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ContextThe Spinal Cord Independence Measure is a comprehensive functional rating scale for individuals with spinal cord lesion (SCL).ObjectiveTo validate the scores of the three subscales of SCIM IV, the fourth version of SCIM, using advanced statistical methods.Study DesignMulti-center cohort study.SettingNineteen SCL units in 11 countries.MethodsSCIM developers created SCIM IV following comments by experts, included more accurate definitions of scoring criteria in the SCIM IV form, and adjusted it to assess specific conditions or situations that the third version, SCIM III, does not address. Professional staff members assessed 648 SCL inpatients, using SCIM IV and SCIM III, at admission to rehabilitation, and at discharge. The authors examined the validity and reliability of SCIM IV subscale scores using Rasch analysis.ResultsThe study included inpatients aged 16–87 years old. SCIM IV subscale scores fit the Rasch model. All item infit and most item outfit mean-square indices were below 1.4; statistically distinct strata of abilities were 2.6–6; most categories were properly ordered; item hierarchy was stable across most clinical subgroups and countries. In a few items, however, we found misfit or category threshold disordering. We found SCIM III and SCIM IV Rasch properties to be comparable.ConclusionsRasch analysis suggests that the scores of each SCIM IV subscale are reliable and valid. This reinforces the justification for using SCIM IV in clinical practice and research.

Background: Despite the relevance of telephone-based cognitive screening tests in clinical practice and research, no specific test assessing executive functioning is available. The present study aimed at standardizing and providing evidence of clinical usability for the Italian telephone-based Frontal Assessment Battery (t-FAB). Methods: The t-FAB (ranging 0–12), comprising two subtests, has two versions: one requiring motor responses (t-FAB-M) and the other verbal responses (t-FAB-V). Three hundred and forty-six Italian healthy adults (HPs; 143 males; age range = 18–96 years; education range = 4–23 years) and 40 participants with neurological diseases were recruited. To HPs, the t-FAB was administered along with a set of telephone-based tests: MMSE, verbal fluency (VF), backward digit span (BDS). The in-person version of the FAB was administered to both HPs and clinical groups. Factorial structure, construct validity, inter-rater and test–retest reliability, t-FAB-M vs.t-FAB-V equivalence and diagnostic accuracy were assessed. Norms were derived via Equivalent Scores. Results: In HPs, t-FAB measures yielded high inter-rater/test–retest reliability (ICC = .78–.94), were internally related (p≤ .005) and underpinned by a single component, converging with the telephone-based MMSE, VF, BDS (p≤ .0013). The two t-FAB versions were statistically equivalent in clinical groups (ps of both equivalence bounds < .001). Education predicted all t-FAB scores (p< .001), whereas age only the t-FAB-M score (p≤ .004). t-FAB scores converge with the in-person FAB in HPs and clinical groups (rs= .43–.78). Both t-FAB versions were accurate in discriminating HPs from the clinical cohort (AUC = .73-.76). Discussion: The t-FAB is a normed, valid, reliable and clinically usable telephone-based cognitive screening test to adopt in both clinical and research practice.

In a recent paper, Sharpe and Greco (2019) argue that some clinical conditions, such as chronic fatigue syndrome (sometimes called myalgic encephalomyelitis), should be treated by altering the patient's experience and response to symptoms without necessarily searching for an underlying cause. As a result, we should allow for the existence of ‘illnesses without (underlying) diseases’. Wilshire and Ward (2019) reply that this possibility requires unwarranted causal assumptions about the psychosocial origins of conditions not predicted by a disease model. In so doing, it is argued that Sharpe and Greco introduce epistemological and methodological problems with serious medical consequences, for example, patients feel guilt for seeking treatment for illnesses that only exist ‘all in the mind’, and medical researchers are discouraged from looking for more effective treatments of such conditions. We propose a view that integrates the insights of both papers. We abandon both the strict distinction between disease and illness and the nai¨ve unidirectional account of causality that accompanies it. This, we claim, is a step towards overcoming the current harmful tendencies to conceptually separate (1) Symptom management and disease-modifying treatments. (2) Rehabilitative-palliative care and ‘causal’ curing. (3) Most importantly, biomedicine and clinical medicine, where the latter is currently at risk of losing its status as scientific.

Few studies have investigated the kinematic aspects of the body centre of mass motion, that is, its three-dimensional path during strides and their changes with child development. This study aimed to describe the three-dimensional path of the centre of mass in children while walking in order to disentangle the effect of age from that of absolute forward speed and body size and to define preliminary pediatric normative values. The three-dimensional path of the centre of mass during walking was compared across healthy children 5–6− years (n = 6), 7–8 years (n = 6), 9–10 years (n = 5), and 11–13 years of age (n = 5) and healthy adults (23–48 years, n = 6). Participants walked on a force-sensing treadmill at various speeds, and height normalization of speed was conducted with the dimensionless Froude number. The total length and maximal lateral, vertical, and forward displacements of the centre of mass path were calculated from the ground reaction forces during complete strides and were scaled to the participant’s height. The centre of mass path showed a curved figure-of-eight shape. Once adjusted for speed and participants’ height, as age increased, there was a decrease in the three-dimensional parameters and in the lateral displacement, with values approaching those of adults. At each step, lateral redirection of the centre of mass requires brisk transient muscle power output. The base of support becomes relatively narrower with increasing age. Skilled shortening of the lateral displacement of the centre of mass may therefore decrease the risk of falling sideways. The three-dimensional path of the centre of mass may represent maturation of neural control of gait during growth.

Twenty-six months after a left hemispheric ischemic stroke an aphasic patient showed a significant improvement in verbal fluency following ten daily sessions of inhibitory 1 Hz repetitive transcranial magnetic stimulation over the right cortex homologous to the Broca’s area.No improvement was observed for other linguistic functions or for executive ones. Results confirm the segregation of neural circuitries subtending phonemic and semantic fluency and suggest a selective usefulness of the repetitive transcranial magnetic stimulation treatment.

Walking on a split-belt treadmill (each of the two belts running at a different speed) has been proposed as an experimental paradigm to investigate the flexibility of the neural control of gait and as a form of therapeutic exercise. However, the scarcity of dynamic investigations challenges the validity of the available findings. The aim of the present study was to investigate the dynamic asymmetries of lower limbs of healthy adults during adaptation to gait on a split-belt treadmill. Ten healthy adults walked on a split-belt treadmill mounted on force sensors, with belts running either at the same speed (‘tied’ condition) or at different speeds (‘split’ condition, 0.4 vs. 0.8 or 0.8 vs. 1.2 m/s). The sagittal power and work provided by ankle, knee and hip joints, joint rotations, muscle lengthening, and surface electromyography were recorded simultaneously. Various tied/split walking sequences were requested. In the split condition a marked asymmetry between the parameters recorded from each of the two lower limbs, in particular from the ankle joint, was recorded. The work provided by the ankle (the main engine of body propulsion) was 4.8 and 2.2 times higher (in the 0.4 vs. 0.8, and 0.8 vs. 1.2 m/s conditions, respectively) compared with the slower side, and 1.2 and 1.1 times higher compared with the same speed in the tied condition. Compared with overground gait in hemiplegia, split gait entails an opposite spatial and dynamic asymmetry. The faster leg mimics the paretic limb temporally, but the unimpaired limb from the spatial and dynamic point of view. These differences challenge the proposed protocols of split gait as forms of therapeutic exercise.

IMPORTANCE: Chronic cerebrospinal venous insufficiency (CCSVI) is characterized by restricted venous outflow from the brain and spinal cord. Whether this condition is associated with multiple sclerosis (MS) and whether venous percutaneous transluminal angioplasty (PTA) is beneficial in persons with MS and CCSVI is controversial. OBJECTIVE: To determine the efficacy and safety of venous PTA in patients with MS and CCSVI. DESIGN, SETTING, AND PARTICIPANTS: We analyzed 177 patients with relapsing-remitting MS; 62 were ineligible, including 47 (26.6%) who did not have CCSVI on color Doppler ultrasonography screening. A total of 115 patients were recruited in the study timeframe. All patients underwent a randomized, double-blind, sham-controlled, parallel-group trial in 6 MS centers in Italy. The trial began in August 2012 and concluded in March 2016; data were analyzed from April 2016 to September 2016. The analysis was intention to treat. INTERVENTIONS: Patients were randomly allocated (2:1) to either venous PTA or catheter venography without venous angioplasty (sham). MAIN OUTCOMES AND MEASURES: Two primary end points were assessed at 12 months: (1) a composite functional measure (ie, walking control, balance, manual dexterity, postvoid residual urine volume, and visual acuity) and (2) a measure of new combined brain lesions on magnetic resonance imaging, including the proportion of lesion-free patients. Combined lesions included T1 gadolinium-enhancing lesions plus new or enlarged T2 lesions. RESULTS: Of the included 115 patients with relapsing-remitting MS, 76 were allocated to the PTA group (45 female [59%]; mean [SD] age, 40.0 [10.3] years) and 39 to the sham group (29 female [74%]; mean [SD] age, 37.5 [10.6] years); 112 (97.4%) completed follow-up. No serious adverse events occurred. Flow restoration was achieved in 38 of 71 patients (54%) in the PTA group. The functional composite measure did not differ between the PTA and sham groups (41.7% vs 48.7%; odds ratio, 0.75; 95% CI, 0.34-1.68; P = .49). The mean (SD) number of combined lesions on magnetic resonance imaging at 6 to 12 months were 0.47 (1.19) in the PTA group vs 1.27 (2.65) in the sham group (mean ratio, 0.37; 95% CI, 0.15-0.91; P = .03: adjusted P = .09) and were 1.40 (4.21) in the PTA group vs 1.95 (3.73) in the sham group at 0 to 12 months (mean ratio, 0.72; 95% CI, 0.32-1.63; P = .45; adjusted P = .45). At follow-up after 6 to 12 months, 58 of 70 patients (83%) in the PTA group and 22 of 33 (67%) in the sham group were free of new lesions on magnetic resonance imaging (odds ratio, 2.64; 95% CI, 1.11-6.28; P = .03; adjusted P = .09). At 0 to 12 months, 46 of 73 patients (63.0%) in the PTA group and 18 of 37 (49%) in the sham group were free of new lesions on magnetic resonance imaging (odds ratio, 1.80; 95% CI, 0.81-4.01; P = .15; adjusted P = .30). CONCLUSION AND RELEVANCE: Venous PTA has proven to be a safe but largely ineffective technique; the treatment cannot be recommended in patients with MS. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01371760

Gait analysis (GA) typically includes surface electromyographic (sEMG) recording from several lower limb muscles, optoelectronic measurement of joint rotations, and force recordings from ground-based platforms. From the latter two variables, the muscle power acting on the lower limb joints can be estimated. Recently, gait analysis on a split-belt force treadmill (GAFT) was validated for the study of adult walking. It showed high reliability of spatiotemporal, kinematic, dynamic, and sEMG parameters, matching those obtainable with GA on the basis of ground walking. GAFT, however, still needs validation in children. Potential differences with respect to adult GAFT relate to (a) possible high signal-to-noise ratio, given the lower forces applied; (b) higher differences between treadmill and over-ground walking; and (c) limited compliance with the experimental setup. This study aims at investigating whether GAFT provides results comparable with those obtainable from ground walking in children and consistent with results from GAFT in adults. GAFT was applied to three groups of healthy children aged 5–6 years (n=6), 7–8 years (n=6), and 9–13 years (n=8) walking at the same average speed spontaneously adopted overground. The results were compared with those obtained from another study applying GA to an age-matched and speed-matched sample of 47 children, and with those obtained from GAFT in adults. The reliability (as indicated by the SD) of both spatiotemporal and dynamic parameters was higher in GAFT compared with GA. In the 5–6-, 7–8-, and 9–13-year-old groups, at average speeds of 0.83, 1.08, and 1.08 m/s, step length was shorter by 9.19, 3.57, and 2.30% compared with GA in controls at comparable speeds, respectively. For the youngest group, a lower power generation from the plantar flexors (peak power: 1.35±0.32 vs. 2.11±1.02 W/kg) and a slightly more flexed posture of the hip, knee, and ankle joints were observed during GAFT compared with GA in controls. The other gait parameters were very similar between the GAFT and the GA groups. The shortening of step length during GAFT, relative to GA at superimposable speed, was on average of all children 6.8%, in line with the 8% decrease found in adults. The profiles of sEMG and joint rotations, and all of the weight-standardized joint power parameters, matched those recorded in adults. The entire experimental session lasted about 1 h. All children complied with the experimental setting and easily completed the requested tests. In conclusion, GAFT seems to be a promising alternative to conventional GA in children.

In hemiplegic gait the paretic lower limb provides less muscle power and shows a briefer stance compared with the unaffected limb. Yet, a longer stance and a higher power can be obtained from the paretic lower limb if gait speed is increased. This supports the existence of a ‘learned non-use’ phenomenon, similar to that underlying some asymmetric impairments of the motion of the eyes and of the upper limbs. Crouch gait (CG) (bent-hip bent-knee, about 30° minimum knee flexion) might be an effective form of ‘forced-use’ treatment of the paretic lower limb. It is not known whether it also stimulates a more symmetric muscle power output. Gait analysis on a force treadmill was carried out in 12 healthy adults and seven hemiplegic patients (1–127 months after stroke, median: 1.6). Speed was imposed at 0.3 m/s. Step length and single and double stance times, sagittal joint rotations, peak positive power, and work in extension of the hip, knee, and ankle (plantar flexion), and surface electromyography (sEMG) area from extensor muscles during the generation of power were measured on either side during both erect and crouch walking. Significance was set at Pless than 0.05; corrections for multiplicity were applied. Patients, compared with healthy controls, adopted in both gait modalities and on both sides a shorter step length (61–84%) as well as a shorter stance (76–90%) and swing (63–83%) time. As a rule, they also provided a higher muscular work (median: 137%, range: 77–250%) paralleled by a greater sEMG area (median: 174%, range: 75–185%). In erect gait, the generation of peak extensor power across hip, knee, and ankle joints was in general lower (83–90%) from the paretic limb and higher (98–165%) from the unaffected limb compared with control values. In CG, peak power generation across the three lower limb joints was invariably higher in hemiparetic patients: 107–177% from the paretic limb and 114–231% from the unaffected limb. When gait shifted from erect to crouch, only for hemiplegic patients, at the hip, the paretic/unaffected ratio increased significantly. For peak power, work, sEMG area, and joint rotation, the paretic/unaffected ratio increased from 55 to 85%, 56 to 72%, 68 to 91%, and 67 to 93%, respectively. CG appears to be an effective form of forced-use exercise eliciting more power and work from the paretic lower limb muscles sustained by a greater neural drive. It also seems effective in forcing a more symmetric power and work from the hip extensor muscles, but neither from the knee nor the ankle.

Knee rotationplasty (KRP) is a type of surgery in which the rotated ankle serves as a new knee after being removed for bone tumor. Although this limb salvage surgery is rarely indicated in properly selected patients, it may offer functional advantages over transfemoral amputation, and more durable results compared with a prosthesis. The walking mechanics of adult patients after KRP is believed to be close to that of below-knee amputees. In this study, we evaluated steady-state walking of KRP patients from the viewpoint of the overall muscle power needed to keep the body centre of mass in motion. Three adult patients after KRP, all athletes, were evaluated. Ground reactions during walking were recorded during six subsequent strides on a force treadmill. The positive mechanical work and power sustaining the motion of the centre of mass and the recovery of muscle energy due to the pendulum-like mechanism of walking were computed and compared with those obtained in previous studies from above-knee, below-knee amputees and healthy individuals. In KRP patients, walking was sustained by a muscle power output which was 1.4–3.6 times lower during the step performed on the rotated limb than on the subsequent step. The recovery of muscle energy was slightly lower (0.9) or higher (1.3–1.4 times) on the affected side. In two out of the three KRP patients, our findings were more similar to those from above-knee amputees than to those from below-knee amputees. After KRP, the rotated limb does not necessarily provide the same power provided by below-knee amputation. This may have a relevance for the paralympic classification of KRP athletes.

Bimanual coordination underlies many daily activities. It is tested by various versions of the old Minnesota Dexterity Test (dating back to 1931, ‘turning’ subtest). This, however, is ill standardized, may be time-consuming, and has poor normative data. A timed-revised form of the turning subtest (MTTrf) is presented. Age-related norms and test–retest reliability were computed. Sixty-four healthy individuals, 24–79 years, comprising 34 women, were required to pick up 60 small plastic disks from wells, rotate each disk, and transfer it to the other hand, which must replace it, as quickly as possible. Two trials were requested for each hand (ABBA sequence). The average time (seconds) across the 4 trials gave the test score. Participants were grouped (CART algorithm) into 3 statistically distinct (P<0.05) age×score strata, with cutoff 53+ and 73+ years, and tested at baseline and after 1 week. Test–retest reliability was measured both as consistency [intraclass correlation coefficient (ICCs) model 2.1] and as agreement (Bland–Altman plot). From the ICCs, the individual test–retest minimal real difference (in seconds) was computed. The whole MTTrf took less than 4 min to administer. Baseline scores ranged from 40 to 78 s. The ICCs ranged from 0.45 to 0.81 and the minimal real difference ranged from 6.68 to 13.40 s across the age groups. Fifty-nine out of 64 observations (92%) fell within the confidence limits of the Bland–Altman plot. The MTTrf is a reliable and practical test of bimanual coordination. It may be a useful addition to protocols of manual testing in occupational therapy.

Rotationplasty (Borggreve-Van Nes operation) is a rare limb salvage procedure, most often applied to children presenting with sarcoma of the distal femur. In type A1 operation, the distal thigh is removed and the proximal tibia is axially rotated by 180°, remodeled, grafted onto the femoral stump, and then prosthetized. The neurovascular bundle is spared. The rotated ankle then works as a knee. The foot plantar and dorsal flexors act as knee extensors and flexors, respectively. Functional results may be excellent. Cortical neuroplasticity was studied in three men (30–31 years) who were operated on the left lower limb at ages between 7 and 11 years and were fully autonomous with a custom-made prosthesis, as well as in three age–sex matched controls. The scalp stimulation coordinates, matching the patients’ brain MRI spots, were digitized through a ‘neuronavigation’ optoelectronic system, in order to guide the transcranial magnetic stimulation coil, thus ensuring spatial precision during the procedure. Through transcranial magnetic stimulation driven by neuronavigation, the cortical representations of the contralateral soleus and vastus medialis muscles were studied in terms of amplitude of motor evoked potentials (MEPs) and centering and width of the cortical areas from which the potentials could be evoked. Map centering on either hemisphere did not differ substantially across muscles and participants. In the operated patients, MEP amplitudes, the area from which MEPs could be evoked, and their product (volume) were larger for the muscles of the unaffected side compared with both the rotated soleus muscle (average effect size 0.75) and the muscles of healthy controls (average effect size 0.89). In controls, right–left differences showed an effect size of 0.38. In no case did the comparisons reach statistical significance (P>0.25). Nevertheless, the results seem consistent with cortical plasticity reflecting strengthening of the unaffected leg and a combination of cross-education and skill training of the rotated leg.

The study provides estimates of reliability and minimal real difference (MRD) (i.e. the minimal change significantly different from zero, expressed in the original units) of 14 parameters obtained from six motor tasks of standing balance on the EquiTest (dynamic) and the Balance Master (static) force platforms. The different tasks and parameters allowed an assessment of balance in three domains: quiet standing, perturbed standing and multidirectional leaning. Fifteen healthy adults (eight men and seven women; age 22–42 years) were studied at baseline and retested 1 and 3 weeks later. The significance level was set at P-value less than 0.05 and adjusted for multiplicity within sets of tests reflecting the same balance domain (Bonferroni corrections). Repeated analysis of variance modelling revealed a moderate yet significant time trend across the three time points, suggesting a practice effect for the mean of one out of the 14 parameters. Changes across pairs of time points did not reach significance (Tukey’s post-hoc test). Test–retest reliability across the three time points and across pairs of time points was estimated for each parameter using the intraclass correlation coefficients (ICCs) (model 3.1; range 0–1, none to perfect reliability). Across the three time points, the ICCs ranged from 0.21 to 0.85 (>0.60 in nine out of the 14 cases). The MRDs were computed from the ICCs. For all 14 parameters showing a time trend, absolute changes (root mean squares of differences) were minimal. Thus, albeit overestimated for one parameter, the MRDs provide useful thresholds for changes to be interpreted as dependent on therapeutic interventions.

Outcome studies in biomedical research usually focus on testing mean changes across samples of subjects and, in so doing, often obscure changes in individuals. These changes, however, may be very informative in studies in which large or homogeneous samples are unavailable and mechanisms of action are still under scrutiny, as is often the case for trials on new exercise treatments. Single measurements of change may be valid, provided that the reliability of the measurement process (i.e. instrument and procedure combined) was ascertained in a dedicated study in which appropriate statistical models and algorithms were applied. This article summarizes the conceptual steps that allow the calculation of the minimal real difference (MRD, also known as the minimal detectable change), on the basis of the assessment of reliability using an intraclass correlation coefficient. Individuals who show changes beyond the MRD can be reliably considered as changed. A numerical example of an MRD calculation is shown, and the pros and cons of the mean change and the MRD approach are discussed.

The study sought to provide norms for a simple test of visual perception of verticality (subjective visual vertical). The study was designed as a cohort study with a balanced design. The setting was the Rehabilitation Department of a University Hospital. Twenty-two healthy adults, of 23–58 years, 11 men (three left handed) and 11 women (three left handed) were enrolled. A luminous bar was displayed on a PC screen, and rotated in steps of 0.4° until the participant perceived it as vertical. A positive sign was attributed to a clockwise rotation of the bar. The detection threshold was set at the angle corresponding to a perceived vertical, which the participant then selected out of three subsequent alternatives (each at 0.4 or −0.4°). The participant’s position (sitting vs. standing) and the preset angle of presentation (clockwise vs. counterclockwise) were balanced across sex. The constant or deviation error (dE, in degrees) and the absolute errors (aE, in degrees) were computed. An analysis of variance model tested the dependence of dE on sex, posture, age, handedness, and the preset angle. Both dE and aE were unrelated to sex, posture, handedness, and the preset angle, but were dependent on age (junior, 43 years; senior, >43 years). The mean dE was −0.14±0.60 in the junior and 0.42±0.64 in the senior group, respectively. The minimal real difference of the dE was 0.75 and 0.25 in the junior and the senior group, respectively. The overall median aE was 0.4 (5th–95th percentile 0–1.2) in the junior and 0.8 (0.4–1.46) in the senior group, respectively. The whole test took no longer than 15 min in healthy participants, and 25 min in stroke patients. The test was applied to three subacute stroke patients with left hemiparesis, of whom two showed left spatial hemineglect. All three patients presented with a significant clockwise dE. This simple test appears to be valid for the routine assessment of spatial disorders in neurological impairments.

In healthy adults, the step lengthcadence ratio walk ratio (WR) in mm(stepsmin) and normalized for height is known to be constant around 6.5 mm(stepmin). It is a speed-independent index of the overall neuromotor gait control, in as much as it reflects energy expenditure, balance, between-step variability, and attentional demand. The speed independence of the WR in patients with multiple sclerosis (MS), and its capacity to discriminate (a) across patients with MS and controls and (b) among disability levels in MS were tested. The WR was computed in 30 outpatients with MS 20 women, 10 men; Extended Disability Status Scale (potential range: 0–10, observed median 3.5, range 2.5–5.0) walking at free speed (range: 0.43–1.67 ms−1), and in 30 healthy controls (20 women, 10 men) at free and slow speed (range: 0.55–1.67 ms−1). The WR was 6.38±0.66 in controls versus 5.36±0.86 in patients with MS (P<0.000), independent of age, sex, and walking speed. The WR was 5.95±0.69 and 4.90±0.70 in patients with an Extended Disability Status Scale score (P<0.001) below or above the median, respectively, independent of the disease duration (P<0.000). In patients with MS, the WR is a disability-sensitive index of neuromotor control of gait, and thus a promising outcome measure for treatments aimed at improving motor coordination.

ABILHAND is, in its original version, a 46-item, 4-level questionnaire. It measures the difficulty perceived by patients with rheumatoid arthritis as they do various daily manual tasks. ABILHAND was originally built through Rasch analysis. In a later study, it was simplified to a generic 23-item, three-level questionnaire, showing both cross-cultural (Belgium vs. Italy) and cross-impairment (rheumatoid arthritis vs. stroke) validity. Later research returned to the development of impairment-specific versions, with modified item sets and levels. Each version has its own Rasch-derived item difficulty calibrations, which are required to extract the patient's measure from the individual string of responses, through computerized algorithms. All of these hamper the practical application of the scale in rehabilitation units, where patients with diverse conditions may share similar impairments and treatment approaches. In this study through Rasch analysis the ‘generic’ scale was applied to 126 chronic patients with different upper limb impairments, and to 24 healthy controls. It was supported that the generic questionnaire remains valid across a variety of motor impairments. To further facilitate clinical application, a normative cut-off (>79 of 100) is suggested. Rasch-based item calibrations are provided together with a software routine designed to calculate, on individual patients, linear 0–100 measures and error estimates from the raw scores.

Back pain affects about 50% of pregnant women, for whom most of the conventional treatments may be contraindicated. We ran a pilot study to test safety and potential effectiveness of a modified version of autotraction (AT), a treatment combining active pulling efforts with the upper limbs and automatical mobilization of the spine.We treated 16 women during weeks 13-26 of pregnancy (median 20), suffering from back and/or sciatica pain unremitting for 4-20 weeks (median 8). Treatment was given in three 25-minute outpatient periods, one every third day. During the first session heart rate and blood pressure were monitored: these never raised by more than 15 bpm and 20 mmHg, respectively. In three cases surface EMG signals recorded unilaterally from rectus abdominis and lumbar paraspinal muscles were compared during Valsalva manoeuvres and AT sessions, in order to obtain indirect information on changes of intra-abdominal pressure. Trunk muscles appeared to act to a comparable extent during both types of manoeuvre.Self report of overall improvement, peak intensity of pain (0-100 score on 100 mm visual analogue scale [VAS]) and its qualitative severity (0-45 score on the short form of McGill Pain Questionnaire [MPQ]) were taken as outcome indicators. AT manoeuvres were always painless.Thirteen out of 16 patients reported to be improved after treatment, whereas three were unchanged. In the responders, the median VAS and MPQ pain scores dropped, as a median, from 50/100 (range 25-77) to 19/100 (0-80) and from 8.5/40 (2-20) to 3.5/45 (0-14), respectively (p<0.001, Wilcoxon signed-rank test). One month after treatment 15 patients were pain free and one reported her improvement to be stable. The deliveries had been normal and the babies healthy.

Fibromyalgia (FM) is a frequent, complex condition of chronic musculoskeletal pain with no evidence for biological correlates. For this reason, despite many efforts from the medical community, its construct still appears ill defined. Promising candidate biomarkers are critically reviewed. A research agenda is proposed for developing a clearer construct of FM. The ideal theoretical framework is one of overcoming the illness–disease dichotomy and considering reciprocal interactions between biology and behaviour. This approach may foster research in other fields of pain medicine and of medicine in general.

In Europe it is common for outcome measures to be translated for use in other languages. This adaptation may be complicated by culturally specific approaches to certain tasks; for example, bathing. In this context the issue of cross-cultural validity becomes paramount.