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Spanish validation of the Neurogenic Bowel Dysfunction score -NBD score- in patients with central neurological injury
Validación al español de la versión en inglés del Neurogenic Bowel Dysfunction score (NBD score) en pacientes con lesión neurológica de origen central
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Survival was statistically lower in both cases in patients with high α1M urinary excretion. See significance in the text.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nicolás R. Robles, Juan Lopez Gomez, Guadalupe Garcia Pino, Julian Valladares, Roman Hernandez Gallego, Isis Cerezo" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Nicolás R." 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Meritxell, Escaldes-Engordany, Andorra" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Validación al español de la versión en inglés del <span class="elsevierStyleItalic">Neurogenic Bowel Dysfunction score (NBD score)</span> en pacientes con lesión neurológica de origen central" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1187 "Ancho" => 2512 "Tamanyo" => 194944 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intervention of bowel dysfunction on disability according to the <span class="elsevierStyleItalic">International Classification of Functioning, Disability and Health (ICF)</span>. Taken from Nevedal et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Neurogenic bowel dysfunction (NBD) is one of the disabilities that occur in central nervous system (CNS) disorders such as: spinal cord injury (SCI), brain injuries of vascular origin: cerebral vascular accident (CVA) or post-traumatic brain injury, multiple sclerosis, Parkinson’s disease and Alzheimer’s syndrome.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Severe NBD affects more than half of SCI (spinal cord injuries), two thirds of subjects with spina bifida and 68% of patients with multiple sclerosis.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The consequences of it are: (a) abnormal intestinal motility, (b) loss of sphincter control, (c) inability to significantly increase intra-abdominal pressure that serves as a trigger to initiate the defecation process.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Despite the fact that NBD has less effects on morbidity and mortality than bladder-sphincter dysfunction, it is, for patients, a cause of anxiety due to the implications it has on quality of life (QoL) and social relationships in this group of disabled patients,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> due to uncontrolled bowel leakage.</p><p id="par0025" class="elsevierStylePara elsevierViewall">An effective NBD management program should be able to address neurogenic bowel problems<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> in its different aspects: inefficient functional motility, faecal incontinence, constipation, ineffective evacuation and prevention of complications.</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is a relationship between satisfaction with bowel management and QoL,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> measured through surveys and affecting specific subscales related to symptoms, bowel problems, work and social functions. Those who are more satisfied with their handling of NBD have a higher QoL score, while those who are less satisfied have a lower QoL in the indicated scores.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Despite patients showing problems with the bowel management programme, there is evidence that two-thirds are satisfied with it.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This information led to the conclusion that problems are common, but do not always contribute to a decrease in satisfaction or QoL, confirming Parse<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>’s theory that health is defined by the individual and not by the problem. The most common problems in this group of patients are: constipation, secondary autonomic dysreflexia, haemorrhoids and faecal impactions<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and, in the long term, dolichocolon and megacolon.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Involuntary bowel movements or faecal incontinence is a common problem ranging from 8.4 to 43%. The discrepancy in the frequency of results, with the presence of this wide range, may be due to definitions of incontinence, sometimes defining incontinence as leaking more than once a month, while other studies do not specify the number of leaks. It is therefore necessary to define it, requiring careful assessment<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in order to be able to apply individual approaches for an accurate diagnosis and for the prescription of treatments for the management of NBD, especially after SCI, but also after any other central neurological involvement.</p><p id="par0045" class="elsevierStylePara elsevierViewall">For a long time the focus remained on isolated strategies such as dietary or pharmacological approaches, electrical stimulation and surgery, and only recently, following the Cochrane systematic reviews,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> has the best evidence and practice in the management of NBD been made available to the scientific community, patients and caregivers, making known the effectiveness of the different strategies used to control bowel complications arising from neurological impairment, and where success is considered to be based on multidimensional management and as such treatments can encompass different actions.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In order to be able to carry out a proper management of NBD, it needs to be correctly assessed, but for this, appropriate measures must be available for its evaluation. The <span class="elsevierStyleItalic">Neurogenic Bowel Dysfunction score (NBD score)</span>,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> dating from 2005, seems to be the most widely used scale in patients with NBD among the international community. Its authors determined the reproducibility and validity in 589 patients with SCI. Associations between items and impact on quality of life were determined by logistic regression analysis. The NBD score was constructed from items with acceptable reproducibility and validity, which were significantly associated with impact on quality of life and based on odds ratios for associations between items and impact on quality of life. Each item was assigned a corresponding number of points in the NBD score, so in its original version the construct reliability as well as the <span class="elsevierStyleItalic">construct validity</span> is already determined.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In order to be able to define in the future and in our environment the incidence and prevalence of bowel dysfunction in disabilities of central neurological origin, mainly SCI and CVA, we first proposed to validate in Spanish a questionnaire that quantifies the severity of bowel dysfunction in patients with disability due to central neurological injury and the individual levels of satisfaction with bowel management.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><p id="par0060" class="elsevierStylePara elsevierViewall">The primary objective is to validate the Spanish version of <span class="elsevierStyleItalic">Neurogenic Bowel Dysfunction score (NBD score)</span><a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> in spinal cord injuries and CVA patients. Secondary objectives were to determine the severity of bowel dysfunction in this group of patients.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0065" class="elsevierStylePara elsevierViewall">Since the objective was to adapt the <span class="elsevierStyleItalic">NBD score</span> to Spanish in its semantic, conceptual, content and criteria equivalence, and although there is no standard guide to carry out the process of cross-cultural adaptation, most of the studies carried out on the translation and adaptation of tools use different methods. We used what was recommended by Bullinger et al.,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> so that a linear translation was carried out with two bilinguals, whose mother tongue was Spanish, who were not previously familiar with the questionnaire, but were familiar with its purpose. From these translations, two study author evaluators (MAGV, MAV), measured the semantic equivalence of the two translated versions, and a first version of the questionnaire was designed, which was tested in five subjects with NBD due to SCI, after which, and once the results had been analysed and some linguistic concepts corrected, the final version of the questionnaire was drawn up (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). A back-translation into the original language was carried out again to check for equivalence, as a quality assurance of the questionnaire adaptation process.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">We obtained authorization from the CRECs of the two hospitals participating in the study to be able to apply it to the subjects participating in it.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Participants</span><p id="par0075" class="elsevierStylePara elsevierViewall">59 patients participated, 30 patients with disability due to SCI and 29 patients with disability due to CVA. Both groups had experienced the disability for more than one year and were willing to answer the questionnaire twice, after signing the informed consent to participate in the study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Methods</span><p id="par0080" class="elsevierStylePara elsevierViewall">With the data from this sample of patients we carried out the measurements at two points in time, one considered as the first evaluation, in outpatient consultations of the Spinal Cord Injury and CVA sequelae Unit of the Rehabilitation services of the participating hospitals and another, with the same sample of subjects, in a period between 15 and 30 days after the first one had been completed, to guarantee the reliable measurement of the construct in the specific research sample, NBD, because the reliability of the scale had already been obtained by the authors of the original questionnaire,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and, in our case, the reliability and inter-administration consistency was obtained, rather than between the items of the tool.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of personal data</span><p id="par0085" class="elsevierStylePara elsevierViewall">In order to maintain data protection, study subjects were not identified by name or medical record number, but by an alphanumeric code.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Sample analysis and measurement</span><p id="par0090" class="elsevierStylePara elsevierViewall">In order to determine the internal consistency of the construct in Spanish, Cronbach’s α<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> was used as a statistical measure, which allows us to estimate the reliability of the measuring tool through a set of categories that are expected to measure the same construct or theoretical domain. The validity of this tool refers to the degree to which it measures what it intends to measure and the reliability of the internal consistency of the tool.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The reliability was measured by analysing the responses of the two questionnaires carried out with a gap period of at least 15 days, determining Cronbach’s α between the categories studied, as this is the method for determining whether they measure the same construct and whether they are highly correlated. The closer the Cronbach’s α value is to one, the higher the internal consistency of the items analysed.</p><p id="par0100" class="elsevierStylePara elsevierViewall">We also determined the <span class="elsevierStyleItalic">test–retest</span> reliability of the questionnaire, administering it to the same population on two different occasions, with an interval between the two administrations of more than 15 and less than 30 days, in order to measure the stability of the scores given to the same subjects and with the same method at two different times.</p><p id="par0105" class="elsevierStylePara elsevierViewall">We performed the analysis using the intraclass correlation coefficient (ICC) for quantitative measurement scales, specifically for the total score on the first and second measure of the questionnaire.</p><p id="par0110" class="elsevierStylePara elsevierViewall">The feasibility or affordability of using it in the field intended for was also determined, establishing the time for its completion, which is related to the brevity, conciseness and clarity of the questions, coding and interpretation of the results, and it was also measured in two different populations with NBD, patients with SCI and those with disability due to CVA. This characteristic was measured by the percentage of non-responses and the time required to complete the questionnaire, but feasibility was not measured by taking into account the patient’s perception of the ease of use of the questionnaire, nor the professional’s perception of its usefulness in clinical practice.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0115" class="elsevierStylePara elsevierViewall">The total number of patients with disabilities was 59. It consisted of 30 patients with SCI, 24 men and 6 women, with a mean age of 43.6 years (SD 11.7) and a range between 23 and 65 years, with a mean disability progression time of 15, 4 years (SD 8.4) and with a range that varies between 2 and 33 years, and a group of patients with disability due to CVA consisting of 29 patients, 12 men and 17 women, 22 CVA of thrombotic origin and seven of haemorrhagic origin, with a mean age of 59.2 years (SD 14.2) and a range between 36 and 92 years, the mean disability progression time for this group was 4.51 years (SD 7.2) with a range between 1 and 33 years.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The construct reliability of the Spanish translation of the <span class="elsevierStyleItalic">NBD score</span> in the group of patients with SCI shows a Cronbach’s α score of 0.897 for all variables.</p><p id="par0125" class="elsevierStylePara elsevierViewall">The reliability result of the <span class="elsevierStyleItalic">NBD score</span> for the SCI group in the <span class="elsevierStyleItalic">test</span>–<span class="elsevierStyleItalic">retest</span> using the ICC on the total score was 0.886 (95% CI 0.764−0.946) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">The construct reliability of the Spanish translation of the <span class="elsevierStyleItalic">NBD score</span> in the CVA patient group shows a Cronbach’s <span class="elsevierStyleItalic">α</span> score for all variables of 0.853.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The reliability result of the <span class="elsevierStyleItalic">NBD score</span> for the CVA group in the <span class="elsevierStyleItalic">test</span>–<span class="elsevierStyleItalic">retest</span> using the ICC on the total score was 0.853 (95% CI 0.686−0.931) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0140" class="elsevierStylePara elsevierViewall">The construct reliability of the Spanish translation of the <span class="elsevierStyleItalic">NBD score</span> for the whole group of patients shows a Cronbach’s α score for all variables of 0.970 and the reliability result of the <span class="elsevierStyleItalic">NBD score</span> for the whole group in the <span class="elsevierStyleItalic">test</span>–<span class="elsevierStyleItalic">retest</span> using the ICC on the total score was 0.970 (95% CI 0.954−0.980) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0145" class="elsevierStylePara elsevierViewall">The feasibility of the questionnaire is adequate because it is user-friendly for the NBD field, takes less than five minutes to complete with an average of three minutes (SD 1.1), is brief and clear regarding questions, recording, coding and interpretation of results in two different NBD populations, patients with SCI and with disability due to CVA. The percentage of non-responses was nil. Feasibility has not been measured through assessing the patient’s perception of the ease of use of the questionnaire, as well as the practitioner’s perception of its usefulness in clinical practice.</p><p id="par0150" class="elsevierStylePara elsevierViewall">NBD severity in the SCI group was 12.6 (SD 5,%), with a median of 12, placing the <span class="elsevierStyleItalic">NBD score</span> in the moderate-high range.</p><p id="par0155" class="elsevierStylePara elsevierViewall">NBD severity in the CVA group was 2.8 (SD 3.7), with a median of 2, placing the <span class="elsevierStyleItalic">NBD score</span> in the low range.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Satisfaction of SCI patients with the management of NBD was on average 5.8 (SD 2.2), with a median of 5.5.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Satisfaction of CVA patients with the management of NBD averaged 7.97 (SD 2.4), with a median of nine.</p><p id="par0170" class="elsevierStylePara elsevierViewall">No correlation was found between satisfaction with the management of NBD and the severity of NBD in patients with SCI, while a correlation was observed between satisfaction with the management of NBD and the severity of NBD in patients with CVA (p < 0.001).</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0175" class="elsevierStylePara elsevierViewall">NBD is one of the added disabilities in spinal cord injury (SCI) but is also present in other neurological disabilities of central origin,<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9,10</span></a> with constipation being a common complaint, with an ill-defined clinical presentation, which is why it is best described as a constellation of signs and symptoms. It is difficult to describe normal bowel function because standards are difficult to define as altered frequency is attributed to various causes.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Once the patient leaves the rehabilitation institution, the management of NBD is often undervalued, or even unknown, in our healthcare system, even though bowel care can require considerable time on the part of caregivers and the patient, resulting in increased anxiety, reduced QoL and social participation.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Although there are different tools that measure bowel dysfunction, such as: <span class="elsevierStyleItalic">Clinical Cleveland Constipation Score</span>,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleItalic">Fecal Incontinence Quality of Life Scale</span>,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> which are used for patients with faecal incontinence, they have not been specifically used in SCI or other NBD due to central neurological injury. We are only aware of the use of the <span class="elsevierStyleItalic">NBD score</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> in this group of patients, which is why we have sought to validate this scale so that it can be used in the Spanish-speaking world for use in patients with NBD due to central neurological processes: SCI, MS, myelomeningocele, CVA, etc.</p><p id="par0190" class="elsevierStylePara elsevierViewall">We have used Cronbach’s α<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> for the validation of the <span class="elsevierStyleItalic">NBD score</span> because according to George and Mallery’s criteria<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> it is the ideal method of analysis for the proposed objective. Both authors indicate that a coefficient result α > 0.9 is excellent, α > 0.8 is good, α > 0.7 is acceptable, α > 0.6 is questionable, α > 0.5 is poor and α < 0.5 is unacceptable. On the other hand, Nunnally<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> indicates that in the early stages of research a reliability value of 0.6 or 0.5 may be sufficient, but since we are dealing with applied research, at least 0.8 is needed. In our case the result is good given that Cronbach’s α was 0.970.</p><p id="par0195" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">test–retest</span> or intra-observer reliability was excellent, with an intraclass correlation coefficient of 0.970 (95% CI 0.954−0.980) when the questionnaire was administered to the same population on two different occasions, over 15 and under 30 days. We use this time period because if the time between the two measurements had been too long, the measured phenomenon could show variations, while if it had been too short, there could be a recall of the answers, the so-called <span class="elsevierStyleItalic">learning effect</span>, so that in both cases a distorted measurement of the repeatability would be obtained.</p><p id="par0200" class="elsevierStylePara elsevierViewall">In relation to NBD caused by neurological disorders of central origin, especially in SCI, this is defined by changes in bowel motility and sphincter control, to which mobility and hand dexterity problems can be added, as well as the use of the drugs required by the patient: antidepressants, painkillers, opioids, antispastics, anticholinergics to treat neurogenic bladder, which can result in bowel management being one of the elements limiting QoL<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and a major source of morbidity, it is therefore not surprising that improvement in bowel or bladder function are ranked among the top priorities for people with these disabilities<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> according to <span class="elsevierStyleItalic">the International Classification of Functioning, Disability and Health (ICF)</span> (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Form principle</span><p id="par0205" class="elsevierStylePara elsevierViewall">There are different patterns in the clinical presentation of NBD depending on the location of the neurological lesion. Lesions above the conus medullaris would be the forms in which upper motor neuron bowel syndrome (UMNBS) occurs, while lesions of the conus medullaris and cauda equina would result in lower motor neuron involvement, the so-called lower motor neuron bowel syndrome (LMNBS).<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">UMNBS or hyperreflexic bowel is characterised by increased tone in the colon wall and in the tone of the external anal sphincter, which disrupts cortical voluntary control of this sphincter, promoting stool retention, although the nerve connections between the spinal cord and the colon remain intact, and therefore reflex coordination and stool propulsion are preserved. UMNBS is typically associated with constipation and faecal impaction due, at least in part, to the overactive external anal sphincter and the evacuation of stool by reflex activity triggered by a stimulus to the rectum, through the insertion of a suppository or by fingering, causing an irritative stimulus that may be accompanied by mucosal erosions or haemorrhoids, caused by slippage of the mucosa, which in the long term hinder reflex evacuation.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">LMNBS or areflexic bowel is characterised by loss of spinal cord-mediated peristalsis and therefore slow propulsion, commonly associated with constipation and a significant risk of incontinence, due to hypotonia or atony of the external anal sphincter and lack of control over the levator ani muscle, which causes the lumen of the rectum to be open.</p><p id="par0220" class="elsevierStylePara elsevierViewall">The depth of the lesion, incomplete vs. complete, has a significant impact on bowel function in people with spinal cord injury, so that incomplete lesions can maintain the sensation of rectal fullness and the ability to evacuate the bowel, so that very complex programmes for evacuation are often not required, however the pathophysiological mechanisms of faecal incontinence and constipation in patients with incomplete SCI are similar to those with complete SCI.</p><p id="par0225" class="elsevierStylePara elsevierViewall">In relation to NBD caused by other neurological diseases of central origin (CVA, multiple sclerosis, myelomeningocele),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the problems are also defined by changes in intestinal motility and sphincter control, which are usually of lesser intensity than in SCI, to which can also be added the problems of mobility and dexterity of the hand and also the drugs required by the patient to control their pathology, which is generally forgotten in the cultural heritage of health professionals, increasing the limitation of quality of life and reducing social participation.</p><p id="par0230" class="elsevierStylePara elsevierViewall">In our study, all patients had UMNBS, and the management of evacuation in neurological conditions of central origin, such as SCI, is a complex issue,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> which should initially be addressed conservatively.</p><p id="par0235" class="elsevierStylePara elsevierViewall">The use of manual evacuation or treatment with oral laxatives<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> and abdominal massage<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> are used as a first step of application, while a second step is transanal irrigation which is considered a safe form that can be used in most patients suffering from NBD. Their results represent a lower total cost of bowel treatment<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>; although their success rate is only 35% after three years.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0240" class="elsevierStylePara elsevierViewall">More recent approaches include sacral neuromodulation, dorsal penile stimulation or clitoral nerve neuromodulation for the treatment of constipation,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> and for some time now, magnetic stimulation<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> has been applied for the treatment of NBD, although there is a greater interventional component.</p><p id="par0245" class="elsevierStylePara elsevierViewall">The choice of the appropriate treatment for NBD is important and requires a decision based on knowledge of the intensity of the impairment and the benefits obtained with the different techniques used.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">We believe that all levels of care: hospital, home, social-health, should be aware of and contemplate the problem and management of NBD based on its severity, but also the knowledge of its application based on the manual skills of patients and caregivers, the social environment and the availability of resources in the community.</p><p id="par0255" class="elsevierStylePara elsevierViewall">The approach to NBD management should not be done without a tool that measures exactly what its intensity is, because quality research is necessary to evaluate the effects of these treatments on each of these disabling conditions.</p><p id="par0260" class="elsevierStylePara elsevierViewall">In conclusion, the results of the study allow us to indicate that the translation into Spanish of the <span class="elsevierStyleItalic">NBD score</span> is a valid, accessible, simple and quick tool to be used in our environment, which will allow us a more realistic approach to the situation of each patient with NBD, and to know the intensity of the condition and the effectiveness of its management by means of the different therapeutic proposals.</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interests</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1589571" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1428617" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1589570" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1428618" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Participants" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of personal data" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Sample analysis and measurement" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 7 => array:3 [ "identificador" => "sec0045" "titulo" => "Discussion" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Form principle" ] ] ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-31" "fechaAceptado" => "2020-06-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1428617" "palabras" => array:2 [ 0 => "Neurogenic bowel" 1 => "Spinal cord injury" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1428618" "palabras" => array:2 [ 0 => "Intestino neurógeno" 1 => "Lesión medular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">To validate into Spanish the Neurogenic Bowel Dysfunction score (NBD score) that quantifies intestinal dysfunction severity in patients with disabilities due to central neurological injury and satisfaction with bowel management.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">59 patients, 30 patients affected by intestinal disability due to spinal cord injury and 29 patients with intestinal disability due to stroke.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The result of the reliability of the construction of the Spanish translation of the NBD Score for the whole group of patients shows a Cronbach’s α for all the variables of 0.970 and the result of the reliability of the NBD score for the whole group in test–retest, using the interclass correlation coefficient, was 0.970 (95% CI 0.954−0.980).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The Spanish version of the NBD score is a valid tool for use in our environment; it will allow a more real approach to the disability situation of each patient in relation to neurogenic intestinal dysfunction and knowledge of the degree and the involvement and effectiveness of management through different therapeutic proposals.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Validar al español el <span class="elsevierStyleItalic">Neurogenic Bowel Dysfunction score</span> (<span class="elsevierStyleItalic">NBD score</span>) que cuantifica la severidad de la disfunción intestinal en pacientes con discapacidad por lesión neurológica central y la satisfacción con el manejo intestinal.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">59 pacientes, 30 pacientes afectos de discapacidad intestinal por lesión medular y 29 pacientes afectos de discapacidad intestinal por accidente vascular cerebral.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">El resultado de la fiabilidad del constructo de la traducción al español del <span class="elsevierStyleItalic">NBD Score</span> para todo el grupo de pacientes muestra una α de <span class="elsevierStyleItalic">Cronbach</span> para todas las variables de 0,970 y el resultado de la fiabilidad del <span class="elsevierStyleItalic">NBD score</span> para todo el grupo en el <span class="elsevierStyleItalic">test–retest</span>, mediante el coeficiente de correlación interclase fue 0,970 (95% IC 0,954−0,980).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La versión traducida al español del <span class="elsevierStyleItalic">NBD score</span> es una herramienta válida para ser utilizada en nuestro medio, permitirá un acercamiento más real a la situación de discapacidad de cada paciente en relación con la disfunción intestinal neurógena y conocer la intensidad de la afectación y la eficacia en su manejo mediante las diferentes propuestas terapéuticas.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0050">Please cite this article as: González Viejo MÁ, Avellanet M, Montesinos Magraner L, Rojas Cuotto K, Launois Obregón P, Perrot Gonzalez J-C. Validación al español de la versión en inglés del <span class="elsevierStyleItalic">Neurogenic Bowel Dysfunction score (NBD score)</span> en pacientes con lesión neurológica de origen central. Med Clin (Barc). 2021;157:361–367.</p>" ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1187 "Ancho" => 2512 "Tamanyo" => 194944 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intervention of bowel dysfunction on disability according to the <span class="elsevierStyleItalic">International Classification of Functioning, Disability and Health (ICF)</span>. Taken from Nevedal et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202110160801335631"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2720218.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Neurogenic Bowel Dysfunction score (NBD score). Spanish validation.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95% CI</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">F test</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Interclass correlation<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower limit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Upper limit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sig. \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single measurements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.796<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,618 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,897 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8,807 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Average measurements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.886<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,764 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,946 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8,807 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2720219.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Correlation coefficients between C-type classes using a definition of consistency; the mean variance is excluded from the variance of the denominator.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The estimator is the same whether the interaction effect is present or not.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The estimate is calculated assuming that the interaction effect is absent.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Interclass correlation coefficient for spinal cord injury.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95% CI</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">F test</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Interclass correlation<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower limit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Upper limit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sig. \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single measurements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.743<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,523 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,871 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6,792 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Average measurements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.853<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,686 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,931 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6,792 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2720217.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Correlation coefficients between C-type classes using a definition of consistency; the mean variance is excluded from the variance of the denominator.</p>" ] 1 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">The estimator is the same whether the interaction effect is present or not.</p>" ] 2 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">The estimate is calculated assuming that the interaction effect is absent.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Interclass correlation coefficient for cerebrovascular accident.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">95% CI</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">F test</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Interclass correlation<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower limit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Upper limit \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Value \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sig. \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Single measurements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.942<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,912 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,961 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33,299 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Average measurements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.970<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,954 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,970 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">33,299 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2720220.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0035">Correlation coefficients between C-type classes using a definition of consistency; the mean variance is excluded from the variance of the denominator.</p>" ] 1 => array:3 [ "identificador" => "tblfn0040" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0040">The estimator is the same whether the interaction effect is present or not.</p>" ] 2 => array:3 [ "identificador" => "tblfn0045" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0045">The estimate is calculated assuming that the interaction effect is absent.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Interclass correlation coefficient for the entire sample (spinal cord injury plus cerebrovascular accident).</p>" ] ] 5 => array:5 [ "identificador" => "202110160801335631" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 3532 "Ancho" => 2508 "Tamanyo" => 890345 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Neurogenic bowel dysfunction in patients with spinal cord injury, myelomeningocele, multiple sclerosis and Parkinson’s disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.A. 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