Pros and Cons of Randomized Controlled Trials and Benchmarking Controlled Trials in Rehabilitation: An Academic Debate within the European Academy of Rehabilitation Medicine.

The European Academy of Rehabilitation Medicine (EARM) held a debate in Hannover, Germany, on 1st of September 2016 on the pros  and cons of randomized controlled trials (RCTs) and observational effectiveness studies (benchmarking controlled trials; BCTs). The  debate involved a chairperson, a person presenting the substance of the debate, an opponent, and a rapporteur. The academicians participated in the discussion. Eight propositions and proposed statements formed the substance of the debate. There was agreement that a study question should be the starting point of an effectiveness study, and not the study method, i.e. RCT or BCT. The term "benchmarking" was questioned: does it mean market-oriented medicine? It was clarified that benchmarking refers to the methodological features of this study design: there must always be a comparison between peers. It was agreed that BCTs might be better than RCTs for use in rehabilitation studies, in which one often needs multi-centred studies, such as in the assessment of the effectiveness of pathways when there is complexity of processes, health systems, organizational issues, structures and facilities; or where interactions between therapists, doctors and patients differ between centres; and when assessing the implementation of rehabilitation. In addition, BCTs may deal with ethical issues, e.g. the acceptability of interventions, more easily than RCTs. Recommendations regarding the different approaches (RCTs or BCTs) should be provided by the scientific rehabilitation societies. Concern over the validity of BCTs was considered justified, as the validity criteria of BCTs cover all those related to RCTs and include the risk of selection bias between treatment arms. Appropriate description of the essentials of the study object, including adequate description of how the interventions were actualized in comparison to the study plan, are essential features for a valid and generalizable study for both RCTs and BCTs. BCTs are necessary to widen the evidence-base of effectiveness in rehabilitation. It was suggested that the rehabilitation field should support the concept of BCTs. It was proposed that education regarding BCTs is indicated, and stakeholders need to be convinced that BCTs are a valid alternative to RCTs. EARM and other physical and rehabilitation medicine (PRM) bodies could advance the use of BCTs for clinical and health policy decision-making.

Analysis of Italian regulations on pathways of care for patients in a vegetative or minimally conscious state.

Different rehabilitation models for persons diagnosed with disorders of consciousness have been proposed in Europe during the last decade. In Italy, the Ministry of Health has defined a national healthcare model, although, to date, there is a lack of information on how this has been implemented at regional level. The INCARICO project collected information on different regional regulations, analysing ethical aspects and mapping care facilities (numbers of beds and medical units) in eleven regional territories. The researchers found a total of 106 laws; differences emerged both between regions and versus the national model, showing that patients with the same diagnosis may follow different pathways of care. An ongoing cultural shift from a treatment-oriented medical approach towards a care-oriented integrated biopsychosocial approach was found in all the welfare and healthcare systems analysed. Future studies are needed to explore the relationship between healthcare systems and the quality of services provided.

Contributing to the growth of Physical and Rehabilitation Medicine (PRM): call for a Cochrane Field in PRM.

The European Society of Physical and Rehabilitation Medicine (ESPRM), together with the European Journal of PRM and the PRM Section and Board of the European Union of Medical Specialists (UEMS), started an action to establish a relationship with Cochrane (formerly the Cochrane Collaboration). Cochrane is a global, independent network of researchers, professionals, patients, carers and people interested in health, with contributors from more than 130 countries. Its aim is to produce credible, accessible health information that is free from any conflicts of interest. Cochrane produces the Cochrane Library, an evidence-based resource that includes today more than 6300 Cochrane systematic reviews. Cochrane is made up of many different review groups and other entities (such as Centres and Branches), distributed around the world, that are mainly focused on specific healthcare problems (diseases, or organs). Inside Cochrane also Fields have been created, that focus on a dimension of health care other than a specific healthcare problem. A Cochrane Field represents a bridge between Cochrane and the stakeholders of the related healthcare area. The medical specialty of PRM is covering a broad medical domain: it deals with function, activities and participation in a large number of health conditions, mostly but not exclusively musculoskeletal, neurological and cardiorespiratory. Consequently, the currently more than 200 existing Cochrane Reviews are scattered among different groups. A PRM Field could greatly serve to the need of the specialty, spreading the actual Cochrane knowledge, focusing needs today not covered by Cochrane Reviews, facing the intrinsic methodological problems of the specialty. This paper introduces a call for the development of a PRM Cochrane Field, briefly reviewing what Cochrane is and how it is organized, defining the value and identifying a pathway toward the development of a PRM Cochrane Field, and finally shortly reviewing the Cochrane reviews of PRM interest.

Italian standardization of the Apples Cancellation Test.

Hemispatial neglect due to right parieto-temporo-frontal lesions has a negative impact on the success of rehabilitation, resulting in poor functional gain. Recent research has shown that different types of neglect can impact in a different way on rehabilitation outcomes. The availability of a sensitive test, useful for distinguishing egocentric and allocentric forms of neglect, may be clinically important as all current clinical instruments fail to distinguish between these forms of disturbance, yet they differentially predict outcome. The Apples Test is a new instrument useful to evaluate both egocentric and allocentric forms of neglect. In order to establish Italian norms for this diagnostic instrument the test was administered to a sample of 412 healthy people of both genders (201 M and 211 F), aged from 20 to 80 years enrolled from 14 different rehabilitation centers in Italy. Based on the data, we established pathological performance cut-offs for the accuracy score (total omission errors), the asymmetry score for egocentric neglect (omission error difference), the asymmetry score for allocentric neglect (commission error difference) and execution time. The usefulness of the Apples Test for diagnostic purposes is illustrated by presenting three patients with different forms of neglect (egocentric, allocentric and mixed neglect).

Recommendations for clinical practice and research in severe brain injury in intensive rehabilitation: the Italian Consensus Conference.

The paper reports the final statements of the jury of a National Consensus Conference organized in November 2010 at Salsomaggiore (Parma) to draw up recommendations on the rehabilitation programs for acquired brain injury (sABI) patients in the intensive hospital phase. Because of the few clinical studies of good quality found by means of the literature research we choose a mixed approach: a systematic review of the published studies and a consensus conference in order to obtain recommendations that come from the clinical evidence and the expert opinion. The final recommendations of the jury, based on the best available evidence combined with clinical expertise and the experience of persons with disabilities and other stakeholders, cover 13 topics: 1) Management of paroxysmal manifestations (sympathetic storms); 2) management of neuroendocrine problems; 3) nutrition; 4) swallowing; 5) ventilation/respiration, 6) clinical and instrument diagnosis and prognosis of vegetative state (VS) and minimally conscious state (MCS), 7) rehabilitative and pharmacological facilitation of renewed contact with surroundings; 8) neurosurgical complications and hydrocephalus; 9) sensorimotor impairment and disability; 10) rehabilitation methods; 11) assessment and treatment of cognitive-behavioural impairment and disability; 12) methodology and organization of care; 13) involving family and caregivers in rehabilitation.

The Italian National Registry of severe acquired brain injury: epidemiological, clinical and functional data of 1469 patients.

BACKGROUND: The lack of knowledge about epidemiological and clinical data of patients with Acquired Brain Injury (ABI) admitted to Rehabilitation facilities in Italy led to the creation, in June 2008, of a data collection on-line registry. AIM: To collect epidemiological and clinical data and to evaluate functional outcome of patients with severe traumatic and non-traumatic ABI admitted to Rehabilitation facilities in Italy between June 2008 and December 2011 and to compare data of patients with ABI of different aetiologies. DESIGN: Observational retrospective study. SETTING: The study involved 29 Italian Rehabilitation facilities. POPULATION: The study enrolled 1469 patients with severe traumatic (TBI) and non-traumatic ABI (NTBI). METHODS: Data collected included demographic (number of patients with TBI and NTBI, gender, age) and clinical characteristics (provenience, number of days elapsed between onset and rehabilitation admission, rehabilitation length of stay, discharge destination, death and vegetative state diagnosis, presence of percutaneous endoscopic gastrostomy, tracheostomy, pressure sores and paraosteoarthropathies). Functional outcome was evaluated using the Disability Rating Scale. RESULTS: Of the whole population studied, 44.31% and 55.69% patients had suffered a TBI and a NTBI, respectively. In the NTBI group 40.09% had a cerebrovascular injury, 12.04% an anoxic brain damage, 3.6% had a brain injury of other causes. The mean age was 43.67 and 56.68 for subjects with TBI and NTBI, respectively. Patients with TBI showed a lower onset-admission interval (OAI), compared with NTBI group; no difference in rehabilitation length of stay (LOS) was recorded between groups. Patients with TBI presented a lower DRS score at admission and discharge and returned home more frequently than NTBI group. CONCLUSIONS: The creation of a National registry allows the collection of data about patients with ABI in order to study the clinical course, the functional outcome and to establish a basis for comparison with other data sources. Clinical Rehabilitation Impact. Data collection could be useful in the evaluation and planning of rehabilitation pathways, and to assess the allocation of healthcare and rehabilitative resources.

Rehabilitation of acquired brain injuries: a multicentric prospective survey.

BACKGROUND: The rehabilitation of the persons with Severe Acquired Brain Injury (ABI) is an important concern to be approached with a comprehensive program aimed to improve the recovery of patients.The efficacy of an early and intensive rehabilitation program has been shown in large number of studies. Few studies focused on the prevalence of TBI and the data are often extrapolated in indirect ways. AIM: An analysis of the demographic characteristics of the population included in the GISCAR (Gruppo Italiano per lo Studio delle Gravi Cerebrolesioni Acquisite e Riabilitazione- Italian Group for the Study of the severe ABI) database, type and conditions associated to the index event; the treatment administered during hospitalization; and the prognosis according to outcome measures. DESIGN: The study was an observational prospective survey looking at management of ABI (both traumatic and non-traumatic). SETTING: In hospital rehabilitation. POPULATION: Patients consecutively admitted in each of the 52 GISCAR centres. METHODS: Every centre included a consecutive cohort and recorded demographic data and index event characteristics. RESULTS: In the study population were included 2626 subjects suffering of a severe ABI. The difference of length of stay (LOS) was significantly different with 67.5 days for traumatic patients compared to the 80 days of non traumatic ones. In the study population the probability of discharge at home is significantly greater for the traumatic condition (odds ratio 0,4587; CI 0.3671-0.5731). The overall benefit of the rehabilitative treatment was encountered in a net gain in all disability scores taken into account: LCF classes; DRS as well as GOS scores. At discharge the main destination for severe ABI patients was home (67.2%). CONCLUSIONS: A large number of patients admitted in Italian rehabilitative facilities for a severe ABI suffered from a TBI, more often these subjects were young male victims of road accident. The majority of subjects during the rehabilitative hospitalization demonstrated a significant recovery. CLINICAL REHABILITATION IMPACT: Considering the evidence of an early treatment benefit the delay ofthe rehabilitation program start is far from being satisfactory. The high frequency of the home discharge indicate a good compliance of national family network.

Pediatric rehabilitation of severe acquired brain injury: a multicenter survey.

BACKGROUND: Epidemiological and descriptive data concerning the clinical and socio-demographic characteristics of severe acquired brain injuries (ABI) in pediatric age are meager. In particular, in Italy we only find data concerning traumatic brain injury (TBI) in adults. Earlier data show that the most prevalent etiology in ABI is traumatic and that greater clinical impairments are reported for patients with non-traumatic etiologies. AIM: The main aims of the GISCAR (Gruppo Italiano per lo Studio delle Gravi Cerebrolesioni Acquisite e Riabilitazione) study are: 1) to define the clinical features of pediatric patients with severe neurological disabilities; 2) to determine the etiology and onset modality of the cerebral lesions; and 3) to analyse the characteristics of the rehabilitation processes and patient outcome in terms of disability, strategies for treatment and clinical picture. DESIGN: Quasi-epidemiologic. SETTING: In-patient. POPULATION: 184 pediatric patients with severe ABI were recruited. METHODS: Data collection was done by means of an assessment protocol created and used by a group of Italian neurorehabilitation centers. Traumatic and non traumatic aetiologies (NTBI) have been treated separately. RESULTS: Traumatic etiology of ABI is the most prevalent (51.6%, N. 95) and about twice as many males as females are involved. Of these cases, 70.5% (N. 67) are the result of a car accident, either as a pedestrian or as a passenger, representing a crucial area for preventive action by the public health services. Eighty-six (46.7%) patients were in the acute state, 19 (10.3%) in subacute state and 76 (42.9%) in chronic condition. The results show that the positive trend for the TBI group was steeper than for NTBIs. Neuropsychological data are also discussed. CONCLUSIONS AND CLINICAL REHABILITATION IMPACT: We report the first Italian descriptive study on pediatric patients affected by ABI of traumatic or non traumatic etiology. The main points concerning rehabilitation are that major differences between aetiologies must be taken into account and that ABI of any severity in the acute phase may lead to long term disability, confirming the high social and economic impact of this pathology. Our study demonstrates the great importance of providing specialised rehabilitation centers for pediatric patients, and increases awareness of the importance of ABI prevention.

Rehabilitation of traumatic brain injury in Italy: a multi-centred study.

OBJECTIVES: The aims of this study were to analyse TBI rehabilitation in Italy, identifying the main factors conditioning motor and functional recovery and destination upon discharge of traumatic severe acquired brain injury (sABI) patients who had undergone intensive rehabilitative treatment. DESIGN: An observational prospective study of 863 consecutive patients admitted to 52 Rehabilitation Centres from January 2001 to December 2003. RESULTS: The main cause of trauma was road accidents (79.8%), the mean length of stay was 87.31 ± 77.26 days and 40.4% access to rehabilitation facilities after a month. Pressure sore rates fell from 26.1% to 6.6% during the rehabilitation programme. After discharge 615 patients returned home, whilst 212 were admitted to other health facilities. DISCUSSION: This study highlights some major criticisms of rehabilitation of TBI. The delay of admission and evitable complications such as pressure sores are correlated to a worse outcome. While LOS causes a problem of cost-effectiveness, the rate of home discharge is prevalent and very high compared with other studies.

National journals of physical rehabilitation medicine in Europe: a survey.

BACKGROUND: The European Physical and Rehabilitation Medicine Journal Network (EPRMJN), a joint initiative between the European Society Physical and Rehabilitation Medicine (ESPRM) and the European Journal of Physical and Rehabilitation Medicine (EJPRM), has the aim to increase scientific knowledge among PRM specialists and foster collaboration among physical and rehabilitation medicine (PRM) journals. This article reports the results of a survey of national PRM journals in Europe we conducted to obtain an overview of the current state of PRM research in the European setting. RESULTS: Every year 682 PRM papers are published in a total of 66 issues per 3 294 page in the 16 national journals that responded to our survey, out of the 21 published in 15 countries; 12 countries have no PRM journals and two did not respond. Some 94% of the journals responding to the survey have a research aim and 88% an educational aim; all journals use a peer-review process (75% blinded); on average, 58.8 submissions are received per year, of which 6.7% are invited papers; the rejection rate is 21.4%. The majority of papers report original research, and main topics are musculoskeletal and neurological rehabilitation. CONCLUSION: Since the national journals published in Europe have a good peer review process and publish mainly original articles, it is possible that good research can be found. A major problem is the English language barrier to wider readerships, as many researchers publish only in their native language. The EPRMJN aims to discover this research and make it accessible to international audiences through systematic collection of articles appearing in the national journals of the EPRMJN and publication of content summaries on the ESPRM website.

The European physical and rehabilitation medicine journal network: historical notes on national journals.

AIM: In the last 40 years, physical and rehabilitation medicine (PRM) has made significant steps forward in Europe with the foundation of the European Federation of Physical Medicine and Rehabilitation (EFPMR) (1963) which gave rise to the European Society of Physical and Rehabilitation Medicine (ESPRM) (2004) the European Academy of Rehabilitation Medicine (1970), the PRM Section of the European Union of Medical Specialists (1974), and the European Board of PRM (1991). Our journal, formerly Europa Medico-physica (1964), the official journal of the EFPMR, now European Journal of Physical and Rehabilitation Medicine (EJPRM) and official journal of the ESPRM since 2008, is distinct for its steadfast European vocation, long-standing Mediter-ranean interests and connections with various national scientific societies. Jointly with the ESPRM, efforts are under way to set up the European Physical and Rehabilitation Medicine Journal Network (EPRMJN). The aim of this article is to present a profile of the national journals in the EPRMJN so as to give a better overview of how the scientific part of PRM in Europe has developed within a national perspective. METHODS: A profile of the following national journals is presented: Annals of Physical and Rehabilitation Medicine (France), Fizikalna i rehabilitacijska medicina (Physical and Rehabilitation Medicine) (Croatia), Neurorehabilitation (Bulgaria), Physical and Rehabilitation Medicine Portuguese Society Journal (Portugal), Physical Medicine, Rehabilitaton, Health (Bulgaria), Physikalische Medizin - Rehabilitationsmedizin - Kurort-medizin/Journal of Physical and Rehabilitation Medicine (Germany and Austria) Prevention and Rehabilitation (Bulgaria), Rehabilitacija (Rehabilitation) (Slovenia), Rehabilitación (Madr) (Spain), Turkish Journal of Physical Medicine and Rehabilitation (Turkey). CONCLUSION: Some national journals in Europe have a very long history and tradition of research and education. Having a better knowledge of these realities, usually hidden to the international readership owing to the English language barrier, could promote science in our specialty.

Rehabilitation in patients affected by different types of stroke. A one-year follow-up study.

AIM: Stroke is the third highest cause of death and the leading cause of chronic disability in adults in Italy. More than half of patients who survive the first month after a stroke will require specialised rehabilitation. Rehabilitation is, however, an expensive and limited resource, and its success depends on careful selection of patients. The aim of this study was to identify the functional ability at discharge and after one-year of follow-up in a large sample of first-time stroke patients from a rehabilitation hospital according to the stroke Oxfordshire Community Stroke Project (OCSP) criteria. METHODS: A multicenter observational study was conducted among 1023 first-time stroke patients who were admitted to 18 different Italian inpatient rehabilitation centres between February 1999 and November 2000. The study population consisted of 946 (92.4%) of the 1023 enrolled at baseline. Each patient has been first evaluated within 72 h after admission and, on a second occasion, within 72 h before discharge. From the 722 ischemic strokes evaluated at baseline, after one-year of follow-up 76 participants died. From the survived 646 patients, we had 513 (79.0%) participants both evaluated at baseline and after one-year of follow-up. Clinical data regarding stroke type and ischemic stroke clinical syndrome, according to the Oxfordshire Community Stroke Project (OCSP) criteria; the degree of impairment, both motor (assessed by Barthel Index [BI], Motricity Index, and Trunk Control Test) and neuropsychological (assessed by the Mini Mental State Examination, and the presence of aphasia or neglect); the extent of disability, as assessed by Functional Independence Scale (FIM) and the evidence of concomitant prespecified medical complications, as well as of dysphasia and of the need of indwelling urinary catheter. Other variables were taken into account, such as the time interval between stroke onset and admission to rehabilitation ward and the length of stay. To assess stroke outcome, two different indexes were selected: the frequency of home discharge and the extent of functional recovery. RESULTS: There were 722 (76.3%) ischemic and 224 (23.7%) hemorrhagic strokes. Among ischemic strokes, the partial anterior circulation infarct was the most frequent syndrome, accounting for the 33.2% of cases. The posterior circulation infarct syndrome was the less frequent (14.1%). Lacunar anterior circulation infarct was present for the 29.5% and finally, the total anterior circulation infarct (TACI) was present for the 23.2%. According to the OCSP criteria, the TACI syndrome received 76.1±52.9 (mean±SD) days of rehabilitation, which were statistically different from the other three types of stroke. At discharge, the BI and the FIM of patients affected by TACI was significantly lower and higher, respectively, from the other three type of stroke. However, this difference disappear after one-year of follow-up. CONCLUSION: The TACI subtype of stroke required higher days of rehabilitation from the other type of stroke according to the OCSP criteria. Rehabilitation program is efficacious for improving functional ability of patients affected by stroke although the program should be tailored according to the stroke type.

Cervical artery dissection: emerging risk factors.

Cervical artery dissection (CAD) represents an increasingly recognized cause of stroke and the most common cause of ischemic stroke in young adults. Many factors have been identified in association with CAD such as primary disease of arterial wall (fibrodysplasia) and other non-specific diseases related to CAD like Ehlers Danlos-syndrome IV, Marfan's syndrome, vessel tortuosity. Moreover, an underlying arteriopathy which could be in part genetically determined, has been suspected. The rule of emerging risk factors for CAD such as recent respiratory tract infection, migraine and hyperhomocysteinemia are still a matter of research. Other known risks factors for CAD are major head/neck trauma like chiropractic maneuver, coughing or hyperextension injury associated to car. We examined emerging risks factors for CAD detected in the last years, as CAD pathogenesis is still not completely understood and needs further investigations.

Developing a minimum data set for stroke patients assessment: the " Protocollo di Minima per l'Ictus (PMIC) as a starting point towards an Italian stroke registry.

AIM: The complex nature of stroke sequelae requires several assessment instruments to quantify correctly every residual symptom. As there was no general consensus on stroke evaluation among Italian Physiatrists, in 2004 the Italian Society of Physical Medicine and Rehabilitation and S. Lucia Foundation (a Scientific Institute for hospitalization and treatment) established a Project Group to propose a standardized assessment tool (''Protocollo di Minima per l'Ictus PMIC'') for acute, post-acute and community-living stroke patients. This tool aimed to be easy to use and comprehensive of all the elements necessary for accurately address the great range of different rehabilitation needs. The objective was to provide physiatrists with a standard assessment battery and to make prognostic factors available on large community samples. METHODS: From end 2004 to early 2006, the Project Group examined literature data on stroke assessment, prognostic factors and outcome and selected the specific data elements to be included in a data collection tool. RESULTS: A consensus was reached on a ''minimum'' core set of data. This protocol was peer submitted in early 2006, to test the burden of data collection, and to allow modifications and adjustments. Specific forms (file to download) for data collection and database to be shared (a dedicated ''Client'' software) are now freely offered by the Project Group for data collection. CONCLUSION: PMIC is an evaluation procedure manageable in every-day practice and in every setting, a quick screening instrument that, given its large diffusion, can be expanded from a National Database into a National Rehabilitation Stroke Registry.

Spinal cord lesion management in Italy: a 2-year survey.

DESIGN: Prospective 2-year survey from 1 February 1997 to 31 January 1999. OBJECTIVES: To compare the route from injury to rehabilitation, and the outcome of care in a large sample of traumatic (T) and nontraumatic (NT) spinal cord lesion (SCL) patients at their 'first admission'. SETTING: T and NT SCI patients consecutively admitted to 37 SCL centres in Italy. METHOD: Data were recorded on simple, computerised, closed-question forms, which were Centrally collected and analysed. Descriptive and inferential analysis was conducted to define the characteristics and compare the T and NT populations, and to identify correlations among the variables examined: time from the event to admission (TEA); pressure sores (PS) on admission; length of stay (LoS) and destination on discharge. RESULTS: A total of 1014 SCL patients, 67.5% with a lesion of T and 32.5% of NT aetiology were analysed. The subjects in the T group were younger (median 34 versus 58 years), with higher probability of cervical involvement (OR 2.47, CI 1.8-3.4) and completeness of the lesion (OR 3.0, CI 2.3-4.0), shorter median TEA (37 versus 64 days, P<0.0001) and less frequent admission from home (3.6 versus 17.4%) compared to the NT group. TEA and PS on admission were analysed as indicators of the efficacy of the courses from injury to rehabilitation. Longer TEA was reported for people with NT aetiology, admitted to rehabilitation centre (RC), not locally resident, transferred from certain wards and to a lesser degree female subjects and those with complications on admission. PS were associated to completeness of lesion, longer TEA, admission to RC, nonlocal residence and coming from general intensive care units, or general surgery wards. Median LoS was 99 days (mean 116 and range 0-672), and was statistically shorter in the NT group (122 versus 57 median, P<0.00001). Upon discharge, bladder and bowel autonomy were, respectively, obtained in 68.1 and 64.5% of the whole population without significant difference between the T and NT groups. A total of 80.2% of patients were discharged home and the following factors: not living alone, being discharged after longer LoS, having sphincterial autonomy and no PS, were all independent predictors of outcome. CONCLUSION: There are important obstacles in the admission route to rehabilitation facilities, greater for NT, as longer TEA and more complications on admission testify. Moreover, the LoS is shorter for NT population. Our findings suggest that rehabilitation outcome could be improved through an early multidisciplinary approach and better continuity between acute and rehabilitation care, especially for the 'neglected' NT SCL patients.

Spinal cord injury in Italy: A multicenter retrospective study.

OBJECTIVE: To investigate certain factors influencing the length of stay (LOS) in a rehabilitation center, the incidence of pressure ulcers, and the neurologic improvement of patients with traumatic (T/SCI) and nontraumatic spinal cord injury (NT/SCI). DESIGN: A multicenter retrospective study of patients with SCI admitted to rehabilitation centers between 1 January 1989 and 31 December 1994 (only first admissions). SETTING: Seven Italian rehabilitation centers. PATIENTS: A total of 859 consecutively admitted adult patients with SCI. INTERVENTION: Examined medical records of patients admitted to rehabilitation centers. MAIN OUTCOME MEASURES: Pressure ulcers on admission as an indicator of nursing care in acute phase, LOS in rehabilitation centers, and neurologic improvement on discharge (using the Frankel classification system). Other measures included level of lesion, associated lesions (if T/SCI), surgical stabilization (if T/SCI), and time from the event to admission to a rehabilitation center. RESULTS: In all cases, the time from event to admission to a rehabilitation center exceeded 30 days (average +/- standard deviation: T/SCI, 54.6 +/- 43.7d; NT/SCI, 166.9 +/- 574d); pressure ulcers on admission were present in 34.1% of T/SCI and 17.1% of NT/SCI patients. The average LOS in a rehabilitation center was 143.1 +/- 89.1 days for T/SCI and 91.7 +/- 78.9 days for NT/SCI; Frankel grades improved by 1 or more in 34.4% of T/SCI and 34.1% of NT/SCI patients. The presence of pressure ulcers on admission, rehabilitation LOS, and neurologic improvement on discharge correlated highly with severe neurologic damage on admission in both T/SCI and NT/SCI patients as well as with management of the patient immediately before admission to a rehabilitation center, mainly in NT/SCI patients. CONCLUSIONS: Severe neurologic damage is the major determining factor in predicting neurologic recovery. Pressure ulcer prevention is statistically associated with neurologic improvement and the shortening of rehabilitation LOS. Patient management immediately before admission to rehabilitation has a statistical correlation with neurologic improvement in all patients studied and on both rehabilitation LOS and incidence of pressure ulcers in the NT/SCI patients.