Actionable Factors Fostering Health Value Generation and Scalability of Prehabilitation: A Prospective Cohort Study.

IMPORTANCE: Prehabilitation has potential for improving surgical outcomes as shown in previous randomized controlled trials. However, a marked efficacy-effectiveness gap is limiting its scalability. Comprehensive analyses of deployment of the intervention in real-life scenarios are required. OBJECTIVE: To assess health outcomes and cost of prehabilitation. DESIGN: Prospective cohort study with a control group built using propensity score-matching techniques. SETTING: Prehabilitation Unit in a tertiary-care university hospital. PARTICIPANTS: Candidates for major digestive, cardiac, thoracic, gynecologic, or urologic surgeries. INTERVENTION: Prehabilitation program, including supervised exercise training, promotion of physical activity, nutritional optimization, and psychological support. MAIN OUTCOMES AND MEASURES: The comprehensive complication index, hospital and intensive care unit length of stay, and hospital costs per patient until 30 days after surgery. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis. RESULTS: The analysis of the entire study group did not show differences in study outcomes between prehabilitation and control groups (n=328 each). The per-protocol analysis, including only patients completing the program (n=112, 34%), showed a reduction in mean hospital stay [9.9 (7.2) vs 12.8 (12.4) days; P =0.035]. Completers undergoing highly aggressive surgeries (n=60) additionally showed reduction in mean intensive care unit stay [2.3 (2.7) vs 3.8 (4.2) days; P =0.021] and generated mean cost savings per patient of €3092 (32% cost reduction) ( P =0.007). Five priority areas for action to enhance service efficiencies were identified. CONCLUSIONS AND RELEVANCE: The study indicates a low rate of completion of the intervention and identifies priority areas for re-design of service delivery to enhance the effectiveness of prehabilitation.

Role of Co-creation for Large-Scale Sustainable Adoption of Digitally Supported Integrated Care: Prehabilitation as Use Case.

Introduction: The efficacy-effectiveness gap constitutes a well-known limitation for adoption of digitally enabled integrated care services. The current report describes the co-creation process undertaken (2016-2021) to deploy a prehabilitation service at Hospital Clínic de Barcelona with the final aim of achieving sustainable adoption and facilitate site transferability. Methods: An implementation research approach with a population-based orientation, combining experience-based co-design and quality improvement methodologies, was applied. We undertook several design-thinking sessions (Oct-Nov 2017, June 2021 and December 2021) to generate and follow-up a work plan fostering service scalability. The implementation process was assessed using the Comprehensive Framework for Implementation Research, leading to the identification of key performance indicators. Discussion: Personalization and modularity of the intervention according to patients' surgical risk were identified as core traits to enhance patients' adherence and value generation. A digitally enabled service workflow, with an adaptive and collaborative case management approach, should combine face-to-face and remotely supervised sessions with intelligent systems for patients' and professionals' decision support. The business model envisages operational costs financed by savings generated by the service. Conclusions: Evidence-based co-creation, combining appropriate methodologies and a structured evaluation framework, was key to address challenges associated with sustainable prehabilitation service adoption, scalability and transferability.

Loss of smell in patients with traumatic brain injury is associated with neuropsychiatric behavioral alterations.

OBJECTIVE: We sought to identify and correlate the severity of traumatic brain injuries (TBIs) associated with olfactory dysfunction with cognitive and behavioral profiles. PARTICIPANTS AND SETTING: Patients with TBI undergoing treatment in a specialized neuro-rehabilitation hospital. DESIGN: Prospective study. MAIN MEASURES: Glasgow Coma Scale (GCS) at the time of injury and during posttraumatic amnesia. Motor functions were assessed with the Functional Instrument Measure and Disability Rating Scales. The Wechsler Adult Intelligence test was used for neuropsychologic assessment and the Neuropsychiatric Inventory was used to assess behavioral changes. The Barcelona Smell Test-24 was used to study subjective smell loss. RESULTS: A total of 111 patients with TBI were enrolled (33 females; mean age 32.86 years); 38.73% exhibited smell loss. Patients with no olfactory impairment (OI) had worse TBIs than those with OI (GCS scores 5.65 and 7.74, respectively); no significant differences in cognitive behaviors, such as attention memory, visuoperception, and visuoconstruction, were observed. However, patients with TBI and olfactory dysfunction showed statistically significant alterations in neuropsychiatric behavioral performances such as feeding when compared with patients with TBI without smell loss. CONCLUSION: Olfactory dysfunction in patients with a TBI correlates with altered neuropsychiatric behavioral performances such as feeding, sleeping, and motor behavior.

Evidence of chronic stroke rehabilitation interventions in activities and participation outcomes: systematic review of meta-analyses of randomized controlled trials.

INTRODUCTION: Stroke is a leading cause of long-term disabilities worldwide. A great deal of meta-analyses of randomized controlled trials (RCTs) address rehabilitation in chronic stroke, several of them with focus on activities and participation, considered critical outcomes of successful rehabilitation. Nevertheless, substantial heterogeneity might exist between studies, the reported associations may be causal, but they might also be flawed, as inherent study biases such as residual confounding and selective reporting of positive results may exaggerate the effect of interventions in chronic phase. Furthermore, most RCTs might focus on specific rehabilitation domains, not paying the same attention to others. EVIDENCE ACQUSITION: Formal evaluation of published systematic reviews of meta-analyses (January 2008 to November 2018) of rehabilitation in chronic phase to 1) assess the strength of evidence: participants, publication biases, heterogeneity, prediction intervals (PIs) 2) grade the evidence to perform qualitative analysis on effects sizes and heterogeneity, 3) perform meta-regressions and sensitivity analysis on relevant covariates 4) map outcomes to activities and participation domain of the World Health Organization's International Classification of Functioning, Disability and Health (ICF). Systematic review on meta-analyses of RCTs addressing activities and participation will be performed in Medline, Web of Science, Scopus, Cochrane and Google Scholar. EVIDENCE SYNTHESIS: A total of 97 meta-analyses on 31 different rehabilitation interventions involving 25,275 participants were included. Thirty-nine meta-analyses (40.74%) reported statistically significant findings (P<0.05) in both fixed and random effects sizes. Their magnitude was small in 62.96% cases, moderate in 19.75% and large in 17.28%. Heterogeneity was low in 48,48%, moderate and high in 21.2%. The mean number of participants is 815, far away from the convincing, highly suggestive, or suggestive required evidence levels. All PIs include the null value. Mobility is addressed by 87% of the identified meta-analyses, with 75% of them focusing exclusively in mobility. CONCLUSIONS: The findings of this study show a clear need for high quality RCTs examining the effectiveness of rehabilitation interventions addressing activities and participation. The ICF framework may contribute to a holistic approach in chronic stroke rehabilitation, including not only motor functioning but also the ability to participate in everyday life activities.

Stroke Survivors on Twitter: Sentiment and Topic Analysis From a Gender Perspective.

BACKGROUND: Stroke is the worldwide leading cause of long-term disabilities. Women experience more activity limitations, worse health-related quality of life, and more poststroke depression than men. Twitter is increasingly used by individuals to broadcast their day-to-day happenings, providing unobtrusive access to samples of spontaneously expressed opinions on all types of topics and emotions. OBJECTIVE: This study aimed to consider the raw frequencies of words in the collection of tweets posted by a sample of stroke survivors and to compare the posts by gender of the survivor for 8 basic emotions (anger, fear, anticipation, surprise, joy, sadness, trust and disgust); determine the proportion of each emotion in the collection of tweets and statistically compare each of them by gender of the survivor; extract the main topics (represented as sets of words) that occur in the collection of tweets, relative to each gender; and assign happiness scores to tweets and topics (using a well-established tool) and compare them by gender of the survivor. METHODS: We performed sentiment analysis based on a state-of-the-art lexicon (National Research Council) with syuzhet R package. The emotion scores for men and women were first subjected to an F-test and then to a Wilcoxon rank sum test. We extended the emotional analysis, assigning happiness scores with the hedonometer (a tool specifically designed considering Twitter inputs). We calculated daily happiness average scores for all tweets. We created a term map for an exploratory clustering analysis using VosViewer software. We performed structural topic modelling with stm R package, allowing us to identify main topics by gender. We assigned happiness scores to all the words defining the main identified topics and compared them by gender. RESULTS: We analyzed 800,424 tweets posted from August 1, 2007 to December 1, 2018, by 479 stroke survivors: Women (n=244) posted 396,898 tweets, and men (n=235) posted 403,526 tweets. The stroke survivor condition and gender as well as membership in at least 3 stroke-specific Twitter lists of active users were manually verified for all 479 participants. Their total number of tweets since 2007 was 5,257,433; therefore, we analyzed the most recent 15.2% of all their tweets. Positive emotions (anticipation, trust, and joy) were significantly higher (P<.001) in women, while negative emotions (disgust, fear, and sadness) were significantly higher (P<.001) in men in the analysis of raw frequencies and proportion of emotions. Happiness mean scores throughout the considered period show higher levels of happiness in women. We calculated the top 20 topics (with percentages and CIs) more likely addressed by gender and found that women's topics show higher levels of happiness scores. CONCLUSIONS: We applied two different approaches-the Plutchik model and hedonometer tool-to a sample of stroke survivors' tweets. We conclude that women express positive emotions and happiness much more than men.

Olfactory Training Prevents Olfactory Dysfunction Induced by Bulbar Excitotoxic Lesions: Role of Neurogenesis and Dopaminergic Interneurons.

Glutamatergic excitotoxicity is involved in pathologies affecting the central nervous system, including traumatic brain injury (TBI) and neurodegenerative diseases, such as Parkinson's disease (PD), in which olfactory dysfunction is an early symptom. Interestingly, our group has recently shown that bilateral administration of the glutamate agonist, N-methyl-D-aspartate (NMDA) in the olfactory bulbs (OBs) induces an olfactory dysfunction 1 week after lesions. Although a wide range of treatments have been attempted, no standard therapy has been established to treat olfactory disorders. Increasing evidence suggests a beneficial effect of olfactory training (OT) in olfactory function. However, the mechanisms underlying OT effects remain unknown. We investigated the effects of OT on the olfactory dysfunction induced by excitotoxicity in bilateral OB NMDA-lesioned animals. We compared OT effects with the ones obtained with neuroprotective therapies (pramipexole and MK801). We studied the underlying mechanisms involved in OT effects investigating the changes in the subventricular zone (SVZ) neurogenesis and in the number of periglomerular dopaminergic interneurons. One week after lesion, NMDA decreased the number of correct trials in the olfactory discrimination tests in the non-trained group (p < 0.01). However, OT performed for 1 week after lesions prevented olfactory dysfunction (p < 0.01). Pramipexole did not prevent olfactory dysfunction, whereas MK801 treatment showed a partial recovery (p < 0.05). An increase in SVZ neurogenesis (p < 0.05) associated with an increase in OB dopaminergic interneurons (p < 0.05) was related to olfactory function prevention induced by OT. The present results suggest a role for dopaminergic OB interneurons underlying the beneficial effects of OT improving olfactory dysfunction in bilaterally OB NMDA-lesioned animals.

Which interventions are useful for managing muscle spasticity in individuals who sustained traumatic brain injury? - A Cochrane Review summary with commentary.

BACKGROUND: Spasticity is a frequent symptom after traumatic brain injury. OBJECTIVE: To assess the effects of different interventions used for muscle spasticity after TBI. METHODS: To summarize a rehabilitation perspective "Cochrane Review" conducted by Synnot et al.RESULTS:Nine studies were involved for the Cochrane review. Poor report on the results of the studies that tested the effectiveness of interventions in spasticity are responsible for the low quality of the evidence. Most of the studies reported results in terms of decreasing spasticity and limiting effects in terms of how the decrease spasticity and no reports on the beneficial effects in terms of improving activities and participation. CONCLUSIONS: High quality adequately powered trials in patients with TBI should be encouraged.

Evidence-based position paper on Physical and Rehabilitation Medicine professional practice for Adults with Acquired Brain Injury. The European PRM position (UEMS PRM Section).

BACKGROUND: Acquired brain injury (ABI) is damage to the brain that occurs after birth caused either by a traumatic or by a nontraumatic injury. The rehabilitation process following ABI should be performed by a multi-professional team, working in an interdisciplinary way, with the aim of organizing a comprehensive and holistic approach to persons with every severity of ABI. This Evidence Based Position Paper represents the official position of the European Union through the UEMS Physical and Rehabilitation Medicine (PRM) Section and designates the professional role of PRM physicians for people with ABI. The aim was to formulate recommendations on the PRM physician's professional practice for persons with ABI in order to promote their functioning and enhance quality of life. METHODS: This paper has been developed according to the methodology defined by the Professional Practice Committee of the UEMS-PRM Section: a systematic literature search has been performed in PubMed and Core Clinical Journals. On the basis of the selected papers, recommendations have been made as a result of five Delphi rounds. RESULTS: The literature review as well as thirty-one recommendations are presented. CONCLUSIONS: The expert consensus is that structured, comprehensive and holistic rehabilitation program delivered by the multi-professional team, working in an interdisciplinary way, with the leadership and coordination of the PRM physician, is likely to be effective, especially for those with severe disability after brain injury.

Olfactory Training in Post-Traumatic Smell Impairment: Mild Improvement in Threshold Performances: Results from a Randomized Controlled Trial.

Traumatic Brain Injury (TBI) can be associated with partial or total smell loss. Recent studies have suggested that olfactory outcome can be positively modulated after olfactory training (OT). This study's aim was to investigate OT's potential role in smell recovery after TBI-induced olfactory loss. A prospective, randomized, and controlled study was developed. Patients with TBI-induced olfactory dysfunction (n = 42) were randomized into an experimental group with OT and a control group without (nOT). OT was performed twice daily with a six odor training set during 12 weeks. Olfactory loss was assessed using subjective olfactometry (Barcelona Smell Test [BAST] 24), a visual analogue scale (VAS), and n-butanol threshold (n-BTt) at baseline at 4, 12, and 24 weeks. Additionally, patients underwent MRI of the olfactory brain and olfactory bulbs (OB). Based on the MRI results, an overall score (0-16) was developed to associate the structural neurological damage with olfactory outcomes. The primary outcome was the change in olfactory measurements (VAS and BAST-24) between baseline and 12 weeks. The secondary outcome was the association of the MRI score with olfactory outcomes at baseline, and the impact on quality of life (QoL). After 12 weeks of training, OT patients showed a significant improvement in n-BTt (0.6 ± 1.7 OT vs. -0.6 ± 1.8 nOT, p < 0.05), but not in the smell VAS and BAST-24 scores. Olfactory outcomes (VAS, BAST-24, and n-BTt) were significantly associated with MRI structural findings (p < 0.001), but not with the OB volume or olfactory sulcus length. The present study suggests that 12 weeks of OT mildly improves the olfactory threshold in TBI, whereas the overall MRI score may be used as an imaging marker of olfactory dysfunction and disease severity in TBI patients.

Olfactory function in an excitotoxic model for secondary neuronal degeneration: Role of dopaminergic interneurons.

Secondary neuronal degeneration (SND) occurring in Traumatic brain injury (TBI) consists in downstream destructive events affecting cells that were not or only marginally affected by the initial wound, further increasing the effects of the primary injury. Glutamate excitotoxicity is hypothesized to play an important role in SND. TBI is a common cause of olfactory dysfunction that may be spontaneous and partially recovered. The role of the glutamate excitotoxicity in the TBI-induced olfactory dysfunction is still unknown. We investigated the effects of excitotoxicity induced by bilateral N-Methyl-D-Aspartate (NMDA) OB administration in the olfactory function, OB volumes, and subventricular zone (SVZ) and OB neurogenesis in rats. NMDA OB administration induced a decrease in the number of correct choices in the olfactory discrimination tests one week after lesions (p<0.01), and a spontaneous recovery of the olfactory deficit two weeks after lesions (p<0.05). A lack of correlation between OB volumes and olfactory function was observed. An increase in SVZ neurogenesis (Ki67+ cells, PSANCAM+ cells (p<0.01) associated with an increase in OB glomerular dopaminergic immunostaining (p<0.05) were related to olfactory function recovery. The present results show that changes in OB volumes cannot explain the recovery of the olfactory function and suggest a relevant role for dopaminergic OB interneurons in the pathophysiology of recovery of loss of smell in TBI.

tDCS does not enhance the effects of robot-assisted gait training in patients with subacute stroke.

BACKGROUND: Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique, which can modulate cortical excitability and combined with rehabilitation therapies may improve motor recovery after stroke. OBJECTIVE: Our aim was to study the feasibility of a 4-week robotic gait training protocol combined with tDCS, and to study tDCS to the leg versus hand motor cortex or sham to improve walking ability in patients after a subacute stroke. METHODS: Forty-nine subacute stroke patients underwent 20 daily sessions (5 days a week for 4 weeks) of robotic gait training combined with tDCS. Patients were assigned either to the tDCSleg group (n = 9), receiving 2 mA anodal tDCS over the motor cortex leg representation (vertex), or an active control group (n = 17) receiving anodal tDCS over the hand motor cortex area (tDCShand). In addition, we studied 23 matched patients in a control group receiving gait training without tDCS (notDCS). Study outcomes included gait speed (10-meter walking test), and quality of gait, using the Functional Ambulatory Category (FAC) before and after the 4-week training period. RESULTS: Only one patient did not complete the treatment because he presented a minor side-effect. Patients in all three groups showed a significantly improvement in gait speed and FAC. The tDCSleg group did not perform better than the tDCShand or notDCS group. CONCLUSION: Combined tDCS and robotic training is a safe and feasible procedure in subacute stroke patients. However, adding tDCS to robot-assisted gait training shows no benefit over robotic gait training alone.

La dificultad en la toma de decisiones subrogadas en la atrofia muscular espinal / Difficulty in surrogate decision making in spinal muscular atrophy type 1

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Emulando a Plutarco, "la doctora no solo ha de ser una buena profesional, sino que también ha de parecerlo" / Paraphrasing Plutarch, "female physicians must not only be good professionals, they must be seen to be so"

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Descripción de la evolución funcional del traumatismo craneoencefálico en una población pediátrica tras un programa de rehabilitación integral / Description of functional outcome in pediatric traumatic brain injury after a comprehensive rehabilitation programme

Introducción: El traumatismo craneoencefálico es la principal causa de mortalidad y de discapacidad en la infancia en los países desarrollados. A pesar de la plasticidad típica de la infancia, una lesión en una edad precoz de la vida puede dejar secuelas importantes y alterar la funcionalidad a largo plazo. El conocimiento del espectro funcional es importante para la planificación de recursos y tratamientos una vez fracasada la fase de prevención de los traumatismos. Material y métodos: Se realizó un estudio retrospectivo de los pacientes ingresados en una unidad específica de daño cerebral como consecuencia de un traumatismo craneoencefálico con el objetivo de determinar su funcionalidad tras un programa integral de rehabilitación. Resultados: Se revisaron 65 historias de niños con una media de edad de 10,38 años que habían sido ingresados para realizar un programa de rehabilitación. El 89,2% habían tenido un traumatismo craneoencefálico grave como consecuencia de accidentes de tráfico. La media de ingreso hospitalario durante la fase de rehabilitación intensiva fue de 79,35 días. Un 72% logró capacidad de marcha al alta, pero un 76,9% mostró alguna alteración cognitiva. A pesar de la mejoría física, solo un 29,2% de los niños pudieron regresar a su colegio. Un 21,5% de los niños permanecieron con secuelas que les impidieron cualquier tipo de escolarización. Conclusiones: Tras la fase aguda, la población infantil se caracterizó por una ausencia de complicaciones médicas y una buena recuperación a nivel físico y a nivel de movilidad. Sin embargo, la afectación cognitiva ha sido notoria y responsable de alteraciones en la escolarización normal del niño

Introduction: Traumatic brain injury is the leading cause of mortality and disability in children in the developed countries. Despite the plasticity of an infant’s brain, injury at this early stage can lead to important sequelae that will affect functioning later in life. The understanding of the functional profile after a traumatic brain injury is important for planning interventions and treatment resources once the preventive phase has failed. Material and methods: This was a retrospective study of the patients admitted in a neurorehabilitation unit with the aim of describing their functioning after an intensive rehabilitation programme. Results: A total of 65 records of children with a mean age of 10.38 years that had been admitted to a rehabilitation programme were reviewed. Of the traumatic brain injuries, 89.2% were severe and 78.4% were secondary to traffic accidents. The mean length of stay was 79.35 days. At discharge, 72% were able to walk, but 76.9% showed some cognitive impairment. Despite good physical recovery, only 29.2% of the children were able to return to school. Permanence of deficits made 21.5% of the children unable to return to any type of education. Conclusions: The population under study was characterised by a good clinical outcome as well as good physical improvement. Nevertheless, cognitive problems were notable and were the main factor responsible for the changes in school attendance and return to normal life

[Description of functional outcome in pediatric traumatic brain injury after a comprehensive rehabilitation programme]. / Descripción de la evolución funcional del traumatismo craneoencefálico en una población pediátrica tras un programa de rehabilitación integral.

INTRODUCTION: Traumatic brain injury is the leading cause of mortality and disability in children in the developed countries. Despite the plasticity of an infant's brain, injury at this early stage can lead to important sequelae that will affect functioning later in life. The understanding of the functional profile after a traumatic brain injury is important for planning interventions and treatment resources once the preventive phase has failed. MATERIAL AND METHODS: This was a retrospective study of the patients admitted in a neurorehabilitation unit with the aim of describing their functioning after an intensive rehabilitation programme. RESULTS: A total of 65 records of children with a mean age of 10.38 years that had been admitted to a rehabilitation programme were reviewed. Of the traumatic brain injuries, 89.2% were severe and 78.4% were secondary to traffic accidents. The mean length of stay was 79.35 days. At discharge, 72% were able to walk, but 76.9% showed some cognitive impairment. Despite good physical recovery, only 29.2% of the children were able to return to school. Permanence of deficits made 21.5% of the children unable to return to any type of education. CONCLUSIONS: The population under study was characterised by a good clinical outcome as well as good physical improvement. Nevertheless, cognitive problems were notable and were the main factor responsible for the changes in school attendance and return to normal life.

Rehabilitation of traumatic brain injury in the light of the ICF.

INTRODUCTION: Traumatic brain injury is a sudden and unexpected condition that gives rise to different impairments in body functions and structures leading to dramatic life changes, not only to the patient but also to his or her family and ultimately in the wider society. As a health strategy, rehabilitation aims to reduce disability and increasing the quality of life of those people that suffer from TBI but also to reduce the social burden associated with it. Functioning is the starting point of rehabilitation and the use of measurement instruments and classifications are commonly used tools for its definition. Within the endorsement of the ICF by WHO, there is now a classification and a conceptual framework for the description of functioning providing an opportunity of a full understanding of the experience of TBI. OBJECTIVE: This paper aims to identify the utility of ICF in TBI as well as bringing new challenges for further clinical practice and research. CONCLUSIONS: ICF has shown itself to be useful in the content comparison of measurement instruments. It has also been used to describe the functional profile of individuals with TBI in both acute and chronic phases making it possible to draw comparisons across other health conditions. Furthermore, the development of the TBI ICF Core Sets provided an item bank to describe not only functional status but also to set goals and plan interventions. Overall, we now have a potentially useful tool in rehabilitation of TBI that allows us to understand the full burden of traumatic brain injury.