Evidence-Based Medicine and Clinical Practice: the first Italian attempt to define the appropriateness of rehabilitation admission criteria through the application of the Delphi method.

BACKGROUND: One of the consequences of today's global economic crisis is the need to control healthcare spending, in particular by improving the level of appropriateness. Thus, admission to rehabilitation has become an issue, especially as regards inappropriateness of resource allocation. The scientific literature suggests that more attention should be paid to the problem of clinical appropriateness in order to better identify the patients' actual needs. For the first time in Italy, this study aims at defining the appropriateness of intensive rehabilitation admission criteria through use of the Delphi method involving a panel of national experts. MATERIAL AND METHODS: A three-round Delphi survey was conducted according to international guidelines. Electronic questionnaires were individually sent via e-mail to ensure the participants' anonymity throughout the process. Questions were mostly based on rehabilitation literature. RESULTS: During the Delphi process, a total of 79 items were submitted to a heterogenous panel of rehabilitation experts who were asked to express their level of agreement to the item contents on a five-point Likert scale. At the end of the survey, a list of 19 appropriate criteria for admission to intensive rehabilitation facilities and 21 reasons for inappropriateness was drawn up. CONCLUSION: This study represents the first attempt in Italy to define shared and objective appropriateness criteria for admission to intensive rehabilitation. Out of the total number of experts invited to participate (31), only 16 completed the entire survey. This poor participation rate unfortunately demonstrates the lack of awareness among Italian rehabilitation professionals, which is a further sign of both the scarcity of scientific evidence in this area and the need to reach consensus on admission criteria.

Cross-cultural adaptation and preliminary test-retest reliability of the Italian version of the Complexity Rehabilitation Scale-Extended (13th version).

BACKGROUND: In Italy, the lack of appropriate use of intensive rehabilitative services is an acknowledged issue, as demonstrated by periodic epidemiological surveys. Rehabilitation activities are planned without considering the clinical complexity, known to be one of the most fundamental factors able to outline the real patients' needs on recently clinical practice rehabilitation guidelines. Alternative diagnostic systems become, therefore, necessary. For this reason, we would like to propose the Rehabilitation Complexity Scale - Extended version (RCS-E) within intensive rehabilitation units in Emilia Romagna. AIM: This study aims at submitting an Italian translation, cross-cultural adaptation and preliminary reliability evaluation of the Rehabilitation Complexity Scale Extended (13th Version) (RCS-E). DESIGN: Face validity and test-retest reliability. SETTING: The study was conducted in three different rehabilitation units of the Emilia Romagna region, Northern Italy. POPULATION: Ten expert physicians and 51 Intensive (code 56) rehabilitation in-patients were recruited. METHODS: A cross-cultural adaptation of the scale was built from English into Italian, closely complying with international guidelines. Face validity and test-retest reliability were carried out to evaluate the comprehensibility and goodness of fit of the new scale. RESULTS: An overall positive judgement was obtained with the face validity test. No significant differences were observed between the original and the adapted scale scoring. Internal consistency measured on 51 patients by Cronbach's alpha was 0.702 for the scale. The estimated SEM was 1.211. ICCconsistency was 0.702. Split-Half reliability and the Spearman-Brown prophecy were 0.633 and 0.775, respectively. Test-retest reliability of the RCS-E measured with ICCagreement was 0.903. CONCLUSION: The adapted RCS-E provides a sensitive and reliable tool that appears to be suitable for measuring clinical complexity in Italian code 56 rehabilitation units. It is the first Italian version of the scale to be devised. CLINICAL REHABILITATION IMPACT: Further statistical validation will assess the Italian RCS-E as a possible instrument for guiding the patients' assignment to the rehabilitation settings that best suit their specific needs. These preliminary data represent the first step through this purpose.

Trunk Recovery Scale: a new tool to measure posture control in patients with severe acquired brain injury. A study of the psychometric properties.

BACKGROUND: Posture control appears deeply impaired in patients with severe Acquired Brain Injury (ABI). One of the main goals of neurorehabilitation specialists is to try to assess this neural function in a standardized manner. However, the tests available to evaluate posture control recovery after brain damage were developed for patients with focal neurological signs. We therefore developed a new test, the Trunk Recovery Scale (TRS). AIM: To evaluate the inter-rater reliability, internal consistency, external validity, and sensitivity of TRS in patients with ABI. DESIGN: Validation study. SETTING: We examined 59 patients hospitalized after a brain injury in the Intensive and the Extensive Rehabilitation Units of our hospital. POPULATION: Patients with diagnosis of severe ABI with the capacity to respond to simple verbal orders and with a Level of Cognitive Functioning Scale (LCF scale) ≥ 4. METHODS: Three raters independently assessed 20 subjects. One of the raters also assessed 39 additional subjects using TRS, Trunk Control Test (TCT), and Functional Independence Measure (FIM), and repeated the evaluation after 30 days. RESULTS: The Inter-rater reliability was generally high (ICC=0,97 and 0,92 for total score and different subscales). Weighted Kappa values indicated "substantial agreement" except for items 2, 7, and 12. Internal consistency was good: Cronbach's coefficients were 0.900 and 0.910 for different subscales, and the elimination of one item at a time did not substantially improve the internal consistency. External validity was excellent (Spearman rank correlations =0.943 and 0.849 for TCT and FIM). Sensitivity was good. CONCLUSIONS: Our data confirm that TRS reliably assesses posture control in patients with severe ABI. However, as the sample size of internal consistency and validity was limited, the results may be overestimated. We therefore propose that this study be considered the first in a series of similar studies. This series should include a Rasch Analysis, which would further evaluate the suitability of keeping or removing items with less consistency and would define the mathematical properties of different subscales and the total score. CLINICAL REHABILITATION IMPACT: Our data confirm that TRS detects subtle but potentially meaningful motor changes in patients and can therefore allow clinicians to document treatment effectiveness and define treatment objectives.

Traumatic brain injury in childhood: intellectual, behavioural and social outcome into adulthood.

In order to obtain indicative data regarding intellectual, behavioural and social outcome into adulthood of subjects with a history of childhood head injury (CHI), twenty adults were selected who had been referred to the Neuropsychology Unit at the University of Parma at the time of a traumatic brain injury (TBI) at an age between 8 and 14 years. The level of intellectual and behavioural impairment was determined and rated by WISC and WAIS IQa and by the frequency of maladjustive behaviour. GOS score and Barthel index were used to detect the level of disability. Social adjustment and community integration were determined by the Social Adjustment Scale (SAS) and the Community Integration Questionnaire (CIQ) respectively. Results indicate that (1) subjects who suffer a severe CHI present a higher pre-injury incidence of character disturbances than the normal population and injury-related difficulties to socialize which persist long-term and add to other problems; (2) even though intellectual and functional sequelae are frequent in these children in adulthood and do not improve in their correlation to age, these do not appear to be the prevailing problems and (3) the prevailing problems seem to be social maladjustment and poor quality of life, which are still present several years post-injury and seem to be related to behavioural and psychosocial disorders in spite of an increased ADL-functioning. This has already been clearly demonstrated in the case of adulthood trauma.

[Standard parameters in gait analysis in an Italian multicenter case study]. / Parametri normativi dell'analisi del cammino in una casistica multicentrica italiana.

The study reports the results of a group who, in a multicentric trial, using a gait analysis laboratory Italian made, and a standard procedure, examined 127 normal subjects. The gait laboratory is composed of contacts to relieve the support on the ground, goniometric transducers with an articulated parallelogram, active sensors for cutaneous electromyography, patient unit for data collection and transmission, interface modules for signal reconstruction, software for data elaboration. All data was elaborated in order to give normative data for Italian population. There were no differences between right and left side, nor between male and female subjects. Values of the present study was compared with previous foreign literature and a critical comment is proposed.

Reaction time responses in parkinsonian and hemiparkinsonian patients.

Twenty-one normal subjects, 32 bilateral parkinsonian patients (BPs) and 29 hemiparkinsonian patients (HP) were submitted to separate or sequentially associated motor tasks that included simple reaction times (RT), choice RTs, directional RTs, and movement RTs. The results showed that simple RTs, directional RTs, and movement times (MT) were slower in BPs as compared to normal subjects; for choice RTs there was no difference. Response patterns were similar in normal controls and BPs. In both groups RTs became more prolonged as sequentially programmed operations increased. If movement occurred at the end of the sequence, they prolonged the RTs of the preceding operations, but MTs per se did not vary. In HPs the same results were observed on the "bad" hand side versus normal controls and versus the healthy side, but a significant statistical level was reached mainly when the "bad" hand was the right one.

Head-injured subjects aged over 50 years: correlations between variables of trauma and neuropsychological follow-up.

Neuropsychological follow-up was studied in 70 consecutive head-injured subjects aged over 50 years. Diffuse deterioration (28%), moderate deterioration (25%) and dementia (21%) were the most frequent sequelae. Analysis of correlations between neuropsychological sequelae and trauma variables showed that: (1) mild trauma did not necessarily imply good prognosis and could be followed by very severe consequences; (2) duration of post-traumatic amnesia was correlated with coma duration but not with neuropsychological outcome; (3) on the whole, no prognostic predictor of the outcome was found.