A Systematic Review of Clinical Practice Guidelines for Persons With Non-specific Low Back Pain With and Without Radiculopathy: Identification of Best Evidence for Rehabilitation to Develop the WHO's Package of Interventions for Rehabilitation.

OBJECTIVE: To Identify evidence-based rehabilitation interventions for persons with non-specific low back pain (LBP) with and without radiculopathy and to develop recommendations from high-quality clinical practice guidelines (CPGs) to inform the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR). DATA SOURCE: We searched MEDLINE, EMBASE, CINAHL, PsycINFO, National Health Services Economic Evaluation Database, Health Technology Assessment Database, PEDro, the Trip Database, the Index to Chiropractic Literature and the gray literature. STUDY SELECTION: Eligible guidelines were (1) published between 2009 and 2019 in English, French, Italian, or Swedish; (2) included adults or children with non-specific LBP with or without radiculopathy; and (3) assessed the benefits of rehabilitation interventions on functioning. Pairs of independent reviewers assessed the quality of the CPGs using AGREE II. DATA SYNTHESIS: We identified 4 high-quality CPGs. Recommended interventions included (1) education about recovery expectations, self-management strategies, and maintenance of usual activities; (2) multimodal approaches incorporating education, exercise, and spinal manipulation; (3) nonsteroidal anti-inflammatory drugs combined with education in the acute stage; and (4) intensive interdisciplinary rehabilitation that includes exercise and cognitive/behavioral interventions for persistent pain. We did not identify high-quality CPGs for people younger than 16 years of age. CONCLUSION: We developed evidence-based recommendations from high-quality CPGs to inform the WHO PIR for people with LBP with and without radiculopathy. These recommendations emphasize the potential benefits of education, exercise, manual therapy, and cognitive/behavioral interventions.

A Systematic Review of Quality Dementia Clinical Guidelines for the Development of WHO's Package of Interventions for Rehabilitation.

BACKGROUND AND OBJECTIVES: As part of the WHO Rehabilitation 2030 call for action, the WHO Rehabilitation Programme is developing its Package of Interventions for Rehabilitation (PIR) to support ministries of health around the globe in integrating rehabilitation services into health systems. As a vital step for this PIR development, we conducted a systematic review of clinical practice guidelines (CPGs) for dementia to identify interventions for rehabilitation and related evidence. RESEARCH DESIGN AND METHODS: Following WHO Rehabilitation Programme and Cochrane Rehabilitation's methodology, quality CPGs published in English between January 2010 and March 2020 were identified using PubMed, Embase, CINAHL, PEDro, Google Scholar, guideline databases, and professional society websites. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (II). RESULTS: Of the 22 CPGs that met the selection criteria, 6 satisfied the quality evaluation. Three hundred and thirty rehabilitation-related recommendations were identified, mostly concentrated in the areas of cognition, emotion, and carer support. There were many strong interventions, with moderate- to high-quality evidence that could be easily introduced in routine practice. However, major limitations were found both in the quality of evidence and scope, especially in areas such as education and vocation, community and social life, and lifestyle modifications. DISCUSSION AND IMPLICATIONS: Further rigorous research is needed to build quality evidence in dementia rehabilitation in general, and especially in neglected areas for rehabilitation. Future work should also focus on the development of CPGs for dementia rehabilitation. A multipronged approach is needed to achieve Universal Health Coverage for dementia rehabilitation.

A systematic review of clinical practice guidelines for persons with osteoarthritis. A "Best Evidence for Rehabilitation" (be4rehab) paper to develop the WHO's Package of Interventions for Rehabilitation: A systematic review of Clinical Practice Guidelines for persons with osteoarthritis for the identification of best evidence for rehabilitation.

AIM: Identifying existing interventions for rehabilitation and related evidence presents a crucial step in developing the World Health Organization's (WHO) Package of Interventions for Rehabilitation. This paper reports the results of a systematic search that aimed to identify clinical practice guidelines (CPGs) relevant to the rehabilitation of people with osteoarthritis and presents the CPG recommendations and the current state of evidence available for the interventions in the CPGs. METHODS: This paper is part of the "Best Evidence for Rehabilitation" (be4rehab) series, developed according to the methodology presented in the WHO's Package of Interventions for Rehabilitation introductory paper by Rauch et al, published in 2019. It is a systematic review of the existing CPGs on osteoarthritis published between 2009 and 2019. Identified CPGs were screened taking into consideration conflict of interest, the provision of information regarding the strength of recommendation(s), and quality to be selected. Quality of CPGs was assessed using the AGREE II tool. RESULTS: After title and abstract screening, 51 CPGs were identified. Considering the inclusion/exclusion criteria, 26 CPGs were selected. After checking for quality, comprehensiveness, multi-professionality, and publication date, five CPGs were finally included in the review. The strong recommendations for people with knee and hip osteoarthritis consistently included in all the selected CPGs, sometimes called "core treatments", were patient education, exercise training, and weight reduction if overweight or obese. Generally, recommendations overlap in the CPGs. CONCLUSION: The systematic search revealed high-quality CPGs on osteoarthritis for the identification of "Best Evidence for Rehabilitation (be4rehab)" regarding interventions for rehabilitation of people with osteoarthritis.

A systematic review of Clinical Practice Guidelines for the management of fractures in children to develop the WHO's Package of Interventions for Rehabilitation.

INTRODUCTION: Fractures have been identified as one of the 20 major health conditions for the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR) - that includes also the needs of children and youth. The identification of existing interventions for rehabilitation and related evidence is a crucial step along the development of the PIR. The methods for the identification have been developed by WHO Rehabilitation Program and Cochrane Rehabilitation under the guidance of WHO's Guideline Review Committee Secretariat. EVIDENCE ACQUISITION: This paper is part of the "Best Evidence for Rehabilitation" (be4rehab) series, developed according to the methodology presented in the PIR introductory paper. It is a systematic review of the existing Clinical Practice Guidelines (CPGs) on fractures in pediatric population published between 2009 to 2019. EVIDENCE SYNTHESIS: We identified seven relevant CPGs after title and abstract screening. According to inclusion/exclusion criteria and after checking for quality, publication time, multidisciplinarity and comprehensiveness, we have been able to include two CPGs: one addresses the treatment of supracondylar humerus fractures and the other provides recommendations on the treatment of diaphyseal femur fractures. CONCLUSIONS: The selected CPGs on the management of supracondylar humerus and diaphyseal femur fractures in pediatric population include few recommendations considered as interventions for rehabilitation, of low quality of evidence and weak strength. We found several gaps in specific rehabilitative topics. High quality studies are absolutely needed to upgrade the quality of available evidence to inform future development of guidelines.

Systematic Review: Recommendations for Rehabilitation in ASD and ID From Clinical Practice Guidelines.

OBJECTIVE: To identify and summarize clinical practice guidelines for autism spectrum disorder (ASD) and intellectual disability (ID) for the Package of Interventions for Rehabilitation for the World Health Organization (WHO). DATA SOURCES: Academic databases, Google Scholar, guideline databases, and professional society websites were searched using the general criteria "ASD/ID" AND "rehabilitation" AND "guideline," restricted to English-only guidelines. STUDY SELECTION: Work group members independently screened titles and abstracts (1952 ASD; 1027 ID) and excluded articles if not (1) a guideline; (2) about rehabilitation; (3) published since 2008; or (4) about ASD/ID. Full-text screening (29 ASD; 5 ID) involved 3 additional exclusion criteria: (1) contained conflict of interest; (2) lacked information on strength of recommendation; or (3) failed the Appraisal of Guidelines for Research and Evaluation II instrument. Six guidelines (4 ASD: 2 on youth, 1 on adults, 1 on all ages; 2 ID: 1 on challenging behaviors, 1 on mental health) resulted. DATA EXTRACTION: Work group members extracted 524 recommendations (386 ASD; 138 ID) from the guidelines including the level of evidence, diagnostic and age group, recommendation type (assessment, intervention, service), target, and valence. DATA SYNTHESIS: Of the 270 intervention recommendations (212 ASD; 58 ID), only 36 for ASD and 47 for ID were empirically based. Most comprised biomedical (23%), pharmacologic (29%), and psychosocial (21%) interventions for ASD and behavioral (14%), pharmacologic (29%), and psychological (14%) interventions for ID. Intervention recommendations primarily targeted coexisting conditions (56% ASD; 93% ID), whereas core symptoms received much less attention (26% ASD). CONCLUSIONS: Clinical practice guidelines reviewed for ASD and ID primarily contained recommendations based on expert opinion, with the plurality of recommendations relating to pharmacologic treatment. Vital next steps include identifying relevant interventions for inclusion in the WHO Package and continuing to conduct rigorous intervention research, particularly on core symptoms of these conditions, to extend recommendations for high-quality guidelines.

Cochrane collaborates with the World Health Organization to establish a Package of Rehabilitation Interventions based on the best available evidence.

The World Health Organization (WHO) and Cochrane have been collaborating for a long time. As a part of "Rehabilitation 2030: a call for action", WHO's Department of Noncommunicable Diseases is developing a Package of Rehabilitation Interventions (PRI) which provides a set of prioritized evidence-based interventions, along with resource requirements for their delivery. Cochrane Rehabilitation were asked to contribute to the methodological development of the PRI, with particular involvement in the initial phases of the evidence selection and extraction. The whole project comprises six phases of development: 1) definition of the 20 health relevant conditions; 2) selection and extraction of the current best evidence and expertise; 3) identification of the interventions to be included by expert consensus and (4) definition of the resources needed for their provision; 5) external review of the preliminary PRI and (6) dissemination of the final version of PRI. This joint WHO-Cochrane project is a major contribution to the Cochrane Knowledge Translation Strategy. PIR will be provided by WHO to all countries, particularly to help health policy makers in planning and implementing rehabilitation into Healthcare Systems.

Systematic Review of Clinical Guidelines Related to Care of Individuals With Cerebral Palsy as Part of the World Health Organization Efforts to Develop a Global Package of Interventions for Rehabilitation.

OBJECTIVE: The World Health Organization's (WHO) Rehabilitation 2030 initiative is working to develop a set of evidence-based interventions selected from clinical practice guidelines for Universal Health Coverage. As an initial step, the WHO Rehabilitation Programme and Cochrane Rehabilitation convened global content experts to conduct systematic reviews of clinical practice guidelines for 20 chronic health conditions, including cerebral palsy. DATA SOURCES: Six scientific databases (Pubmed, EMBASE, Scopus, Web of Science, PEDro, CINAHL), Google Scholar, guideline databases, and professional society websites were searched. STUDY SELECTION: A search strategy was implemented to identify clinical practice guidelines for cerebral palsy across the lifespan published within 10 years in English. Standardized spreadsheets were provided for process documentation, data entry, and tabulation of the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Each step was completed by 2 or more group members, with disagreements resolved by discussion. Initially, 13 guidelines were identified. Five did not meet the AGREE II established threshold or criteria for inclusion. Further review by the WHO eliminated 3 more, resulting in 5 remaining guidelines. DATA EXTRACTION: All 339 recommendations from the 5 final guidelines, with type (assessment, intervention, or service), strength, and quality of evidence, were extracted, and an International Classification of Functioning, Disability and Health Functioning (ICF) category was assigned to each. DATA SYNTHESIS: Most guidelines addressed mobility functions, with comorbid conditions and lifespan considerations also included. However, most were at the level of body functions. No guideline focused specifically on physical or occupational therapies to improve activity and participation, despite their prevalence in rehabilitation. CONCLUSIONS: Despite the great need for high quality guidelines, this review demonstrated the limited number and range of interventions and lack of explicit use of the ICF during development of guidelines identified here. A lack of guidelines, however, does not necessarily indicate a lack of evidence. Further evidence review and development based on identified gaps and stakeholder priorities are needed.

Systematic Review of Clinical Practice Guidelines for Individuals With Amputation: Identification of Best Evidence for Rehabilitation to Develop the WHO's Package of Interventions for Rehabilitation.

OBJECTIVES: To report the results of the systematic search performed to identify interventions and related evidence for rehabilitation of individuals with amputation based on the current evidence from clinical practice guidelines (CPG). DATA SOURCES: Pubmed, Pedro, CINAHL, Embase, Google Scholar, and multiple guideline databases (date restriction, 2008-2018). STUDY SELECTION: Exclusion criteria were no CPG, not reporting on rehabilitation, published before 2008, developed for health conditions other than amputation, presence of conflict of interest (financial or nonfinancial), lack of information on the strength of the recommendation, and lack of quality assessed by the "Appraisal of Guidelines for Research and Evaluation." DATA EXTRACTION: Data extraction was done using a standardized form, which comprised information on the recommendation, the strength of recommendation and the quality of the evidence used to inform the recommendation. DATA SYNTHESIS: We included 4 guidelines, providing a total of 217 recommendations (20 on assessments, 131 on interventions, and 66 on service provision). Most recommendations concerned pain management, education, pre- and postoperative management, and residual limb care. The strength of recommendation was generally weak to intermediate. The level of evidence mostly compromised expert opinions, with only 6.9% (15 of 217) being provided by randomized controlled trials, systematic reviews, or meta-analyses. CONCLUSIONS: The field of amputation is well covered for recommended interventions, but the level of evidence is generally low and is based mostly on expert opinion. Some important domains are not covered (eg, vocation and education, sexual and/or intimate relationships, activities of daily living or leisure activities, education concerning socket/liner fitting). There is also a lack of description of the contents of training and rehabilitation programs. This should be taken into account for the development of future guidelines.

Systematic review of clinical practice guidelines for adults with fractures: identification of best evidence for rehabilitation to develop the WHO's Package of Interventions for Rehabilitation.

BACKGROUND: The identification of existing rehabilitation interventions and related evidence represents a crucial step along the development of the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR). The methods for such identification have been developed by the WHO Rehabilitation Programme and Cochrane Rehabilitation under the guidance of the WHO's Guideline Review Committee secretariat. The aim of this paper is to report on the results of the systematic search for clinical practice guidelines (CPGs) relevant to the rehabilitation of adults with fractures and to present the current state of evidence available from the identified CPGs. METHODS: This paper is part of the Best Evidence for Rehabilitation (be4rehab) series, developed according to the methodology presented in the World Health Organization's (WHO) Package of Interventions for Rehabilitation (PIR) introductory paper. It is a systematic review of existing CPGs on fractures in adult population published from 2009 to 2019. RESULTS: We identified 23 relevant CPGs after title and abstract screening. According to inclusion/exclusion criteria, we selected 13 CPGs. After checking for quality, publication time, multiprofessionality, and comprehensiveness, we finally included five CPGs dealing with rehabilitative management of fractures in adult population, two CPGs addressing treatment of distal radius fracture and three the treatment of femoral/hip fracture. CONCLUSION: The selected CPGs on management of distal radius and femoral/hip fracture include few recommendations regarding rehabilitation, with overall low to very low quality of evidence and weak/conditional strength of recommendation. Moreover, several gaps in specific rehabilitative topics occur. Further high-quality trials are required to upgrade the quality of the available evidence. LEVEL OF EVIDENCE: Level 1.

Toward Strengthening Rehabilitation in Health Systems: Methods Used to Develop a WHO Package of Rehabilitation Interventions.

Achieving Universal Health Coverage (UHC) is a World Health Organization (WHO) strategic priority. UHC means "all people receive quality health services that meet their needs without being exposed to financial hardship in paying for the services." Rehabilitation is among the services included in UHC. As part of the WHO Rehabilitation 2030 call for action, WHO is developing its Package of Rehabilitation Interventions (PRI) to support ministries of health in planning, budgeting, and integrating rehabilitation interventions into health systems. The aim of this paper is to introduce and describe the PRI and its methodology. An advisory board composed of members from different WHO departments is overseeing the project, which is led by the WHO Rehabilitation Programme in collaboration with Cochrane Rehabilitation. The development of the PRI is conducted in 6 steps: (1) selection of health conditions (for which rehabilitation interventions will be included in the PRI) based on prevalences, related levels of disability, and expert opinion; (2) identification of rehabilitation interventions and related evidence for the selected health conditions from Clinical Practice Guidelines and Cochrane Reviews; (3) expert agreement on the inclusion of rehabilitation interventions in the PRI; (4) description of resources required for the provision of selected interventions; (5) peer review process, and (6) production of an open source web-based tool. Rehabilitation experts and consumers from all world regions will collaborate in the different steps. In developing the PRI, WHO is taking an important step toward strengthening rehabilitation in health systems, thus enabling more people to benefit from rehabilitation.

External Beam Radiation Therapy for Resectable Soft Tissue Sarcoma: A Systematic Review and Meta-Analysis.

PURPOSE: The aim of this study was to evaluate the role of preoperative and postoperative external beam radiation therapy (EBRT) in the treatment of resectable soft tissue sarcomas (STSs) of different tumor locations. METHODS: A systematic literature search was performed to identify studies investigating the effects of EBRT (versus no EBRT) on local recurrence (LR) and overall survival (OS) or comparing different EBRT sequences. Random effects meta-analyses were calculated and presented as cumulative odds ratios (ORs). RESULTS: Sixteen studies (n = 3958 patients) comparing EBRT versus no EBRT, including one randomized controlled trial (RCT) in extremity sarcoma, were analyzed. EBRT appeared to reduce LR in both retroperitoneal tumors (OR 0.47, p < 0.0001) and other locations (OR 0.49, p = 0.001). OS was improved by EBRT in retroperitoneal STSs (OR 0.37, p < 0.0001) but not in other tumor locations. Eleven studies (n = 2140), including one RCT, compared preoperative and postoperative radiotherapy. LR was less frequent following preoperative EBRT in retroperitoneal STSs (OR 0.03, p = 0.02), as well as in other tumor locations (OR 0.67, p = 0.01), while wound complications in extremity sarcoma were more frequent following preoperative EBRT (OR 2.92, p < 0.0001). Several studies included in this meta-analysis bear a high risk of bias and no RCT has been published for retroperitoneal STS. CONCLUSIONS: This meta-analysis supports the use of EBRT for local tumor control in patients with resectable STSs. Based on a small number of non-randomized studies, a positive effect on OS may exist in the subgroup of retroperitoneal STSs.

Factors Associated With Choroidal Blood Flow Regulation in Healthy Young Subjects.

PURPOSE: To analyze regulation of subfoveal choroidal blood flow (FLOW) during isometric exercise in healthy subjects in dependence of intraocular pressure (IOP), mean arterial pressure (MAP), ocular perfusion pressure (OPP), age, sex, fasting glucose, cholesterol, triglycerides, creatinine, and C-reactive protein levels and hematocrit. METHODS: We retrospectively analyzed results obtained in 261 healthy subjects who underwent a period of 6 minutes of isometric exercise during which FLOW was measured continuously and MAP was measured every minute. From these data, OPP and choroidal pressure/flow curves were calculated. Subjects were grouped into tertiles with regard to the dependent variables, and pressure/flow relationships were compared. RESULTS: Choroidal blood flow started to increase at OPP values of approximately 65% dependent on the MAP/IOP tertile. A significant increase of FLOW from baseline was noted at 67.7 ± 2.1% in the lowest MAP tertile, at 67.7 ± 2.0% in the second MAP tertile, and at 61.8 ± 2.0% in the highest MAP tertile (P = 0.01). At the three IOP levels, FLOW started to increase at an OPP increase of 69.8 ± 2.1%, 70.1 ± 2.2%, and 65.4 ± 1.9% above baseline, respectively (P = 0.03). Choroidal pressure/flow curves were independent of the other variables. CONCLUSIONS: The present analysis indicates that FLOW regulation during isometric exercise is dependent on absolute MAP as well as IOP levels. This indicates that regulation depends on pressure levels at both the arterial and the venous side of the choroidal circulation and highlights the complexity of FLOW regulation during changes in OPP that cannot be simply characterized by classical autoregulation models.

Temporary Intraoperative Porto-Caval Shunts in Piggy-Back Liver Transplantation Reduce Intraoperative Blood Loss and Improve Postoperative Transaminases and Renal Function: A Meta-Analysis.

BACKGROUND: The value of temporary intraoperative porto-caval shunts (TPCS) in cava-sparing liver transplantation is discussed controversially. Aim of this meta-analysis was to analyze the impact of temporary intraoperative porto-caval shunts on liver injury, primary non-function, time of surgery, transfusion of blood products and length of hospital stay in cava-sparing liver transplantation. METHODS: A systematic search of MEDLINE/PubMed, EMBASE and PsycINFO retrieved a total of 909 articles, of which six articles were included. The combined effect size and 95 % confidence interval were calculated for each outcome by applying the inverse variance weighting method. Tests for heterogeneity (I 2) were also utilized. RESULTS: Usage of a TPCS was associated with significantly decreased AST values, significantly fewer transfusions of packed red blood cells and improved postoperative renal function. There were no statistically significant differences in primary graft non-function, length of hospital stay or duration of surgery. CONCLUSION: This meta-analysis found that temporary intraoperative porto-caval shunts in cava-sparing liver transplantation reduce blood loss as well as hepatic injury and enhance postoperative renal function without prolonging operative time. Randomized controlled trials investigating the use of temporary intraoperative porto-caval shunts are needed to confirm these findings.

Factors Determining Flicker-Induced Retinal Vasodilation in Healthy Subjects.

PURPOSE: The purpose of this study was to analyze factors determining retinal arterial and venous responses to stimulation with diffuse luminance flicker in healthy subjects. METHODS: We retrospectively analyzed results obtained in 374 healthy subjects who had previously participated in clinical studies in our department. A total of 153 subjects underwent a protocol in which flicker stimulation was delivered through the fundus camera at 8 Hz (protocol 1), separating measurement and stimulation light depending on the wavelength, and 221 subjects underwent a protocol in which diffuse luminance flicker was delivered at 12.5 Hz with high modulation depth (protocol 2). We investigated whether sex, systemic blood pressure, baseline vessel size, blood plasma concentration of fasting glucose and hematocrit, and serum concentration of cholesterol, triglycerides, creatinine and C-reactive protein influenced the retinal vascular response to flicker stimulation. RESULTS: Flicker responses in arteries and veins were more pronounced in protocol 2 than in protocol 1 (P < 0.001, each). In both of the protocols the vascular response to stimulation with diffuse luminance flicker was larger in smaller vessels (P between 0.001 and 0.016). In protocol 2 the retinal arterial flicker response was negatively associated with cholesterol serum levels (P = 0.033); in protocol 1, only a tendency toward this effect was observed (P = 0.056). CONCLUSIONS: The present analysis indicates that retinal arterial and venous responses to stimulation with diffuse luminance flicker depend on the way the stimulation is delivered through the fundus camera. In addition, the flicker response varied with vessel size, that is, the smaller the vessel width, the larger the flicker response. Finally, our data indicate that, even within the normal range, higher cholesterol serum levels are associated with lower hyperemic flicker responses.

Do people with spinal cord injury meet the WHO recommendations on physical activity?

OBJECTIVES: To describe physical activity (PA) levels in persons with spinal cord injury (SCI) and to investigate associated factors. METHODS: PA behavior of people with SCI in Switzerland was assessed in a community survey with four items from the Physical Activity Scale for individuals with physical disabilities (PA of light, moderate, and strenuous intensity and muscle-strengthening exercises). In addition to descriptive analyses, the odds of performing PA according to the WHO recommendations (at least 2.5 h/week of at least moderate intensity) were analyzed by multivariable logistic regression. RESULTS: Participants (n = 485; aged 52.9 ± 14.8; 73.6 % male) carried out PA a total of 6.0 h/week (median). 18.6 % were physically inactive, 50.3 % carried out muscle-strengthening exercises, and 48.9 % fulfilled the WHO recommendations. Regression analyses showed that women, people aged 71+, and people with complete tetraplegia had significantly lower odds of fulfilling the WHO recommendations than participants in the respective reference category (men, ages 17-30, incomplete paraplegia). CONCLUSIONS: PA levels of people with SCI in Switzerland are rather high. However, some subgroups need special consideration when planning interventions to increase PA levels.

Participation in physical activity in persons with spinal cord injury: a comprehensive perspective and insights into gender differences.

BACKGROUND: To prevent secondary conditions and to improve and maintain health, regular physical activity is recommended as an important component of a health-promoting lifestyle for persons with spinal cord injury (SCI). However, participation in physical activity is low in persons with SCI, especially in women. OBJECTIVE: The objective of this study is to identify (1) categories of functioning, the environment and personal factors that influence participation in physical activity in persons with SCI and (2) gender differences within identified factors. METHODS: An explorative qualitative study design using both focus groups and individual interviews based on a semi-structured interview guide was used. Statements were linked to categories or chapters of the four components of functioning (body structures, body functions, activities and participation) and of the environment included in the International Classification of Functioning, Disability and Health (ICF) and a recently developed list of personal factors. An in-depth analysis of the statements was performed to identify relevant associations and gender differences. RESULTS: Twenty-six persons (13 female, 13 male) participated in the study. Sixty-seven categories and four chapters from all components of functioning and environmental factors included in the ICF and 33 subdivisions of personal factors were found to be associated with physical activity in persons with SCI. Gender differences could be assigned to areas of gender roles, social support, athletic identity, interests, and general behavioral patterns. CONCLUSION: This study contributes to a comprehensive understanding of participation in physical activity in persons with SCI and presents a first step toward the identification of gender differences. The results should be validated by further quantitative research.

Social support and functioning in a patient with spinal cord injury: the role of social skills.

This study reports on a patient with spinal cord injury (SCI) in whom the interaction between social skills and social support seems to influence functioning. The International Classification of Functioning, Disability and Health (ICF) was used as a reference framework. Qualitative (i.e. observation, structured, and open interviews with the patient and health professionals) and quantitative data (i.e. spinal cord independence measure, medical records) were collected. Content analysis of the interviews was carried out to identify aspects of social skills and social support. An ICF-based documentation tool (i.e. ICF Assessment Sheet) was used to structure information about the level of functioning of body functions and structures, activity and participation, and environmental and personal factors of a 57-year-old man with incomplete paraplegia during first rehabilitation. The patient presented a variety of effective social skills (i.e. assertiveness, goal direction). However, the adaptation of skills, such as asking for help social problem-solving, sensitivity, and expressivity in social relations, became necessary to acquire. The patient received different types of social support (i.e. emotional, informational, and instrumental) from different sources (e.g. family and friends). The qualitative interviews provided indications for an interaction between social skills and social support. The impact of social skills and social support on functioning is discussed. Social skills can mobilize social support and enhance functioning. However, better understanding of social skills, social support, and their interaction in relation to functioning in SCI is required to develop targeted and effective interventions to strengthen psychosocial resources for the enhancement of functioning in patients with SCI.