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Purpose: The purpose of this study is to assess and describe the meanings given to "gender" in scientific publications that evaluate multidisciplinary, interdisciplinary or multimodal rehabilitation for patients with chronic musculoskeletal pain.

Method: A systematic literature search for papers evaluating multimodal rehabilitation was conducted. The PubMed and EBSCO databases were searched from 1995 to 2015. Two or three researchers independently read each paper, performed a quality assessment and coded meanings of gender using qualitative content analysis.

Results: Twenty-seven papers were included in the review. Gender was used very differently in the MMR studies investigated but primarily it referred to factual differences between men and women. Only one paper provided a definition of the concept of gender and how it had been used in that study. In the content analysis, the meaning of gender formed three categories: "Gender as a factual difference", "The man is the ideal" and "Gender as a result of social role expectations".

Conclusions: The meaning of the concept of gender in multimodal rehabilitation is undefined and needs to be developed further. The way the concept is used should be defined in the design and evaluation of multimodal rehabilitation in future studies.

Implications for rehabilitation

Healthcare professionals should reflect on gender relations in encounters with patients, selection of patients into rehabilitation programs and design of programs. In rehabilitation for chronic pain the patients' social circumstances and cultural context should be given the same consideration as biological sex and pain symptoms.

In this investigation, we show the presence of both free glutamate (microdialysis) and glutamate NMDAR1 receptors (immunohistochemical analyses of tendon biopsies), in tendons from patients with chronic Achilles tendon pain (Achilles tendinosis) and in controls (pain-free tendons). The NMDAR1 immunoreaction was usually confined to acetylcholinesterase-positive structures, implying that the reaction is present in nerves. Glutamate is a potent pain mediator in the human central nervous system, and in animals it has been shown that peripherally administered glutamate NMDA receptor antagonists diminish the response to formalin-induced nociception. Our present finding of glutamate NMDA receptors in human Achilles tendons might have implications for pain treatment.

Background: Non-invasive treatment is not always successful in patients with Achilles tendon disorders, and surgical treatment is instituted as the next step. There is sparse knowledge about the diagnoses, pain levels before surgery, surgically confirmed pathologies and postoperative complications in large patient groups.

Aims: To study the diagnoses, pain scores before surgery, macroscopic surgical findings and postoperative complications in a series of patients treated for Achilles disorders.

Material and methods: One surgeon operated on 771 Achilles tendons of 481 men and 290 women during a 10-year period. The clinically and ultrasound confirmed diagnoses, pre-operative pain and functional scores (Visual Analogue Scale, VAS, range 0-100; Victorian Institute Sports Tendon Assessment - Achilles questionnaire, VISA-A), macroscopic findings during surgery and postoperative complications, were retrospectively collected from a database.

Results: Clinically, by ultrasound and during surgery midportion Achilles tendinopathy was confirmed in 519 (67%) patients, 41% of them had a thickened plantaris tendon located close the Achilles tendon. Partial midportion rupture was found in 31 (4%) patients, chronic midportion rupture in 12 (2%) patients and insertional Achilles tendinopathy, including superficial and retro-calcaneal bursitis, Haglund deformity, distal Achilles tendinopathy, plantaris tendon pathology, and bone spurs, in 209 (27%) patients. The mean pre-operative pain scores for midportion Achilles tendinopathy were 73 (VAS) and 45 (VISA-A), and for insertional Achilles tendinopathy 77 (VAS) and 39 (VISA-A). For midportion Achilles tendinopathy there were 14 (3%), and for insertional Achilles tendinopathy 10 (5%), postoperative complications.

Conclusions: Patients presenting high pain scores from midportion Achilles tendinopathy were the most common. Plantaris tendon involvement is a frequent observation. For insertional Achilles tendinopathy the combination of pathology in the subcutaneous and retrocalcaneal bursa, a Haglund deformity and distal Achilles tendinopathy/tendinosis was most frequent. 

Background Insertional Achilles tendinopathy is well known to be difficult to treat, especially when there is intra-tendinous bone pathology. This study is a case series on patients with chronic insertional Achilles tendon pain and major intra-tendinous bony pathology together with bursa and tendon pathology, treated with excision of the subcutaneous bursa alone. Methods Eleven patients (eight men and three women) with a mean age of 44 years (range 24-62) and a chronic (>6 months) painful condition from altogether 15 Achilles tendon insertions were included. In all patients, ultrasound examination showed intra-tendinous bone pathology together with pathology in the tendon and subcutaneous bursa, and all were surgically treated with an open excision of the whole subcutaneous bursa alone. This was followed by full weight-bearing walking in a shoe with open heel for 6 weeks. Results At follow-up 21 (median, range 12-108) months after surgery, 9/11 patients (12/15 tendons) were satisfied with the result of the operation and 10/11 (13/15 tendons) were back in their previous sport and recreational activities. The median VISA-A score had improved from 41 (range 0-52) to 91 (range 33-100) (p<0.01). Conclusion In patients with chronic painful insertional Achilles tendinopathy with intra-tendinous bone pathology, tendon and bursa pathology, open removal of the subcutaneous bursa alone can relieve the pain and allow for Achilles tendon loading activities. The results in this case series highlight the need for more studies on the pain mechanisms in insertional Achilles tendinopathy and the need for randomised studies to strengthen the conclusions.

OBJECTIVE: To characterise Achilles tendon structure and thickness a minimum of 8 years after intra-tendinous surgery. Material and METHODS: Fourteen patients (16 tendons; 9 men and 5 women, mean age 43 years, range 27-55) surgically treated (intra-tendinous surgery) for chronic painful midportion Achilles tendinosis, were followed with clinical examination and grey-scale ultrasonography for a minimum of 8 years (range 8-16 years, mean 13 years). RESULTS: All patients were satisfied with the result of surgery and were active in Achilles tendon loading activities without restrictions. In all operated tendons, structural abnormalities remained and tendons remained thicker than normal tendons. CONCLUSIONS: Resection of tendinosis is associated with persistent structural abnormalities and thickening of the tendon 13 years after surgery, despite successful clinical outcomes.

Objective: Neurophysiological investigation has shown that patients with clinically complete spinal cord injury can have residual motor sparing ("motor discomplete"). In the current study somatosensory conduction was assessed in a patient with clinically complete spinal cord injury and a novel ethodology for assessing such preservation is described, in this case indicating "sensory discomplete" spinal cord injury. Methods: Blood oxygenation level-dependent functional magnetic resonance imaging (BOLD fMRI) was used to examine the somatosensory system in a healthy subject and in a subject with a clinically complete cervical spinal cord injury, by applying tactile stimulation above and below the level of spinal cord injury, with and without visual feedback. Results: In the participant with spinal cord injury, somatosensory stimulation below the neurological level of the lesion gave rise to BOLD signal changes in the corresponding areas of the somatosensory cortex. Visual feedback of the stimulation strongly modulated the somatosensory BOLD signal, implying that cortico-cortical rather than spino-cortical connections can drive activity in the somatosensory cortex. Critically, BOLD signal change was also evident when the visual feedback of the stimulation was removed, thus demonstrating sensory discomplete spinal cord injury. Conclusion: Given the existence of sensory discomplete spinal cord injury, preserved but hitherto undetected somatosensory conduction might contribute to the unexplained variability related to, for example, the propensity to develop decubitus ulcers and neuropathic pain among patients with clinically complete spinal cord injury.

Background: Traumatic brain injury (TBI) is one of the most common causes of disability and mortality. While some patients recover quickly, especially at the mild side of the injury severity continuum, many will experience symptoms for years to come. In this chronic phase, patients report a wide array of symptoms, where fatigue is one the most common. This fatigue makes huge impact in several areas of these patients’ lives. Despite the prevalence of fatigue after TBI, the underlying mechanisms are unclear. Further, there are no standardized way for assessment and diagnosis, and there are no treatments with satisfying empirical support. The aim of this thesis was to examine the effects of the novel compound OSU6162 on fatigue in patients with TBI, and to explore functional and structural brain imaging correlates of fatigue after TBI.

Methods: Studies I and III were based on a placebo-controlled, double-blinded clinical trial examining the effects of the monoaminergic stabilizer OSU6162 on fatigue in patients in the chronic phase of traumatic brain injury. In study I, self-assessment scales of fatigue and neuropsychological tests were used as outcomes, while functional magnetic resonance imaging (fMRI) blood-oxygen-level dependent (BOLD) signal was the primary outcome in study III. Studies II and IV used cross-sectional designs, comparing patients with TBI with age- and gender matched healthy controls. Study II examined whether fMRI BOLD signal could be used to detect and diagnose fatigue in patients with TBI, and study IV whether white matter hyperintensities (WMH) contribute to lower cognitive functioning and presence of fatigue after TBI.

Results: Study I revealed no effects of OSU6162 during 28 days of treatment at maximum doses of 15 mg twice daily on measures of fatigue or any other outcome. The results from study II indicated that fatigue after TBI is linked to alterations in striato-thalamic-cortical loops, and suggested that fMRI could be a promising technique to use in the diagnosis of fatigue after TBI. In study III the results revealed effects of treatment in the right occipitotemporal and orbitofrontal cortex. In these areas, the BOLD response was normalized in the OSU6162 group as compared to healthy controls, while the placebo group showed a steady low activity in these areas. The regional effects were located outside the network shown to be linked to fatigue in study II, which might explain why there were no effects on fatigue after treatment with OSU6162 in study I. Study IV showed that WMH lesions increased with increased TBI severity, but the presence and extent of lesions did not explain lower neuropsychological functioning or fatigue in subjects with previous TBI.

Conclusions: In summary, although no effects on fatigue after treatment with OSU6162 were seen, the results provide support to the theory that fatigue after TBI is linked to alterations in striato-thalamic-cortical loops, and on how fatigue after TBI could be assessed or diagnosed using fMRI. Structural damage within white matter was however not related to fatigue.

Introduction: There are great potential benefits of being able to conduct neuropsychological assessments remotely, especially for hard-to-reach or less mobile patient groups. Such tools need to be equivalent to standard tests done in the clinic and also easy to use in a variety of clinical populations.

Methods and analysis: This study protocol describes a cross-sectional study aimed at validating the newly developed digitalized neuropsychological test battery Mindmore Remote in patients with neurological disorders and injuries. Diagnoses comprise traumatic brain injury, stroke, Parkinson’s disease, multiple sclerosis, brain tumour and epilepsy. 50 patients in each patient group will be included. In addition, 50 healthy controls will be recruited. All participants will undergo both testing with Mindmore Remote at home and traditional neuropsychological assessment face-to-face in a randomised order. The primary outcome is the association between tests from the Mindmore Remote battery and their equivalent traditional neuropsychological tests. Further, bias between methods and differences between groups will also be investigated.

Ethics and dissemination: The study protocol has been approved by the Swedish Ethical Review Authority (2022-06230-01) and adheres to the declaration of Helsinki. All participants will be given oral and written information about the study and sign informed consent forms before entering the study. All participants are informed that they can terminate their participation in the study at any given time, without giving any explanation, and participating in the study or not will not affect their care at the clinic. Neither authors nor personnel involved in the research project are affiliated with Mindmore AB. The results from the study will be published in peer-reviewed scientific journals and presented at national and international conferences on the topic.

Trial registration number: NCT05819008.

Objective: To examine the prevalence of white matter hyperintensities (WMHs) in patients with traumatic brain injury (TBI) as compared to healthy controls, and to investigate whether there is an association between WMH lesion burden and performance on neuropsychological tests in patients with TBI.

Methods: A total of 59 patients with TBI and 27 age- and gender- matched healthy controls underwent thorough neuropsychological testing and magnetic resonance imaging. The quantification of WMH lesions was performed using the fully automated Lesion Segmentation Tool.

Results: WMH lesions were more common in patients with TBI than in healthy controls (p = 0.032), and increased with higher TBI severity (p = 0.025). Linear regressions showed that WMH lesions in patients with TBI were not related to performance on any neuropsychological tests (p > 0.05 for all). However, a negative relationship between number of WMH lesions in patients with TBI and self-assessed fatigue was found (r = –0.33, p = 0.026).

Conclusion: WMH lesions are more common in patients with TBI than in healthy controls, and WMH lesions burden increases with TBI severity. However, these lesions do not seem to explain the decreased cognitive functioning or the increased fatigue in patients with TBI.

Dysfunction in executive functions is common among patients with chronic pain. However, the relationships between executive functioning and pain management have not been extensively studied. In this study, 189 outpatients (160 women, 29 men; mean age 33.15) with chronic pain underwent an extensive neuropsychological assessment, including several tests of executive functions. In addition, all participants completed self-assessment questionnaires regarding pain and interference of pain in everyday life. After adjusting for effects of age, education, and depression, several aspects of executive functioning were significantly associated with self-assessed everyday interference of pain (rs = 0.13–0.22, all ps < 0.05). This indicates that lower performance on tests of executive functioning was significantly associated with a higher degree of pain interference and a lower degree of life control. Pain characteristics such as pain intensity, pain duration, and pain spreading were not associated with executive functioning. These results suggest that preserved executive functions are related to better coping with pain, but not directly to the pain itself, in patients with chronic pain. Depression was also associated with self-management of pain, indicating that patients with lower executive functioning in combination with depression may need special attention during rehabilitation.

Purpose: To evaluate body awareness and perceived health in patients with chronic pain after participation in a multimodal rehabilitation (MMR) programme and at 1-year follow-up.

Method: Thirty-nine patients participated in a 5-week outpatient MMR programme. They were evaluated with the main outcome measures: the Body Awareness Scale (BAS) using an interview (BAS-I) and a movement test (BAS-Obs), the Nottingham Health Profile (NHP) and the Sense of Coherence (SOC). A subgroup analysis was conducted based on the BAS-Obs scores at the start of the MMR programme with cut-off at the upper quartile ≥ 26 point, classified as low body awareness; the three lower quartiles were classified as moderate/high body awareness.

Results: All patients improved on the BAS-Obs and the BAS-I from the start to the end of the MMRP (p < 0.001) and at 1-year follow-up on four of the BAS-Obs subscales (p < 0.005). The moderate/high body awareness group improved on BAS-I, NHP and SOC (p < 0.01) and on two BAS-I subscales (p < 0.005), while the low body awareness group improved on one subscale (p = 0.003).

Conclusion: Our results suggest that the use of the BAS-Obs assessment to identify patients with high or low levels of body awareness could play an important part in understanding the individual's clinical needs and be useful for developing an effective rehabilitation programme for patients with chronic pain.

Perceptual and motor functions and self-care ability after stroke were assessed within two weeks (n:109; mean age 69±10) and 4-6 years (n:75;70±9) after admission to a non-intensive care stroke unit. Sixty-two of the long-term stroke survivors reported on their life satisfaction (7 items) as experienced (in retrospect) before the stroke and at the time of the investigation. Perceptual functions and actual levels of life satisfaction were registered in 60 clinically healthy subjects aged about 60 or about 80 years.

Both early on and late after stroke the 16 items of perceptual function were clearly grouped into two factors, which neatly fitted an ecological perceptual concept. One factor characterized low-order and the other higher-order perception. Impairments of low-order perception occurred for about 10% of the patients, whether investigated early or late after stroke. No one among the reference populations had such impairments. Higher-order perceptual impairments prevailed in 60% early on and in 57% late after stroke and were often more pronounced than those occurring in the reference populations, among whom 35% of the 60 year olds and significantly more - 77% - of the 80 year olds had such impairments. Hence, perceptual impairments are common after stroke, but slight age-dependent reductions should be considered when higher-order perceptual function is assessed and treated after stroke.

Together with motor function, which was impaired in 52% of the early and 36% of the late stroke samples, higher-order perceptual function and to a limited extent low-order perception could predict the level of self-care ability in 70% and 62% of the early and late samples, respectively.

Whereas levels of global and of domain specific variables of life satisfaction were similar in the two reference populations, the stroke had lead to a reduction in life satisfaction for 61% of the long-term survivors. Reductions were particularly pronounced for global life satisfaction and for satisfaction with leisure and sexuality. Although significantly associated with motor impairment and self-care disability, these reductions could not be attributed only to impairments and disability.

The findings are discussed with particular reference to assessment and treatment in occupational therapy.

The relative importance of motor, perceptual, and some cognitive functions for self-care ability was analyzed in a representative sample of 109 subjects within 2 weeks of acute stroke. Forty-nine patients (45%) were dependent or partly dependent in self-care. Profound motor dysfunction was present in 39%, low-order perceptual deficits in 10%, high-order perceptual deficits in 60%, and disorientation in time and space in 13% of the patients. There was a significant covariation between motor function and self-care ability and between low-order perception and orientation function. Low-order and high-order perception covaried only weakly. Discriminant analyses showed that the actual level of self-care proficiency could be correctly predicted in 70% of the cases by the 4 indexes of motor function, low-order perception, high-order perception, and orientation. The dominating predictor was motor function, and the next highest was high-order perception. When a program for early training is designed with the aim to alleviate long-term self-care disability after stroke, correct assessment of motor and perceptual functions in the individual stroke patient is essential.

Perceptual function was assessed in 60 clinically healthy subjects aged about 60 (n=34) and 80 (n=26), and in stroke survivors who were assessed either early (n=109) or four to six years (n=75) after the stroke. Using two indices, one characterising low-order perception and the other higher-order perception, the clinically healthy subjects invariably had no impairment in the low-order index. Slight impairments occurred in 35% of 60-year-old and 77% of 80-year-old healthy subjects. Considerably more pronounced disturbances occurred in the stroke victims, among whom about 60% had impairment or higher-order perceptual function and about 10% had low-order perceptual deficits. Thus as higher-order perception is age dependent, it appears that in rehabilitation of stroke allowance should be made for predictable signs of advancing age.

Long-term symptoms after whiplash injury often comprise neck pain, headache, anxiety, depression, functional impairment and low quality of life. In an observational cohort study, we examined physical and mental health effects in patients with subacute to chronic whiplash-associated disorders (WAD) after participation in a multimodal rehabilitation (MMR) program. MMR is a team-based multi-professional method based on a bio-psycho-social model with a cognitive focus to reach an individualized and common goal for the team and patient together. Standardized self-report questionnaires were filled in three times: before MMR, after MMR, and one year after MMR. A total of 322 participants completed the program, 161 of whom responded in full and were further analyzed. At one-year follow-up after MMR, a significant improvement was seen in the evaluation of the primary outcomes (physical and mental health) and secondary outcomes (anxiety, depression, pain intensity and interference with life). Women improved on all outcomes while men did not improve on the psychological measures (mental health, depression and anxiety). This study indicates that a MMR program could be beneficial for patients with subacute to chronic WAD, at least for women, since the outcomes at one-year follow-up were positive.

Objective: To examine the effect of using a mitt during shortened constraint-induced movement therapy for patients in the subacute phase after stroke.

Subjects: Twenty-four patients with stroke (mean age 57.6 (standard deviation 8.5) years; average 7 weeks post-stroke) with mild to moderate impaired hand function.

Methods: The patients were randomized to mitt use or no mitt use on the less affected hand for 90% of waking hours for 12 days. All patients received 3 h of arm and hand training per day for 2 weeks. Assessments were made by blinded observers using the modified Motor Assessment Scale, the Sollerman hand function test, the 2-Point Discrimination test and Motor Activity Log test.

Results: Patients in both groups showed significant improvements in arm and hand motor performance and on self-reported motor ability after 2 weeks of therapy and at 3 months follow-up. However, no statistically significant differences between the groups were found in any measures at any point in time.

Conclusion: In this study, no effect of using a restraint in patients with subacute stroke was found. Thus, this component in the constraint-induced therapy concept seems to be of minor importance for the outcome.

The Swedish Quality Registry for Pain rehabilitation (SQRP) is a well-established clinical registry for adult patients with complex chronic pain conditions. SQRP registers patient-reported outcome measures from a majority of specialist chronic pain units/departments in Sweden. Up to four International Classification of Diseases version 10 (ICD-10) diagnoses can be registered in SQRP. The aim of the paper is to describe how we envision the new chronic pain category MG30 in ICD-11 can be used in SQRP. We envision that the first diagnosis in SQRP shall always be a MG30 diagnosis, which will ensure broad implementation of ICD-11 in Swedish pain care. However, at first glance, there seems to be specificity problems with ICD-11 codes that might impair their useability in SQRP or other registries. But ICD-11 offers more than meets the eye. First, the entries at the level of the so-called foundational layer have unique resource identifiers (URI) that can be used to enhance specificity. Second, ICD-11 contains numerous extension codes that can be combined with the MG30 codes – for instance, concerning the anatomical location of pain. Third, to enrich the description of the clinical concept at hand, it is possible to create clusters of stem codes. These three options are briefly discussed. We conclude that the full potential of the MG30 category can be better exploited in registries such as SQRP if foundational codes, extension codes, and/or clustering of stem codes are used to enhance diagnostic specificity.

Background: Pain in the orofacial region is often reported after whiplash trauma. However, prospective studies evaluating clinical signs related to orofacial pain and disability in whiplash populations are rare. The aim of the present study was to evaluate clinical signs related to pain and dysfunction in orofacial and neck regions after whiplash trauma, in a short- and long-term perspective.

Methods: In total, 84 cases (48 women) diagnosed with neck distortion after a car accident and 116 controls (68 women) were examined within 1 month, and 49 cases (27 women) and 71 controls (41 women) were re-examined 2 years later. Outcome measures were pain on palpation of jaw and neck muscles and maximal jaw opening. Analysis was performed using mixed-models.

Results: Cases and women were at higher risk for pain on palpation of jaw muscles (OR:7.7; p < 0.001 and OR:3.2; p = 0.010 respectively) and neck muscles (OR:12.7; p < 0.001 and OR:2.9; p = 0.020 respectively) but with no significant effect of time. Cases and women also had lower maximal jaw opening (−3.1; p = 0.001 and −3.3; p = 0.001 respectively). There was no significant time effect, but a significant interaction between cases and time (2.2; p = 0.004).

Conclusion: Individuals with a whiplash trauma present a higher risk for pain on palpation in jaw and neck muscles both in a short- and long-term perspective, but show normal jaw movements. No time effect suggests that cases do not spontaneously improve nor get worse. Investigating pain on palpation in the jaw and neck muscles after whiplash trauma can identify individuals at risk for developing long-term orofacial pain and dysfunction.

Significance: Orofacial pain is often reported after whiplash trauma but most previous studies concerning orofacial pain in whiplash populations have been questionnaire studies. Cases with a previous whiplash trauma and women, in general, had higher risk for pain on palpation in the jaw and neck region. Investigating pain on palpation after a whiplash trauma can help to identify individuals at risk of developing long-lasting pain in the orofacial region.

Objectives: To explore predictive factors for the development and maintenance of jaw pain over a 2-year period.

Methods: One hundred nineteen cases (73 women) and 104 controls (59 women), mean age 34.9 years (SD 13.9), attended baseline and 2-year follow-up examinations. The whiplash cases visited the emergency department at Umeå University Hospital, Sweden, with neck pain within 72 h following a car accident, and baseline questionnaires were answered within a month after trauma. Controls were recruited via advertising. Inclusion criteria were age 18–70 years, living in Umeå municipality and Swedish speaking. The exclusion criterion was neck fracture for cases and a previous neck trauma for controls. Validated questionnaires recommended in the standardized Research Diagnostic Criteria for temporomandibular disorders were used. Jaw pain was assessed by two validated screening questions answered with “yes” or “no.” A logistic regression analysis was used to predict the outcome variable jaw pain (yes/no) after 2 years.

Results: Whiplash trauma did not increase the odds of development of jaw pain over a 2-year period (OR 1.97, 95% CI 0.53–7.38). However, non-specific physical symptoms (OR 8.56, 95% CI 1.08–67.67) and female gender (OR 4.89, 95% CI 1.09–22.02) did increase the odds for jaw pain after 2 years.

Conclusion: The development and maintenance of jaw pain after whiplash trauma are primarily not related to the trauma itself, but more associated with physical symptoms.

Clinical relevance: The development of jaw pain in connection with a whiplash trauma needs to be seen in a biopsychosocial perspective, and early assessment is recommended.

Background: Mild traumatic brain injury (MTBI) is a major public-health concern and represents 70-90% of all treated traumatic brain injuries. The last best-evidence synthesis, conducted by the WHO Collaborating Centre for Neurotrauma, Prevention, Management and Rehabilitation in 2002, found few quality studies on prognosis. The objective of this review is to update these findings. Specifically, we aim to describe the course, identify modifiable prognostic factors, determine long-term sequelae, and identify effects of interventions for MTBI. Finally, we will identify gaps in the literature, and make recommendations for future research.

Methods: The databases MEDLINE, PsychINFO, Embase, CINAHL and SPORTDiscus were systematically searched (2001 to date). The search terms included 'traumatic brain injury', 'craniocerebral trauma', 'prognosis', and 'recovery of function'. Reference lists of eligible papers were also searched. Studies were screened according to pre-defined inclusion and exclusion criteria. Inclusion criteria included original, published peer-reviewed research reports in English, French, Swedish, Norwegian, Danish and Spanish, and human participants of all ages with an accepted definition of MTBI. Exclusion criteria included publication types other than systematic reviews, meta-analyses, randomized controlled trials, cohort studies, and case-control studies; as well as cadaveric, biomechanical, and laboratory studies. All eligible papers were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers performed independent, in-depth reviews of each eligible study, and a third reviewer was consulted for disagreements. Data from accepted papers were extracted into evidence tables, and the evidence was synthesized according to the modified SIGN criteria.

Conclusion: The results of this study form the basis for a better understanding of recovery after MTBI, and will allow development of prediction tools and recommendation of interventions, as well as informing health policy and setting a future research agenda.

Objective

To synthesize the best available evidence on prognosis after sport concussion.

Data Sources

MEDLINE and other databases were searched (2001–2012) with terms including “craniocerebral trauma” and “sports.” Reference lists of eligible articles were also searched.

Study Selection

Randomized controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to have a minimum of 30 concussion cases.

Data Extraction

Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network (SIGN) criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables.

Data Synthesis

Evidence was synthesized qualitatively according to modified SIGN criteria, and studies were categorized as exploratory or confirmatory based on the strength of their design and evidence. After 77,914 records were screened, 52 articles were eligible for this review, and 24 articles (representing 19 studies) with a low risk of bias were accepted. Our findings are based on exploratory studies of predominantly male football players at the high school, collegiate, and professional levels. Most athletes recover within days to a few weeks, and American and Australian professional football players return to play quickly after mild traumatic brain injury. Delayed recovery appears more likely in high school athletes, in those with a history of previous concussion, and in those with a higher number and duration of postconcussion symptoms.

Conclusions

The evidence concerning sports concussion course and prognosis is very preliminary, and there is no evidence on the effect of return-to-play guidelines on prognosis. Our findings have implications for further research. Well-designed, confirmatory studies are urgently needed to understand the consequences of sport concussion, including recurrent concussion, across different athletic populations and sports.

Objective

To synthesize the best available evidence on return to work (RTW) after mild traumatic brain injury (MTBI).

Data Sources

MEDLINE and other databases were searched (2001–2012) with terms including “craniocerebral trauma” and “employment.” Reference lists of eligible articles were also searched.

Study Selection

Controlled trials and cohort and case-control studies were selected according to predefined criteria. Studies had to assess RTW or employment outcomes in at least 30 MTBI cases.

Data Extraction

Eligible studies were critically appraised using a modification of the Scottish Intercollegiate Guidelines Network criteria. Two reviewers independently reviewed and extracted data from accepted studies into evidence tables.

Data Synthesis

Evidence was synthesized qualitatively according to modified Scottish Intercollegiate Guidelines Network criteria and prioritized according to design as exploratory or confirmatory. After 77,914 records were screened, 299 articles were found eligible and reviewed; 101 (34%) of these with a low risk of bias were accepted as scientifically admissible, and 4 of these had RTW or employment outcomes. This evidence is preliminary and suggests that most workers RTW within 3 to 6 months after MTBI; MTBI is not a significant risk factor for long-term work disability; and predictors of delayed RTW include a lower level of education (<11y of formal education), nausea or vomiting on hospital admission, extracranial injuries, severe head/bodily pain early after injury, and limited job independence and decision-making latitude.

Conclusions

Our findings are based on preliminary evidence with varied patient characteristics and MTBI definitions, thus limiting firm conclusions. More well-designed studies are required to understand RTW and sustained employment after MTBI in the longer term (≥2y post-MTBI).

This study determined the day-to-day reliability of NIRS-derived oxygenation responses (a dagger StO(2)%) for isometric contractions and for cuff occlusion. Twenty-four subjects (12 males and 12 females) were tested for 2 days (4-6 days interval). Variables generated were: (1) a dagger StO(2)% for isometric contractions (10, 30, 50 and 70% MVC) for descending trapezius (TD) and extensor carpi radialis (ECR) muscles; (2) slope changes in total haemoglobin (HbTslope) and deoxyhaemoglobin (HHbslope) for the ECR using upper arm venous (VO, 50 mmHg) and arterial occlusion (AO, 250 mmHg); (3) recovery slopes (Rslope) for oxygen saturation (StO(2)) following isometric contractions and AO. For each variable, an intraclass correlation (ICC) was calculated to assess the ability to differentiate between subjects, and limits of agreement (LOA) were computed to assess day-to-day consistency of the measurement. ICCs for Delta StO(2)% were lowest at 10% MVC for both ECR (0.58) and TD (0.55), and highest at 30% MVC for ECR (0.95) and at 70% MVC for TD (0.79). For both muscles, LOA for Delta StO(2)% was lowest at 10% and highest at 50 and 70% MVC. ICC for HbTslope was 0.17. For HHbslope ICC was higher for AO (0.83) than for VO (0.73), and LOA was lower for AO. For the ECR Rslope ICCs ranged from 0.88 to 0.90 for contraction, but was lower for AO (0.33); LOA was lowest at 70% MVC. For trapezius Rslope ICCs ranged from 0.63 to 0.73 and LOA was lowest at 30% MVC. For this study, establishing reliability data for the ECR and TD and including variables commonly reported are expected to have meaning for future NIRS studies of work-related upper-extremity pain as well as for other NIRS research and clinical applications.

STUDY DESIGN: Prospective, population-based study. This paper is part of the Stockholm Thessaloniki Acute Traumatic Spinal Cord Injury Study (STATSCIS).

OBJECTIVES: To evaluate and compare outcomes, length of stay (LOS), associated conditions and medical complications at 1-year post-trauma.

SETTINGS: The Greater Thessaloniki region, Greece, and the Greater Stockholm region, Sweden. While Stockholm follows a SCI system of care, Thessaloniki follows a fragmented 'non-system' approach.

SUBJECTS: Out of the 87 cases in Thessaloniki and the 49 cases in Stockholm who comprised the study population of STATSCIS, 75 and 42 cases respectively were successfully followed-up during the first year post-trauma.

RESULTS: Significantly superior outcomes (that is, survival with neurological recovery, functional ability and discharge to home) and shorter LOS for initially motor complete cases occurred in Stockholm. Management routines known to increase long-term morbidity, for example, long-term tracheostomy and indwelling urethral catheters were significantly more common in Thessaloniki. Major medical complications, that is, multiple pressure ulcers, heterotopic ossification and bacteremia/sepsis were more frequent in Thessaloniki.

CONCLUSIONS: Our findings show how two rather similar cohorts of TSCI manifest large discrepancies in terms of 1-year outcomes and complications, depending on the type of management they receive. As the major difference between regions was the presence or absence of a SCI system of care, rather than differences in availability of modern medicine, the mere presence of the latter does not seem to be sufficient to guarantee adequate outcomes. This study provides strong evidence as to the urgent need of implementing a SCI system of care in Greece.

STUDY DESIGN: Prospective, population-based study. This paper is part of the Stockholm Thessaloniki Acute Traumatic Spinal Cord Injury Study (STATSCIS). OBJECTIVES: To characterize patient populations and to compare acute management after traumatic spinal cord injury (TSCI). SETTINGS: The Greater Thessaloniki region in Greece and the Greater Stockholm region in Sweden. METHODS: Inception cohorts with acute TSCI that were hospitalized during the study period, that is September 2006 to October 2007, were identified. Overall, 81 out of 87 cases consented to inclusion in Thessaloniki and 47 out of 49 in Stockholm. Data from Thessaloniki were collected through physical examinations, medical record reviews and communication with TSCI cases and medical teams. Data from Stockholm were retrieved from the Nordic Spinal Cord Injury Registry. RESULTS: There were no significant differences between study groups with regard to core clinical characteristics. In contrast, there were significant differences in (1) transfer logistics from the scene of trauma to a tertiary-level hospital (number of intermediate admissions, modes of transportation and duration of transfer) and (2) acute key therapeutic interventions, that is, the use of mechanical ventilation (49% in Thessaloniki versus 20% in Stockholm), and performance of tracheostomy (36% in Thessaloniki versus 15% in Stockholm); spinal surgery was performed significantly more often and earlier in Stockholm than in Thessaloniki. CONCLUSIONS: Despite largely similar core clinical characteristics, Stockholm and Thessaloniki cases underwent significantly different acute management, most probably to be attributed to adaptations to the differing regional approaches of care one following a systematic approach of SCI care and the other not.

BACKGROUND: Little is known about the possible impact of the system of care on mortality during the first year after acute traumatic spinal cord injury (TSCI).

OBJECTIVE: To evaluate late mortality (i.e., >7 days after trauma) during the first year after acute TSCI in 2 European Union (EU) regions, Thessaloniki in Greece and Stockholm in Sweden.

METHODS: This paper is part of the Stockholm Thessaloniki Acute Traumatic Spinal Cord Injury Study (STATSCIS), which is a prospective, population-based study. Incidence cohorts of TSCI cases were identified and followed up in both study regions through STATSCIS. Data from Thessaloniki region were collected through physical examination, medical records review, and interviews with TSCI individuals and the medical teams. Data from Stockholm were retrieved mainly from the Nordic Spinal Cord Injury Registry, as well as from direct contact with all intensive care facilities of the region.

RESULTS: The annual case mortality rate after acute TSCI was nearly 20% in Thessaloniki and 0% in Stockholm. The mean time of survival after trauma for the 12 mortality cases of Thessaloniki was 47 days (median = 24, SD +/- 67, range = 8-228). Factors associated with mortality were higher age and presence of comorbid spinal disorders but also the inefficient transfer logistics, initially missed spinal instability, and unsuccessfully treated complications.

CONCLUSIONS: The annual case mortality rate in Thessaloniki was dramatically higher than in Stockholm. The different approaches to care, one systematic and the other not, is postulated to be an important factor leading to such major discrepancies between the outcomes of these 2 EU regions.

The aim of this study was to explore the content of rehabilitation plans after multimodal rehabilitation (MMR) for chronic pain patients, focusing on occupation-oriented measures. A secondary aim was to study how the individual rehabilitation plans had been carried out and implemented during 1 year after MMR. A multiple methods approach with quantitative and qualitative data was used. The quantitative part was descriptive and examined whether the rehabilitation plans were carried out, the number of recommendations in each plan and the type of measures suggested. The qualitative part constituted a content analysis of interviews. Vocational rehabilitation was the second most common recommendation for the whole group. The analysis of the interviews resulted in seven categories divided into two main categories: impeding factors and facilitating factors for rehabilitation. The compliance of professionals and external parties with the patients’ rehabilitation plans, and the patients’ positive experience of their change in behaviour, contributed to the completion of the rehabilitation plans. In conclusion, lack of follow-up from the professionals and negative bodily signals inhibited the completion of rehabilitation. Flexibility on the part of professionals and external actors regarding patients’ rehabilitation plans as well as their own positive experiences of striving for change facilitated rehabilitation.