Introduction: Clinical practice guidelines in neurorehabilitation for adults with disorders of consciousness by the Spanish Neurorehabilitation Society. This document is based on a review of international clinical practice guidelines published between 2015 and 2022. Method: A total of seven articles, corresponding to five clinical practice guidelines published between 2015 and 2022, were selected by the group of authors from a pool of 48 bibliographic references extracted from various databases in accordance with predefined search criteria. Following this review, 40 recommendations were formulated and subjected to evaluation by an expert committee using a 9-point Likert scale: 1-3 (inappropriate recommendation), 4-6 (uncertain recommendation), and 7-9 (appropriate recommendation), following the methodology of the Modified Nominal Group Technique. Any recommendation endorsed by at least 75% of the experts as << appropriate>> (with a score of 7-9) was considered accepted. Conclusions: This document presents 40 recommendations categorized according to the level of evidence provided by the reviewed studies. These recommendations represent a consensus among experts and pertain to various aspects related to: (1) clinical assessment; (2) complementary diagnostic tests; (3) prognosis, and (4) treatment in this specific population. (c) 2024 Sociedad Espaniola de Neurolog & imath;a. Published by Elsevier Espania, S.L.U. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

INTRODUCTION:We present the guidelines for pain management in neurorehabilitation of brain injury in adults of the Spanish Society of Neurorehabilitation based on the review and analysis of the available literature on the subject. We establish recommendations according to the level of evidence offered by the reviewed studies. DEVELOPMENT:The methodology followed by the Spanish Society of Neurorehabilitation for the elaboration of the present guide is based on the analysis of the national and international clinical practice guidelines of the last seven years, carried out according to the management considerations dictated by the evidence for the usual types of pain in the population of people who have suffered an acquired brain injury. CONCLUSIONS:Pain is a common symptom in patients who have suffered brain damage, having a negative impact on quality of life and adherence to the rehabilitation process. When classifying the type of pain according to etiological characteristics, in order to optimise the type of therapeutic approach, we usually refer to pain as nociceptive, and neuropathic pain, although pain in such patients often has "mixed" characteristics. The most common type of pain is nociceptive ahead of neuropathic. The most common pain syndromes in this population are headache, hemiplegic shoulder pain and poststroke central pain. As pain is a subjective experience, people with impaired level of consciousness, severe cognitive impairment and/or severe language problems may have greater difficulty or even being unable to communicate it. An adequate clinical history and a directed physical examination, as well as the use of specific scales for its correct diagnosis are therefore important. Finally, many of the drugs used for its management have a negative impact on rehabilitation, affecting cognitive processes, and/or worsening other neurological symptoms. Furthermore, these patients often have several comorbidities and are frequently on several drugs which means that the approach to pain management must be carefully elaborated by a multidisciplinary team approach.

INTRODUCTION:Obesity is a chronic disease that influences the evolution and functional prognosis of many of the pathologies for which patients are referred to physical medicine and rehabilitation (PMR) departments. Patients with more complex obesity present different associated comorbidities that require a multidisciplinary approach and adaptations in the material resources of the services of rehabilitation. The objective is to know how rehabilitation doctors address this condition in their healthcare practice. MATERIALS AND METHODS:This is a descriptive cross-sectional study using a 20-question survey designed by the Obesity Working Group of the Spanish Society of Physical Medicine and Rehabilitation (SERMEF), which includes both qualitative and quantitative variables. RESULTS:Of the participants, a high percentage consider obesity as a disease, but 52% consider that obesity determines the functional outcome in these patients. Regarding the level of training in the approach to patients with obesity, 74.1% of those surveyed consider that they do not have the appropriate skills to manage patients with obesity in their usual practice and a high percentage also reports not having the necessary resources for evaluation and treatment. In order to assess body composition 12.2% of the participants used electrical bioimpedance analysis and less than 5% used ultrasound. Another aspect worth highlighting is that 21% of those surveyed report the existence of multidisciplinary units for the management of people with morbid obesity, and in 30% of those units the PMR physician participates in the development of care protocols for patients with bariatric surgery. CONCLUSION:This first study carried out in Spain on the perception of the impact of obesity and the approach in rehabilitation consultations reveals the lack of specific training and basic tools for the evaluation of this pathology. That is why, from the SERMEF Obesity and Sarcopenia Working Group, we consider increasing knowledge among Physical Medicine and Rehabilitation specialists as priority objective.

IntroducciónLa Guía para el manejo del dolor en neurorrehabilitación del daño cerebral sobrevenido (DCS) de personas adultas de la Sociedad Española de Neurorrehabilitación (SENR) está basada en la revisión y análisis de la bibliografía disponible sobre el tema. Estableciéndose recomendaciones según el nivel de evidencia que ofrecen los estudios revisados.DesarrolloLa metodología seguida por la SENR para la elaboración de la presente guía se basa en el análisis de las guías de prácticas clínicas nacionales e internacionales de los últimos siete años, llevado a cabo en función de las consideraciones del manejo que dicta la evidencia para las clases de dolor habituales en la población de personas que han sufrido un DCS.ConclusionesEl dolor es un síntoma habitual en personas que han sufrido daño cerebral teniendo un impacto negativo en la calidad de vida y en la adherencia al proceso rehabilitador. A la hora de clasificar el tipo de dolor según las características etiológicas, para optimizar el tipo de abordaje terapéutico, se suele hablar de dolor nociceptivo y dolor neuropático, aunque con frecuencia el dolor en estos pacientes presenta características «mixtas». El tipo de dolor más habitual es el nociceptivo frente al neuropático. Los cuadros sindrómicos dolorosos que aparecen con más frecuencia en esta población son la cefalea, el hombro doloroso del hemipléjico (HDH) y el dolor central posictus (DCPI). Al ser el dolor una experiencia subjetiva, las personas con afectación del nivel de consciencia, alteraciones cognitivas severas y/o problemas severos de lenguaje pueden tener muchas dificultades o ser incapaces de comunicarlo. Es importante, por tanto, una adecuada anamnesis y exploración física dirigida, así como el uso de escalas específicas para su correcto diagnóstico. Finalmente, muchos de los fármacos utilizados para su manejo tienen un efecto negativo en la rehabilitación, afectando a procesos cognitivos, y/o empeorando otros síntomas neurológicos. Este hecho, junto a la circunstancia de que muchas veces se trate de personas con otras patologías y polimedicadas, hace que el abordaje del dolor deba ser especialmente meticuloso y desde un enfoque multidisciplinar.

Introducción Guía para la práctica clínica en neurorrehabilitación de personas adultas en estado alterado de la consciencia (EAC) de la Sociedad Española de Neurorrehabilitación. Documento basado en la revisión de guías de práctica clínica internacionales publicadas entre 2015 y 2022. Método Un total de 7 artículos correspondientes a 5 guías de práctica clínica publicadas entre 2015 y 2022 fueron seleccionadas por el grupo de autores de un total de 48 referencias bibliográficas extraídas de diferentes bases de datos de acuerdo a los criterios de búsqueda. En base a dicha revisión se establecieron 40 recomendaciones sometidas a evaluación por un comité de expertos que evaluaron cada recomendación con una escala de 9 puntos de tipo Likert: 1-3 (recomendación inapropiada), 4-6 (recomendación incierta) y 7-9 (recomendación apropiada), de acuerdo a la metodología del Modified Nominal Group Technique. Toda recomendación valorada por al menos un 75% de los expertos como «apropiada» (puntuación: 7-9) se consideró como aceptada. Conclusiones Se establecen 40 recomendaciones según el nivel de evidencia que ofrecen los estudios revisados referentes a aspectos consensuados entre expertos dirigidos a definir aspectos relacionados con: 1)la evaluación clínica; 2)las pruebas complementarias; 3)el pronóstico, y 4)el tratamiento, en esta población.

Valorar el estado actual y el potencial de innovación del colectivo de profesionales de la especialidad médica de medicina física y rehabilitación (MFRHB) en España.Se aplicaron 3 técnicas consecutivas mediante herramientas digitales para el consenso entre profesionales: primero de forma síncrona a un colectivo de 17 profesionales, después se extendió a un colectivo de 169 que participaron de forma asíncrona y la tercera técnica se realizó de forma síncrona con 25 médicos especialistas en MFRHB.Se dispuso del análisis consensuado por los propios profesionales sobre el potencial de innovación del colectivo realizado en octubre y noviembre del 2020: situación de partida, puntos fuertes y puntos débiles, así como sus prioridades en innovación.Los médicos especialistas en MFRHB consideran que la innovación podría mejorar el coste efectividad de los servicios y podría aumentar su eficiencia clínica; también consideran que para innovar necesitan una relación estrecha con la industria.To measure by consensus the level of innovation and its potential within the physical medicine and rehabilitation (PM&R) medical specialists.Three consecutive techniques are applied using digital tools for consensus among professionals, first synchronously to a group of 17 professionals; posteriorly extended to a group of 169 professionals who participate asynchronously and the third technique is done synchronously with 25 physiatrists.The analysis of the consensus done by the PM&R physicians on the innovation potential of the group during October and November 2020 shows: starting situation, strengths and weaknesses, as well as their innovation priorities.PM&R physicians believe that innovation could improve the cost-effectiveness of their departments, and could increase their clinical efficiency, also that to innovate they need a close relationship with the industry.

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.

To understand uncertainties and knowledge gaps regarding lymphatic drainage in renal tumors, we performed 2 prospective studies to demonstrate regional lymph node (LN) drainage with sentinel lymph node (SN) imaging and biopsy. Here, we report the technique and perioperative safety of retroperitoneal SN dissection with different surgical approaches.Seventy three patients from the 2 trials were included in the analysis. Patients had cT1-2N0M0 renal tumors (=10 cm) and underwent nephrectomy (46/63%) or partial nephrectomy (27/37%) with SN dissection after intraoperative detection with a γ-probe, and locoregional LND. Twenty-nine of 73 patients had open surgery, 27 of 73 laparoscopic, and 17 of 73 robot-assisted laparoscopic (partial) nephrectomy. Surgery time, intraoperative adverse events (AE) according to CTCAE 5.0, and postoperative AE according to Clavien-Dindo (CD) were retrospectively assessed.There were no grade ≥3 intraoperative CTCAE 5.0 AEs. Postoperative AE rate was 16.4% of which 7 (9.6%) were CD grade 1-2 and 5 (6.8%) were 3a grade complications. There were no statistically significant differences between presence of AE, CD grade, and surgical modality (P = .27 and P = .13, respectively). Blood loss was a median of 550 ml (IQR 200-900 ml) and 225 (IQR 42-751 ml) for partial nephrectomy (PN) and radical nephrectomy, respectively. Length of the procedure was 170 minutes (IQR 149-184 minutes), 155 minutes (IQR 130-177 minutes) 180 minutes (IQR 162-202 minutes) in open, laparoscopic, and robot-assisted procedures, respectively.The addition of retroperitoneal SN dissection combined with locoregional LND during (partial) nephrectomy is surgically safe. Complication rate is low and does not differ between surgical approaches.

INTRODUCTION:The role of gender in functional independence for activities of daily living after ischemic stroke is still controversial. We aim to a) compare clinical characteristics of men and women at inpatient rehabilitation admission b) compare their functional independence at admission and discharge c) identify predictors of functional independence. MATERIALS AND METHODS:Retrospective observational cohort study. State-of-the-art variables were used for admission and discharge comparisons and to predict total FIM (Functional Independence Measure) at discharge, FIM gain, FIM efficiency and FIM effectiveness using multivariate linear regressions. RESULTS:144 patients (33% women) admitted to inpatient rehabilitation in a Spanish specialized center, with less than 3 weeks since ischemic stroke onset were included. Men were older (p = 0.039), 19.6% of men had diabetes mellitus (6.4% of women) (p = 0.038), with 52.6% of men being non-smokers (72.3% of women) (p = 0.022). No significant differences were observed in FIM at admission, discharge, FIM gain, efficiency or effectiveness (total, motor either cognitive FIM). Regression analysis identified sex (ß = -0.13), stroke severity (ß = -0.25) and admission total FIM (ß = -0.69) as significant predictors of total FIM gain (R2 = 0.42). The same variables predicted discharge total FIM: sex (ß = -0.12), severity (ß = -0.23) and admission total FIM (ß = 0.59) (R2 = 0.51). FIM efficiency was predicted by admission total FIM (ß = -0.64), severity (ß = -0.24), age (ß = -0.17) and length of stay (ß = -0.45) (R2 = 39.9%). FIM effectiveness model explained only 13.5% of the variance. CONCLUSIONS:No functional differences between men and women in any independence measure were found. Sex was a significant predictor but leaving half of the variance unexplained.

Background: Prehabilitation shows efficacy to improve surgical outcomes, but scalability is limited by a marked efficacy-effectiveness gap. The intervention is a ‘teachable moment’ to encourage patients, particularly with chronic conditions, for positive lifestyles changes reducing disease burden. Objective: To assess health outcomes and cost of prehabilitation. Methods: Prospective cohort study in a real-life setting, with a control group built using propensity score matching, in candidates for major surgical procedures. Outcomes: comprehensive complication index, hospital and intensive care unit (ICU) stays and hospital costs per patient. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis. Results: In the intention-to-treat analysis, no differences were found between study arms (n=328 each). The per-protocol analysis, including only patients completing the prehabilitation program (n=112, 34%), showed a reduction in mean hospital stay (9.9 (7.2) vs. 12.8 (12.4) days; p=0.035). Completers undergoing highly aggressive surgeries (n=60) additionally showed a reduction in ICU stay (2.3 (2.7) vs. 3.8 (4.2) days; p=0.021) and generated mean cost savings per patient of 3,092€ (32% cost reduction) (p=0.007). Five priority areas for action to enhance effectiveness of prehabilitation were identified. Conclusions: The study indicates low rate of completion and identifies priority areas for re-design of service delivery to enhance effectiveness of prehabilitation. Lessons learnt can be generalized to rehabilitation of chronic patients. Funding: ISCIII "FIS-Smart PITeS project (PI18/00841)", co-funded by FEDER/FSE “Una manera de hacer Europa”.

INTRODUCTION:Patients presenting sequelae of poliomyelitis may present new symptoms, known as post-polio syndrome (PPS).OBJECTIVE:To identify the clinical and functional profile and epidemiological characteristics of patients presenting PPS.PATIENTS AND METHODS:We performed a retrospective study of 400 patients with poliomyelitis attended at the Institut Guttmann outpatient clinic, of whom 310 were diagnosed with PPS. We describe patients' epidemiological, clinical, and electromyographic variables and analyse the relationships between age of poliomyelitis onset and severity of the disease, and between sex, age of PPS onset, and the frequency of symptoms.RESULTS:PPS was more frequent in women (57.7%). The mean age at symptom onset was 52.4 years, and was earlier in women. Age at primary infection >2 years was not related to greater poliomyelitis severity. The frequency of symptoms was: pain in 85% of patients, loss of strength in 40%, fatigue in 65.5%, tiredness in 57.8%, cold intolerance in 20.2%, dysphagia in 11.7%, cognitive complaints in 9%, and depressive symptoms in 31.5%. Fatigue, tiredness, depression, and cognitive complaints were significantly more frequent in women. Fifty-nine percent of patients presented electromyographic findings suggestive of PPS.CONCLUSIONS:While the symptoms observed in our sample are similar to those reported in the literature, the frequencies observed are not. We believe that patients' clinical profile may be very diverse, giving more weight to such objective parameters as worsening of symptoms or appearance of weakness; analysis of biomarkers may bring us closer to an accurate diagnosis.

Resumen: Introducción: Guía para la práctica clínica en neurorrehabilitación de personas adultas con daño cerebral adquirido de la Sociedad Española de Neurorrehabilitación. Documento basado en la revisión de guías de práctica clínica internacionales publicadas entre 2013-2020. Desarrollo: Se establecen recomendaciones según el nivel de evidencia que ofrecen los estudios revisados referentes a aspectos consensuados entre expertos dirigidos a definir la población, características específicas de la intervención o la exposición bajo investigación. Conclusiones: Deben recibir neurorrehabilitación todos aquellos pacientes que, tras un daño cerebral adquirido, hayan alcanzado una mínima estabilidad clínica. La neurorrehabilitación debe ofrecer tanto tratamiento como sea posible en términos de frecuencia, duración e intensidad (al menos 45-60 minutos de cada modalidad de terapia específica que el paciente precise). La neurorrehabilitación requiere un equipo transdisciplinar coordinado, con el conocimiento, la experiencia y las habilidades para trabajar en equipo tanto con pacientes como con sus familias. En la fase aguda, y para los casos más graves, se recomiendan programas de rehabilitación en unidades hospitalarias, procediéndose a tratamiento ambulatorio tan pronto como la situación clínica lo permita y se puedan mantener los criterios de intensidad. La duración del tratamiento debe basarse en la respuesta terapéutica y en las posibilidades de mejoría, en función del mayor grado de evidencia disponible. Al alta deben ofrecerse servicios de promoción de la salud, actividad física, apoyo y seguimiento para garantizar que se mantengan los beneficios alcanzados, detectar posibles complicaciones o valorar posibles cambios en la funcionalidad que hagan necesario el acceso a nuevos programas de tratamiento. Abstract: 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 45–60 min 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.