Quantitative Dynamic Allodynograph-A Standardized Measure for Testing Dynamic Mechanical Allodynia in Chronic Limb Pain.

BACKGROUND: Dynamic mechanical allodynia (DMA) is both a symptom and a central sensitization sign, yet no standardized method for quantifying the DMA area has been reported. This study aimed to establish psychometric properties for Quantitative Dynamic Allodynography (QDA), a newly developed protocol measuring the DMA area as a percentage of the body surface. METHODS: Seventy-eight patients aged 18-65 diagnosed with chronic complex regional pain syndrome (CRPS) participated in this study. Test-retest reliability was conducted twice, one week apart (N = 20), and inter-rater (N = 3) reliability was conducted on 10 participants. Disease severity (CRPS Severity Score, CSS), pain intensity (VAS), and quality of life (SF-36) measures were utilized to test construct validity. RESULTS: High inter-rater reliability (intraclass correlation coefficient (ICC) = 0.96, p < 0.001) and test-retest reliability (r = 0.98, p < 0.001) were found. Furthermore, the QDA score was found to be correlated with the CSS (r = 0.47, p < 0.001), VAS (r = 0.37, p < 0.001), and the SF-36 physical health total (r = -0.47, p < 0.001) scores. CONCLUSION: The QDA is the first developed reliable and valid protocol for measuring DMA in a clinical setting and may be used as a diagnostic and prognostic measure in clinics and in research, advancing the pain precision medicine approach.

Bedside patient engagement monitor for rehabilitation in disorders of consciousness - demonstrative case-reports.

AIM: A chronic disorder of consciousness (DOC) is a devastating condition for the patients and their families. Achieving improved communication with patients in this state is of utmost importance. Over recent years we have seen some progress in the development of rehabilitation protocols for patients with DOC by which the patient's limited actions impact the environment (e.g. activate music) based on the principle of contingent stimulation. However, one of the major factors, which hinders further progress, is the limited overt responsiveness of the patient, which poses a severe limitation on the ability of the therapists to evaluate whether specific interventions have an impact. In this work, we harness a novel electrophysiological marker the Brain Engagement Index (BEI), which enables simple monitoring of patient's engagement during interventions, intending to overcome this limitation. METHODS: We combine the BEI marker with the contingent stimulation principle, to propose a 4-levels protocol for advancing communication with DOC patients. RESULTS: The potential of the evolving protocol is demonstrated with 4 representative case reports. Each case report demonstrates one level of the protocol. CONCLUSIONS: The protocol seems to be both feasible and effective for better clarification of the communication abilities of DOC patients. We recommend its continued evaluation employing a more structured study.IMPLICATIONS FOR REHABILITATIONWe suggest a systematic method for rehabilitation of patients with disorders of consciousnessIt is based upon monitoring patient engagement in real-time and selecting interventions accordingly.

Central Sensitization and Psychological State Distinguishing Complex Regional Pain Syndrome from Other Chronic Limb Pain Conditions: A Cluster Analysis Model.

Complex regional pain syndrome (CRPS) taxonomy has been updated with reported subtypes and is defined as primary pain alongside other chronic limb pain (CLP) conditions. We aimed at identifying CRPS clinical phenotypes that distinguish CRPS from other CLP conditions. Cluster analysis was carried out to classify 61 chronic CRPS and 31 CLP patients based on evoked pain (intensity of hyperalgesia and dynamic allodynia, allodynia area, and after-sensation) and psychological (depression, kinesiophobia, mental distress, and depersonalization) measures. Pro-inflammatory cytokine IL-6 and TNF-α serum levels were measured. Three cluster groups were created: 'CRPS' (78.7% CRPS; 6.5% CLP); 'CLP' (64.5% CLP; 4.9% CRPS), and 'Mixed' (16.4% CRPS; 29% CLP). The groups differed in all measures, predominantly in allodynia and hyperalgesia (p < 0.001, η² > 0.58). 'CRPS' demonstrated higher psychological and evoked pain measures vs. 'CLP'. 'Mixed' exhibited similarities to 'CRPS' in psychological profile and to 'CLP' in evoked pain measures. The serum level of TNF-αwas higher in the 'CRPS' vs. 'CLP' (p < 0.001) groups. In conclusion, pain hypersensitivity reflecting nociplastic pain mechanisms and psychological state measures created different clinical phenotypes of CRPS and possible CRPS subtypes, which distinguishes them from other CLP conditions, with the pro-inflammatory TNF-α cytokine as an additional potential biomarker.

[EXECUTIVE FUNCTIONS AND DAILY FUNCTIONS, ROAD SIGN RECOGNITION AND DRIVING SELF-REPORT AMONG HEALTHY AND POST-STROKE DRIVERS].

INTRODUCTION: Driving is an essential part of occupational performance. In determining potential driving competence, there is a lack of screening tools to ascertain who should be referred for further assessment in Occupational Therapy or at the Medical Institute for Road Safety. AIMS: To assess the relationship between executive-function, daily-functions and driving behavior measures in unimpaired and neurologically impaired populations. BACKGROUND: Although the research findings were not statistically significant, the trend points to the correlation between executive-function measures and self-report driving ability. Road sign recognition tests and daily-functions were found to be potential screening tools for assessing driving potential, but a larger sample size is recommended to confirm results. METHODS: An exploratory study that included 19 subjects - 10 without neurological impairments - and 9 post-stroke. Self-report questionnaires on driving ability, executive-functions and daily-function were administered. Post-stroke subjects were also assessed on road sign recognition. RESULTS: The research hypothesis was not confirmed. Three moderately correlated but statistically insignificant correlations were found: in unimpaired subjects between the driving self-report and functional status; in post-stroke subjects - between the driving self-report and self-monitoring and behavioral-regulation skills and in the road sign recognition tests - between executive and daily-function measures. CONCLUSIONS: If the trends were strengthened in a larger sample size the use of driving behavior self-report questionnaires, executive-function, daily-function and road sign recognition tests as screening tools for the unimpaired and post-stroke populations would be effective/recommended. DISCUSSION: Present findings of correlations between self-report of driving skills and behavioral regulation skills confirm previous research findings.

Detailed behavioral assessment promotes accurate diagnosis in patients with disorders of consciousness.

INTRODUCTION: Assessing the awareness level in patients with disorders of consciousness (DOC) is made on the basis of exhibited behaviors. However, since motor signs of awareness (i.e., non-reflex motor responses) can be very subtle, differentiating the vegetative from minimally conscious states (which is in itself not clear-cut) is often challenging. Even the careful clinician relying on standardized scales may arrive at a wrong diagnosis. AIM: To report our experience in tackling this problem by using two in-house use assessment procedures developed at Reuth Rehabilitation Hospital, and demonstrate their clinical significance by reviewing two cases. METHODS: (1) Reuth DOC Response Assessment (RDOC-RA) -administered in addition to the standardized tools, and emphasizes the importance of assessing a wide range of motor responses. In our experience, in some patients the only evidence for awareness may be a private specific movement that is not assessed by standard assessment tools. (2) Reuth DOC Periodic Intervention Model (RDOC-PIM) - current literature regarding assessment and diagnosis in DOC refers mostly to the acute phase of up to 1 year post injury. However, we have found major changes in responsiveness occurring 1 year or more post-injury in many patients. Therefore, we conduct periodic assessments at predetermined times points to ensure patients are not misdiagnosed or neurological changes overlooked. RESULTS: In the first case the RDOC-RA promoted a more accurate diagnosis than that based on standardized scales alone. The second case shows how the RDOC-PIM allowed us to recognize late recovery and promoted reinstatement of treatment with good results. CONCLUSION: Adding a detailed periodic assessment of DOC patients to existing scales can yield critical information, promoting better diagnosis, treatment, and clinical outcomes. We discuss the implications of this observation for the future development and validation of assessment tools in DOC patients.

Triple task Clock Completion Test (CCT) as a predictor of functional outcome in geriatric rehabilitation.

Cognitive status is considered as a predictor of the rehabilitation outcome. The triple task Clock Completion Test (CCT), which evaluates visuospatial skill, has been demonstrated to be a sensitive predictor of functional capacity. The objective of the study was to test the predictive validity of the CCT for assessing functional outcome in geriatric rehabilitation. Functional evaluation using the Functional Independence Measure (FIM) and cognitive evaluation using the Mini Mental State Examination (MMSE) as well as the CCT, were performed in 77 elderly patients (35 men, 42 women, median age 81.5 years) on admission and discharge. Significant positive coefficients of correlation were found between the admission and discharge CCT scores, and negative coefficients, between CCT and FIM scores, both on admission and discharge. CCT and MMSE scores correlated significantly just on admission. The MMSE and the FIM scores were significantly higher among those who succeeded than in those who failed on the CCT in the task of setting the hour on admission and discharge, whereas in the task of reading the hour, just on admission. The triple task CCT is a sensitive tool for identifying cognitive impairment affecting the executive functions and an important functional outcome predictor.