Guidelines: basic principles of neurorehabilitation for patients with acquired brain injury. Recommendations of the Spanish Society of Neurorehabilitation

INTRODUCTION

We present the Spanish Society of Neurorehabilitation's guidelines for adult acquired brain injury (ABI) rehabilitation. These recommendations are based on a review of international clinical practice guidelines published between 2013 and 2020.

DEVELOPMENT

We establish recommendations based on the levels of evidence of the studies reviewed and expert consensus on population characteristics and the specific aspects of the intervention or procedure under research.

CONCLUSIONS

All patients with ABI should receive neurorehabilitation therapy once they present a minimal level of clinical stability. Neurorehabilitation should offer as much treatment as possible in terms of frequency, duration, and intensity (at least 45-60minutes of each specific form of therapy that is needed). Neurorehabilitation requires a coordinated, multidisciplinary team with the knowledge, experience, and skills needed to work in collaboration both with patients and with their families. Inpatient rehabilitation interventions are recommended for patients with more severe deficits and those in the acute phase, with outpatient treatment to be offered as soon as the patient's clinical situation allows it, as long as intensity criteria can be maintained. The duration of treatment should be based on treatment response and the possibilities for further improvement, according to the best available evidence. At discharge, patients should be offered health promotion, physical activity, support, and follow-up services to ensure that the benefits achieved are maintained, to detect possible complications, and to assess possible changes in functional status that may lead the patient to need other treatment programmes.

[Effectiveness, adherence and usability of a teleneurorehabilitation programme to ensure continuity of care for patients with acquired brain injury during the COVID-19 pandemic]

INTRODUCTION

The health pandemic brought about by SARS-CoV-2 (COVID-19) has limited access to neurorehabilitation programmes for many patients who have suffered stroke, traumatic brain injury or acquired brain damage due to some other cause. As telerehabilitation allows for the provision of care in situations of social distancing, it may mitigate the negative effects of confinement. The aim of this study was to determine the efficacy, adherence and usability of a teleneurorehabilitation intervention for patients with acquired brain injury.

PATIENTS AND METHODS

All patients included in a face-to-face neurorehabilitation programme at the time of the declaration of the state of alarm in Spain due to COVID-19 and who agreed to participate in the study were included in a teleneurorehabilitation programme. The effectiveness of the programme, understood as an improvement in independence, was quantified with the Barthel index. Adherence to the programme and usability of the tool were explored through questionnaires.

RESULTS

Altogether, 46 patients, accounting for 70.6% of the total, participated in the study. Participants significantly improved their independence and showed an improvement in the Barthel index between the start (77.3 ± 28.6) and the end of the programme (82.3 ± 26). Adherence to the intervention was very high (8.1 ± 2.2 out of 10) and the online sessions were the most highly rated content. The tool used showed a high usability (50.1 ± 9.9 out of 60) and could be used without assistance by more than half the participants.

CONCLUSION

The teleneurorehabilitation intervention was found to be effective in improving patients' independence, and promoted a high degree of adherence and usability.

Current validity of diagnosis of permanent vegetative state: A longitudinal study in a sample of patients with altered states of consciousness

INTRODUCTION

Altered states of consciousness have traditionally been associated with poor prognosis. At present, clinical differences between these entities are beginning to be established.

METHOD

Our study included 37 patients diagnosed with vegetative state/unresponsive wakefulness syndrome (UWS) and 43 in a minimally conscious state (MCS) according to the Coma Recovery Scale-Revised (CRS-R). All patients were followed up each month for at least 6 months using the CRS-R. We recorded the time points when vegetative state progressed from 'persistent' to 'permanent' based on the cut-off points established by the Multi-Society-Task-Force: 12 months in patients with traumatic injury and 3 months in those with non-traumatic injury. A logistic regression model was used to determine the factors potentially predicting which patients will emerge from MCS.

RESULTS

In the UWS group, 23 patients emerged from UWS but only 9 emerged from MCS. Of the 43 patients in the MCS group, 26 patients emerged from that state during follow-up. Eight of the 23 patients (34.7%) who emerged from UWS and 17 of the 35 (48.6%) who emerged from MCS recovered after the time points proposed by the Multi-Society-Task-Force. According to the multivariate regression analysis, aetiology (P<.01), chronicity (P=.01), and CRS-R scores at admission (P<.001) correctly predicted emergence from MCS in 77.5% of the cases.

CONCLUSIONS

UWS and MCS are different clinical entities in terms of diagnosis and outcomes. Some of the factors traditionally associated with poor prognosis, such as time from injury and likelihood of recovery, should be revaluated.

Priorities for cancer control in Spain

Spanish cancer strategy is being developed in the context of a decentralised health care system. The advantages and challenges posed by this system are reviewed, particularly vis-à-vis the need to build consensus among regional health services as regards priorities in cancer control. Analysis of the impact of cancer in Spain enables smoking prevention and obesity reduction to be highlighted, especially among adolescents, as targets for primary prevention. Two-yearly colorectal cancer screening using the faecal occult blood test and targeting persons aged 50-69 years is a new goal that should be pursued countrywide, as should population-based breast cancer screening. Insofar as health care is concerned, the focus is on promoting and consolidating multidisciplinary cancer care based on evidence-based clinical guidelines, and on ensuring that cancer patients enjoy prompt access to diagnosis and therapy. Psychosocial support, with experience gained in several health services, should be expanded. Palliative care must be consolidated as a necessary therapy for patients who require it. Finally, the important boost to cancer research witnessed in recent years should be sustained. The approach adopted is based on building a co-operative strategy among all of Spain's autonomous regions (Comunidades Autónomas), which must then apply the interventions in their respective health services. A shared understanding of the main priorities for cancer control, through a review of the evidence and a consensus embracing all stakeholders, including scientific societies and patients' associations, is an essential step in the implementation of cancer strategy in Spain.

APOE genotype and verbal memory recovery during and after emergence from post-traumatic amnesia

OBJECTIVE

To determine if APOE genotype is linked to memory function after moderate-severe traumatic brain injury (TBI).

METHODS

Eighty-two patients in post-traumatic amnesia (PTA) and 107 patients who had emerged from PTA were selected from 239 consecutive patients admitted to the facility. Verbal memory assessments, including the Spanish version of the California Verbal Learning Test and the Working-Memory Index of the WAIS-III, were conducted immediately after PTA resolution or during the first week after admission for patients who were out of PTA. Both groups were reassessed 6 months after inclusion in a multidisciplinary rehabilitation programme.

RESULTS

Patients with the APOE-epsilon 4 allele (n = 17 in the PTA group and n = 9 in the out of PTA group) entered rehabilitation at a more impaired level, but made remarkable progress during follow-up. Fifty-five patients from the initial sample emerged from PTA during the follow-up period. Age, GOAT at admission and chronicity, but not APOE genotype or initial trauma severity, were significant predictors of emergence from PTA.

CONCLUSIONS

APOE genotype seems to be associated with the trajectory of cognitive recovery after TBI, but does not play a determinant role in the efficacy of memory rehabilitation in this population.

eBaViR, easy balance virtual rehabilitation system: a study with patients

eBaViR is a virtual rehabilitation system, which has been developed for balance rehabilitation for patients suffering from acquired brain injury. It is a game-based system that uses a low-cost interface, the Nintendo Wii Balance Board. The games have been specifically designed with the help of experts in the rehabilitation of balance disorders and can be adapted to patients according to their needs. We present an experimental study that has been carried out using the system. The aim of the study is to determine whether this setup could be applied as a Virtual Rehabilitation System for balance rehabilitation in Acquired Brain Injury. We randomly divided patients into two groups: a trial group and a control group. The trial group used eBaViR system during the rehabilitation sessions, and the control group followed traditional rehabilitation sessions. We obtained encouraging results.

Does the liberalisation of abortion laws increase the number of abortions? The case study of Spain

BACKGROUND

Over the course of the 1980s a public debate on abortion took place in Spain culminating in a more permissive social climate and, in 1985, the partial decriminalisation of abortion. Before this, women were forced to abort illegally or abroad in countries which had decriminalised abortions. The aim of this study is to present jointly the evolution of abortions in Spanish women in England and Wales between 1974 and 1995, The Netherlands between 1980 and 1995 and Spain since the start of the register in 1987 through to 1995 and to compare trends both before and after the law in Spain.

METHODS

Incidence rates were calculated in each of the countries studied and the slopes of the curves for 1974-1984 and 1987-1995 were compared. Data were obtained from reports published by the offices of abortion surveillance in England and Wales, The Netherlands and Spain.

RESULTS

The rates increased constantly throughout the study period. From 1974 to 1985, a total of 204,736 Spanish women aborted in England and Wales and The Netherlands. After the law was passed, 34,895 Spanish women had abortions in those countries over the period 1986-1995. During 1987-1995, 340,214 Spanish women terminated their pregnancies in Spain. The regression coefficients before and after the passing of the law were beta = 0.3538 (0.307-0.400) and beta = 0.319 (0.243-0.394) respectively; no difference was observed.

CONCLUSIONS

During the study period a significant proportion of reproductive-aged Spanish women had abortions in England and Wales and The Netherlands. Decriminalisation has had no observed effect on the trends in abortion, but rather it has benefited Spanish women by making abortion available locally and, therefore, reducing the inequalities implied by lack of access to proper health care services. These data demonstrate the impact of the liberalisation of abortion on the trends of procedures performed in other countries.

[The importance of the gender perspective in health interview surveys]

The identification and measurement of the population health needs should be the first step in health planning. In order to guarantee equity criteria, to know the situation of the whole population, and therefore also that of women, is a key issue. Health interview surveys are a good tool for pinpointing the needs of the population, but mainly they are usually focused on health risk factors that explain men's health status such as health behaviours and paid job. These factors often fail to capture aspects that are relevant for women's health, such as household work. The main objective of this paper is to emphasise the importance of a gender perspective in the design and analysis of health interview surveys, and to propose variables that should be included in health surveys in order to better know gender health inequalities. Likewise, this article deals with the gender concept and its importance as a health inequality factor. Gender is an analytical construct based on the social organisation of the sexes that can be used to better understand the conditions and factors influencing women's and men's health beginning by the social roles that each culture and society assigns to people based on their sex. Health is a complex process determined by a wide range of factors: biological, social, environmental and health services related factors. Gender, because of its close relation to all of them, plays a key role. The gender approach is characterised by the analysis of the social relation between men and women, taking into account that sex is a determinant of social inequalities. This paper presents the variables that health interview surveys should include from a gender approach point of view: reproductive work, productive work, social class, social support, self-perceived health status, quality of life, mental health and chronic conditions. In addition, issues related to the wording of questions, data collection and analysis are discussed.

Who quits smoking during pregnancy?

The aim of this paper is to investigate the distribution of smoking cessation during pregnancy in relation to sociodemographic and professional characteristics. The study population are, primiparous or secundiparous women who gave birth in a large public hospital in the city of Valencia (Spain) and who have carried out paid work during pregnancy. A sample of 593 women were personally interviewed in the maternity hospital. A simple analysis was carried out on the data subsequently adjusting a logistic regression model. Sixty-two per cent of the women smoked before pregnancy. Of them, 28% gave up smoking during pregnancy. Giving up smoking during pregnancy is more common among women of between 26-30 years of age (ORadjusted = 2.1), those with secondary level of education (ORadjusted = 2.6) and among those for whom daily cigarette intake before pregnancy was between 1-9 cigarettes (ORadjusted = 12.3) or between 10-19 (ORadjusted = 2.7). The modification of smoking during pregnancy requires interventions prior to and throughout the course of pregnancy which should be aimed at risk groups such as younger women, those less educated and heavy smokers.

[Maternity protection legislation: a tool for promoting mother-child health]

OBJECTIVE

To describe the legislation existing in Spain on the protection of women in paid work after giving birth.

SETTING

Spanish legislation was reviewed and the following aspects examined: time off for childbirth, leave to care for children, hours for breast-feeding, reduction in the working day for the care of small children and time off because of children being ill.

MEASUREMENTS AND MAIN RESULTS

Time off for childbirth is 16 weeks, of which 6 must be after the birth. If both parents work, the father can opt for the last 4 weeks. The amount paid is 100% of the regulated basic wage and will be paid directly by the relevant managing body. Both workers under the general regimen and those under special regimens can receive this benefit. Workers in normal employment can have unpaid leave for a period of up to three years. Other measures are the daily period of one hour for breast-feeding a child under 9 months, the reduction in the working day by between a third and a maximum of half its length to care for children under 6 and the possibility of being away from work for two days because of a child's serious illness.

CONCLUSIONS

The existence of specific legislation protecting maternity is an important, though insufficient, step towards guaranteeing equal opportunities for men and women in the labour market. Specially noteworthy is the reconciliation of paid work and family responsibilities.

Pediatric hospitalization due to ambulatory care-sensitive conditions in Valencia (Spain)

BACKGROUND

Studies in the United States have demonstrated that rates of hospitalization for conditions sensitive to primary care are related to socioeconomic factors. Our objective was to identify those sociodemographic and primary care factors associated with pediatric hospitalization for ambulatory care-sensitive conditions, in a country (Spain) with a health system that provides universal coverage.

METHODS

Cross-sectional survey of 504 children hospitalized in a District General Hospital in Valencia, Spain. Data were gathered on sociodemographic variables, type of physician providing primary care and ambulatory care use prior to hospitalization. Analysis consisted of bivariate statistical tests and logistic regression techniques.

RESULTS

Children who were under 2 years old and female were at significantly higher risk for hospitalization due to ambulatory care-sensitive conditions. Socioeconomic variables, type of physician or a previous visit to primary care services were not associated with a different risk of hospitalization due to these conditions.

CONCLUSION

Characteristics unrelated to difficulties in access, or to type of provider, influence the risk of hospital admissions for conditions that could be prevented or managed without hospitalization. More specific classification of conditions potentially could be useful for determining which factors of structure or process of health services are related to hospitalization.

Research on lifestyles and health: searching for meaning

This paper is based on an alternative approach to standard quantitative analyses in research on behavior and health. Theory and methods focused on the elaboration of complex situational and behavioral influences on health are used in secondary analyses of data from a population health survey in Spain. Findings showing fundamental differences in the relationships among the behavioral and health variables within various age, gender and social groups illustrate the importance of studying interacting influences in relevant subgroups of the population. Quite meaningful findings can be hidden in behavioral research limited to identifying global statistical correlations in cross-sectional and longitudinal data. The impact that statistical methods can have on the findings from analyses that are not guided by theory and logic based on substantive questions derived from the research literature is discussed. The results point to the need to study patterns of behavior in their contexts of occurrence in research on lifestyles and health.

[Induced abortions among Spanish women in England and Wales (1974-1988)]

To assess the importance of travelling for abortion in Spanish women from 1974 to 1988, a descriptive epidemiologic study was undertaken, based on information from the United Kingdom Office for Population Censuses and Surveys. Additionally, the effect of the democratic restitution in Spain (1978) and of the passing of the Spanish abortion law in Spain is explored. During the study period, close to 200,000 Spanish women travelled to England and Wales to have an abortion. The annual figures range from 2,978 in 1974 to 22,002 in 1983. In 1988, in spite of the partial decriminalization of abortion in Spain, still 3,188 travelled to the UK for an abortion. In average, 1 out 35 Spanish women in fertile ages travelled to England and Wales for this reason in the study period. The likelihood was higher for the cohort of women born between 1955 and 1959, for which the risk was 4.5%. The proportional distribution by age shows that teenagers increased their relative importance from 9.3% in 1974 to 17% in 1988, suggesting less benefits for this age group than for older women from the democratization of the country and the abortion law.

[Health inequalities in Barcelona and Valencia]

BACKGROUND

Inequalities in health have been internationally recognized as an important public health problem with a reduction of 25% being the first target of WHO--Europe for the year 2000. It is, therefore, important to describe and monitor the same.

METHODS

An ecological study was performed using secondary data from the statistics of mortality (years 1985-1988) and the municipal censuses from the year 1986 to describe and compare inequalities in health in the cities of Valencia and Barcelona with neighborhoods being the unit of observation and analysis.

RESULTS

Although the rates of mortality in Barcelona city are slightly inferior and those of Valencia slightly higher to those of Spain, both cities demonstrate important inequalities in regard to mortality in their neighborhoods with respect to standardized mortality which ranged from 78 to 182 in Barcelona and from 63 to 147 in Valencia. The privileged zones in Barcelona are those of Pedralbes and Sant Gervasi and in Valencia in the neighborhoods of Sant Pau and Jaume Roig with the most unfavorable neighborhoods being District I in Barcelona (Gothic Quarter, City Park, Barceloneta and Raval) and the Na Rovella and Fuensanta neighborhoods of Valencia. The level of inequality in both cities is very similar. Statistically significant associations have been found in both cities between the state of health and the level of poverty in the neighborhoods according to an approximation to the Townsend et al indexes.

CONCLUSIONS

The description of important inequalities in two large Spanish cities suggests the possibility of its existence in other cities and established the urgent need for a study using comparable methodologies. With the use of routine and presently available data sources it is possible to describe and posteriorly monitor the level of inequality in large cities in Spain. The development of policies to diminish the inequalities in the large cities would provide considerable gains in terms of human lives. The present results support the hypothesis that material conditions in everyday life play an important role as a condition for public health inequality.

[Health indicators in urban areas. Variations in function of social coherence of the geographic areas used]

The detection of health inequalities in the urban environment and their magnitude depends to a great extent on the internal social coherence of the geographical division used. Using an existing social map of Alicante which divides the city into Basic Units for Social Intervention (BUSI), we have compared the distribution of an indicator with wellknown relationship with the socio-economic level such as Low Birth Weight, using both the BUSI and the municipal districts as analysis units. The data of the newborn were obtained from the records of the Hospital of Alicante corresponding to the years 1985, 1986 and 1987, analysing the 177 Low Birth Weights of the 7,728 born within the period. Using the BUSI we found a dose-response relationship between the socio-economic level and the LBW frequency with a range varying from 86.3 to 123.2. Using the municipal districts, the range varied from 62.5 to 159.6. We conclude that, although the geographical divisions with internal social coherence are better to detect health inequalities, municipal districts can be an analysis unit of easy access and useful for describing inequalities in the cities.

[Presence of caries and periodontal disease in Spanish students. Overview of results obtained in different localities]

Results of our survey in 11 locations of Spain are assembled in an overview showing percentages of persons according to the highest C.P.I.T.N. code defected for each one, the prevalence of caries-free-children and mean D.M.F.T. scores. We have also studied the differences between urban and rural populations. Rural children presented higher D.M.F.T. an D.T. scores.

Anaemia during pregnancy as a risk factor for infant iron deficiency: report from the Valencia Infant Anaemia Cohort (VIAC) study

A prospective cohort study with a 1-year follow-up of 156 neonates was carried out specifically designed to test the hypothesis that there is a positive relationship between iron deficiency during pregnancy and the development of the same disease in newborn infants. Exposure was defined as being born of a mother with ferropenic anaemia at delivery, and cases as the infants who developed iron deficiency during their first year of life. A statistically significant positive association was detected with an odds ratio of 6.57 (95% confidence limits 1.81-25.97). A stratified analysis was also performed to control the effect of potential confounders such as socio-economic variables, feeding practices and other factors linked with the iron status of infants. This second analytical procedure showed no alteration in the association detected in the simple analysis but that there was a statistically significant strong interaction between the quantity of cow's milk intake and the ferropenic status of the mother. These results show a relationship between iron deficiency of the mother at delivery and the development of iron deficiency in the infants. These new findings could be important in the development of new prevention programmes applied to pregnant women.

[Immunity in hypothyroid children (author's transl)]

For a long time investigators have focused attention on the relationship between specific immunity and hormones. In the present paper, authors investigated on 26 children, 9 males and 17 females, from 9 months to 14 and 10/12 years old, with primary hypothyroidism. All patients were in substitutive treatment. The following studies were done to all the patients: serum IgG, IgA, IgM and complement. Blood lymphocyte counts, percentages of B and T lymphocytes, as well as the response of lymphocytes to PHA. Skin tests were also carried out: tuberculin, candidin and streptokinase-streptodornase. All results obtained in both, hypothyroid and control groups fell within the range of normal age-matched values for our laboratory, and by results of statistics studies carried out they were considered of little significance, except the percentage of circulating B lymphocytes that was lower in hypothyroid group (p less than or equal to 0.01).