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Purpose To date, the relationship between footstrike pattern and performance, as well as with injury incidence in endurance running remains unclear. For these reasons, it is currently not recommended to modify footstrike pattern in an uninjured long-distance runner. The purpose of this study was to analyse whether athletic coaches apply these current scientific recommendations with their endurance runners on the field. Methods A Delphi method study was used to develop an online survey that was administered to French-speaking athletic coaches in Belgium. The survey comprised three sections: 1) coaches’ profile, 2) coaches’ perception of footstrike patterns, 3) practices pertaining to footstrike patterns. Results One hundred and fourteen respondents completed the entire questionnaire. Ninety-six (84%) athletic coaches reported modifying the footstrike pattern of their endurance runners. They reported that they modify their runners’ rearfoot and forefoot strike more often than a midfoot strike (P < 0.0001) to prevent injury (83%) and to improve performance (66%). According to them, midfoot strike is considered as the best landing pattern for endurance performance (47%) and injury prevention (36%) whereas rearfoot strike is considered as the worst (respectively, 50% and 52%). Summary and conclusion This study highlights the disparities between scientific recommendations and athletic coaches’ field practices for modifying footstrike patterns in endurance runners. Contrary to current scientific literature recommendations, a large proportion of coaches modify the natural footstrike pattern of their endurance runners towards a midfoot strike pattern to improve performance and prevent injury.

Characterize the temporal profile of recovery of communication after severe brain injury.Retrospective cohort study.Inpatient rehabilitation hospital.Patients with severe acquired brain injury and no evidence of communication on the Coma Recovery Scale-Revised (CRS-R) (N=175).Time from injury to recovery of intentional communication (IC, inconsistent yes/no responses) and functional communication (FC, consistent and accurate yes/no responses) on the CRS-R Communication subscale.Patients (N=175) were included in the primary observation period of the first 8 weeks of inpatient rehabilitation (median [interquartile range, IQR]: 48 [27-61] years old, 105 men, 28 [21-38] days postinjury, 100 traumatic etiology). Fifty-four patients (31%) did not recover IC or FC. Thirty patients (17%) recovered IC only (median [IQR] days from injury to IC= 40 [34-54]), 72 patients (41%) recovered IC followed by FC (days from injury to FC=50 [42-61]), and 19 patients (11%) recovered FC without first recovering IC (43 [32-63]). The patients who recovered neither IC nor FC within 8 weeks of admission were admitted to rehabilitation later than those who recovered IC and/or FC (P.01). Sixteen patients who did not recover communication within 8 weeks of admission to rehabilitation subsequently recovered FC prior to discharge.In patients with severe brain injury receiving inpatient rehabilitation, discernible yes-no responses emerged approximately 6 weeks postinjury and became reliable 1 week later. Approximately 1 in 3 patients did not demonstrate IC or FC within 8 weeks of admission to rehabilitation, although 33% of these individuals recovered communication prior to discharge. In total, 61% of patients recovered FC prior to discharge from rehabilitation.

Background. The minimally conscious state (MCS) is subcategorized into MCS− and MCS+, depending on the absence or presence, respectively, of high-level behavioral responses such as command-following. Objective. We aim to investigate the functional and structural neuroanatomy underlying the presence of these responses in MCS− and MCS+ patients. Methods. In this cross-sectional retrospective study, chronic MCS patients were diagnosed using repeated Coma Recovery Scale–Revised assessments. Fluorodeoxyglucose-positron emission tomography data were acquired on 57 patients (16 MCS−; 41 MCS+) and magnetic resonance imaging with voxel-based morphometry analysis was performed on 66 patients (17 MCS−; 49 MCS+). Brain glucose metabolism and gray matter integrity were compared between patient groups and control groups. A metabolic functional connectivity analysis testing the hypothesis of preserved language network in MCS+ compared with MCS− was also done. Results. Patients in MCS+ presented higher metabolism mainly in the left middle temporal cortex, known to be important for semantic processing, compared with the MCS− group. The left angular gyrus was also functionally disconnected from the left prefrontal cortex in MCS− compared with MCS+ group. No significant differences were found in gray matter volume between patient groups. Conclusions. The clinical subcategorization of MCS is supported by differences in brain metabolism but not in gray matter structure, suggesting that brain function in the language network is the main support for recovery of command-following, intelligible verbalization and/or intentional communication in the MCS. Better characterizing the neural correlates of residual cognitive abilities of MCS patients contributes to reduce their misdiagnosis and to adapt therapeutic approaches.

Background Spasticity management in severely brain-injured patients with disorders of consciousness (DOC) is a major challenge because it leads to complications and severe pain that can seriously affect quality of life. Objectives We aimed to determine the feasibility of a single session of transcranial direct current stimulations (tDCS) to reduce spasticity in chronic patients with DOC. Methods We enrolled 14 patients in this double-blind, sham-controlled randomized crossover pilot study. Two cathodes were placed over the left and right primary motor cortex and 2 anodes over the left and right prefrontal cortex. Hypertonia of the upper limbs and level of consciousness were assessed by the Modified Ashworth Scale (MAS) and the Coma Recovery Scale-Revised (CRS-R). Resting state electroencephalography was also performed. Results At the group level, spasticity was reduced in only finger flexors. Four responders (29%) showed reduced hypertonicity in at least 2 joints after active but not sham stimulation. We found no behavioural changes by the CRS-R total score. At the group level, connectivity values in beta2 were higher with active versus sham stimulation. Relative power in the theta band and connectivity in the beta band were higher for responders than non-responders after the active stimulation. Conclusion This pilot study highlights the potential benefit of using tDCS for reducing upper-limb hypertonia in patients with chronic DOC. Large-sample clinical trials are needed to optimize and validate the technique.

Primary Objective: Patients with disorders of consciousness (DOC) face a lack of treatments and risk of misdiagnosis, potentially due to motor impairment. Transcranial direct current stimulation (tDCS) showed promising results over the prefrontal cortex in DOC and over the primary motor cortex (M1) in stroke. Tis pilot study aimed at evaluating the behavioral effects of M1 tDCS in patients with DOC. Research Design: In this randomized double-blind sham-controlled crossover trial, we included 10 patients (49 ± 22 years, 7 ± 13 months since injury, 4 unresponsive wakefulness syndrome, 6 minimally conscious state, 5 traumatic etiologies). Methods and Procedures: One session of tDCS (2 mA for 20 min) and one session of sham tDCS were applied over M1 in a randomized order with a washout period of minimum 24 h and behavioral effects were assessed using the CRS-R. At the group level, no treatment effect was identified on the total score (p= .55) and on the motor subscale (p= .75). Two patients responded to tDCS by showing a new sign of consciousness (visual pursuit and object localization). Conclusions: One session of M1 tDCS failed to improve behavioral responsiveness in patients with DOC. Other application strategies should be tested.

Opioid misuse leading to dependence is a major health issue. Recent studies explored valid alternatives to treat pain in postsurgical settings. This systematic review aims to discuss the role of transcranial direct current stimulation (tDCS) in preventing and treating postoperative pain and opioid dependence. PubMed and Embase databases were screened, considering studies testing tDCS effects on pain and opioid consumption in surgical settings and opioid addiction. Eight studies met our inclusion criteria. Results showed a reduction of postoperative pain, opioid consumption and cue-induced craving following cortical stimulation. Despite the limited number of studies, this review shows preliminary encouraging evidence regarding the analgesic role of tDCS. However, future studies are needed to further investigate the application of tDCS in postsurgical settings.

Background and objectivesPost-concussion syndrome (PCS) consists of neurologic and psychological complaints persisting after a mild traumatic brain injury (mTBI). It affects up to 50% of mTBI patients, causes long-term disability and reduces quality of life. The aim of this scoping review was to examine possible uses of different neuroimaging modalities in PCS.MethodsArticles from Pubmed database were screened to extract studies that investigated the relationship between any neuroimaging features and symptoms of PCS. Descriptive statistics were applied to report results.Results88 out of 939 papers were included in the final review. 12 examined conventional MRI (42% specificity), 27 diffusion weighted imaging (56% specificity), 25 functional MRI (84% specificity), 10 electro(magneto)encephalography (80% specificity), and 14 examined other techniques (71% specificity).ConclusionMRI was the most widely used technique, while functional techniques seem to be the most sensitive tools to evaluate PCS. Common patterns associated with symptoms of PCS were a decreased anticorrelation between the default mode network and the task positive network and reduced brain activity in specific areas (most often prefrontal cortex).SignificanceOur findings highlight the importance to use functional approaches which demonstrated a functional alternation in brain connectivity and activity in most studies assessing PCS.Highlightspost-concussion syndrome causes long term problems for up to 50% of patients after concussion.Among different neuroimaging techniques, fMRI and EEG show to be the most sensitive tools for PCS assessment.Heterogeneity of axonal injury, symptoms, and populations limits having a specific prognostic criteria for the PCS patients.

Background Recommendations are available for assessment criteria for safe return-to-play (RTP) after a lateral ankle sprain. However, their current use among physicians is unknown. Methods French-speaking physicians in Belgium, France and Switzerland were asked to complete an online survey and report their clinical assessment of selected RTP criteria. Results The respondent sample (n = 109) included physicians with and without Sports Medicine education, varied level of experience and proportion of athletes in their practice population. Pain was the most selected criterion for safe RTP (90% of physicians), followed by ability to engage in functional tasks (82%), functional instability (73%), range of motion (61%), proprioception (47%), mechanical instability (39%), strength (38%) and swelling (31%). A low proportion of physicians use quantitative measures to assess these criteria (between 4% and 53%). Conclusions A large proportion of physicians consider the recommended criteria for RTP decisions. However, physicians do not frequently use quantitative measures.

The right matching of patients to an intended treatment is routinely performed by doctor and physicians in healthcare. Improving doctor’s ability to choose the right treatment can greatly speed up patient’s recovery. In a clinical study on Disorders of Consciousness patients in Minimal Consciousness State (MCS) have gone through transcranial Electrical Stimulation (tES) therapy to increase consciousness level. We have carried out the study of MCS patient’s response to tES therapy using as input the EEG data collected before the intervention. Different Machine Learning approaches have been applied to the Relative Band Power features extracted from the EEG. We aimed to predict tES treatment outcome from this EEG data of 17 patients, where 4 of the patients sustainably showed further signs of consciousness after treatment. We have been able to correctly classify with 95% accuracy the response of patients to tES therapy. In this paper we present the methodology as well as a comparative evaluation of the different employed classification approaches. Hereby we demonstrate the feasibility of implementing a novel informed Decision Support System (DSS) based on this methodological approach for the correct prediction of patients’ response to tES therapy in MCS.

Transcranial direct current stimulation (tDCS) applied over the prefrontal cortex has been shown to improve behavioral responsiveness in patients with disorders of consciousness following severe brain injury, especially those in minimally conscious state (MCS). However, one potential barrier of clinical response to tDCS is the timing of stimulation with regard to the fluctuations of vigilance that characterize this population. Indeed, a previous study showed that the vigilance of MCS patients has periodic average cycles of 70 min (range 57−80 min), potentially preventing them to be in an optimal neural state to benefit from tDCS when applied randomly. To tackle this issue, we propose a new protocol to optimize the application of tDCS by selectively stimulating at high and low vigilance states. Electroencephalography (EEG) real-time spectral entropy will be used as a marker of vigilance and to trigger tDCS, in a closed-loop fashion. We will conduct a randomized controlled crossover clinical trial on 16 patients in prolonged MCS who will undergo three EEG-tDCS sessions 5 days apart (1. tDCS applied at high vigilance; 2. tDCS applied at low vigilance; 3. tDCS applied at a random moment). Behavioral effects will be assessed using the Coma Recovery Scale-Revised at baseline and right after the stimulations. EEG will be recorded throughout the session and for 30 min after the end of the stimulation. This unique and novel approach will provide patients’ tailored treatment options, currently lacking in the field of disorders of consciousness.

The Coma Recovery Scale-Revised (CRS-R) is the gold standard to assess severely brain-injured patients with prolonged disorders of consciousness (DoC). However, the amount of time needed to complete this examination may limit its use in clinical settings.We aimed to validate a new faster tool to assess consciousness in individuals with DoC.This prospective validation study introduces the Simplified Evaluation of CONsciousness Disorders (SECONDs), a tool composed of 8 items: arousal, localization to pain, visual fixation, visual pursuit, oriented behaviors, command-following, and communication (both intentional and functional). A total of 57 individuals with DoC were assessed on 2 consecutive days by 3 blinded examiners: one CRS-R and one SECONDs were performed on 1 day, whereas 2 SECONDs were performed on the other day. A Mann-Whitney U test was used to compare the duration of administration of the SECONDs versus the CRS-R, and weighted Fleiss' kappa coefficients were used to assess inter-/intra-rater reliability as well as concurrent validity.In the 57 participants, the SECONDs was about 2.5 times faster to administer than the CRS-R. The comparison of the CRS-R versus the SECONDs on the same day or the best of the 3 SECONDs led to "substantial" or "almost perfect" agreement (kappa coefficients ranging from 0.78 to 0.85). Intra-/inter-rater reliability also showed almost perfect agreement (kappa coefficients from 0.85 to 0.91 and 0.82 to 0.85, respectively).The SECONDs appears to be a fast, reliable and easy-to-use scale to diagnose DoC and may be a good alternative to other scales in clinical settings where time constraints preclude a more thorough assessment.

Background Although emergence from the minimally conscious state (eMCS) is associated with symptoms including disorientation, memory and attention impairment, restlessness, and significant functional disability, the neurobehavioral profile of eMCS has not been empirically characterized. Objective Determine degree of cognitive impairment, presence of clinical symptoms and functional disability at time eMCS in patients with traumatic and non-traumatic brain injury (TBI, nTBI). Methods Retrospective observational study of 169 adults (median [interquartile range] age: 51 [29, 62] years; male: 116; TBI: 103) who emerged from MCS based on the Coma Recovery Scale-Revised while in an inpatient Disorders of Consciousness program. Outcome measures include the Confusion Assessment Protocol (CAP) and Disability Rating Scale (DRS). Results CAP administration was attempted in 54 subjects. Twenty-eight subjects had valid scores on all CAP items, with a median [interquartile range] of 4 [3-5] symptoms of confusion. Scores in 93% of this subsample were consistent with an acute confusional state. The most common symptoms were cognitive impairment (98% of subjects), disorientation (93%), and agitation (69%). The median DRS score upon emergence from MCS was 14.5 [13, 16], indicating severe disability (n = 140). Conclusions eMCS is associated with an acute confusional state and severe disability. This finding may inform the lower boundary of confusion as well as approach to treatment and caregiver education.

Auditory localization (i.e. turning the head and/or the eyes towards an auditory stimulus) is often part of the clinical evaluation of patients recovering from coma. The objective of this study is to determine whether auditory localization could be considered as a new sign of minimally conscious state, using a multimodal approach. The presence of auditory localization and the clinical outcome at 2 years of follow-up were evaluated in 186 patients with severe brain injury, including 64 with unresponsive wakefulness syndrome, 28 in minimally conscious state minus, 71 in minimally conscious state plus and 23 who emerged from the minimally conscious state. Brain metabolism, functional connectivity and graph theory measures were investigated by means of 18F-fluorodeoxyglucose positron emission tomography, functional MRI and high-density electroencephalography in two subgroups of unresponsive patients, with and without auditory localization. These two subgroups were also compared to a subgroup of patients in minimally conscious state minus. Auditory localization was observed in 13% of unresponsive patients, 46% of patients in minimally conscious state minus, 62% of patients in minimally conscious state plus and 78% of patients who emerged from the minimally conscious state. The probability to observe an auditory localization increased along with the level of consciousness, and the presence of auditory localization could predict the level of consciousness. Patients with auditory localization had higher survival rates (at 2-year follow-up) than those without localization. Differences in brain function were found between unresponsive patients with and without auditory localization. Higher connectivity in unresponsive patients with auditory localization was measured between the fronto-parietal network and secondary visual areas, and in the alpha band electroencephalography network. Moreover, patients in minimally conscious state minus significantly differed from unresponsive patients without auditory localization in terms of brain metabolism and alpha network centrality, whereas no difference was found with unresponsive patients who presented auditory localization. Our multimodal findings suggest differences in brain function between unresponsive patients with and without auditory localization, which support our hypothesis that auditory localization should be considered as a new sign of minimally conscious state. Unresponsive patients showing auditory localization should therefore no longer be considered unresponsive but minimally conscious. This would have crucial consequences on these patients’ lives as it would directly impact the therapeutic orientation or end-of-life decisions usually taken based on the diagnosis., This study provides evidence that auditory localization should be considered as a new sign of minimally conscious state. The prevalence of auditory localization increases with the level of consciousness, and patients with unresponsive wakefulness syndrome and auditory localization have higher brain functioning and better outcome than unresponsive patients who do not show auditory localization., Graphical Abstract Graphical Abstract

Running biomechanics and its evolution that occurs over intensive trials are widely studied, but few studies have focused on the reproducibility of stride evolution in these runs. The purpose of this investigation was to assess the reproducibility of changes in eight biomechanical variables during exhaustive runs, using three-dimensional analysis. Ten male athletes (age: 23 ± 4 years; maximal oxygen uptake: 57.5 ± 4.4 ml02·min-1·kg-1; maximal aerobic speed: 19.3 ± 0.8 km·h-1) performed a maximal treadmill test. Between 3 to 10 days later, they started a series of three time-to-exhaustion trials at 90% of the individual maximal aerobic speed, seven days apart. During these trials eight biomechanical variables were recorded over a 20-s period every 4 min until exhaustion. The evolution of a variable over a trial was represented as the slope of the linear regression of these variables over time. Reproducibility was assessed with intraclass correlation coefficients and variability was quantified as standard error of measurement. Changes in five variables (swing duration, stride frequency, step length, centre of gravity vertical and lateral amplitude) showed moderate to good reproducibility (0.48 ≤ ICC ≤ 0.72), while changes in stance duration, reactivity and foot orientation showed poor reproducibility (-0.71 ≤ ICC ≤ 0.04). Fatigue-induced changes in stride biomechanics do not follow a reproducible course across the board; however, several variables do show satisfactory stability: swing duration, stride frequency, step length and centre of gravity shift.

Background Patients with chronic disorders of consciousness face a significant lack of treatment options. Objective We aimed at investigating the feasibility and the behavioral effects of home-based transcranial direct current stimulation (tDCS), applied by relatives or caregivers, in chronic patients in minimally conscious state (MCS). Methods Each participant received, in a randomized order, 20 sessions of active and 20 sessions of sham tDCS applied over the prefrontal cortex for 4 weeks; separated by 8 weeks of washout. Level of consciousness was assessed using the Coma Recovery Scale-Revised before the first stimulation (baseline), at the end of the 20 tDCS sessions (direct effects) and 8 weeks after the end of each stimulation period (long-term effects). Reported adverse events and data relative to the adherence (i.e., amount of sessions effectively received) were collected as well. Results Twenty-seven patients completed the study and 22 patients received at least 80% of the stimulation sessions. All patients tolerated tDCS well, no severe adverse events were noticed after real stimulation and the overall adherence (i.e., total duration of stimulation) was good. A moderate effect size (0.47 and 0.53, for modified intention to treat and per protocol analysis, respectively) was observed at the end of the 4 weeks of tDCS in favor of the active treatment. Conclusions We demonstrated that home-based tDCS can be used adequately outside a research facility or hospital by patients' relatives or caregivers. In addition, 4 weeks of tDCS moderately improved the recovery of signs of consciousness in chronic MCS patients.

Resume Les progres de la medecine et des soins intensifs ont conduit a une augmentation du nombre de patients survivant a une lesion cerebrale severe. Bien que certains patients recuperent rapidement, d’autres demeurent dans un etat de conscience alteree (ECA). Ces derniers peuvent evoluer du coma vers un etat vegetatif/syndrome d’eveil non repondant (EV/ENR), puis vers un etat de conscience minimale (ECM). Dans cette revue, nous proposons tout d’abord de decrire les differentes methodes, comportementales et de neuro-imagerie, utilisees dans le diagnostic des patients en ECA. Nous decrirons ensuite les facteurs susceptibles d’influencer le pronostic et la recuperation de ces patients, ainsi que les traitements et la prise en charge qui peuvent etre proposes dans le but d’ameliorer leur etat de conscience. Enfin, nous cloturerons cette revue avec une reflexion sur les considerations ethiques et les questions de fin de vie.

Transcranial direct current stimulation (tDCS) applied over the dorsolateral prefrontal cortex (DLPFC) has induced promising behavioral improvement, both in acute and chronic minimally conscious state (MCS - [ 1 ]) patients [ 2 , 3 ]. We previously defined a tDCS-responder as a patient who demonstrates a new sign of consciousness following stimulation, which was neither present beforehand, nor before or after the sham stimulation [ 2 ]. In a study investigating the metabolic and structural differences between DLPFC-tDCS-responders and non-responders, we have identified that tDCS-responders presented a preservation of brain metabolism and grey matter integrity under the stimulated area, but also in the thalamus and the precuneus, areas involved in consciousness recovery [ 4 ]. Even if these results provided relevant insights into potential biomarkers of responsiveness, the access to such neuroimaging techniques (positron emission tomography - PET - and magnetic resonance imaging - MRI) remains limited. Recently, it has been demonstrated that high-density electroencephalography (hdEEG) network metrics in the alpha band correlates with the level of consciousness [ 5 ]. In addition, a strong correlation between brain metabolism and hdEEG network metrics was reported, making this bedside assessment a robust way to evaluate patients’ brain function.

The International Olympic Committee (IOC) has supported athletes’ health protection1 by funding research centres dedicated to prevention and treatment of sports-related injuries and illnesses.2 After establishing four centres in 2009,2 the IOC research centres network expanded to 9 institutions in 20143 and the 2019 round recognised 11 centres.4 Here we introduce ReFORM—an international French-speaking network of five institutions.5 ReFORM stands for Reseau Francophone Olympique de la Recherche en Medecine du Sport , and we embrace the IOC’s vision to foster international collaborations.5 Five intercontinental countries created this French-speaking Olympic network for Research in Sports Medicine, with support from their national Olympic Committees (table 1): View this table: Table 1 ReFORM members and respective expertise Together, they serve hundreds of elite athletes and are at the forefront of high-level sports medicine and research in their respective countries. ReFORM is …

The present report shows the case of a patient who came with the diagnosis of UWS and who was then diagnosed as being in MCS minus following repeated standardized behavioral assessments. Neuroimaging data further suggested that the patient presented preservation of brain activity closer to what is usually observed in healthy subjects.The presence of a minimal sign of consciousness (i.e., localization to noxious stimuli) was only observed once out of seven behavioral assessments, and active tasks using fMRI and EEG suggested the presence of covert command-following. During this week of assessments, overt response to command was never observed at the patient's bedside. This behavior was solely seen following the experimental procedure of tDCS, after which the patient could reproducibly answer a simple behavioral command. Based on these findings, we hypothesize that tDCS may facilitate motor execution of the command when cognitive functions are preserved in patients with cognitive-motor dissociation.

Near-death experiences (NDEs) are usually associated with positive affect, however, a small proportion are considered distressing. We aimed to look into the proportion of distressing NDEs in a sample of NDE narratives, categorise distressing narratives according to Greyson and Bush's classification (inverse, void or hellish), and compare distressing and "classical" NDEs. Participants wrote down their experience, completed the Memory Characteristics Questionnaire (assessing the phenomenology of memories) and the Greyson scale (characterising content of NDEs). The proportion of suicidal attempts, content and intensity of distressing and classical NDEs were compared using frequentist and Bayesian statistics. Distressing NDEs represent 14% of our sample (

Objective To investigate the influence of the presence of a tracheostomy tube to assess pain with the Nociception Coma Scale-Revised (NCS-R) in patients with disorders of consciousness (DOC). Design A cohort study in which patients were evaluated at a single time point. Setting Patients were evaluated in a tertiary care hospital. Participants Patients (N=125) (unresponsive wakefulness syndrome [UWS]: 46 patients, minimally conscious state [MCS]: 74 patients, emerging from MCS [eMCS]: 5 patients, mean age: 46±16y, time since injury: 817±1280d) in a convenience sample were evaluated with the NCS-R after noxious stimulation. Interventions Not applicable. Main Outcome Measures We compared the NCS-R scores of patients with and without tracheostomy with a Mann-Whitney U test. A secondary outcome was to evaluate the influence of the presence of a tracheostomy on the previously described cutoff score of 2. Results The presence of a tracheostomy was associated with lower verbal subscores (P=.002) as well as total scores (P=.039). The cutoff score of 2 remained valid for the group of patients with tracheostomy with a high sensitivity (71.43%) and specificity (89.29%), as well as when we excluded the verbal subscore of the NCS-R (sensitivity=83.2% and specificity=92.4%). Conclusion Our study confirms the validity of the NCS-R in DOC patients with a tracheostomy. However, the presence of a nonspeaking tracheostomy should be clearly mentioned when applying the NCS-R, because it significantly lowers the verbal subscore.