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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.

Objective: To explore the muscle activation patterns in relation to pain complaints in bassists studied during a musical task. This study was based on the assumption that pain complaints are caused by increased muscle activation during playing or relaxation and/or faster onset of fatigue of muscles.Design: Cross-sectional study.Setting: Nonclinical.Participants: Student bass guitarists (N=36) from conservatories in the Netherlands.Interventions: Not applicable.Main Outcome Measures: Bassists played a standard music piece for 30 minutes. Muscle activation levels and pain were recorded. Pain was registered with a Numeric Rating Scale (NRS 0-10). The muscle activation level of both the trapezius muscles and flexor carpi radialis was measured with sEMG: sEMG as the percentage of the maximal voluntary isometric contraction (%MVC) and the slope of the sEMG (slope of % MVC) were calculated. The %MVC as a function of time and the slope of %MVC were calculated during playing and for rest periods before and after playing. For statistic analysis, the Mann-Whitney U test and a multilevel multiregression analysis were used for comparing the sEMG data of bassists with and without pain.Results: No significant differences in %MVC or the slope of %MVC were between the bassists with and without pain complaints.Conclusions: The results surprisingly indicate that pain complaints of bassists may not be associated with another muscle activation pattern. It is, therefore, not likely that pain is caused by increased muscle activation during playing and/or relaxation, nor by faster onset of fatigue. (C) 2013 by the American Congress of Rehabilitation Medicine

Objective To compare the safety and efficacy of hyaluronan (HA) injections with standard extracorporeal shock wave therapy (ESWT) in the treatment of painful midportion Achilles' tendinopathy. Design Multinational, prospective, randomized controlled, blinded-observer trial. Setting Ambulatory care. Participants Adults (N=62) with Achilles' midportion tendinopathy for ≥6 weeks and a pain score of at least 40mm (Huskisson visual analog scale [VAS], 100mm) were randomized, and 59 were analyzed in the intention-to-treat data set. There were no withdrawals because of adverse effects. Interventions Two peritendinous HA injections versus 3 ESWT applications at weekly intervals. Main Outcome Measures Primary efficacy criterion was changed from the Victorian Institute of Sports Assessment–Achilles' questionnaire (VISA-A) score to the percent change in pain (VAS) at 3 months posttreatment, compared with baseline values. Main secondary parameters were VISA-A, Clinical Global Impression (CGI), and clinical parameters. Results HA treatment provided a clinically relevant improvement in Achilles' midportion tendinopathy. A large superiority of the HA group, compared with ESWT application, was observed for percent change in pain (VAS), and this superiority was proven to be statistically significant (Mann-Whitney statistic [MW]=.7507 with P =.0030 lower than required α=.025 significance level 1-sided; Mann-Whitney U test) at 3 months posttreatment. Similar findings for HA were also observed at 4 weeks (MW=.6425, P =.0304) and 6 months (MW=.7172, P =.0018). Advantage of HA treatment was confirmed by VISA-A questionnaire, CGI, and clinical parameters. Ten adverse events, 4 in the HA group and 6 in the ESWT group, were reported, but none were classified as serious. Conclusions Two peritendinous HA injections showed greater treatment success in Achilles' midportion tendinopathy compared with standard ESWT.

Munguia-Izquierdo D, Legaz-Arrese A. Reliability and validity of a low load endurance strength test for upper and lower extremities in patients with fibromyalgia. Objective To evaluate the reliability, standard error of the mean (SEM), clinical significant change, and known group validity of 2 assessments of endurance strength to low loads in patients with fibromyalgia syndrome (FS). Design Cross-sectional reliability and comparative study. Setting University Pablo de Olavide, Seville, Spain. Participants Middle-aged women with FS (n=95) and healthy women (n=64) matched for age, weight, and body mass index (BMI) were recruited for the study. Interventions Not applicable. Main Outcome Measures The endurance strength to low loads tests of the upper and lower extremities and anthropometric measures (BMI) were used for the evaluations. The differences between the readings (tests 1 and 2) and the SDs of the differences, intraclass correlation coefficient (ICC) model (2,1), 95% confidence interval for the ICC, coefficient of repeatability, intrapatient SD, SEM, Wilcoxon signed-rank test, and Bland-Altman plots were used to examine reliability. A Mann-Whitney U test was used to analyze the differences in test values between the patient group and the control group. We hypothesized that patients with FS would have an endurance strength to low loads performance in lower and upper extremities at least twice as low as that of the healthy controls. Results Satisfactory test-retest reliability and SEMs were found for the lower extremity, dominant arm, and nondominant arm tests (ICC=.973–.979; P P >.05 for all). The Bland-Altman plots showed 95% limits of agreement for the lower extremity (4.7 to –4.5), dominant arm (3.8 to –4.4), and nondominant arm (3.9 to –4.1) tests. The endurance strength to low loads test scores for the patients with FS were 4-fold lower than for the controls in all performed tests ( P Conclusions The endurance strength to low loads tests showed good reliability and known group validity and can be recommended for evaluating endurance strength to low loads in patients with FS. For individual evaluation, however, an improved score of at least 4 and 5 repetitions for the upper and lower extremities, respectively, was required for the differences to be considered as substantial clinical change. Patients with FS showed impaired endurance strength to low loads performance when compared with the general population.

de Laat FA, Rommers GM, Geertzen JH, Roorda LD. Construct validity and test-retest reliability of the Climbing Stairs Questionnaire in lower-limb amputees. Arch Phys Med Rehabil 2010;91:1396-401.Objective: To investigate the construct validity and test-retest reliability of the Climbing Stairs Questionnaire, a patient-reported measure of activity limitations in climbing stairs, in lower-limb amputees.Design: A cross-sectional study. Setting: Outpatient department of a rehabilitation center.Participants: Lower-limb amputees (N=172; mean +/- SD age, 65 +/- 12y; 71% men; 82% vascular cause) participated in the study; 33 participated in the reliability study.Interventions: Not applicable.Main Outcome Measure(s): Construct validity was investigated by testing 10 hypotheses: limitations in climbing stairs according to the Climbing Stairs Questionnaire will be greater in lower-limb amputees who: (1) are older, (2) have a vascular cause of amputation, (3) have a bilateral amputation, (4) have a higher level of amputation, (5) have more comorbid conditions, (6) had their rehabilitation treatment in a nursing home, and (7) climb fewer flights of stairs. Furthermore, limitations in climbing stairs will be related positively to activity limitations according to: (8) the Locomotor Capabilities Index, (9) the Questionnaire Rising and Sitting down, and (10) the Walking Questionnaire. Construct validity was quantified by using the Mann-Whitney U test, Kruskal-Wallis test, and Spearman correlation coefficient. Test-retest reliability was assessed with a 3-week interval and quantified using the intraclass correlation coefficient (ICC).Results: Construct validity (8 of 10 null hypotheses not rejected) and test-retest reliability were good (ICC=.79; 95% confidence interval, .57-.90). Conclusion: The Climbing Stairs Questionnaire has good construct validity and test-retest reliability in lower-limb amputees.

To evaluate the effectiveness of reinforced feedback in virtual environment (RFVE) treatment combined with conventional rehabilitation (CR) in comparison with CR alone, and to study whether changes are related to stroke etiology (ie, ischemic, hemorrhagic).Randomized controlled trial.Hospital facility for intensive rehabilitation.Patients (N=136) within 1 year from onset of a single stroke (ischemic: n=78, hemorrhagic: n=58).The experimental treatment was based on the combination of RFVE with CR, whereas control treatment was based on the same amount of CR. Both treatments lasted 2 hours daily, 5d/wk, for 4 weeks.Fugl-Meyer upper extremity scale (F-M UE) (primary outcome), FIM, National Institutes of Health Stroke Scale (NIHSS), and Edmonton Symptom Assessment Scale (ESAS) (secondary outcomes). Kinematic parameters of requested movements included duration (time), mean linear velocity (speed), and number of submovements (peak) (secondary outcomes).Patients were randomized in 2 groups (RFVE with CR: n=68, CR: n=68) and stratified by stroke etiology (ischemic or hemorrhagic). Both groups improved after treatment, but the experimental group had better results than the control group (Mann-Whitney U test) for F-M UE (P.001), FIM (P.001), NIHSS (P≤.014), ESAS (P≤.022), time (P.001), speed (P.001), and peak (P.001). Stroke etiology did not have significant effects on patient outcomes.The RFVE therapy combined with CR treatment promotes better outcomes for upper limb than the same amount of CR, regardless of stroke etiology.

Kuhtz-Buschbeck JP, Stolze H, G[ouml ]lge M, Ritz A. Analyses of gait, reaching, and grasping in children after traumatic brain injury. Arch Phys Med Rehabil 2003;84:424-30. Objective: To evaluate motor behavior in children after traumatic brain injury (TBI) with quantitative instrumented measures of gait and of functional hand movements (reaching, grasping) and with clinical assessments. Design: Case-control study. Setting: Tertiary pediatric trauma rehabilitation center in Germany. Participants: Twenty children (age range, 6[ndash ]13y) with moderate or severe TBI were examined 1[plusmn]1.2 years (mean [plusmn] standard deviation) postinjury. Fifteen were reexamined 2 months later. Control data were obtained from 20 healthy children and matched for age, gender, and school grade. Interventions: Not applicable Main Outcome Measures: Quantitative measures included 10 spatiotemporal gait parameters and 6 variables describing reaching and grasping. Qualitative scores of gait and upper-limb movements were also obtained. Results: Gait velocity and step and stride lengths were significantly smaller in children after TBI than in control subjects (Mann-Whitney U test, P[lt ].05). Reach-to-grasp movements of the TBI children were characterized by a significantly longer reaction time (Mann-Whitney U test, P[lt ].05) and movement duration, reduced velocity, and coordination deficits. The instrumented measures did not change significantly in 2 months. Several significant correlations between clinical and instrumented measures were obtained. Conclusion: Functional motor behavior is affected in children after moderate or severe TBI. To supplement clinical assessments with objective data, impairments of gait, reaching, and grasping movements can be recorded with instrumented measures. [copy ] 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

This study investigated the aerobic fitness, body composition, spirometric variables, Human Activity Profile, and level of adherence to physical activity subsequent to completion of a progressive walking program of six month's duration (T1). Sixty-six women previously randomized to training (TG) and control (CG) groups were reassessed six months after finishing the six month walking program (T2). During the follow-up period, 77.8% of the TG subjects continued with exercise and maintained lower (p0.005) exercise heart rates compared to the CG. A Mann-Whitney U test on the difference scores (T2-T1) revealed no difference (p0.05) between the TG and CG for changes in Maximum Current Activity and Normative Impairment Index, which are both components of the Human Activity Profile, with the earlier increases (p0.05) in these parameters by the TG having been maintained. Participation in a previous low frequency training regimen therefore resulted in elderly women adopting and sustaining a higher level of habitual physical activity. This is important because a favorable modification of lifestyle factors is likely to be indicative of an enhanced outlook for independence.

Objective: To assess the effects of acetic acid iontophoresis (AAI) and ultrasound on calcifying tendinitis of the shoulder, and to determine the relation between changes in the radiological measures of calcium deposit (CD) and shoulder function. Design: Randomized control trial. Setting: General community, private practice. Patients: Twenty-two adults (7 men, 15 women) with a calcifying tendinitis of the shoulder, without associated conditions, stratified according to the type of lesions (X-ray: type I, fleecy appearance; type II, homogeneous), were randomly allocated to an experimental (EXP, n = 11) or to a control (CTL, n = 10) group. Interventions: CTL group, no treatment; EXP group, nine treatments including AAI (5% acetic acid solution via the negative electrode, 5mA galvanic current, 20 minutes) followed by continuous ultrasound (0.8w/cm 2 , 1MHz, 5 minutes). Main Outcome Measures: Area and density of the CD, passive shoulder abduction (range of motion [Rom]), pain intensity. Results: Significant reduction in the area and density of CD (ANCOVA, p = .01 and .03) over time in the EXP and CTL groups, but no significant difference between groups for any of the variables measured. The decrease in the area of CD in type I lesions ( n = 5) was larger (Mann-Whitney U test, p n = 16) lesions. The relation was stronger ( r s = .90) between changes in area and density of CD than between ROM and pain ( r s = .67). Correlations were weak ( r s = .21 to .41) between radiological and functional changes. Conclusion: The reduction in CD area and density likely results from a natural process rather than treatment (AAI and ultrasound); type I lesions (resorptive phase) are more likely to display resorption of the CD than type II lesions (formative phase). Reduction of the CD area does not necessary result in a functional improvement.

Objective: To test the hypothesis that percutaneous endoscopic gastrostomy (PEG) placement, while signaling an increased risk of medical complications and death, allows survivors to achieve functional recovery and home discharge rates similar to those of case-matched controls. Design: Retrospective case-matched control study. Setting: Acute stroke rehabilitation inpatient unit. Participants: 364 patients admitted for stroke rehabilitation, 182 with PEG tubes in place and 182 case controls without PEG were matched at the time of admission for sex, age, FIM™ instrument score (mean, 2.5), and interval poststroke (mean, 1.5d). Interventions: Not applicable. Main Outcome Measures: Outcomes of interest were change in FIM scores, length of rehabilitation hospital stay, need for intercurrent transfer back to the acute hospital, final discharge destination, and survival status. All data were recorded concurrently in a computerized stroke rehabilitation data bank by rehabilitation team members unaware of the study hypothesis. Statistical analyses were as follows: the Student t test for linear data, Mann-Whitney U test for ordinal data, the chi-square test for categorical data. Variances are provided as mean ± SEM. Results: Outcomes for the 2 groups, PEG versus controls, respectively, were as follows: change in FIM scores from admission to discharge (17.3±1.3 vs 20.5±1.2, P =.07); length of rehabilitation hospital stay (45.4±1.8d vs 44.1±1.5d, P =.57); need for intercurrent transfer back to the acute hospital (51/182 vs 22/182, P =.0001); final discharge destination home/institutional care (92/74 vs 97/80, P =.91); and survival status dead/alive (16/166 vs 5/177, P =.01). Conclusions: Patients who require PEG placement are at increased risk for medical complications and death. Those who survive, however, show similar functional recovery and rate of home discharge as case-matched controls.