and various demographic characteristics (lower age, living in rural areas/larger cities, tobacco-smoking and high alcohol intake) were associated with cannabis use. Most participants had started using cannabis before their spinal cord injury. There was considerable overlap between recreational and disability-related use.