Debates in Rehabilitation Medicine: A Collaborative Initiative of the European Academy of Rehabilitation Medicine and the Journal of Rehabilitation Medicine & Dear readers and authors of the Journal of Rehabilitation Medicine.

No abstract is available.

Factors affecting return to oral intake in inpatient rehabilitation after acquired brain injury.

PRIMARY OBJECTIVE: To extend previous observations by investigating if differences exist in time to initiation or to recovery of total oral intake in patients with acquired brain injury assessed by either Facial-Oral Tract Therapy (F.O.T.T.) or Fibreoptic Endoscopic Evaluation of Swallowing (FEES) and to investigate whether other factors influence these outcomes. RESEARCH DESIGN: Randomized controlled trial. METHODS: One hundred and nineteen patients with dysphagia in inpatient neurorehabilitation were randomized. The main outcome was time to maximum on the Functional Oral Intake Scale. RESULTS: There was no difference in time to initiation or recovery of total oral intake using F.O.T.T. or FEES. Oral intake was initiated for 42% on admission and 92% at discharge; 2.5% of the patients were on total oral intake within 24 hours of admission and 37% at discharge. The likelihood of recovery to total oral intake before discharge was found to depend on age, Functional Independence Measure score, length of stay and number of dysphagia interventions. CONCLUSION: There was no significant difference in time to initiation and recovery of total oral intake before discharge, whether assessed by F.O.T.T. or FEES, indicating that an instrumental assessment is unnecessary for standard evaluation. Age, functional independence and length of stay had a significant influence.

Changes in multidimensional pain inventory profile after a pain rehabilitation programme indicate the risk of receiving sick leave benefits one year later.

OBJECTIVES: To determine whether coping profile changes after rehabilitation, assessed with the Multidimensional Pain Inventory (MPI), can predict which persons disabled by chronic musculoskeletal pain will be in receipt of sick leave benefits in the long term. METHODS: Study of MPI data from 2,784 patients (709 men and 2,075 women) collected from the Swedish Quality Register for Pain Rehabilitation (SQRP) before and at the end of rehabilitation and compared with independent sick leave data for 1 year later. RESULTS: After rehabilitation there was a significantly decreased share of Dysfunctional profiles (DYS) among both men (44% before, 31% after) and women (39% before, 26% after), but an increased share of Adaptive Coper profiles (men 15% before, 24% after, women 14% before, 24% after). The number of patients on full-time sick leave decreased significantly among men (from 57% to 46%) and women (from 57% to 50%). Persons with a DYS profile after rehabilitation had a low probability of having no or part-time sick leave. CONCLUSION: The number of persons with DYS profiles decreased after rehabilitation. Those with other profiles had less full-time sick leave one year later than those with DYS profiles, indicating that leaving the DYS profile is a positive prognostic sign long-term. Furthermore, the gender differences observed suggest the need to tailor rehabilitative strategies differently for men and women.

Randomized trial of two swallowing assessment approaches in patients with acquired brain injury: Facial-Oral Tract Therapy versus Fibreoptic Endoscopic Evaluation of Swallowing.

OBJECTIVE: To examine whether patients assessed for initiation of oral intake only by Facial-Oral Tract Therapy had a greater risk of developing aspiration pneumonia during neurorehabilitation than patients assessed by Fibreoptic Endoscopic Evaluation of Swallowing. DESIGN: Randomized controlled trial. SETTING: Specialized, national neurorehabilitation centre. SUBJECTS: Adult patients with acquired brain injury. Six hundred and seventy-nine patients were assessed for eligibility and 138 were randomly allocated between June 2009 and April 2011. INTERVENTIONS: Assessment by Facial-Oral Tract Therapy (control group) or Fibreoptic Endoscopic Evaluation of Swallowing (intervention group). MAIN MEASURE: Primary outcome was the number of aspiration pneumonias that developed after initiation of oral intake. RESULTS: One hundred and nineteen patients were included in the analysis of the primary outcome (62 controls/57 interventions). Sixteen patients were clinically diagnosed with pneumonia (4 controls/12 interventions). Nine patients had to be excluded: 6 patients got pneumonia before initiating oral intake; 3 patients with the clinical diagnosis of pneumonia did not show radiological signs. Seven patients were left for analysis, 4 of whom developed aspiration pneumonia within 10 days after initiating oral intake (1 control/3 interventions). CONCLUSION: In the presence of a structured clinical assessment with the Facial-Oral Tract Therapy approach, it is unnecessary to undertake an instrumental investigation of swallowing before initiation of oral intake.

Honorary authorship.

This issue of Archives of Physical Medicine and Rehabilitation includes an article by Rajasekaran et al that addresses the persistent, difficult, and unsettled issue of unwarranted authorship as it applies to physical medicine and rehabilitation. The findings that it exists and that its frequency is similar to the 25% to 50% rates reported in other medical specialties are discouraging but, unfortunately, not surprising. They do, however, warrant discussion. This commentary attempts to do so and begins with a review of Rajasekaran's findings. It then proceeds to compare them with other work in the literature and concludes with a discussion of (1) why unwarranted authorship matters; (2) if it matters, why does it matter; and (3) what we as authors, editors, and the publishing world can do about it. Our goal is to give us all an improved understanding of the situation as well a little more backbone when dealing with the pressures associated with both overt and covert suggestions for the inclusion of authors that we may believe are unwarranted.

Pain when walking: individual sensory profiles in the foot soles of torture victims - a controlled study using quantitative sensory testing.

BACKGROUND: With quantitative sensory testing (QST) we recently found no differences in sensory function of the foot soles between groups of torture victims with or without exposure to falanga (beatings under the feet). Compared to matched controls the torture victims had hyperalgesia to deep mechano-nociceptive stimuli and hypoesthesia to non-noxious cutaneous stimuli. The purpose of the present paper was to extend the group analysis into individual sensory profiles of victims' feet to explore possible relations between external violence (torture), reported pain, sensory symptoms and QST data to help clarify the underlying mechanisms. METHODS: We employed interviews and assessments of the pain and sensory symptoms and QST by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli. An ethnically matched control group was available.The normality criterion, from our control group data, was set as the mean +/- 1.28SD, thus including 80% of all values.QST data were transformed into three categories in relation to our normality range; hypoesthesia, normoesthesia or hyperesthesia/hyperalgesia. RESULTS: Most patients, irrespective of having been exposed to falanga or not, reported severe pain when walking. This was often associated with hyperalgesia to deep mechanical pressure. Hypoesthesia to mechanical stimuli co-occurred with numbness, burning and with deep mechanical hyperalgesia more often than not, but otherwise, a hypoesthesia to cutaneous sensory modalities did not co-occur systematically to falanga, pain or sensory symptoms. CONCLUSION: In torture victims, there seem to be overriding mechanisms, manifested by hyperalgesia to pressure pain, which is usually considered a sign of centralization. In addition there was cutaneous hypoesthesia, but since there was no obvious correlation to the localization of trauma, these findings may indicate centrally evoked disturbances in sensory transmission, that is, central inhibition. We interpret these findings as a sign of changes in central sensory processing as the unifying pathological mechanism of chronic pain in these persons.

Sensory functions in the foot soles in victims of generalized torture, in victims also beaten under the feet (falanga) and in healthy controls - A blinded study using quantitative sensory testing.

BACKGROUND: Falanga torture (beatings on the foot soles) produces local chronic pain and severe walking difficulties. We have previously reported signs of neuropathic pain in the feet of falanga victims. The objective here was to clarify underlying pain mechanisms by quantifying sensory impairments in the feet of torture victims who had experienced both generalized torture and those who had been exposed to falanga in addition. An ethnically matched control group was available. METHODS: We employed quantitative sensory testing (QST) by investigators blinded to whether the patients, 32 male torture victims from the Middle East, had (n=15), or had not (n=17) been exposed to falanga. Pain intensity, area and stimulus dependence were used to characterize the pain as were interview data on sensory symptoms. QST included thresholds for touch, cold, warmth, cold-pain, heat-pain, deep pressure pain and wind-up to cutaneous noxious stimuli in the foot soles. Clinical data on anxiety and depression were retrieved. RESULTS: Almost all falanga victims had moderate or strong pain in their feet and in twice as large an area of their foot soles as other torture victims. One-third of the latter had no pain in their feet and many reported slight pain; in spite of this, there were no differences in foot sole QST data between the tortured groups. A comparison with normal data indicated that both tortured groups had hypoesthesia for all cutaneous sensory fibre groups except those transmitting cold and heat pain, in addition to deep mechano-nociceptive hyperalgesia. CONCLUSION: A comparison of the QST data between victims having been exposed to generalized torture and victims who in addition had been exposed to falanga, showed no differences on the group level. The sensory disturbances in relation to our control group are compatible with central sensitization and de-sensitization, pointing to a core role of central mechanisms. A further analysis to create individual sensory profiles from our measurements is in progress.

Using data from Multidimensional Pain Inventory subscales to assess functioning in pain rehabilitation.

The aim of this study was to examine whether Multidimensional Pain Inventory (MPI) subscale score changes can be used for monitoring interdisciplinary cognitive behavioural pain rehabilitation programmes, using the Psychological General Well-Being (PGWB) index as an independent variable of rehabilitation outcome. Data from 434 consecutively referred patients disabled by chronic pain were analysed. The intervention was a 4-week interdisciplinary pain rehabilitation group programme (5 h/day), based on biopsychosocial and cognitive behavioural principles. Mean PGWB total scores improved after rehabilitation (P<0.0001) with clinically relevant effect sizes for patients with 'dysfunctional' and 'interpersonally distressed' MPI profiles. Substantial correlations (r=0.7-0.3; P<0.001) were found between the changes in PGWB total scores and four of the MPI subscale scores. These were combined into a composite variable ['pain severity', 'interference', 'life control' (given reversed scores) and 'affective distress'], and were labelled as the Pain Rehabilitation Index. The subscales, 'support' and 'general activity level', were omitted, as changes were ambiguous with respect to functioning. 'Dysfunctional' and 'interpersonally distressed' profile patients showed a marked improvement in Pain Rehabilitation Index after rehabilitation (effect sizes of 0.77 and 0.43; P<0.0001, respectively). Conversely, the 'adaptive copers' may have deteriorated somewhat (effect size -0.28; P=0.036). We propose that scores from four MPI subscales are integrated and the difference pre-post rehabilitation is used to indicate composite rehabilitation outcomes, making it possible to interpret all included MPI subscales in the same direction. Psychometric evaluation of the index is warranted.

Self-reported activity in tortured refugees with long-term sequelae including pain and the impact of foot pain from falanga--a cross-sectional study.

PURPOSE: To describe activity limitations in tortured refugees referred for rehabilitation, particularly the impact of neuropathic pain resulting from falanga (beatings under the feet). METHODS: Physiotherapists assessed 103 consecutively referred torture victims with a long history of sequelae, among them pain and mobility problems. All had been subjected to various forms of physical and psychological torture and 71 victims had also suffered falanga. Main outcome measures used were: the Disability Rating Index (DRI; 12 items) to assess self-reported capacity to carry out daily activities; for falanga victims, a specific foot assessment of sensory function in the feet. RESULTS: All patients perceived clear activity limitations according to the DRI. The falanga victims' feet were categorised according to the type of foot pain: stimulus-independent pain; stimulus-evoked pain; no pain. The two groups with foot pain displayed sensory dysfunction and suffered more extensive activity limitations. After correction for confounding factors, these two groups reported significantly more activity limitations in 7 out of 12 DRI items than those who were not exposed to falanga. CONCLUSION: In this group of victims who had chronic pain for at least 5 years after torture, all perceived activity limitations, but pain from falanga had a greater overall impact on disability assessed in terms of daily activities.

Do Multidimensional Pain Inventory scale score changes indicate risk of receiving sick leave benefits 1 year after a pain rehabilitation programme?

PURPOSE: To study whether scale score changes in the Multidimensional Pain Inventory (MPI) can predict which persons disabled by pain will receive sick leave benefits 1 year after completing a pain rehabilitation programme. METHOD: An observational study of MPI data derived from 1468 patients, 388 men and 1080 women, who had participated in multidisciplinary cognitive-behavioural oriented pain rehabilitation programmes in Sweden, collected from the Swedish Quality Register for Pain Rehabilitation, before, at the end and 1 year after the programme. RESULTS: Most MPI scale scores showed improvements after completing a pain rehabilitation programme and this improvement was sustained after 1 year. Moreover, we found that a decrease in MPI scales scores for Pain severity and Interference immediately after the pain rehabilitation programme decreased the risk of being on full-time sick leave 1 year later [OR 0.85, (95% CI 0.73-0.99) and OR 0.73, (95% CI 0.61-0.87), respectively]. The Interference scale, which may be considered to include ICF components of both activities and participation, might represent the core of suffering among persons disabled with pain. CONCLUSIONS: A rehabilitation intervention directed to combating the consequences of pain in activities and participation rather than against pain per se might lead to improved working capacity.

Swedish quality registry for pain rehabilitation: purpose, design, implementation and characteristics of referred patients.

OBJECTIVE: In order to facilitate comparisons of pain rehabilitation programmes in Sweden and to enable audit spirals for single programmes as well as outcome studies, the Swedish Association for Rehabilitation Medicine initiated a national quality registry in 1995. PATIENTS: Referred for rehabilitation due to pain-related disability. METHODS: The registry collects standardized self-reports before assessment, after rehabilitation and one year later, covering demographic, educational and psychometric data, pain intensity, physical disability and life satisfaction. Sick leave data are collected from the National Insurance Board before and up to two years after rehabilitation. At each programme unit self-reports are processed into individual assessment profiles relevant to plan rehabilitation. Data are sent annually to the central registry for analysis and compared with "return to work" data. Each unit can compare its results with national means. RESULTS AND CONCLUSION: The organization of the registry is described. Data indicating that contextual factors, but not pain characteristics, depression or activity limitations vary between patients referred to different centres, makes comparisons difficult. As of 2007, data from the multidisciplinary assessment of 19,833 patients have been collected. A total of 7289 patients attended a rehabilitation programme, generating two more self-reports. A limitation of the study is a lack of follow-up data from some units.

Mode of hand training determines cortical reorganisation: a randomized controlled study in healthy adults.

OBJECTIVE: To evaluate two commonly used forms of hand training with respect to influence on dexterity and cortical reorganization. SUBJECTS: Thirty healthy volunteers (mean age 24.2 years). METHODS: The subjects were randomized to 25 min of shaping exercises or general activity training of the non-dominant hand. The dexterity and the cortical motor maps (number of excitable positions) of the abductor pollicis brevis muscle were evaluated pre- and post-training by the Purdue Peg Board test and transcranial magnetic stimulation, respectively. RESULTS: After shaping exercises the dexterity increased significantly (p < or = 0.005) for both hands, mostly so in the non-dominant hand. The cortical motor map of the abductor pollicis brevis muscle shifted forwardly into the pre-motor area without expanding. After general activity training, no significant improvements in dexterity were found for the non-dominant hand. The cortical motor map of the non-dominant abductor pollicis brevis muscle expanded significantly (p = 0.03) in the posterior (sensory) direction. CONCLUSION: These results indicate that shaping exercises, but not general activity training, increase dexterity of the trained non-dominant hand in parallel with a shift of location of active transcranial magnetic stimulation positions. Shifts of active cortical areas might be important for the interpretation of brain plasticity in common behavioural tasks.

Validity of electrical stimulus magnitude matching in chronic pain.

OBJECTIVE: To examine the validity of the PainMatcher in chronic pain. DESIGN: Comparison of parallel pain estimates from visual analogue scales with electrical stimulus magnitude matching. PATIENTS: Thirty-one patients with chronic musculoskeletal pain. METHODS: Twice a day ongoing pain was rated on a standard 100-mm visual analogue scale, and thereafter magnitude matching was performed using a PainMatcher. The sensory threshold to electrical stimulation was tested twice on separate occasions. RESULTS: In 438 observations visual analogue scale ranged from 3 to 95 (median 41) mm, and PainMatcher magnitudes from 2.67 to 27.67 (median 6.67; mean 7.78) steps. There was little correlation between visual analogue scale and magnitude data (r = 0.29; p < 0.0001). The mean sensory threshold was 3.67 steps, indicating that the PainMatcher, on average, stimulated at 2.1 times the perception threshold at matching point. CONCLUSION: Electrical magnitude matching of chronic pain intensity elicited limited activation of nerve fibres at 2.0-2.2 times sensory threshold, indicating that the induced pain was evoked by coarse nociceptive Adelta fibres. While the visual analogue scale estimates covered the whole range of the instrument, the PainMatcher readings utilized only a small part of the instrument range and, importantly, had little or no relation to the visual analogue scale estimates. The validity of the PainMatcher procedure is doubtful.

Rehabilitating torture survivors.

Refugees have often been exposed to torture in their countries of origin. A core issue is the resulting multifaceted presentation of somatic, psychological and social problems in the same individual, leading to severe activity limitations and participation restrictions. An international conference, "Rehabilitating Torture Survivors", was organized by the Rehabilitation and Research Centre for Torture Victims (a rehabilitation clinic and global knowledge and research centre with government support) in collaboration with the Centre for Transcultural Psychiatry at Rigshospitalet in Copenhagen, Denmark, in December 2008. The main topics were: the context of torture; mental problems including psychotherapy; internet-based therapy and pharmaco-therapy; chronic pain; social integration and family; and functioning and rehabilitation. Available evidence highlights the importance of an interdisciplinary approach to rehabilitation, but scientifically rigorous studies of comprehensive rehabilitation programmes for torture survivors are lacking. Therefore, effect studies are urgently warranted. Nevertheless, by combining expertise from different scientific and professional areas, important elements in the problems of torture survivors can be addressed from an evidence base generated both from traumatized and non-traumatized patient populations. Thus, trauma-focused cognitive behavioural therapy and/or eye movement desensitization and reprocessing, as well as interdisciplinary pain rehabilitation, should be components of a successful rehabilitation process, and great attention should be paid to contextual components.

Shortened constraint-induced movement therapy in subacute stroke - no effect of using a restraint: a randomized controlled study with independent observers.

OBJECTIVE: To examine the effect of using a mitt during shortened constraint-induced movement therapy for patients in the subacute phase after stroke. SUBJECTS: Twenty-four patients with stroke (mean age 57.6 (standard deviation (SD) 8.5) years; average 7 weeks post-stroke) with mild to moderate impaired hand function. METHODS: The patients were randomized to mitt use or no mitt use on the less affected hand for 90% of waking hours for 12 days. All patients received 3 h of arm and hand training per day for 2 weeks. Assessments were made by blinded observers using the modified Motor Assessment Scale, the Sollerman hand function test, the 2-Point Discrimination test and Motor Activity Log test. RESULTS: Patients in both groups showed significant improvements in arm and hand motor performance and on self-reported motor ability after 2 weeks of therapy and at 3 months follow-up. However, no statistically significant differences between the groups were found in any measures at any point in time. CONCLUSION: In this study, no effect of using a restraint in patients with subacute stroke was found. Thus, this component in the constraint-induced therapy concept seems to be of minor importance for the outcome.

Intra- and inter-rater reliability of the Sollerman hand function test in patients with chronic stroke.

PURPOSE: To examine whether the Sollerman hand function test is reliable in a test-retest situation in patients with chronic stroke. METHOD: Three independent examiners observed each patient at three experimental sessions; two days in week 1 (short-term test-retest) and one day in week 4 (long-term test-retest). A total of 24 patients with chronic stroke (mean age; 59.7 years, mean time since stroke onset 29.6 months) participated. The examiners simultaneously assessed the patients' ability to perform 20 subtests. Both ordinal data (generalized kappa) and total sum scores (Spearman's rank correlation coefficient (Spearman's rho), intra class correlation coefficient (ICC2, 1) and mean differences) were used in the statistical analysis. RESULTS: There was agreement (kappa >or= 0.4) between the examiners for 15 out of the 20 subtests. Using total sum scores, the agreement within the examiners, both short- and long-term, was higher than 0.96 (for Spearman's rho and ICC, respectively). The mean differences were 0.29 - 1.0/80 points within each examiner. Agreement between the examiners at each session was higher than 0.96 (Spearman's rho) and 0.92 (ICC), respectively. Systematic differences (p < 0.05) were, however, found between examiners A and B/C for all sessions. CONCLUSIONS: The Sollerman hand function test seems to be a reliable test in patients with chronic stroke, but we recommend that the same examiner evaluates a patient's hand function pre- and post-treatment.

Pressure pain threshold changes after repeated mechano-nociceptive stimulation of the trapezius muscle: possible influence of previous pain experience.

UNLABELLED: We examined the relation between repeated noxious pressure over the trapezius muscle and changes in pressure pain thresholds (PPTs) in a before-after trial design. A conditioning series of 30 mechano-nociceptive stimuli was applied manually with a handheld algometer probe, and PPTs were measured over 1 trapezius muscle (skin anaesthetized) in 27 healthy women before and after the intervention. With a mean stimulation rate of 0.40 Hz and a mean nociceptive stimulation intensity of 1.78 x Threshold, subjects were found to systematically react with a change in PPT, either a decrease or an increase. Normalized data, transformed into mean unidirectional PPT differences, showed statistically highly significant changes after intervention. The relative risk of reacting with lowered PPTs on noxious stimulation was 3.7 times higher for subjects who had not given birth to children than for subjects who had given birth to 1 or several children (P<.046). When 11 subjects were tested at a second session, a clear correlation of PPT reactions (r=0.527; P<.001) was found. In summary, repetitive mechano-nociceptive stimulation of the trapezius muscle in healthy females evokes moderate and temporary changes in PPT that last for at least 35 minutes after cessation of stimulation. PERSPECTIVE: A possible development of the response with transiently decreased PPTs into a model for human muscle pain is an intriguing possibility, since other models usually involve the introduction of chemical or thermal agents in the muscle, but this must await further research.

Constraint-induced movement therapy in patients with stroke: a pilot study on effects of small group training and of extended mitt use.

OBJECTIVE: (1) To evaluate constraint-induced movement therapy for chronic stroke patients modified into group practice to limit the demand on therapist resources. (2) To explore whether extended mitt use alone may enhance outcome. DESIGN: A combined case-control and randomized controlled study with pre- and post-treatment measures by blinded observers. SETTING: A university hospital rehabilitation department. PARTICIPANTS: Sixteen stroke patients (nine men and seven women; mean age 56.7 years; on average 28.9 months post stroke, five of whom were 6-9 months post stroke) with moderate motor impairments in the contralateral upper limb. INTERVENTION: Constraint-induced therapy (mitt on the less affected hand 90% of waking hours for 12 days) with 2-3 patients per therapist and 6 h of group training per day. After the training period, the patients were randomized either to using the mitt at home every other day for two-week periods for another three months (in total 21 days) or to no further treatment. OUTCOME MEASURES: Modified Motor Assessment Scale, Sollerman Hand Function Test, Two-Point Discrimination test and Motor Activity Log. RESULTS: The mean motor performance improved significantly after two weeks of constraint-induced group therapy on Motor Assessment Scale (1.44 (95% confidence interval (95% CI) 0.59-2.28) points; P = 0.003) and on Sollerman Hand Function Test (3.81 (95% CI 0.26-7.36) points; P = 0.037) but showed no sensory change in the Two-Point Discrimination Test (P = 0.283). The median difference in self-reported motor ability (Motor Activity Log) also improved (P < 0.001). However, no additional effect was seen from wearing a mitt for another three months. CONCLUSION: Constraint-induced group therapy, allowing several patients per therapist, seems to be a feasible alternative to improve upper limb motor function. The restraint alone, extended in time, did not enhance the treatment effect.