Health System's Role in Facilitating Health Service Access among Persons with Spinal Cord Injury across 22 Countries.

(1) Background: Despite efforts to improve access to health services, between- and within-country access inequalities remain, especially for individuals with complex disabling conditions like spinal cord injury (SCI). Persons with SCI require regular multidisciplinary follow-up care yet experience more access barriers than the general population. This study examines health system characteristics associated with access among persons with SCI across 22 countries. (2) Methods: Study data are from the International Spinal Cord Injury Survey with 12,588 participants with SCI across 22 countries. Cluster analysis was used to identify service access clusters based on reported access restrictions. The association between service access and health system characteristics (health workforce, infrastructure density, health expenditure) was determined by means of classification and regression trees. (3) Results: Unmet needs were reported by 17% of participants: lowest (10%) in Japan, Spain, and Switzerland (cluster 1) and highest (62%) in Morocco (cluster 8). The country of residence was the most important factor in facilitating access. Those reporting access restrictions were more likely to live in Morocco, to be in the lowest income decile, with multiple comorbidities (Secondary Conditions Scale (SCI-SCS) score > 29) and low functioning status (Spinal Cord Independence Measure score < 53). Those less likely to report access restriction tended to reside in all other countries except Brazil, China, Malaysia, Morocco, Poland, South Africa, and South Korea and have fewer comorbidities (SCI-SCS < 23). (4) Conclusions: The country of residence was the most important factor in facilitating health service access. Following the country of residence, higher income and better health were the most important facilitators of service access. Health service availability and affordability were reported as the most frequent health access barriers.

Ageing, functioning patterns and their environmental determinants in the spinal cord injury (SCI) population: A comparative analysis across eleven European countries implementing the International Spinal Cord Injury Community Survey.

BACKGROUND: As the European population with Spinal Cord Injury (SCI) is expected to become older, a better understanding of ageing with SCI using functioning, the health indicator used to model healthy ageing trajectories, is needed. We aimed to describe patterns of functioning in SCI by chronological age, age at injury and time since injury across eleven European countries using a common functioning metric, and to identify country-specific environmental determinants of functioning. METHODS: Data from 6'635 participants of the International Spinal Cord Injury Community Survey was used. The hierarchical version of Generalized Partial Credit Model, casted in a Bayesian framework, was used to create a common functioning metric and overall scores. For each country, linear regression was used to investigate associations between functioning, chronological age, age at SCI or time since injury for persons with para- and tetraplegia. Multiple linear regression and the proportional marginal variance decomposition technique were used to identify environmental determinants. RESULTS: In countries with representative samples older chronological age was consistently associated with a decline in functioning for paraplegia but not for tetraplegia. Age at injury and functioning level were associated, but patterns differed across countries. An association between time since injury and functioning was not observed in most countries, neither for paraplegia nor for tetraplegia. Problems with the accessibility of homes of friends and relatives, access to public places and long-distance transportation were consistently key determinants of functioning. CONCLUSIONS: Functioning is a key health indicator and the fundament of ageing research. Enhancing methods traditionally used to develop metrics with Bayesian approach, we were able to create a common metric of functioning with cardinal properties and to estimate overall scores comparable across countries. Focusing on functioning, our study complements epidemiological evidence on SCI-specific mortality and morbidity in Europe and identify initial targets for evidence-informed policy-making.

Does stronger primary care improve access to health services for persons with spinal cord injury? Evidence from eleven European countries.

OBJECTIVE: To determine the association between the strength of primary care and perceived access to follow-up care services among persons with chronic spinal cord injury (SCI). DESIGN: Data analysis of the International Spinal Cord Injury (InSCI) cross-sectional, community-based questionnaire survey conducted in 2017-2019. The association between the strength of primary care (Kringos et al., 2003) and access to health services was established using univariable and multivariable logistic regression analysis, adjusted for socio-demographic and health status characteristics. SETTING: Community in eleven European countries: France, Germany, Greece, Italy, Lithuania, the Netherlands, Norway, Poland, Romania, Spain and Switzerland. PARTICIPANTS: 6658 adults with chronic SCI. INTERVENTION: None. OUTCOME MEASURES: Share of persons with SCI that reported unmet healthcare needs as a measure of access. RESULTS: Twelve percent of the participants reported unmet healthcare needs: the highest in Poland (25%) and lowest in Switzerland and Spain (7%). The most prevalent access restriction was service unavailability (7%). Stronger primary care was associated with lower odds of reporting unmet healthcare needs, service unavailability, unaffordability and unacceptability. Females, persons of younger age and lower health status, had higher odds of reporting unmet needs. CONCLUSIONS: In all investigated countries, persons with chronic SCI face access barriers, especially with service availability. Stronger primary care for the general population was also associated with better health service access for persons with SCI, which argues for further primary care strengthening.

Quality of Life and the Health System: A 22-Country Comparison of the Situation of People With Spinal Cord Injury.

OBJECTIVE: To analyze and compare how performance of the health system are linked to the self-reported quality of life (QOL) of people with spinal cord injury (SCI) in 22 countries participating in the International Spinal Cord (InSCI) community survey. DESIGN: Cross-sectional survey. SETTING: Twenty-two countries representing all 6 World Health Organization regions, community setting. PARTICIPANTS: Persons (N=12,591) with traumatic or nontraumatic SCI aged ≥18 years. INTERVENTIONS: Not applicable. MAIN OUTCOMES: Self-reported satisfaction on several indicators that include: health, ability to perform daily activities, oneself, personal relationships, and living conditions. A total score of QOL was calculated using these 5 definitions. RESULTS: The most important indicators for self-reported QOL of persons with SCI were social attitudes and access to health care services, followed by nursing care, access to public spaces, the provision of vocational rehabilitation, transportation, medication, and assistive devices. In general, persons with SCI living in higher-income countries reported a higher QOL than people in lower-income countries, with some exceptions. The top performing country was The Netherlands with an estimated median QOL of 66% (on a 0%-100% scale). CONCLUSIONS: The living situation of people with SCI is highly influenced by the performance of the health system. Measuring and comparing health systems give accountability to a country's citizens, but it also helps to determine areas for improvement.

Fostering the highest educational standards in Physical and Rehabilitation Medicine: The European PRM board strategy for ensuring overall quality of rehabilitation education and care.

The harmonization of staff education is a key element for ensuring the highest standard of rehabilitation care across Europe. With this aim, the European Union of Medical Specialists (UEMS) has created a Common Training Framework, which consists of a common set of knowledge, skills and competencies for postgraduate medical training. As a body linked to the Physical and Rehabilitation (PRM) Section of the UEMS, the European PRM Board is committed to promoting the harmonization of PRM physicians qualifications. The European PRM Board accomplishes this mission, not only by determining the theoretical knowledge necessary for the practice of the PRM specialty, and the core competencies (training outcomes) to be achieved at the end of training, but also by ascertaining that a standard level of education is achieved and maintained by PRM physicians, through a medically driven system of certification. This paper provides an overview of the methodology and outcomes of the European PRM Board examination, while showing how the approach to PRM education should be considered as a reference point by scientific societies, higher education institutions, health policymakers, patients associations, and all the other bodies caring for high-quality rehabilitation provision to disabled people, at the national and European level.

Effects of robot-assisted training on upper limb functional recovery during the rehabilitation of poststroke patients.

BACKGROUND: The study aims to determine the effectiveness of robot-assisted training in the recovery of stroke-affected arms using an exoskeleton robot Armeo Spring. OBJECTIVE: To identify the effect of robot training on functional recovery of the arm. METHODS: A total of 34 stroke patients were divided into either an experimental group (EG; n= 17) or a control group (n= 17). EG was also trained to use the Armeo Spring during occupational therapy. Both groups were clinically assessed before and after treatment. Statistical comparison methods (i.e. one-tailed t-tests for differences between two independent means and the simplest test) were conducted to compare motor recovery using robot-assisted training or conventional therapy. RESULTS: Patients assigned to the EG showed a statistically significant improvement in upper extremity motor function when compared to the CG by FIM (P< 0.05) and ACER (P< 0.05). The calculated treatment effect in the EG and CG was meaningful for shoulder and elbow kinematic parameters. CONCLUSIONS: The findings show the benefits of robot therapy in two areas of functional recovery. Task-oriented robotic training in rehabilitation setting facilitates recovery not only of the motor function of the paretic arm but also of the cognitive abilities in stroke patients.

Necessity of early-stage verticalization in patients with brain and spinal cord injuries: Preliminary study.

BACKGROUND: Integration of the verticalization robot, Erigo, with functional electric stimulation and passive leg movements in the postacute rehabilitation of neurological patients could reduce the risk of secondary complications and improve functional outcomes (i.e. orthostatic hypotension, postural control and walking ability). OBJECTIVE: The aim of this study was to estimate and quantify changes in the postacute stage, mainly related to heart rate and blood pressure in functional recovery, postural parameters, walking ability and psychoemotional reactions, during training using the verticalization robot Erigo. METHODS: Six patients [three suffering from a stroke (ST) and three with spinal cord injuries (SCI)] participated in 10 sessions of physical therapy with the verticalization robot during primary inpatient rehabilitation. Functional state changes were assessed using clinical tests before and after the treatment, and the loading tolerance during Erigo training was noted. RESULTS: In early rehabilitation, Erigo training was safe and effective at improving orthostatic tolerance, posture and positive emotional reactions in both the ST and SCI patients (P< 0.05). In addition, advanced technologies were more effective at boosting the orthostatic tolerance in SCI patients, while they were more effective at increasing the dynamic balance and walking ability in ST patients (P< 0.05).

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for people with respiratory conditions. The European PRM position (UEMS PRM Section).

Chronic respiratory conditions are among the top causes of death and disability. The aim of the paper was to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for people with chronic respiratory conditions in order to promote their functioning and to reduce activity limitations and/or participation restrictions. A systematic review of the literature and a Consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. The systematic literature review is reported together with twenty-three recommendations resulting from the Delphi procedure. The professional role of PRM physicians having expertise in the rehabilitation of chronic respiratory conditions is to lead pulmonary rehabilitation programs in multiprofessional teams, working in collaboration with other disciplines in a variety of settings to improve functioning of people with chronic respiratory conditions. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians for people with respiratory conditions.

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for people with cardiovascular conditions. The European PRM position (UEMS PRM Section).

Cardiovascular conditions are significant causes of mortality and morbidity leading to substantial disability. The aim of the paper is to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for people with cardiovascular conditions in order to promote their functioning and to reduce activity limitations and/or participation restrictions. A systematic review of the literature and a Consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. The systematic literature review is reported together with thirty recommendations resulting from the Delphi procedure. The professional role of PRM physicians having expertise in the rehabilitation of cardiovascular conditions is to lead cardiac rehabilitation programs in multiprofessional teams, working in collaboration with other disciplines in a variety of settings to improve functioning of people with cardiovascular conditions. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians in persons with cardiovascular conditions.

Aerobic Training Effect on Arterial Stiffness in Metabolic Syndrome.

BACKGROUND: Metabolic syndrome, physical inactivity, and central obesity contribute to early vascular aging, which leads to increased risk of cardiovascular disease. This study aimed to assess the effect of heart rate (HR)-targeted aerobic exercise training on the indices of early vascular aging, in particular, arterial stiffness, and on anthropometric and clinical profile of metabolic syndrome subjects. METHODS: There were 126 metabolic syndrome subjects randomly selected. Anthropometric parameters, blood pressure (BP), blood sample, and arterial wall functional and structural parameters were obtained prior to and after the 8-week (84 patients) supervised training program. The age- and sex-matched control group (42 patients) followed the same protocol, except for the HR-targeted training program. RESULTS: In the study group, HR-targeted training was associated with decreased aortic pulse wave velocity (8.47 ± 1.40 vs 8.01 ± 1.06 m/s; P = .005), HR (P < .001), systolic (P < .015) and diastolic (P < .004) BP, waist circumference (P < .004), total and low-density-lipid cholesterol (respectively, 6.42 ± 1.41 vs 5.89 ± 1.32, P = .003 and 4.2 ± 1.18 vs 3.8 ± 1.21, P = .002), and an increase in aerobic capacity (P < .001). In the control group there were no statistically significant changes of arterial stiffness parameters. Multivariate analysis revealed that reduction of arterial stiffness was BP dependent. CONCLUSIONS: In subjects with metabolic syndrome, HR-targeted exercise training is associated with BP-dependent decrease in aortic stiffness and improvement of metabolic and fitness parameters.

Practice, science and governance in interaction: European effort for the system-wide implementation of the International Classification of Functioning, Disability and Health (ICF) in Physical and Rehabilitation Medicine.

Since its launch in 2001, relevant international, regional and national PRM bodies have aimed to implement the International Classification of Functioning, Disability and Health (ICF) in Physical and Rehabilitation Medicine (PRM), whereby contributing to the development of suitable practical tools. These tools are available for implementing the ICF in day-to-day clinical practice, standardized reporting of functioning outcomes in quality management and research, and guiding evidence-informed policy. Educational efforts have reinforced PRM physicians' and other rehabilitation professionals' ICF knowledge, and numerous implementation projects have explored how the ICF is applied in clinical practice, research and policy. Largely lacking though is the system-wide implementation of ICF in day-to-day practice across all rehabilitation services of national health systems. In Europe, system-wide implementation of ICF requires the interaction between practice, science and governance. Considering its mandate, the UEMS PRM Section and Board have decided to lead a European effort towards system-wide ICF implementation in PRM, rehabilitation and health care at large, in interaction with governments, non-governmental actors and the private sector, and aligned with ISPRM's collaboration plan with WHO. In this paper we present the current PRM internal and external policy agenda towards system-wide ICF implementation and the corresponding implementation action plan, while highlighting priority action steps - promotion of ICF-based standardized reporting in national quality management and assurance programs, development of unambiguous rehabilitation service descriptions using the International Classification System for Service Organization in Health-related Rehabilitation, development of Clinical Assessment Schedules, qualitative linkage and quantitative mapping of data to the ICF, and the cultural adaptation of the ICF Clinical Data Collection Tool in European languages.

Intrathecal Baclofen Therapy for the Treatment of Spasticity in Lithuania.

Spasticity of cerebral or spinal origin severely impairs an individual's functional ability and quality of life. Intrathecal baclofen (ITB) therapy via an implantable pump is indicated for use in patients unresponsive to oral antispasmodics. ITB therapy improves the daily caring for and relief of painful spasms. In Lithuania, ITB therapy was introduced in clinical practice just recently. We share our experience of spasticity management with the ITB pump system in five patients at Vilnius University Hospital Santariskiu Klinikos. Four patients had spastic tetraplegia associated with cerebral palsy, and one patient developed spastic paraplegia after a spinal epidural abscess.

Education of physical and rehabilitation medicine specialists across Europe: a call for harmonization.

BACKGROUND: Physical and rehabilitation medicine (PRM) is well established in Europe and officially recognized by the European Union of Medical Specialists (UEMS). The European PRM Board works to promote patient safety and quality of care through the development of the highest standards of medical training and healthcare across Europe as well as the harmonization of PRM specialists' qualifications. In its Action Plan for 2014-2018, the UEMS PRM Board has included the harmonization of the PRM curriculum among the EU countries, as one of its main goals. Based on a European Directive, the Belgian Superior Council is envisaging a reform of the PRM curriculum. AIM: The aim of this paper is to present the current situation of PRM education in Europe according to the survey carried out by the Belgium Task Force. DESIGN: An online survey was posted on May 3rd 2015 to all delegates of the UEMS PRM Section and Board. Two questions were formulated: 1) What is the duration and curriculum of PRM training in your country? 2) Does a Postgraduate Rehabilitation training exist for other medical specialties? RESULTS: The majority of the PRM training programs in Europe have a duration ranging from 4 to 5 years, and are not aiming at downsizing the duration to the European minimal training period of 3 years. The vast majority (70%) of the responding countries don't offer an additional accreditation of Rehabilitation for other medical specialties. CONCLUSIONS: Comparing PRM training programs in Europe can support the long-awaited reform of the PRM postgraduate curriculum in Belgium and gives perspective to agree on a transparent and comparable specialty training throughout Europe. Providing a more comparable training promotes the establishment of PRM and its rehabilitation service provisions in the world.

Cardiorespiratory parameters of exercise capacity in a healthy Lithuanian population: the pilot study.

INTRODUCTION: The normative values of exercise capacity used for the interpretation of exercise testing results are influenced by a variety of internal and external factors specific to certain populations. Therefore, in clinical practice it is recommended that population-specific reference values be employed. Cardiorespiratory fitness norms have not yet been established for a healthy Lithuanian population over a wide age span. The purpose of the present study was to determine the main cardiorespiratory fitness parameters for healthy adults living in Lithuania and to compare these parameters with the reference values established for different foreign populations. METHODS: This was a cross-sectional, community-based study involving 168 healthy adults aged from 20 to 60 years who were randomly selected from the general population. All subjects performed a progressive incremental exercise test on the cycle ergometer. The main cardiorespiratory fitness parameters analysed were peak oxygen consumption (VO2peak), ventilatory anaerobic threshold, and peak heart rate (HRpeak). RESULTS: The average estimated VO2peak was 35.02 ± 7.37 mL.kg(-1).min(-1) for men and 28.27 ± 6.33 mL.kg(-1).min(-1) for women. According to the results presented by other authors, this parameter is approximately 9-22% lower compared to other populations in all age groups, with the exception of the 20-29 year old group who alone satisfied fair aerobic fitness criteria. The average age-related decline in VO2peak was 0.016 L.min(-1) per year for men and 0.011 L.min(-1) per year for women. However, age itself explained only 12-14% of the variance. After VO2peak was adjusted relative to body mass, the difference in the decline between men and women remained insignificant: VO2peak decrease was 0.34 mL.kg(-1).min(-1) per year for men (coefficient of determination R(2) 0.250) and 0.32 mL.kg(-1).min(-1) per year for women (R(2) 0.330). A decline in peak heart rate of approximately 9 beats per minute was observed in each following age decade, which was well explained by the advancing age (R(2) 0.512 for men and R(2) 0.484 for women). CONCLUSIONS: Cardiorespiratory fitness parameters estimated for healthy adults living in Lithuania appeared to be lower compared to different foreign populations, despite the relatively similar general trends in the age-related decline in exercise capacity. Exercise testing laboratories and rehabilitation clinics in Lithuania may use these results in clinical practice when evaluating patients' exercise capacity, or as a promotional tool for physical activity in the general public.