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Chronic disorders of consciousness (DOC) develop after severe traumatic and non-traumatic brain damage and are characterized by the restoration of wakefulness in a patient after a coma without the recovery of consciousness. To optimize the diagnosis and treatment of patients with chronic DOC, a Russian working group on the problems of chronic DOC was organized, which included specialists in various areas, primarily anesthesiologists, critical care physicians and neurologists. While discussing the terminology of chronic DOC, the group identified that currently there is no definition for the state that falls into the period from the recovery of wakefulness and until 28 days after the brain damage when vegetative state/unresponsive wakefulness syndrome (VS/UWS) or minimally conscious state (MCS) may be diagnosed. In the intensive care unit (ICU) setting, there is often no consultant to provide critical care physicians with the correct diagnosis of the latter clinical syndromes, and neurophysiological tests are not feasible either. Therefore, there is a need to create a set of simple, understandable and easily reproducible strategies for managing this category of patients in the ICU. Thus, the working group proposed the term “prolonged disorders of consciousness” to be used for the patients with the signs of VS/UWS or MCS syndromes during their stay in the ICU until 28 days after initial brain damage and/or until the correct differential diagnosis of a type of chronic DOC is made. With the introduction of prolonged disorders of consciousness definition, the regular ICU staff will better understand how to provide an optimal set of supportive therapy and early rehabilitation activities in the lack of specific diagnostics techniques and dedicated specialists. Allocation of this category of patients allows us to create an algorithm for their better diagnosis and management and ensures consistent and effective interdisciplinary care at various levels. On the one hand, this approach will help us allow to free up ICU beds that are in high demand, while on the other, it will maximize the opportunity to realize the rehabilitation potential of DOC patients due to timely transfer to specialized centers. Conclusion. If the term “prolonged disorder of consciousness” is accepted by professional communities of specialists (critical care physicians, neurologists, neurosurgeons, etc.), it will be used in guidelines for the management of DOC patients.

The link between rehabilitation, functioning, and the International Classification of Functioning, Disability and Health (ICF) is nothing new. This is reflected not only in the numerous peer-reviewed papers on applying the ICF in rehabilitation but also in the indispensable role of functioning and the ICF in developing the conceptual descriptions of rehabilitation as a health strategy and of physical and rehabilitation medicine (PRM) as a medical specialty. Since the World Health Organization's (WHO's) Rehabilitation 2030 Call for Action in 2017, functioning and the ICF have gained an even more prominent role in rehabilitation. This paper provides an overview of the current efforts toward strengthening rehabilitation in health systems throughout the world by applying information on functioning in rehabilitation practice, Clinical Quality Management for Rehabilitation (CQM-R), and policy, using the ICF as a reference framework. These initiatives are led by rehabilitation and rehabilitation-related societies and academic institutions in various countries and regions of the world. This paper briefly describes them and puts them into the context of WHO's call for strengthening rehabilitation. It concludes by highlighting lessons learned from these initiatives, introducing Cochrane Rehabilitation as a conduit for promoting the use of ICF in evidence gathering and calling for collaboration from new partners who have not yet been active in promoting ICF implementation. This call for collaboration from the International Society of PRM strives to diversify the representation of contributors and experiences in implementing the ICF in rehabilitation practice, CQM-R, and policy.

Introduction In light of global mandates and in recognition of the value of data collection and reporting based on the International Classification of Functioning, Disability and Health (ICF), the UEMS PRM Section and Board established an action plan to implement the ICF in Physical and Rehabilitation Medicine, rehabilitation and health care at large. This includes, among other steps, the development of a framework of rehabilitation service types for Europe (European Framework) and corresponding clinical assessment schedules (CLASs) for each service type. A CLAS encompasses the recommendation for what aspects of functioning to document, for whom and when, and the data collection tools to use. The objective of this paper is to report on the development of the CLASs for the European Framework developed in Stockholm in 2018, with focus on what to document. Methods Involving UEMS PRM delegates across European regions, a multistage Delphi process comprised the development of an initial proposal of the CLASs (i.e. default and optional ICF Sets to document), two feedback (pre- and post-Stockholm) rounds via e-mail, and a deliberation by the UEMS PRM during its March 2019 meeting in Budapest. In both Delphi rounds, participants were asked whether the initially proposed default and optional ICF Sets represent what is currently documented at an exemplary service provider in the country or in consideration of their own expertise. The European Framework was revised between the two Delphi rounds, requiring a revision of the CLAS proposal accordingly. Participants were additionally asked whether they support the suggested ICF Sets as the specification of the CLAS. Level of support (strong = ≥80%, moderate = between 80-60%, weak =≤59%) was calculated as the percentage of countries supporting the suggested CLAS over the number of responding countries. The results of the post-Stockholm round were presented for discussion, revision and approval at the Budapest meeting. Results Pre-Stockholm Delphi round: due to low response rate only a summary of comments made by the responding countries was provided as reference information for the post-Stockholm round. Post-Stockholm Delphi round: results indicated moderate to strong support for the proposed CLASs. Deliberation Budapest Meeting - Motions for specific revisions to the CLASs based on the results of the Post-Stockholm round were predominately accepted. With additional minor revisions, the UEMS PRM General Assembly approved a version of the CLASs for the European Framework. Conclusions To kick-off the implementation of these CLASs, UEMS PRM plans demonstration projects in at least one rehabilitation facility in each delegate country that exemplifies the rehabilitation service types of the European Framework which exist in the respective country. The demonstration projects are intended to orient service providers and clinicians to the CLASs and illustrate how the CLASs can be implemented.

Background Effectiveness in health services is achieved if desired clinical outcomes are reached. In rehabilitation the relevant clinical outcome is functioning, with the International Classification of Functioning, Disability and Health (ICF) as the reference system for the standardized reporting of functioning outcomes. To foster the implementation of the ICF in clinical quality management (CQM) across the rehabilitation services continuum, the UEMS-PRM Section and Board approved an ICF implementation action plan that includes the identification of types of currently provided rehabilitation services in Europe. The objective of this paper is to report on the development of a European framework of rehabilitation service types that can provide the foundation for the standardized reporting of functioning outcomes and CQM programs. Methods A multistage consensus process involving delegates (participants) from the UEMS-PRM Section and Board as well as external experts across European regions comprised the development of an initial framework by an editorial group, two feedback rounds via e-mail and a deliberation by the UEMS-PRM Section and Board in its September 2018 meeting in Stockholm (Sweden). In the first feedback round, participants were asked whether: 1) the initial framework of service types exists in their respective country: 2) the description represents the service type: and 3) an existing service type was missing. Based on the first-round results, the framework proposal was modified by the editorial group. In the second feedback round, participants were asked to confirm or comment on each of the service types in the revised framework. Based on the second-round results, the framework proposal was again modified and presented for discussion, revision and approval at the Stockholm meeting. Results In the first feedback round, eight rehabilitation services were added to the framework proposal and two service types that were deemed "missing" were not included. In the second round, all seven initially proposed and six of the added service types were reconfirmed, while two of the added service types were not supported. Based on deliberations at the Stockholm meeting, some modifications were made to the proposed framework, and the UEMS-PRM general assembly approved a European Framework of Rehabilitation Service Types that comprises of: Rehabilitation in acute care, General post-acute rehabilitation, Specialized post-acute rehabilitation, General outpatient rehabilitation, Specialized outpatient rehabilitation, General day rehabilitation, Specialized day rehabilitation, Vocational rehabilitation, Rehabilitation in the community, Rehabilitation services at home (incl. nursing home), Rehabilitation for specific groups of persons with disability, Rehabilitation in social assistance, Specialized lifelong follow-up rehabilitation, and Rehabilitation in medical health resorts. Conclusions The European Framework of Rehabilitation Services Types presented in this paper will be continuously updated according to new and emerging service types. Next steps of the UEMS-PRM effort to implement the ICF in rehabilitation include the specification of clinical assessment schedules for each service type and case studies illustrating service provision across the spectrum of rehabilitation service types. The European Framework will enable the accountable reporting of functioning outcomes at the national level and the continuous improvement of rehabilitation service provision in CQM.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper addresses the structure, organization and activities of PRM bodies in Europe. There are four main bodies, the Section of Physical and Rehabilitation Medicine of the European Union of Medical Specialists (UEMS) very close to the European Union and is committed to define the professional competencies of PRM, the quality management and accreditation and with the Board the educational matters. The European College of PRM is served by the UEMS PRM Board and its main activities are analyzed below in the description of the Board of the UEMS PRM Section. The European Society of Physical and Rehabilitation Medicine (ESPRM) mainly dedicated to promoting research in rehabilitation and create a network of knowledge of PRM across the Europe. The European Academy of Rehabilitation Medicine mainly dedicated to defining the ethical issues in rehabilitation and finding strategies for better educational approaches in rehabilitation. There are 2 further bodies (the regional Fora) aimed to create bridges across the Mediterranean area (Mediterranean Forum of PRM) and across the northern Europe including the eastern countries such as Russia, Belarus and Ukraine (Baltic and North Sea Forum of PRM). To support the knowledge, we have in Europe 7 main journals dedicated to Rehabilitation with a growing impact factor. Last but not least the PRM bodies have an important role across the world with a connection with the International Society of PRM and WHO. The UEMS Section approved motion of international collaboration. In conclusion, PRM activity in Europe is not limited to the official border but in the network included eastern countries and Mediterranean area. The European extended network is strongly connected with the international PRM bodies, first of all the International Society of PRM.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the fundamentals of PRM from a physiological perspective, looking at the human mechanisms both physical and behavioral which are at the base of PRM physicians’ work. After a discussion on the development and evolution of PRM that leads to its unique and specific approach, the mechanisms considered include: - repairing processes (and potential of recovery evaluation): repairing processes are mainly related to the quantity and natural history of diseases and impairments, while potential of recovery is also linked to the individual and environmental factors ; PRM physicians work on impairments to favor healing or recovery, and propose rehabilitation if there is a potential of recovery: this is related to the prognostic role of PRM physicians ; - learning processes: PRM is the specialty of teaching new physical ways and behavioral approaches to make patients participate at best through improvement of impairments and modification of activities ; in this perspective, during repair and rehabilitation processes, PRM physicians and the rehabilitation team are teachers of new motor and behavioral strategies ; - compensatory processes (adaptation/habilitation/rehabilitation): PRM physicians teach patients how to adapt to the new (acquired) health condition using compensatory mechanisms based on other body structures/functions, behavioral changes and/or assistive devices (or technical aids) (prosthesis and orthosis) ; during growth PRM physicians aim at allowing a complete (and compensatory) development of the intact function, not to be impaired by the original disease ; compensatory processes are related to activities ; - management skills: PRM physicians are managers of people and resources ; they manage patients and their caregivers, to teach and allow them to reach the best possible participation, also focusing on maintenance ; they lead the team, with the aim to make it function at best for the sake of the patient ; finally, they manage resource allocation for the functioning of patients and team ; - communication skills: PRM physicians need to develop very good communication skills, so to teach, inform and educate patients and their caregivers: this will allow the proper behavioural changes and also the correct physical compensations.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with a global overview of the role of PRM in healthcare systems in Europe. Several documents and reports by WHO and the UN call for the worldwide strengthening of rehabilitation as a key health strategy of the 21st century. Therefore, further implementation of PRM in healthcare systems is crucial. Many aspects need to be considered when implementing PRM in a health system. Since PRM should be provided along the whole continuum of care, a specific phase model has been developed. Those phases depend on patients’ functional needs as well as on temporal aspects of a health condition: it can be congenital or acquired, and the disorder can have an acute onset or a progressive or degenerative course. The following phases are described in the paper: habilitation, prehabilitation, PRM in acute settings, in post-acute and in long-term settings. Regular triage and reassessment to assign the patient to the appropriate level and setting of rehabilitation care is mandatory. Therefore, rehabilitation services should be stratified and organized in networks, in order to allow for the best possible care adapted to the individual’s needs and goals, over the continuum of care. Providing correct PRM services requires good planning of service delivery, capacity building and resource allocation. The needed resources are human (with complex multi-professional teams), technical (diagnostic and therapeutic equipment, equipment for performing complementary diagnostic means, rehabilitation technology and assistive devices), and financial. Decisions on the allocation of the usually limited resources require a reasoned process and clear and fair criteria. Principles of clinical governance must be respected, and appropriate competencies are required. Disease prevention (primary, secondary and tertiary), health maintenance and support in chronic conditions as well as global health promotion are gaining growing importance in PRM. They include encouraging physical activity and promoting healthy behavior aiming at the maintenance of maximum function and avoiding complications in disabling or progressive conditions. This is discussed in the paper together with some ethical reflections on the choices PRM physicians continuously have to make during service delivery.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the history of the PRM medical specialty. The specialty evolved in different European countries, and sometimes also into the single countries, from different medical streams that finally joined. These included among others: balneology, gymnastic, use of physical agents (water, heat, cold, massage, joint manipulations, physical exercise, etc.). Another important role has been played by the increasing number of people experiencing or likely to experience disability due to improvement of medicine and consequent survivals from wars, accidents and/or big infective epidemics (like polio) ; these evolutions happened in strict relationship with other specialties like cardiology, neurology, orthopaedics, pneumology, rheumatology, traumatology, creating a knowledge transversal to all of them. Consequently, the PRM specialty has been gradually introduced in the different European countries, however with no uniformity. Subsequently, European Organizations were created for its diffusion and coordination at the level of medical competences and patient care as well as medical teaching and research: The European Federation of Physical Medicine and Rehabilitation - later European Society (ESPRM), The Académie Médicale Européenne de Médecine de Réadaptation (EARME), The PRM Section of the European Union of Medical Specialists and the European College of PRM (served by the UEMS-PRM Board), were created and work today regarding these general aims. Nowadays a uniform definition of the specialty exists in Europe, which is concordant with the internationally accepted description of PRM (based on the ICF-model). Moreover, research in PRM has been mainly improved during recent decades in Europe due to some external as well as internal scientific influences, thus increasing its scientific importance, together with a parallel increase in rehabilitation journals, many of them indexed and some with impact factor (Cr, EJPRM, JRM, among others), as well as a parallel increase in scientific congresses and courses. Last but not least, the recent creation of the Cochrane Rehabilitation field will also give a great boost to this primary medical specialty, as well as the discovery on new physical agents and technologies that diminish activity limitation and participation restriction of disable persons.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with Research, the future of PRM. PRM students and specialists are mainly involved in biomedical research, investigating the biological processes, the causes of diseases, their medical diagnosis, the evaluation of their consequences on functioning, disability and health and the effects of health interventions at an individual and a societal level. Most of the current PRM research, often interdisciplinary, originates from applied research which, using existing knowledge, is directed towards specific goals. Translational medical research, research and development, implementation research and clinical impact research are in this field. PRM physicians, mainly master or PhD students, are nowadays increasing their participation in basic research and in pre- clinical trials. PRM physicians are involved in primary research, which is an original first hand research, but also in secondary research, which is the analysis and interpretation of primary research publications in a field, with a specific methodology. Secondary research remains an important activity of the UEMS PRM section and it will be the field of the new created Cochrane Rehabilitation. Secondary research with interest for persons with disabilities, will be developed world wide on the basis of evidence based medicine, with the participation of PRM physicians and of all other health and social professionals involved in rehabilitation. The development of research activities with interest for PRM in Europe is a challenge for the future, which has to be faced now. The European PRM schools, the European master and PhD program with their supporting research and clinical facilities, the European PRM organizations with their websites, the PRM scientific journals and European congresses are a strong basis to develop research activities, together with the development of Cochrane Rehabilitation field and of our cooperation with European high level research facilities, European and international scientific societies in different fields. PRM will be a leader in this field of research.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM), this paper deals with the education of PRM physicians in Europe. To acquire the wide field of competence needed, specialists in Physical and Rehabilitation Medicine have to undergo a well organised and appropriately structured training of adequate duration. In fact they are required to develop not only medical knowledge, but also competence in patient care, specific procedural skills, and attitudes towards interpersonal relationship and communication, profound understanding of the main principles of medical ethics and public health, ability to apply policies of care and prevention for disabled people, capacity to master strategies for reintegration of disabled people into society, apply principles of quality assurance and promote a practice-based continuous professional development. This paper provides updated detailed information about the education and training of specialists, delivers recommendations concerning the standards required at a European level, in agreement with the UEMS rules of creating a Common Training Framework, that consists of a common set of knowledge, skills and competencies for postgraduate training. The role of the European PRM Board is highlighted as a body aimed at ensuring the highest standards of medical training and health care across Europe and the harmonization of PRM physicians’ qualifications. To this scope, the theoretical knowledge necessary for the practice of PRM specialty and the core competencies (training outcomes) to be achieved at the end of training have been established and the postgraduate PRM core curriculum has been added. Undergraduate training of medical students is also focused, being considered a mandatory element for the growth of both PRM specialty and the medical community as a whole, mainly in front of the future challenges of the ageing population and the increase of disability in our continent. Finally, the problems of continuing professional development and medical education are faced in a PRM European perspective, and the role of the European Accreditation Council of Continuous Medical Education (EACCME) of UEMS is outlined.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper describes the background to the context of PRM services and comprises the following: - Epidemiological Aspects of Functioning and Disability - Ethical Aspects and Human Rights - Rehabilitation and Health Systems - Economic Burden of Disability - Effects of Lack of Rehabilitation Health care service planning accounts for the burden of disability among society and the chapter describes the justification for specialist rehabilitation, the background of PRM and why making a functional diagnosis and a management plan based on function is its core competence. The chapter describes the increasing burden of disability due to conditions seen in PRM practice rather than on all those diseases contributing to physical disablement and does not include mental illness, learning disabilities, etc. Ten percent of Western Europe’s population have a disability and are surviving longer, resulting in higher costs for health and social care and a greater impact of co-morbidities. The chapter also describes the impact and increased costs in the absence of rehabilitation. Not only is money spent on rehabilitation recovered with five to nine-fold savings (e.g. in return to work), but rehabilitation is effective in all phases of health conditions. Specialized rehabilitation (as delivered by PRM services) is highly cost- efficient for all neurological conditions, producing substantial savings in ongoing care costs, especially in high-dependency patients. Disability discrimination has been outlawed and the text describes the legal context and status of a person living in Europe with a disability. The second part highlights the United Nations Conventions on human rights, confirmed in the World Report on Disability, but also on the principles of ethical practice among PRM physicians. The third part addresses the variability of access to and funding of rehabilitation services across countries. The chapter also distinguishes highly specialist interventions (such as those provided by a PRM physician) from specialized therapies, (such as pressure ulcer management) and generic therapies (e.g. after an uncomplicated limb fracture). It will be important for healthcare authorities, public health organizations, payers, providers, healthcare professionals, consumers and the community. The economic and social burden of disability on society is considerable and will get worse, although this is difficult to quantify. Direct costs are variable and include disabled persons’ additional costs for daily living and state disability benefits. Rehabilitation has a pivotal role in reducing these costs through promoting personal recovery and increasing function through altering environmental factors. This part describes cost savings studies through rehabilitation for persons with severe disabilities.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the future perspectives of PRM in Europe according to the actual vision of the European Bodies. All Chapters stress the big changes that Europe is facing in terms of demography, life expectancy, survival rates, disability burden, increasing prevalence of long- term health conditions, progress in technology, but also health costs and society changes in terms of requirements of wellness and quality of life together with health. All these challenges combined with the specificities of PRM, that is the medical specialty focusing on the whole person and its functioning in the various health conditions, with the aim to guarantee the best possible participation through improvement of activities and reduction of impairments. The possible consequences of these changes in the future evolution of PRM clinical practice, services, education, research are presented ; moreover, the vision on the progress to harmonization of the development of PRM across Europe, and the possible contribution of PRM to policy planning are presented.

In the context of the White Book of Physical and Rehabilitation Medicine (PRM) in Europe, this paper deals with the core concepts at the base of the PRM specialty. These are the essential constituents that make PRM a primary medical specialty, different from all the other medical specialties, and PRM physician the primary medical specialist among the rehabilitation professionals. The core concepts that will be discussed in this Section include: - PRM is a person/functioning oriented specialty, and this makes the specialty different from the organ/disease oriented, or treatment/age specific medical specialties. - PRM physicians have medical responsibilities, like all the other medical specialists, but with an additional specificity of making a functional assessment. - Like the other specialists, PRM physicians provide direct treatments, but they also work leading the multi-professional rehabilitation team, that works in a collaborative way with other professionals and medical specialists. - Due to its function oriented approach, PRM has a multimodal approach including a wide variety of treatment tools (frequently provided by other rehabilitation professionals) and manages all persons’ morbidities (health conditions), since it focuses on decreasing impairments and activity limitations to allow the best possible participation of patients. - As PRM bases its work on functioning, it has a transversal role to other specialties: it overlaps with several of them, sharing part of their knowledge, but it is also totally independent from all of them, since it is based on a different and transversal body of knowledge. - PRM is focused on the person and neither on the disease nor on the setting ; in fact, PRM is not only transversal to specialties, but also to the settings of care, and PRM physicians should know these different realities: persons with disabilities and those with long-term health conditions in fact move inside the national health systems between various facilities to obtain the best possible functioning and participation through an appropriate rehabilitation process.

Introduction/Background Patients with multiple sclerosis (MS) since the earliest stages experiencing motor and cognitive problems, such as lower motor fluidity, reduced attention spans, memory impairments. The progressive loss of integration ability of the central nervous system resulting in a disconnection damage. First affected are fast systems with high level of integration. “Dual tasking” often leads to a poorer performance. Aim of the study is to verify the value of early rehabilitation in reducing the impact of these symptoms on daily living. Material and method We conducted a case-control study including 15 patients with EDSS Patients had initial and final motor-cognitive assessments using Berg Balance Scale (BBS), Ten Meter Walking Test (TMWT) at different speeds and performing a cognitive task (Word List Generation-WLG), Brief Repeatable Battery of Neuropsychological Tests (BRB-NT), Trail Making Test (TMT) and Digit Span. Results TMWT final evaluation showed variations in IRP and APA. The number of words generated in usual and quick speed, not changed in Control, was reduced in APA, increased in IRP. BBS score variation was statistically significant in IRP and APA (IRP initial median score: 52, final median score: 55). At BRB-NT, after cognitive training, results a significant improvement in IRP (t-test: p 0,005). Conclusion IRP and APA show a greater ability in balance control and global fluidity; IRP has better performance in “dual tasking”, probably related to an exercise focused on individual specific impairments. These data support the value of individualized rehabilitation treatment, since the early stage of the disease, moreover APA could represent a good tool in the maintenance phase.

Introduction/Background This study comes from needs of people with disabilities after the earthquake in central Italy in 2016. People with disabilities that lose their house undergo changes in living conditions, housing, social life and health services. That leads to a reduction in activities, in assistance skills of families, in participation and in quality of life. We plan to project Accessible Emergency Housing Solutions (SAE) in accord with “design for all” criteria, to assessing people with disabilities, to provide and personalize Accessible SAE, to plan rehabilitative interventions solutions to improve participation, quality of life in the new life context post earthquake. Material and method The project involves the Rehabilitation Department of USL Umbria 2, the Assistive Technology Products Centre, Health Districts, Municipalities, Umbria Region Civil Protection. We defined appropriate tools based on ICF, adapted to the specific needs in earthquake emergency, to systematically assess disability related problems. We used a direct semi-structured interview to collect informations about health, functioning, family context and assistance need. We created functioning profiles to define the appropriateness of SAE's assignment and house adaptation needs to improve accessibility. Results We included 194 people with disabilities candidate for Accessible SAE; 102 people had functional limitation or other conditions that required adapted temporary accessible houses, personalized and with appropriate size. 783 SAE will be realized in earthquake areas, 102 of them (13%) will be Accessible SAE.People will be checked after the entrance in the Accessible SAE to define the impact of them on quality of life and to plan eventual rehabilitation and assistance programs. Conclusion The application of ICF based assessment tools improved disability management, allowing the identification of accessible housing, technologies and rehabilitation needs to improve participation and social inclusion. The study shows the importance of standardising the assessment of disability in a more complete biopsychosocial framework to support disability in disaster areas.

Markku Kaste ja Filip Scheperjans työryhmän jäsenenä. Background: The kidney-brain interaction has been a topic of growing interest. Past studies of the effect of kidney function on intracerebral hemorrhage (ICH) outcomes have yielded inconsistent findings. Although the second, main phase of the Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) suggests the effectiveness of early intensive blood pressure (BP) lowering in improving functional recovery after ICH, the balance of potential benefits and harms of this treatment in those with decreased kidney function remains uncertain. Study Design: Secondary analysis of INTERACT2, which randomly assigned patients with ICH with elevated systolic BP (SBP) to intensive (target SBP 90, 60-90, and Outcomes: The effect of admission eGFR on the primary outcome of death or major disability at 90 days (defined as modified Rankin Scale scores of 3-6) was analyzed using a multivariable logistic regression model. Potential effect modification of intensive BP lowering treatment by admission eGFR was assessed by interaction terms. Results: Of 2,623 included participants, 912 (35%) and 280 (11%) had mildly and moderately/severely decreased eGFRs, respectively. Patients with moderately/severely decreased eGFRs had the greatest risk for death or major disability at 90 days (adjusted OR, 1.82; 95% CI, 1.28-2.61). Effects of early intensive BP lowering were consistent across different eGFRs (P = 0.5 for homogeneity). Limitations: Generalizability issues arising from a clinical trial population. Conclusions: Decreased eGFR predicts poor outcome in acute ICH. Early intensive BP lowering provides similar treatment effects in patients with ICH with decreased eGFRs. Am J Kidney Dis. 68(1): 94-102. (C) 2016 The Authors. Published by Elsevier Inc. on behalf of the National Kidney Foundation, Inc. This is an open access article under the CC BY-NC-ND license.

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

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

Lo sviluppo delle moderne tecniche di immagini non invasive ha determinato un notevole progresso nelle conoscenze del recupero funzionale dopo ictus, potenzialmente di grande utilità per la messa a punto di programmi terapeutici e riabilitativi. Diversi meccanismi sono stati proposti, quali l'attivazione di vie derivanti dalle aree corticali motorie omolaterali al lato paretico, il reclutamento di aree corticali adiacenti alla lesione, il rinforzo di circuiti neuronali preesistenti, lo stabilirsi di nuove connessioni a livello sinaptico. Considerati i dati contraddittori della letteratura, abbiamo effettuato un studio mediante Risonanza Magnetica funzionale (fMRI) con lo scopo di definire meglio il ruolo delle proiezioni omolaterali e i fenomeni di riorganizzazione plastica post-ictale delle aree corticali motoria primaria (M1), premotoria laterale (PML) e supplementare motoria (SMA). Sono stati studiati 14 pazienti con pregresso ictus ischemico sottocorticale in buon recupero funzionale, 7 con emiparesi destra e 7 con emiparesi sinistra, ad una distanza mediana di 61 giorni dall'evento ischemico. I risultati hanno evidenziato durante il movimento della mano paretica un'attivazione bilaterale della M1 ed in misura minore delle PML e SMA, mentre si è registrata un'attivazione controlaterale più selettiva durante il movimento della mano sana. I dati sembrerebbero dimostrare che una maggiore attivazione delle aree motorie corticali omolaterali alla lesione sia un importante meccanismo di compenso al danno funzionale conseguente ad ictus non solo nella fase postacuta ma anche nella fase di stabilizzazione.

We observed a young patient with slight mental retardation, suffering from drug-resistant tonic-clonic seizures, who presented a status epilepticus (SE), in two separate periods when valproic acid (VPA) was added to the phenobarbital (PB) already being used in the patient's therapy. The VPA-induced SE was characterized by normal plasma levels of antiepileptic drugs (AEDs), normal ammonemia and normal liver function. The case we studied represents the first report on a VPA-induced SE. Furthermore the case confirms that VPA, as well as causing encephalopathy secondary to hyperammonemia, may also provoke a primary involvement of the central nervous system (CNS), specially when used in young epileptic, mentally retarded subjects. In an attempt to explain the paradoxical effect of VPA we hypothesise that the SE could be due to an increase in excitatory activity producing a consequent epileptogenic effect in those subjects with a predisposition for toxic reaction to VPA therapy due to congenital anomalies of neural networks.

1H-MRS examinations were carried out on 14 patients, recovering from traumatic brain injury (TBI), who were in a stabilized clinical status and showed a good clinical outcome. Magnetic resonance spectra were recorded in subcortical (SC) and mid-brain (MB) areas where no detectable lesions appeared under magnetic resonance imaging. These two brain areas were selected because they are crucial sites of damage due to the physiopathologic mechanisms of TBI. A significant increase in inositol and choline peaks was found in MB compared to a control group of healthy individuals, whereas lower N-acetyl-aspartate peaks in the same area were detected. Reduced levels in the latter metabolite were also evident in the SC area. A significant correlation emerged between the inositol concentration in MB and the Glasgow Coma Scale Score measured just after the trauma. No correlation was found between the Glasgow Outcome Scale (GOS) at the time of the 1H-MRS examination and the peaks of all the metabolites. Our study demonstrated that 1H-MRS is a sensitive tool to evidentiate brain metabolic damage after TBI even in areas with lesions that are not detectable with current imaging techniques. The present research also shows an association between the alteration in one of the brain metabolites and the clinical parameters of TBI severity, but does not provide a clinical index of the patient's recovery. Further longitudinal studies on more conspicuous groups of patients with TBI could help to clarify whether metabolite modifications revealed by 1H-MRS could be predictive of clinical outcome.

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

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

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

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

Patient’s and operator’s satisfaction is one of the major requirements to be addressed in the implementation of a tele-rehabilitation service, to render it a valuable and effective means to administer remote rehabilitation treatment. This aspect was deeply investigated within the European Project HELLODOC (acronym for “HEaLthcare Service Linking Tele-rehabilitation to Disabled PeOple and Clinicians”; March 2005 - February 2007). The project focused on a home care upper limb tele-rehabilitation service delivered to a wide number - 81 patients in all - of neurological patients affected by traumatic brain injury (TBI), stroke (S) or multiple sclerosis (MS). The core of the service was the Portable Unit (PU) to be installed at patient’s home; the PU allows the execution of daily-like tasks and the measurement of some related kinetic and kinematic quantities.

The main objective of this study was demonstrating the clinical effectiveness of the Home Care Activity Desk (HCAD) system in a home setting. The study was partly a randomized control trial study in which HCAD is compared to usual care. The patients using the HCAD system show during the month of treatment significant improvements on the individual tasks measured by the execution time. The overall results of the HCAD system concerning clinical effectiveness are positive. The HCAD system for chronic Stroke, TBI and MS patients is shown to be at least as effective as usual care.

The possibility that N-methyl-D-aspartate (NMDA) receptor activation plays a role in inducing the vestibular compensation following hemilabyrinthectomy (HL) in guinea pigs, was verified by means of continuous intraventricular osmotic pumping of DL-2-Amino-5-phosphono-valeric acid (APV). Our results show that high doses (40 and 20 mM) of APV decrease both the combined OKR and VOR and the nystagmus following HL. Low doses of APV (2.5 mM), affect the time course of the ocular compensation by maintaining a higher level of nystagmus beat frequency and by delaying the nystagmus disappearance. On the contrary, the compensation time course is not affected by administering APV later on in the compensation period. Therefore, it appears that NMDA receptors are activated during the precocious phase of vestibular compensation, when a large vestibular imbalance is present. This finding is explained by the development of NMDA receptor hypersensitivity, in the functionally inactivated commissural system or by the occurrence of NMDA-mediated long-term potentiation.

Negli ultimi anni lo studio dei meccanismi di recupero funzionale dopo ictus è progredito grazie all'utilizzo di nuove tecniche di indagine sia con immagini che con registrazione elettrofisiologiche. L'interesse è accentuato dal potenziale utilizzo di queste conoscenze per mettere a punto opportuni programmi terapeutici e riabilitativi. Scopo di questo lavoro è stato quello di indagare mediante Risonanza Magnetica funzionale (fMR) quali aree motorie fossero coinvolte nel recupero dopo ictus cerebrale. Sono stati studiati 10 pazienti con ictus sottocorticale ischemico (5 con emiparesi destra e 5 con emiparesi sinistra) in buon recupero funzionale. L'età media era 59,1 anni (min 37, max 84). Tutti i pazienti sono stati indagati effettuando uno studio per immagini e funzionale. La fMR è stata realizzata con apparecchiatura General Electric 1,5 T mediante sequenze SPGR (TR/TE 64/48 ms, Flip Angle 17°, FOV 22×6 cm2, matrice 256times128, spessore di strato 6 mm) costituite da 3 sezioni assiali oblique contigue, parallele alla linea inter-commissurale, condotte a livello della corteccia motoria. L'esame funzionale è stato preceduto da uno studio convenzionale utilizzato per dimostrare le lesioni, per programmare le sequenze funzionali e per fornire una correlazione anatomica ai pixel attivati. La fMR è stata effettuata alternando acquisizioni ottenute durante un movimento delle dita con sequenze eseguite in condizioni di riposo sia per la mano paretica che per quella sana. Per l'elaborazione è stata usata la tecnica “cross correlation” con soglia usando la “box-car” come forma d'onda di riferimento. Sono stati considerati “attivati” i pixel con coefficiente di correlazione (CC) ≥ 70% del CC massimo. I pixel selezionati, codificati mediante colorazione e sovrapposti alle immagini anatomiche, sono stati quantificati con apposito programma, suddivisi per aree motorie corticali. I risultati hanno evidenziato un'attivazione bilaterale durante il movimento della mano paretica mentre si è registrata un'attivazione controlaterale più selettiva durante il movimento della mano sana. Nell'emisfero omolaterale alla paresi si è inoltre rilevato un incremento dell'attivazione nelle aree premotoria e supplementare motoria. Questi dati sembrerebbero dimostrare che una maggiore attivazione delle aree motorie corticali omolaterali alla lesione sia un importante meccanismo di compenso al danno funzionale conseguente ad ictus. Tale attivazione può avere un duplice significato: un rinforzo delle vie discendenti cortico-spinali già presenti nel soggetto sano e un ausilio funzionale da parte delle aree premotoria e supplementare motoria verso il lato lesionato.

Water-wave and photic stimulation of the sensilla elicits synaptic potentials identical to those elicited by electrical stimulation of the segmental roots. Mechanical stimulation elicits a localized IPSP and a generalized EPSP in the RCs and an IPSP in the AE motoneurons. Photic stimulation gives rise to a generalized EPSP in the RCs alone. The impulse discharges elicited in the afferent fibers by the two kinds of stimuli is transmitted along the cord both anteriorly and posteriorly to the stimulated segment. This implies that the afferent impulses excite a pool of intersegmental neurons in each ganglion, which distribute their discharges to the adjacent ganglia. The evidence for occlusion between cordal and photically elicited volleys indicates that it shares with the sensillar input a common pool of interneurons. The possible functional significance of the inhibitory and excitatory inputs is discussed.