Autore: CSLSRN134

  • Advancing from Item-Level to Total Score-Based diagnosis in the Coma Recovery Scale–Revised: Evidence from a Diagnostic Accuracy Study

    Advancing from Item-Level to Total Score-Based diagnosis in the Coma Recovery Scale–Revised: Evidence from a Diagnostic Accuracy Study

    Passaggio dalla diagnosi basata sugli item a quella sul punteggio totale nella Coma Recovery Scale–Revised: uno studio di accuratezza diagnostica

    Autori

    Caselli Serena (Unità Operativa Complessa di Medicina Riabilitativa, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy)

    Pellicciari Leonardo (IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy)

    Leonardi Matilde (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

    Magnani Francesca Giulia (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

    Cacciatore Martina (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

    Barbadoro Filippo (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

    Ippoliti Camilla (SC Neurologia, Salute Pubblica, Disabilità, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy)

    Kreiner Svend (Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark)

    La Porta Fabio (IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy)

    Background and aims

    The Coma Recovery Scale-Revised (CRS-R) is the gold standard for diagnosing patients with Disorder of Consciousness (DOC). Five items out of six provide scores linked to a diagnosis of Unresponsive Wakefulness Syndrome (UWS), Minimally Conscious State (MCS), or emergence from MCS (eMCS). However, no diagnostic criteria are linked to the total score.

    Therefore, this study proposes to define and compare the diagnostic accuracy of total score cutoffs based on item-level diagnostic criteria proposed recently[1] as a reference standard, and to improve the diagnostic accuracy of these total score cutoffs using a modified version of the original rule (i.e., the diagnostic category coincides with the highest category defined at least by one item)[2] currently in use.

    Methods

    Patients with DOC as a consequence of a severe acquired brain injury and admitted to post-acute and follow-up neuro-rehabilitation services were included. Diagnostic accuracy (DA) of the total score cutoffs based on each of the item-level diagnostic criteria set proposed recently[1-4], and the agreement indexes between item-level and total score-level diagnosis were computed. Finally, the comparison of the diagnostic accuracy of the total score cutoffs according to Giacino’s original rule[2] and the “modified rule” (i.e., the diagnostic category coincides with the highest category defined at least by two/three/four items) with Caselli’s criteria[1] was performed.

    Results

    380 patients with DOC (mean±SD: 52.1±16.8 years, 65% male) were included for a total of 727 CRS-R assessments.

    The comparison of total score cutoffs for each diagnostic criterion showed that for MCSplus and eMCS, the DA value is 90-95% (Table I), with high false negatives (FN) for most criteria sets (MCSplus: Bodien 12pt 22.5%; Caselli 11pt 16.7%; eMCS: Giacino and Bodien 19pt 23%; Weaver 16pt 19%). For MCSminus, the four cutoffs (8pt) had high specificity, essential for identifying patients with early signs of consciousness. Weighted Cohen’s k between the item and total score diagnoses was 0.82 for all four criteria sets.

    Applying the “modified rule” with Caselli’s criteria resulted in the highest DA values for both MCSplus (14pt 97%) and eMCS (19pt 99%), with a lower FN rate (<11%) (Tables II and III).

    Conclusion

    Being the diagnosis based on individual items, the initial total score cutoffs partly addressed the low reliability of item-level cutoffs. The introduction of the “modified rule,” which requires at least two items per diagnostic category for diagnosis, allowed for advancing from item-level to a reliable total score-based diagnosis with less measurement error.

    REFERENCES

    1. Caselli S, Leonardi M, Magnani FG, Cacciatore M, Barbadoro F, Ippoliti C, Kreiner S, Pellicciari L, La Porta F. Comparing the Different Sets of Item-Level Diagnostic Criteria of the Coma Recovery Scale-Revised (CRS-R): A Measurement-Based Approach Driven by Rasch Analysis. Arch Phys Med Rehabil. 2024 Dec 18:S0003-9993(24)01406-0. doi: 10.1016/j.apmr.2024.12.009.
    2. Giacino JT, Kalmar K, Whyte J. The JFK Coma Recovery Scale-Revised: measurement characteristics and diagnostic utility. Arch Phys Med Rehabil. 2004 Dec;85(12):2020-9. doi: 10.1016/j.apmr.2004.02.033.
    3. Bodien YG, Chatelle C, Taubert A, Uchani S, Giacino J T, Ehrlich-Jones L. Updated measurement characteristics and clinical utility of the Coma Recovery Scale-Revised among individuals with acquired brain injury. Arch Phys Med Rehabil. 2021;102(1):169-171. doi: 10.1016/j.apmr.2020.09.369.
    4. Weaver JA, Cogan AM, O’Brien KA, Hansen P, Giacino JT, Whyte J, Bender Pape T, van der Wees P, Mallinson T. Determining the Hierarchy of Coma Recovery Scale-Revised Rating Scale Categories and Alignment with Aspen Consensus Criteria for Patients with Brain Injury: A Rasch Analysis. J Neurotrauma. 2022 Oct;39(19-20):1417-1428. doi: 10.1089/neu.2022.0095.
  • Come standardizzare i fattori di rischio per le cadute in ospedale? Un nuovo approccio multifase attraverso un proof-of-concept study

    Come standardizzare i fattori di rischio per le cadute in ospedale? Un nuovo approccio multifase attraverso un proof-of-concept study

    Come standardizzare i fattori di rischio per le cadute in ospedale? Un nuovo approccio multifase attraverso un proof-of-concept study

    How to standardize reported risk factors for falls in hospital? A new multi-phase approach using a proof-of-concept study

    Autori

    Caselli Serena [Unità Operativa Complessa di Medicina Riabilitativa, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy]

    La Porta Fabio [IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy]

    Valpiani Giorgia [Research and Innovation Unit, Biostatistics and Clinical Trial Area, University Hospital of Ferrara, Ferrara, Italy]

    Lullini Giada [IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy]

    Negro Antonella [Innovation in Healthcare and Social Services, Emilia-Romagna Region, Bologna, Emilia-Romagna, Italy]

    Pellicciari Leonardo [IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy]

    Bassi Erika [Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy]

    Pecoraro Valentina [Department of Laboratory Medicine and Pathology, AUSL Modena, Modena, Italy]

    Govoni Erika [[Innovation in Healthcare and Social Services, Emilia-Romagna Region, Bologna, Emilia-Romagna, Italy – Unità Organizzativa Riabilitazione Ospedaliera, Dipartimento Assistenziale Tecnico e Riabilitativo, Ausl Bologna, Bologna, Italy]

    Introduction

    In-hospital falls are a public health issue resulting in enormous individual, social and health costs. To prevent in-hospital falls, it is essential to know the risk factors (RFs) so that they can be recognized and prevented or modified through clinical interventions. The literature reports uncertainty and inconsistency in RF terminology for in-hospital falls that could be reduced by linking RFs to standardized health concepts, such as those provided by the conceptual categories of the WHO International Health Classifications. Therefore, this study, conducted by Innovation in Healthcare and Social Services of Emilia-Romagna Region, aims: 1) to perform a literature review to identify fall RFs among hospitalized adults; 2) to link the found RFs to the corresponding health classification categories to reduce the heterogeneity of their definitions; 3) to perform a meta-analysis on risk categories to identify significant RFs; and 4) to refine the definitive list of significant categories to avoid redundancies.

    Methods

    The review protocol was registered prospectively on the PROSPERO register (CRD42022328922). Four databases were queried. We included observational studies assessing patients who had experienced in-hospital falls, published in English or Italian until March 2022. Two independent reviewers performed the inclusion and extrapolation process. They evaluated the methodological quality (using National Institute of Health (NIH) quality assessment tools for case-control studies and observational cohort and cross-sectional studies) of the included studies. RF records were linked to the categories of three health classifications (International Classification of Functioning, Disability, and Health [ICF], International Classification of Diseases version 10 [ICD-10], Anatomical Therapeutic Chemical Classification [ATC]). Meta-analyses were performed to obtain an overall pooled odds ratio (OR) for each category, which aggregated single RFs, using a random effect model. Finally, significant RF categories were considered after the exclusion of redundant RFs across different classifications.

    Results

    Thirty-six articles were included in the meta-analysis. 1,111 RF records were identified; 616 were linked to ICF classification, 450 to ICD-10, and 260 to ATC. Considering the ICF, the meta-analysis identified 50 RF categories linked to 523 records as significant (52 RFs non-significant). Regarding ICD-10, the meta-analysis identified 51 RF categories for a total of 509 records as significant (101 RFs non-significant). Concerning ATC, the meta-analysis identified 26 RF categories linked to 294 records as significant (65 RFs non-significant). 18 RF categories were excluded as they were redundant or protective factors. After this process, the purified list included 53 significant RF categories linked to 328 records. The pooled OR values of the purified list ranged from 1.299 (N06A Antidepressants) to 8.633 (d420 Transferring oneself). Overall, the initial number of RFs was reduced by about 21 times compared to the initial number, i.e., from 1,111 identified RF records to 53 significant RF categories.

    Discussion and Conclusion

    This study aimed to provide a proof-of-concept that it may be feasible to reduce the reported heterogeneity in the description of fall RFs and, subsequently, their number by adopting the standard terminology provided by the International Health Classifications. We achieved this aim in four subsequent steps, and we identified 53 significant RF categories for in-hospital falls. We demonstrated that adopting a clear and consistent terminology derived from standardized international classifications may lead to a marked reduction and systematization of fall RFs among hospitalized adults. The list of significant RFs can be used as a template at the regional level to build more accurate measurement instruments to predict in-hospital falls.

    REFERENCES

    Deandrea, S, Bravi, F, Turati, F, Lucenteforte, E, La Vecchia, C, and Negri, E. Risk factors for falls in older people in nursing homes and hospitals. A systematic review and meta-analysis. Arch Gerontol Geriatr. (2013) 56:407–15. doi: 10.1016/j.archger.2012.12.006

    Cieza, A, Fayed, N, Bickenbach, J, and Prodinger, B. Refinements of the ICF linking rules to strengthen their potential for establishing comparability of health information. Disabil Rehabil. (2019) 41:574–83. doi: 10.3109/09638288.2016.1145258

  • La rilevazione e la predizione del rischio di caduta negli anziani residenti in comunità

    La rilevazione e la predizione del rischio di caduta negli anziani residenti in comunità

    La rilevazione e la predizione del rischio di caduta negli anziani residenti in comunità

    Fall risk detection and prediction in community-dwelling older adults

    Autori

    Caselli Serena [PhD program in Public Health, curriculum in Health Services Research and Technology Assessment, School of Medicine and Surgery, University of Milan Bicocca, Milano, Italy – Unità Operativa Complessa di Medicina Riabilitativa, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy]

    La Porta Fabio [IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy]

    Cortesi Paolo A. [Research Center on Public Health, University of Milan Bicocca, Monza, Italy]

    Mantovani Lorenzo G. [Research Center on Public Health, University of Milan Bicocca, Monza, Italy]

    Introduction

    Falls represent a significant public health issue for the elderly, also with neurological diseases, for their human, health, and material costs. Epidemiological studies identified fall risk factors (RFs), and international guidelines recommend a multifactorial removal approach of the modifiable fall RFs and the implementation of evidence-based effective interventions for people at fall risk. Nevertheless, investigators did not use unique classifications for fall RFs, and despite the use of numerous fall risk tools, it is not possible to detect and predict fallers with optimal diagnostic accuracy. Thus, this thesis aims: 1) to validate a fall risk serial screening algorithm with a high level of diagnostic accuracy in community-dwelling older people, also with associated neurological diseases; 2a) assess the neurological disease effect on the screening tests; 2b) validate an International Classification of Diseases (ICD) & Functioning (ICF) core set for the fall risk in the same sample.

    Methods

    Using data collected in the PRE.C.I.S.A. trial about the efficacy of a tailored intervention on fall risk, we performed the following analyses: 1) we calibrated VAE, VOE1 and VOE2 measurement scales with Rasch analysis (RA) and we calculated the two FRAT-up on the same variables; we studied the diagnostic accuracy of the single tools and the screening algorithms, obtained with serial combinations of the calibrated scales and the two FRAT-up tools, and with logistic regression models, in the prediction of at least one, two, and three (recurrent fallers) falls in the following twelve months; we compared their properties, with a purpose of external validation; 2a) we conducted a Differential Item Functioning (DIF) analysis for the calibrated scales and a t-test comparison for the two FRAT-up; 2b) we reviewed the fall RFs, and we linked them to the classification categories; we compared and integrated the core set with the existing Yen’s ICF core set for falls.

    Results

    The sample consisted of 768 older adults. We calibrated VAE, VOE1, and VOE scales, showing a satisfactory fit to the Rasch model (χ213=43.4; p=0.08; χ212=17.5, p=0.13; χ26=32.9, p=0.04) and adequate reliability for individual measurement. The serial combination with ‘AND’ rule of the calibrated scales generated serial screening algorithms predicting fall risk based on cutoffs defined using an ‘ad hoc’ clinical method, which considered a higher cost for false negatives (≥1 fall: SE=62.4%; SP=71.0%; ≥2 falls: SE=72.8%; SP=63.2%; ≥3 falls: SE=79.3%; SP=60.0%). We calculated cumulative post-test probabilities of the serial combination of the scales, performing more effectively than the single tools, and additional algorithms based on logistic regression models using a parallel combination. We realized an external validation through the comparison with FRAT-up algorithms. We demonstrated that the neurological disease effect on tools’ performance is minor and manageable with RA. We validated an ICD&ICF core set for the fall risk in community-dwelling older adults, also with associated neurological diseases (103 fall RFs linked to 74 categories).

    Discussion and Conclusion

    The described serial algorithms could constitute the first component of an effective fall prevention program in older adults, followed by the delivery of effective multifactorial and multicomponent interventions to people at risk in an outpatient ‘fall clinic’. Further projects are desirable to replicate all these findings in the context of larger, multicenter validation studies, improving the sample representativeness and then providing an economic evaluation of the proposed screening algorithms.

    REFERENCES

    Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146.

    Allen NE, Schwarzel AK, Canning CG. Recurrent falls in Parkinson’s disease: a systematic review. Parkinson’s disease 2013;2013:906274.

    Weerdesteyn V, de Niet M, van Duijnhoven HJ, Geurts AC. Falls in individuals with stroke. J Rehabil Res Dev 2008;45:1195-1213.

    La Porta F, Lullini G, Caselli S, Valzania F, and the PRECISA Group (2022) Efficacy of a multiple-component and multifactorial personalized fall prevention program in a mixed population of community-dwelling older adults with stroke, Parkinson’s Disease, or frailty compared to usual care: The PRE.C.I.S.A. randomized controlled trial. Front.Neurol.13:943918.

    Cieza, A, Fayed, N, Bickenbach, J, and Prodinger, B. Refinements of the ICF linking rules to strengthen their potential for establishing comparability of health information. Disabil Rehabil. (2019) 41:574–83.

  • La scala di Berg è uno strumento adeguato alla misurazione dell’equilibrio nelle persone con sclerosi multipla e avanzata disabilità nel cammino: evidenze dall’analisi di Rasch

    The Berg Balance Scale is a proper tool to measure balance in persons with Multiple Sclerosis and an advanced walking disability: evidence from Rasch analysis

    Introduction

    Persons with Multiple Sclerosis (PwMS) are at high risk of falling, and falls are proven to be consistently associated with balance impairment.

    The Berg Balance Scale (BBS) is one of the most widely used tools to assess balance in PwMS, also within RCTs. Reliability and validity of the BBS in PwMS were evaluated through the Classical Theory Test (concurrent validity with Dynamic Gait Index (r=0.780) and the Timed-Up-and-Go test (r=0.620). It discriminated with a low sensitivity between fallers and non-fallers. Inter-rater and intra-rater reliability were excellent (ICC=0.960).

    Unfortunately, these traditional psychometric procedures cannot assess some crucial requirements underlying the use of rating scales such as the BBS. Indeed, Rasch analysis has emerged as a powerful tool to evaluate the measurement quality of a scale.

    Hence, this study aims to evaluate the BBS measurement properties in a multicenter sample of PwMS through Rasch analysis.

    Methods

    Data were collected retrospectively within the outpatient Neuro-rehabilitation services of three Italian centers for 814 PwMS, adhering to these inclusion criteria: clinically or laboratory-definite multiples sclerosis; ability to stand independently for more than 3 seconds. For each participant, we collected the BBS, the Expanded Disability Status Scale (EDSS), the Activity-specific Balance Confidence (ABC) scale, and the number of falls (previous two months).

    Using the Confirmatory Factor Analysis and Mokken Analysis, a preliminary unidimensional analysis of the BBS total sample (1220 observations) was performed. The sample was splitted into one validating (B1) and three confirmatory subsamples (Figure 1). Following the Rasch analysis performed on B1, item estimates were exported from B1 and anchored to the other subsamples.

    Then, we studied the convergent and discriminant validity of the scale (BBS-MS) with the three external indicators.

    Results

    CFA and MA showed sufficient preliminary unidimensionality. The Rasch analysis on B1 failed monotonicity, local independence, and unidimensionality, and did not fit the Rasch model. After grouping locally dependent items, the BBS-MS fitted the model (χ2df=23.88; p=.003) and satisfied all requirements for adequate internal construct validity (ICV) (Table 1). However, it was mistargeted to the sample (targeting index=1.922), with a distribution-independent Person Separation Index equal to 0.962, sufficient for individual measurements (Figure 2). The B1 final solution was replicated on A1, A2, and B2 subsamples, and the B1 item estimates were anchored to the confirmatory subsamples, satisfying the fit to the model (χ2=[19.0, 22.8], p-value=[.015, .004]) and all ICV requirements (Table 2).
    BBS-MS directly correlated with the ABC scale (rho=.523) and inversely with EDSS (rho=-.573). It significantly differed across groups based on the EDSS, the ABC scale, and the number of falls.

    Discussion and Conclusion

    To our knowledge, this is the first study reporting on the Rasch analysis of the BBS for PwMS. It supports the ICV, reliability, and targeting of the BBS-MS as a measurement tool in an Italian multicentre sample of PwMS. Using one validation and three confirmation subsamples, we demonstrated the BBS-MS fitting to the Rasch model and the satisfaction of all requirements for adequate ICV.

    On the other hand, the scale was slightly mistargeted to our convenience sample as its items were, on average, less difficult than the mean ability of the sample, uncovering significant targeting issues for a precise balance measurement in still ambulatory PwMS.

    Indeed, our study suggested that the BBS-MS may be a precise and responsive measurement scale to assess balance in RCTs targeted to more disabled PwMS with an advanced walking disability. Thanks to this validation, we provided interval-level measures of balance ability, allowing parametric statistics to be used.

    REFERENCES

    1. Nilsagard, C. Lundholm, E. Denison, and L.G. Gunnarsson, Predicting accidental falls in people with multiple sclerosis — a longitudinal study. Clin Rehabil 23 (2009) 259-69
    2. V. Jacobs, and S.L. Kasser, Balance impairment in people with multiple sclerosis: preliminary evidence for the Balance Evaluation Systems Test. Gait & posture 36 (2012) 414-8.
    3. Cattaneo, J. Jonsdottir, and S. Repetti, Reliability of four scales on balance disorders in persons with multiple sclerosis. Disability and rehabilitation 29 (2007) 1920-5.
    4. Hobart J, Cano S. Improving the evaluation of therapeutic interventions in multiple sclerosis: the role of new psychometric methods. Health Technol Assess 13 (2009) (12): iii, ix-x, 1-177.
    5. Tennant, and P.G. Conaghan, The Rasch measurement model in rheumatology: what is it and why use it? When should it be applied, and what should one look for in a Rasch paper? Arthritis Rheum 57 (2007) 1358-62.

  • La scala Early Functional Abilities-revised può colmare il gap misurativo tra le scale per il disordine di coscienza e quelle per l’indipendenza funzionale: uno studio con l’analisi di Rasch

    The Early Functional Abilities-revised may bridge the measurement gap between the disorder of consciousness and the functional independence scales: a Rasch analysis study

    Introduction

    A measurement gap between the disorder of consciousness (DoC) and functional independence scales is present, as both cannot measure the recovery of early functional changes occurring on emergence from DoC. The Early Functional Abilities scale (EFA) was developed to bridge this gap. It describes clinically observable changes concerning purposeful activities, illness and disability awareness, and the ability to comply with medical, nursing, and therapeutic interventions.

    In 2018, Poulsen et al. assessed the internal construct validity (ICV), reliability, and measurement precision of EFA in patients with TBI with Rasch analysis. The analysis rejected unidimensionality and did not recommend summarizing the four subscale measures into an EFA total score.

    This study investigated whether selecting a valid content subset of items (EFA-R) from the original EFA was possible, providing an essentially unidimensional measurement of early functional ability.

    Methods

    In a multicenter observational cross-sectional study, we included three hundred sixty-two adults diagnosed with DoC due to a severe acquired brain injury (sABI) on admission to eleven Italian rehabilitation centers. We excluded patients with pre-existing neurological degenerative pathologies and/or concurrent illnesses likely to compromise survival within six months. Each patient was represented with only one chosen random evaluation in the dataset to avoid the risk of time dependency.

    The Italian version of EFA (20 items with a five-point score grouped in 4 subscales) was administered to the sample and then submitted to Mokken analysis (MA), Confirmatory Factor Analysis (CFA), Rasch analysis, Confirmatory Bifactor Analysis (CBA), and external construct validity.

    When available, we also collected the Coma Recovery Scale-Revised (CRS-R) and the FIMTM for each person at the same time point for sample description and external validity purposes.

    Results

    According to MA and CFA, the Italian EFA showed sufficient preliminary unidimensionality. Within Rasch Analysis, a final 12-item solution (EFA-R) was calibrated. EFA-R is “essentially unidimensional” according to 1) analysis of residual correlations supporting item essential local independence; 2) a robust correlation between item subtests (rho=0.950); 3) only 2.1% of cases with significant difference between person parameter estimates by different subscales; 4) an explained common variance equal to 0.916 obtained from a final CBA. The invariance requirement (unconditional χ2df=9.8120; p=0.457, conditional class-interval based χ2df=33.135; P=0.557) and monotonicity were also satisfied (Table 1). The reliability (Person Separation Index=0.887) was adequate for person measurements (Figure 1). A practical raw-score-to-measure conversion table based on the EFA-R calibration was devised (Table 2). Finally, EFA-R strongly correlated with CRS-R (rho=0.922) and motor FIM™ (rho=0.808).

    Discussion and Conclusion

    EFA-R is an essentially unidimensional subset of 12 items with adequate ICV and sufficient reliability for individual measurement under the Rasch Model Theory framework in patients with sABI. It has the potential to measure people’s functional abilities whose consciousness is improving despite ongoing severe motor-functional impairments during the early stages of rehabilitation. It covers all four original conceptual domains. The item hierarchy was consistent with the theoretical and expected order of functional recovery in these patients. The raw-score-to-measure conversion table provides interval-level estimates of early functional abilities, essential for correctly interpreting change scores and using parametric statistics.

    Given the strong correlation with CRS-R and mFIMTM, it provides “a measurement bridge” between the DoC and the functional independence scales in patients with sABI, overcoming the ceiling and floor effects of the two scales (Figure 2).

    REFERENCES

    1. Heck G, Steiger-Bächler G, Schmidt T. Early Functional Abilities (EFA) – eine Skala zur Evaluation von Behandlungsverläufen in der neurologischen Frührehabilitation. Neurol Rehabil 2000;6:125–33.
    2. Poulsen I, Kreiner S, Engberg AW. Validation of the Early Functional Abilities scale: an assessment of four dimensions in early recovery after traumatic brain injury. J Rehabil Med 2018;50:165–72.
    3. Tennant A, Conaghan PG. The Rasch measurement model in rheumatology: what is it and why use it? When should it be applied, and what should one look for in a Rasch paper? Arthritis Rheum 2007;57:1358–62.
    4. La Porta F, Caselli S, Ianes AB, Cameli O, Lino M, Piperno R, et al. Can we scientifically and reliably measure the level of consciousness in vegetative and minimally conscious States? Rasch analysis of the coma recovery scale-revised. Arch Phys Med Rehabil 2013;94:527– 535.e1.