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Background: In 2020, The London Royal College of Physicians published "Prolonged disorders of consciousness following sudden-onset brain injury: national clinical guidelines". In 2021, in the journal Brain, Scolding et al. published "a critical evaluation of the new UK guidelines". This evaluation focussed on one of the 73 recommendations in the National Clinical Guidelines. They also alleged that the guidelines were unethical., Criticisms: They criticised our recommendation not to use activation protocols using fMRI, electroencephalography, or Positron Emission Tomography. They claim these tests can (a) detect 'covert consciousness', (b) add predictive value and (c) should be part of routine clinical care. They also suggest that our guideline was driven by cost considerations, leading to clinicians deciding to withdraw treatment at 72 h., Evidence: Our detailed review of the evidence confirms the American Academy of Neurology Practise Guideline (2018) and the European Academy of Neurology Guideline (2020), which agree that insufficient evidence supports their approach., Ethics: The ethical objections are based on unwarranted assumptions. Our guideline does not make any recommendations about management until at least four weeks have passed. We explicitly recommend that expert assessors undertake ongoing surveillance and monitoring; we do not suggest that patients be abandoned. Our recommendation will increase the cost We had ethicists in the working party., Conclusion: We conclude the "critical evaluation" fails to provide evidence for their criticism and that the ethical objections arise from incorrect assumptions and unsupported interpretations of evidence and our guideline. The 2020 UK national guidelines remain valid.

Objective: We aimed to develop a goal classification of individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity to under-pin a more structured approach to future goal setting., Design: Individualised goals for spasticity treatment incorporating botulinum toxin intervention for upper limb spasticity (n=696) were analysed initially from four studies published in 2008-2012, spanning a total of 18 centres (12 in the UK and 6 in Australia). Goals were categorised and mapped onto the closest matching domains of the WHO International Classification of Functioning. Confirmatory analysis included a further 927 goals from a large international cohort study spanning 22 countries published in 2013., Results: Goal categories could be assigned into two domains, each subdivided into three key goal areas: Domain 1: symptoms/impairment n=322 (46%): a. pain/discomfort n=78 (11%), b. involuntary movements n=75 (11%), c. range of movement/contracture prevention n=162 (23%). Domain 2: Activities/function n=374 (54%): a. passive function (ease of caring for the affected limb) n=242 (35%), b active function (using the affected limb in active tasks) n=84 (12%), c. mobility n=11 (2%).Over 99% of the goals from the large international cohort fell into the same six areas, confirming the international applicability of the classification., Conclusions: Goals for management of upper limb spasticity, in worldwide clinical practice, fall into six main goal areas., (© The Author(s) 2015.)

Objective: A psychometric evaluation of the Needs and Provision Complexity Scale (NPCS)., Main Measure: The NPCS is designed to evaluate both needs for health and social support (NPCS-Needs) and services provided to meet those needs (NPCS-Gets)., Design: A consecutive cohort of patients were recruited from nine specialist neurorehabilitation units in London., Subjects: Four hundred and twenty-eight patients were assessed at discharge (63.1% males; mean age 49 years) of whom 73.6% had acquired brain injury (49.5% stroke/subarachnoid, 14.7% traumatic brain injury, 9.3% 'other acquired brain injury'), 8.9% spinal cord injury, 6.1% peripheral neuropathy, 4.9% progressive neurological and 6.3% other neurological conditions., Results: The NPCS-Needs was completed by the clinical team at discharge and 212 patients reported NPCS-Gets after six months. NPCS-Gets repeatability was tested in a subsample (n = 60). Factor analysis identified two principal domains ('Health and personal care' and 'Social care and support') accounting for 66% of variance, and suggested a large general factor underpinning the NPCS. Internal consistency was high (alpha = 0.94) and repeatability acceptable. Intraclass coefficients for domain scores were healthcare 0.67 (95% confidence interval (CI) 0.48-0.80); personal care 0.83 (0.73-0.90); rehabilitation 0.65 (0.45-0.78); social/family support 0.66 (0.46-0.79) and environment 0.84 (0.74-0.90). Linear-weighted kappas for item-by-item agreement ranged from 0.42 to 0.83. Concurrent validity was demonstrated through correlations with measures of dependency and community integration., Conclusions: Notwithstanding a 50% response rate after six months, the NPCS has good internal consistency, a robust two-factor structure, acceptable test-retest reliability and initial evidence of concurrent validity., (© The Author(s) 2014.)

Objective: To evaluate the psychometric properties of the Arm Activity Measure (ArmA), a patient-reported measure of active and passive function in the paretic upper limb., Design: Psychometric evaluation study., Setting: Two specialist rehabilitation and spasticity management services., Method: Patients (n = 92) with upper limb paresis were recruited from two specialist neurorehabilitation centres. Mean age 44.5 (SD 16.7). Diagnostic distribution: stroke 48 (52%); other brain injury 28 (31%); or other neurological condition 16 (17%). Evaluation of convergent and divergent validity; unidimensionality, scaling, reliability (internal consistency and test-retest); responsiveness to change and feasibility of the ArmA were undertaken., Results: Expected convergent and divergent relationships were seen with the Leeds Adult Spasticity Impact Scale and the Disabilities of Arm Shoulder and Hand (DASH) (rho 0.5-0.63). Principal components analysis confirmed that active and passive function formed two separate constructs in each sub-scale. Mokken analysis corroborated the findings of the principal components analysis and demonstrated scaling using the monotone homogeneity model (Item H>0.5 for all items). Cronbach's alpha was 0.85 and 0.96, respectively, for the passive and active function subscales. Item level test-retest agreement ranged from 92-97.5% (quadratic-weighted Kappa 0.71-0.94). In the subgroup treated for spasticity with botulinum toxin (n = 58), the ArmA passive function scale identified a significant difference between responder and non-responder groups (Mann Whitney U = 0.85, p < 0.01). Respondents reported the ArmA to be relevant (77%), easy to use (90%) and timely to complete (83% under 10 minutes)., Conclusion: The ArmA is a valid and reliable tool feasible for use in the evaluation of upper limb function in the context of treatment for spasticity.

Objective: To describe the rationale and development of a casemix model and costing methodology for tariff development for specialist neurorehabilitation services in the UK., Rationale for Development of a New Methodology: Patients with complex needs incur higher treatment costs. Fair payment should be weighted in proportion to costs of providing treatment, and should allow for variation over time CASEMIX MODEL AND BAND-WEIGHTING: Case complexity is measured by the Rehabilitation Complexity Scale (RCS). Cases are divided into five bands of complexity, based on the total RCS score. The principal determinant of costs in rehabilitation is staff time. Total staff hours/week (estimated from the Northwick Park Nursing and Therapy Dependency Scales) are analysed within each complexity band, through cross-sectional analysis of parallel ratings. A 'band-weighting' factor is derived from the relative proportions of staff time within each of the five bands., Costing Methodology: Total unit treatment costs are obtained from retrospective analysis of provider hospitals' budget and accounting statements. Mean bed-day costs (total unit cost/occupied bed days) are divided broadly into 'variable' and 'non-variable' components. In the weighted costing model, the band-weighting factor is applied to the variable portion of the bed-day cost to derive a banded cost, and thence a set of cost-multipliers. Preliminary data from one unit are presented to illustrate how this weighted costing model will be applied to derive a multilevel banded payment model, based on serial complexity ratings, to allow for change over time.

Unlabelled: This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is 'An understanding of the different international models for funding of health care services and casemix systems, as exemplified by those in the US, Australia and the UK.', Background: Payment for treatment in healthcare systems around the world is increasingly based on fixed tariff models to drive up efficiency and contain costs. Casemix classifications, however, must account adequately for the resource implications of varying case complexity. Rehabilitation poses some particular challenges for casemix development., Objective: The objectives of this educational narrative review are (a) to provide an overview of the development of casemix in rehabilitation, (b) to describe key characteristics of some well-established casemix and payment models in operation around the world and (c) to explore opportunities for future development arising from the lessons learned., Results: Diagnosis alone does not adequately describe cost variation in rehabilitation. Functional dependency is considered a better cost indicator, and casemix classifications for inpatient rehabilitation in the United States and Australia rely on the Functional Independence Measure (FIM). Fixed episode-based prospective payment systems are shown to contain costs, but at the expense of poorer functional outcomes. More sophisticated models incorporating a mixture of episode and weighted per diem rates may offer greater flexibility to optimize outcome, while still providing incentive for throughput., Conclusion: The development of casemix in rehabilitation poses similar challenges for healthcare systems all around the world. Well-established casemix systems in the United States and Australia have afforded valuable lessons for other countries to learn from, but have not provided all the answers. A range of casemix and payment models is required to cater for different healthcare cultures, and casemix tools must capture all the key cost-determinants of treatment for patients with complex needs.

Objective: To determine the range and variation in costs and service characteristics between different levels of specialist neurorehabilitation services in England, and to determine key predictors of service costs., Design: A retrospective analysis of service costs, staffing and activity levels, with comparison across service types., Setting: Specialist neurorehabilitation services (n = 17) from different areas of England, were divided into three types according to predefined criteria: adult level 1 (tertiary) (n = 8) and level 2a (supra-district) (n = 7) services; and children's services (n = 2)., Main Measures: Annual service costs were collated using a standard costing template, and divided according to principal cost type (direct/indirect/overheads) and behaviour (variable/non-variable). For comparison between the level 1 and 2a services, costs and service characteristics were calculated per occupied bed., Results: The percentage breakdown of costs was consistent across all three service types, with direct costs making up 83%, indirect 10%, and overheads 7% of total costs. The median variable component ranged from 75 to 76%. Staff pay made up 66% and accounted for 95% of the variance of the total costs in adult services. Level 1 services had higher total staffing costs, mainly reflecting higher therapy staff numbers (z = -2.0, P = 0.05). The median total costs/bed-day were: level 1 £530 (interquartile range (IQR) 435-574) (equivalent to US$860 or €650) and level 2a £402 (US$650 or €459) (IQR 326-451) (z = -2.5, P = 0.009). Children's services cost almost twice that (£1017-1177)., Conclusions: Expected variations in cost are largely due to differences in staff costs. Total staff costs projected by 150% provided a reasonable estimate of total unit costs.

Objective: to develop and test an algorithm for conversion of the Northwick Park Dependency Scale (NPDS) to a Barthel Index., Design and Setting: conversion criteria were developed to derive a Barthel Index from NPDS data. The criteria were then applied in two community-based datasets of NPDS and Barthel scores, gathered from carers/patients via postal questionnaires. A retrospective exploratory analysis (dataset A) was followed by prospective confirmatory analysis (dataset B)., Subjects: patients with neurological disabilities, mainly following acquired brain injury: dataset A (n = 225) and dataset B (n = 96)., Main Measures: comparison of NPDS-derived Barthel scores with parallel directly rated Barthel scores., Results: the exploratory analysis identified that one Barthel item ('Stairs') could not be derived from the NPDS items alone, and required minor adaptation of one of the five additional questions that are included to translate the NPDS into an assessment of community care needs (Northwick Park Care Needs Assessment, NPCNA). For the prospective confirmatory analysis, the NPCNA 'Stairs' question was adjusted to support full conversion. Very strong intraclass correlations were observed between the total 'direct' and 'derived' Barthel scores (0.97 (dataset A), 0.95 (dataset B), P<0.001); 95% limits of agreement ranged from -2.52 to 2.56 (dataset A) and -3.29-3.91 (dataset B). Item-by-item agreement (linear-weighted Cohen's kappa coefficients) ranged from 0.68 to 0.85 (dataset A) and 0.59-0.83 (dataset B), which represents 'substantial' to 'almost perfect' agreement., Conclusions: this study demonstrates that a Barthel Index can be reliably derived from NPDS and NPCNA data through a conversion algorithm which has now been built into the supporting software package.

Objective: to examine the extent of agreement between Barthel Index scores derived from Northwick Park Dependency Scores (NPDS) and the Functional Independence Measure (FIM) ratings, in an inpatient setting., Design and Setting: previously described conversion criteria were applied in a secondary analysis of a large existing dataset, gathered in a tertiary specialist inpatient neurorehabilitation unit., Subjects: patients with neurological disabilities (N = 1347), mainly following acquired brain injury., Main Measures: comparison of Barthel scores derived from the NPDS (rated by nursing staff) and from parallel FIM scores (rated by the therapy team)., Results: very strong intraclass correlations were observed between the total scores (0.93, P<0.001); 95% limits of agreement ranged from -3.53 to 4.90. Item-by-item agreement (linear-weighted Cohen's kappa coefficients) ranged from 0.41 to 0.77, which represents 'moderate' to 'substantial' agreement. A significant bias towards lower NPDS-derived scores (median 10 (interquartile range (IQR) 6-16) compared with median 11 (IQR 7-16) for the FIM-derived score; Wilcoxon z 11.60, P<0.001) was considered most likely to reflect actual differences in patient performance observed by therapy and nursing staff., Conclusions: this study demonstrates good overall agreement between the Barthel Index ratings derived from NPDS and FIM scores. However, scores may be affected by differential performance with nursing and therapy staff, and should not automatically be regarded as equivalent.

Purpose: To compare two alternative rating systems for goal attainment scaling (GAS) intended to improve capture of goal underachievement., Setting: A tertiary inpatient neurorehabilitation unit., Design: Secondary comparative analysis of prospective cohort data., Participants: A total of 243 patients were included, with 977 goals between them; M:F ratio 146:97, mean age 44.8 (SD 14.2) years., Diagnosis: 200 (82%) acquired brain injury, 21 (9%) spinal cord injury, 22 (9%) other neurological conditions., Methods: Goal attainment scaling-rated achievement of 1-6 patient-selected goals was collected using the standard 5-point scale (-2 to +2) and formula to derive aggregated T-scores, as recommended by its originators. Two alternative 6-point rating systems were applied retrospectively. Version 1 set all baseline scores at '-2' and added '-3' to denote 'worsening'. Version 2 added a '-0.5' score to denote 'partial achievement' for goals starting at '-1', without change to range or baseline scores., Results: Baseline scores were identical for standard rating and version 2 (median 34.9, interquartile range (IQR) 31.9-35.5), but lower for version 1 (median 21.0, IQR 19.8-22.6), which was reflected in the change scores. While median achieved T-scores were 50.0 for all three methods, version 2 marginally overestimated goal attainment (Wilcoxon z -6.8, P < 0.001), while version 1 underestimated it (Wilcoxon z -7.2, P < 0.001), in comparison with standard goal rating., Conclusion: Different goal rating methods may have significant impact on goal attainment scaling results. Version 2 provided the closest match to standard rating, supporting documentation of partial goal achievement without affecting score range. For analysis and reporting, '0.5' scores should be converted to '-1', to maintain parity with standard rating systems.

Objectives: To describe the development and initial validation of the Northwick Park Therapy Dependency Assessment (NPTDA) as a measure of therapy interventions in neurorehabilitation., Design: An iterative development process, followed by comparison with systemic prospective activity analysis, and parallel application of prospective and retrospective scores., Setting: A tertiary specialist inpatient neurorehabilitation service., Participants: A total of 37 patients (M:F 21:16, mean age 41.8 (SD 14.7) years) with complex neurological disability in two consecutive cross-sectional cohorts., Methods: The NPTDA was developed and refined over 18 months, together with an algorithm that converts ordinal scores to estimated therapy hours/week. NPTDA-estimated hours were compared with 'actual' therapy hours/week, identified from activity analysis. In a subsequent cohort analysis, prospectively rated NPTDA scores (reflecting intended levels of intervention) were compared with retrospective NPTDA scores (actual interventions)., Results: NPTDA-estimated therapy hours/week were strongly correlated with those identified from activity analysis, for total scores (Spearman rho 0.77, P<0.0001), and also for all five subdomains for direct (hands-on) intervention (rho 0.70-0.93, P<0.0001). The initial test algorithm overestimated therapy hours (Wilcoxon z =3.9, P<0.001). After adjustment, reanalysis using a revised algorithm showed this bias to be removed (Wilcoxon z =1.4 P =0.15). Prospective and retrospectively applied total NPTDA scores were strongly correlated (rho 0.61, P<0.0001). Although intended levels of intervention were higher than those actually delivered (Wilcoxon z =3.30, P<0.001), the differences corresponded to real deviations from intended practice., Conclusion: In this initial evaluation, after revision of the algorithm, the NPTDA provided acceptable estimate of therapy interventions. Further evaluation is now required in other populations and settings.

Goal attainment scaling is a mathematical technique for quantifying the achievement (or otherwise) of goals set, and it can be used in rehabilitation. Because several different approaches are described in the literature, this article presents a simple practical approach to encourage uniformity in its application. It outlines the process of setting goals appropriately, so that the achievement of each goal can be measured on a 5-point scale ranging from -2 to +2, and then explains a method for quantifying the outcome in a single aggregated goal attainment score. This method gives a numerical T-score which is normally distributed about a mean of 50 (if the goals are achieved precisely) with a standard deviation of around this mean of 10 (if the goals are overachieved or underachieved). If desired, the approach encompasses weighting of goals to reflect the opinion of the patient on the personal importance of the goal and the opinion of the therapist or team on the difficulty of achieving the goal. Some practical tips are offered, as well as a simple spreadsheet (in Microsoft Excel) allowing easy calculation of the T-scores.

Objective: To describe and compare current practice in diagnosis and treatment of depression following acquired brain injury in two countries (UK and the Netherlands) which have different sets of guidelines., Setting and Design: A cross-sectional survey of reported practice among rehabilitation physician members of the British and Dutch specialist societies., Methods: A 12-item postal questionnaire was sent to 496 rehabilitation physicians with two reminders: N=353 (71%) responded, 146 of whom did not manage people with acquired brain injury, leaving 207 questionnaires for analysis (Netherlands N=121, UK N=86). Descriptive summary statistics were compiled. Categorical and dichotomous data were compared between the groups using chi-squared tests., Results: Sixty-seven (78%) of British respondents served a predominantly younger adult (65 years) population, compared with only 27 (22%) of the Dutch, who mainly treated patients of all ages. In line with their respective guidelines, more British respondents reported that they screened all acquired brain injury patients for depression (68/86 (79%) British versus 71/121 (59%) Dutch, P<0.01), and used formal measures (37/68 (54%) versus 14/69 (20%), P<0.001). They also took a more active role in treatment of depression: only 1 (1%) never used antidepressants, compared with 22 (18%) of Dutch respondents (P<0.001). On the other hand, where antidepressants were prescribed, the Dutch respondents were more likely than the British to follow-up their patients (93/98 (95%) versus 67/84 (80%), P<0.01)., Conclusions: The survey demonstrates a broadly similar approach, but highlights some significant variance in practice between the two countries which may stem from differences in population and service provision as well as their respective guidelines.

Aim: To determine whether the Northwick Park Care Needs Assessment (NPCNA) could be used to estimate nursing staff requirements in an inpatient rehabilitation setting., Design: Retrospective analysis of NPCNA data in comparison with nursing staff provision over a six-month period from 1 April 2003 to 30 September 2003., Setting: A specialist neurorehabilitation unit., Methods: Daily care requirements for the ward were calculated at two-week intervals by summing the NPCNA care-hour estimates for all inpatients. Nursing staff hours provided were identified from the unit's duty rota and agency records for each corresponding period., Results: In total, 271 care-hour recordings were extracted from 59 patients. There was a poor relationship between the calculated total ward care-hour requirements and nursing staff hours provided (Pearson's r = 0.31, P = 0.29); but staff hours provided fell significantly short of estimated daily care requirements (mean shortfall 6.2 hours/day, SD 8.6 (95% confidence interval (CI) 0.73, 11.1), P = 0.03)). The shortfall was most obvious during peak care periods in the morning and at bedtime, which resonates with experience reported by nursing staff that they are overstretched at these times. A marked discrepancy between qualified nursing staff hours provided and NPCNA-estimated ;special nursing' care requirements highlights a failure to address important facets of the rehabilitation nursing role., Conclusions: The NPCNA, which was designed to assess only direct care needs in a community setting, requires the further development of a new algorithm before it could be used to estimate nursing staff requirements in a rehabilitation ward setting.

Aim: To identify the standardized outcome measures currently used in routine clinical practice in rehabilitation centres in the UK., Design: Cross-sectional survey by postal questionnaire., Participants: All UK consultant members of the British Society of Rehabilitation Medicine (BSRM) (n = 180)., Results: A total of 108 (60%) responses were received, representing 83 different rehabilitation services. Of these, 71 (86%) collected at least one standardized measure. The Barthel Index and the UK Functional Independence Measure and/or Functional Assessment Measure (FIM +/- FAM) were the most popular global outcome measures: 83% of units measured one or other of these. The Northwick Park Dependency Scale (NPDS) and Care Needs Assessment (NPCNA) (n = 21, 28%) were used for the more dependent patients. Depression and pain scores were more commonly used than general health measures. Sixty (72%) units routinely assessed outcome through the achievement of set goals, but only four transformed data to a goal attainment scale. Outcome measure scores were routinely reported in discharge summaries by 72% of units., Conclusions: The survey demonstrated quite widespread use of outcome assessments in routine clinical rehabilitation within the UK, with an encouraging level of common measurement in some areas of practice. The results have been used to update the BSRM 'basket of recommended measures'.

Objectives: To assess the repeatability of the AbilityQ--a screening tool to assess technical ability to complete a questionnaire--in patients with complex disabilities following stroke. To evaluate the validity of the AbilityQ in predicting repeatability and consistency of response to verbal and visual analogue scale questions in the ShoulderQ in those with shoulder pain., Design: In a cross-sectional study, the AbilityQ and 'ShoulderQ' were administered on two consecutive days by a single investigator., Setting: Six regional rehabilitation centres in the UK managing patients with severe complex neurological disability., Subjects: Forty-nine patients with anterior or posterior circulation strokes: 13 (63%) had cognitive deficits and 28 (57%) had communicative deficits., Results: Thirty-one (63.3%) patients required some degree of help in completing the AbilityQ. Percentage agreement for individual questions between day 1 and day 2 ranged from 55 to 88% with kappa values from 0.07 to 0.79. Repeatability of ShoulderQ responses was 36-72% for the verbal questions (kappa values 0.16-0.56). For visual analogue scale (VAS) questions, agreement +/- 1 on a 10-point scale was 36-59% with intraclass correlation coefficients 0.50-0.60 (p < 0.01). High verbal (> or = 3/4) and VAS scores (3/3) on the AbilityQ had positive predictive values for good repeatability in the ShoulderQ of 80% and 58% respectively. Mismatched AbilityQ responses to verbal and VAS questions showed a positive predictive value of 92% for similar inconsistency in the ShoulderQ and a negative predictive value of 90%., Conclusions: In this preliminary evaluation the AbilityQ and the ShoulderQ each demonstrated a moderate level of repeatability in a group of patients expected to have difficulty in completing questionnaires. The AbilityQ appears to have some clinical usefulness in identifying those able to respond to the ShoulderQ and, where responses to verbal and VAS questions conflict, may offer some guidance as to which are most likely to be accurate in that individual. Further development is underway.

Objective: To determine what items should be included in a clinical assessment tool developed to measure associated reactions in the hemiplegic upper limb and to assess the reliability of the resultant measure., Design: Development through a structured consultative process using focus group methodology. Evaluation of inter- and intra-rater reliability between two independent observers., Subjects: Nineteen consecutive hemiplegic patients admitted to Northwick Park Hospital for rehabilitation following stroke., Methods: Focus groups were conducted in two centres, comprising physiotherapists experienced in the clinical management of brain injury. The groups identified four key characteristics related to severity of associated reactions, which became the items of the rating scale. Evaluation of inter- and intra-rater reliability was undertaken by comparison of agreement between ratings of associated reactions occurring during a single standardized task (sit-to-stand), by two senior physiotherapists in 19 subjects., Results: There were good correlations between the two raters in total (rho 0.89 p < 0.005) and modal scores (rho 0.88 p < 0.005). Reliability testing of each item revealed moderate to very good inter-rater agreement (weighted kappa values 0.43-0.85) and good to very good intra-rater agreement (weighted kappa values 0.61-0.87). A slight tendency for one rater to score more severely than the other only reached significance for one item (excursion). Overall (modal) severity scores showed a good level of agreement (kappa 0.76-0.81) both between and within raters., Conclusion: Items to be included in a clinical assessment tool to measure associated reactions in the hemiplegic upper limb were determined. Reliability of the resultant measure was found to be encouraging. These results however apply only to observations made during a specific standardized task (sit-to-stand) and further study of sensitivity to change and reproducibility in different tasks is required before the findings can be extrapolated into routine practice.

Objective: To develop an evidence-based multidisciplinary integrated care pathway (ICP) for the management of depression following brain injury in a rehabilitation setting, and to assess its impact on standards of care and documentation., Setting: A regional rehabilitation unit providing inpatient rehabilitation for young patients (16-65) with complex disabilities mainly resulting from brain injury., Methods and Design: A completed cycle of audit including: standards set for documentation, assessment, management and review; an initial retrospective audit of documented patient management against those standards during a five-year period (26 patient records); ICP development by a multidisciplinary team of doctors, psychologists and nurses based on clinical opinion and systematic review of the literature; re-audit from the ICP documentation (48 patient records) over a period of 15 months., Results: The initial audit demonstrated borderline acceptable documentation of baseline mood state and start of medication (54-61%), but poor documentation of review (29%) and subsequent treatment (27%). Introduction of the ICP improved all standards of documentation to 94-100%, except for assessment using a validated measure (84%) and follow-up assessment (76%)., Conclusions: This ICP raised staff awareness of depression, leading to improved documentation and possibly also standards of care.

Background: Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to the development of an evidence-based integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting, and is divided into two parts. In part 1 we reviewed the frequency of depression in stroke, its impact on functional recovery and the different methods for assessment., Aims and Objectives: In part 2, we discuss the rationale for treatment of PSD, appraise the evidence for effectiveness of the different antidepressant drugs, and consider whether we can identify a recommended first-line treatment for use in our ICP., Methods: Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews., Main Findings: From the few controlled trials of anti-depressant therapy in PSD, both tricyclics and selective serotonin re-uptake inhibitors (SSRIs) appear to be effective, but the latter may be preferable in stroke because of their prompt action and better side-effect profiles. Within the group of SSRIs there is currently no direct evidence to guide the choice of agent. In the absence of firm guidance, sertraline was chosen on theoretical grounds as one of the most potent with minimal sedative effects and no reported interaction with warfarin. Citalopram may offer an appropriate second choice., Conclusions: A suggested regimen for the use of sertraline in PSD was put forward. Development of an ICP may help to establish a more consistent approach to assessment and treatment of PSD, and form a basis for future comparison of different treatments as they become available.

Background: Depression is a common complication of stroke, leading to increased morbidity and mortality. It can impede the process of rehabilitation, and has been associated with poorer outcomes and increased length of stay in hospital. This systematic review was undertaken as a preliminary step to explore the available evidence on which to base an integrated care pathway (ICP) for the management of post-stroke depression (PSD) in a rehabilitation setting. It is divided into two parts., Aims and Objectives: In part 1 we review the frequency of depression in stroke and its impact on functional recovery. Also the different methods for diagnosis and measurement., Methods: Data sources comprised a computer-aided search of published studies on depression in stroke and references to literature used in reviews., Main Findings: PSD is common and is associated with cognitive, functional and social deficits which potentially limit the outcome from rehabilitation. However, diversity of assessment tools and diagnostic criteria confound assimilation of the available literature. The Beck Depression Inventory (BDI), Hamilton Depression Rating Scale and Zung Self-rating Depression Scale were most commonly used and have demonstrable validity in stroke patients but tend to exclude those with aphasia. Instruments developed specifically to include aphasic patients, such as the Stroke Aphasic Depression Scale, are promising but have yet to be fully evaluated., Conclusions: Further work is required to adapt and evaluate instruments to measure depression in the context of stroke. Development of an integrated care pathway may help to establish a more consistent approach to assessment and diagnosis of PSD.

Aims: To use data generated from an integrated care pathway (ICP) to describe the characteristics of patients presenting with depression in a brain injury rehabilitation programme and to assess their response to treatment with sertraline., Setting: A regional rehabilitation unit providing inpatient rehabilitation for young patients (16-65) with severe complex disabilities., Design: Prospective cohort study of 82 patients admitted to the unit during the 15-month period between between 1 September 1999 and 1 December 2000. Response to sertraline was assessed in an open-label, before-and-after study design., Methods and Design: All admissions were screened and included in the ICP if there was clinical suspicion of depression, past or present. Antidepressant medication was prescribed, where appropriate, according to the ICP protocol. Depression was diagnosed on clinical grounds against DSM-IV criteria, and measured where feasible using the Beck Depression Inventory (BDI-II) administered by interview, pretreatment and at 6-8 weeks., Results: Of 82 admissions 41 (50%) were managed using the ICP and 27 (64%) were either started on or changed to sertraline--21 for depression +/- lability and six for emotional lability only. All of the depressed patients improved clinically at some level and no significant side-effects were observed. The BDI-II was assessable in 17/21 who showed a mean improvement of 14.5 +/- 9.7 (confidence interval (CI) 9.3-19.7, p < 0.001). Eleven patients (52%) had previously failed to respond with a different selective serotonin re-uptake inhibitor (SSRI) agent but still made a significant response when changed to sertraline with a mean reduction in BDI-II of 16.3 +/- 10.9 (CI 8.4-24.11, p < 0.001)., Conclusions: The ICP was practical to use and provided systematic data on assessment of depression and response to treatment in 'real-life' clinical practice in a brain injury rehabilitation setting. Sertraline appears to be useful and well-tolerated in this context. A full placebo-controlled study is now required.

Background: Shoulder pain is a common complication of stroke. It can impede rehabilitation and has been associated with poorer outcomes and prolonged hospital stay. This systematic review was undertaken to inform the development of an evidence-based integrated care pathway (ICP) for the management of hemiplegic shoulder pain (HSP)., Aims and Objectives: 1) To provide a background understanding of the functional anatomy of the shoulder and its changes following stroke. 2) To review the literature describing incidence and causation of HSP and the evidence for factors contributing to its development. 3) To appraise the evidence for effectiveness of different interventions for HSP., Methods: Data sources comprised a computer-aided search of published studies on shoulder pain in stroke or hemiplegia and references to literature used in reviews (total references = 121)., Main Findings: Although a complex variety of physical changes are associated with HSP, these broadly divide into 'flaccid' and 'spastic' presentations. Management should vary accordingly; each presentation requiring different approaches to handling, support and intervention. (1) In the flaccid stage, the shoulder is prone to inferior subluxation and vulnerable to soft-tissue damage. The arm should be supported at all times and functional electrical stimulation may reduce subluxation and enhance return of muscle activity. (2) In the spastic stage, movement is often severely limited. Relieving spasticity and maintaining range requires expert handling; overhead exercise pulleys should never be used. Local steroid injections should be avoided unless there is clear evidence of an inflammatory lesion., Conclusions: HSP requires co-ordinated multidisciplinary management to minimize interference with rehabilitation and optimize outcome. Further research is needed to determine effective prophylaxis and document the therapeutic effect of different modalities in the various presentations. Development of an integrated care pathway provides a reasoned approach to management of this complex condition, thus providing a sound basis for prospective evaluation of different interventions in the future.

Objective: To develop a set of clinical standards for specialist community rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services., Design and Methods: The proposed set of standards was adapted from the previously published standards for inpatient services, by a working party of the British Society for Rehabilitation Medicine (BSRM). Consensus was then achieved by an iterative consultation process in five rounds. A postal survey was conducted on behalf of the BSRM amongst its consultant members providing community rehabilitation services in the UK, who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability., Results: Fifty consultants who ran specialist community rehabilitation services agreed to participate, of whom 29 (58%) actually responded. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Twenty-five (89%) felt the standards were helpful and 26 (93%) felt that they covered the main aspects of specialist community rehabilitation services: 23 (79%) found them at least partially applicable to their own service., Conclusions: Proposed clinical standards have been developed for specialist community rehabilitation services in the UK. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

Objective: We investigated the capacity of brain-injured patients to participate in an aerobic exercise programme early after injury., Design: Retrospective analysis of exercise achievements in patients participating in a randomized controlled trial., Setting and Subjects: Ninety patients participated in an exercise training programme on a cycle ergometer at four inpatient neurological rehabilitation units for younger patients. At intake, impairments and function were rated on: Motricity Index, Ashworth Scale, Berg Balance Scale, Barthel Index and Functional Independence Measure., Interventions: Patients cycled for up to 30 minutes three times weekly for 24-36 sessions over 12 weeks., Main Outcome Measures: Exercise performance was measured by: (a) number of sessions to achieve a cycling time of 30 minutes, (b) overall mean cycling time per session over 24 sessions and (c) mean time per session cycling at >60% of age predicted maximum heart rate (HR max) over 24 sessions., Results: Fifty-five patients completed 24 sessions. Thirty-five withdrew, largely for logistic reasons, before completing training; they were significantly less disabled than the 55 who remained. Forty-four of the 55 patients trained for an average of at least 20 minutes per session, 18 training at >60% HR max for this time. There were no differences in performance on the three exercise parameters between two groups of patients with baseline Barthel scores of < or = 12 and > or = 13., Conclusions: Brain-injured patients with a range of disabilities have the capacity to participate in an exercise programme during early inpatient rehabilitation, though some may take longer to achieve adequate intensity of aerobic exercise.

Objective: To develop a set of clinical standards for specialist inpatient rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services., Design: The proposed set of standards was developed by group consensus followed by an iterative consultation process. A postal survey was conducted on behalf of the British Society for Rehabilitation Medicine (BSRM) amongst its consultant members in the UK (n = 163), who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability., Results: The response rate was 61%, of which 81 respondents ran an inpatient rehabilitation service. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Specific suggestions were incorporated into the revised standards. Further work is required to establish agreed outcomes that are systematically measured and recorded: only half the respondents (50%) routinely recorded a standardized outcome measure, and only a quarter (26%) routinely reviewed patients to record long-term outcome., Conclusions: Clinical standards have been developed for specialist inpatient rehabilitation services in the UK. The BSRM proposes to adopt these standards for a test period of 2-3 years in the first instance. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

Objective: To investigate the acquisition of ability to walk independently in young severely disabled stroke patients unable to walk three months after onset., Setting: A regional rehabilitation unit providing post-acute neurorehabilitation mainly for patients aged 16-65 years., Subjects and Methods: A retrospective analysis of records was undertaken for 152 stroke patients admitted consecutively over a three-year period. All had a combination of physical, cognitive and language impairments; male/female 98/54; median age 54 (IQR 47-60) years., Main Outcome Measures: Time taken from stroke onset to regain the ability to walk safely and independently at least 5 metres around the hospital bay., Results: Seventy-five (49%) regained the ability to walk independently between 3 and 11 months post onset. Patients with cognitive impairments and neglect took longer to walk. Time from stroke onset to admission was longer in patients who did not walk (median 16.3 weeks), than in those who regained walking (median 12.7 weeks; p = 0.009). Independent positive associations were found between the time taken to walk and time from onset to referral for rehabilitation (p = 0.55; p < 0.001), and time from acceptance to admission (p = 0.30; p = 0.008)., Conclusion: With intensive specialist input, significant numbers of severely disabled young stroke patients can regain independent walking many months after onset, though late walkers may follow a slower recovery course. These results argue for investment in appropriate rehabilitation for these patients. Waiting list delays may prolong rehabilitation and potentially compromise cost effectiveness.

Objectives: To determine whether the Northwick Park Care Needs Assessment (NPCNA) is sensitive to change occurring during rehabilitation and provides a reliable estimate of care needs in the community, and to compare the NPCNA with the Functional Independence Measure (FIM)., Design: Prospective cohort study., Setting: Postacute neurorehabilitation unit for young patients with complex disabilities., Subjects: Thirty-nine consecutive patients with brain injury admitted over six months., Measurements and Methods: The NPCNA was assessed on admission and at discharge. Two subsets of patients were also assessed (a) at three-month follow-up in the community (n = 15), and (b) both in hospital and in the home environments at the discharge time point (n = 28). Data were compared with FIM scores on admission and discharge., Results: The median total weekly care hours fell from 52 hours (interquartile range (IQR) 25-66) on admission, to 17 hours (IQR 6-46) on discharge (p<0.001). There was a median reduction of approximate weekly cost of care from 600 pound sterling (IQR 224-824 pound sterling) to 168 pound sterling (IQR 56-280 pound sterling) (p<0.001). These benefits were sustained at follow-up, and the NPCNA measured in hospital at discharge gave a good estimation of the care hours and weekly cost of care in the community at three months after discharge. There was no significant correlation with FIM gain., Conclusions: In this study the NPCNA, measured while the patient was still in hospital, gave a good estimation of care needs in the community and was sensitive to change occurring during rehabilitation in patients with severe complex disabilities.

Background and Aims: The aim of this study was to develop and evaluate the UK version of the Functional Assessment Measure (UK FIM+FAM)., Design: Before and after evaluation of inter-rater reliability., Development: Ten 'troublesome' items in the original FIM+FAM were identified as being particularly difficult to score reliably. Revised decision trees were developed and tested for these items over a period of two years to produce the UK FIM+FAM., Evaluation: A multicentre study was undertaken to test agreement between raters for the UK FIM+FAM, in comparison with the original version, by assessing accuracy of scoring for standard vignettes., Methods: Baseline testing of the original FIM+FAM was undertaken at the start of the project in 1995. Thirty-seven rehabilitation professionals (11 teams) each rated the same three sets of vignettes - first individually and then as part of a multidisciplinary team. Accuracy was assessed in relation to the agreed 'correct' answers, both for individual and for team scores. Following development of the UK version, the same vignettes (with minimal adaptation to place them in context with the revised version) were rated by 28 individuals (nine teams)., Results: Taking all 30 items together, the accuracy for scoring by individuals improved from 74.7% to 77.1% with the UK version, and team scores improved from 83.7% to 86.5%. When the 10 troublesome items were taken together, accuracy of individual raters improved from 69.5% to 74.6% with the UK version (p <0.001), and team scores improved from 78.2% to 84.1% (N/S). For both versions, team ratings were significantly more accurate than individual ratings (p <0.01). Kappa values for team scoring of the troublesome items were all above 0.65 in the UK version., Conclusion: The UK FIM+FAM compares favourably with the original version for scoring accuracy and ease of use, and is now sufficiently well-developed for wider dissemination.

Background: The Northwick Park Dependency Score (NPDS) has been shown to be valid, reliable and practical to use. It was designed to be used together with a short set of additional questions to inform care needs in the community and facilitate discharge planning., Aim: To develop a conversion formula to translate information derived from the NPDS into a generic assessment of care needs in the community -- the Northwick Park Care Needs Assessment (NPCNA) -- and to evaluate its potential as a directly costable measure of outcome in rehabilitation., Setting: An inpatient neurorehabilitation unit for young patients with brain injury., Method: Part 1, DEVELOPMENT: For each task in the NPDS, a set of assumptions was developed to reflect the number of people, the time taken and the frequency of help required. Tasks were collected into a daily timetable and minimum and maximum allocations made for each time slot. From this the weekly care hours can be calculated. A range of care package categories and their approximate costs were identified, and a simple set of criteria developed with experienced community care planners to determine the circumstances under which each category is applied. Part 2, EVALUATION: The assumptions and derived care package were evaluated in a prospective comparative study in 35 cases. Timetables of care needs were drawn up using (a) the NPDS-derived Care Needs Assessment (NPCNA) and (b) detailed structured interview with an independent assessor. The weekly hours of care, care package and approximate cost were then determined for each set of timetables, by a third independent assessor, applying the formula described according to strict rules., Results: Assessment of the total weekly hours of care showed an excellent correlation between the two methods (rho 0.90, p <0.01) with no significant differences. There was also a high correlation in the category of care package allotted and thus the weekly cost of care (rho 0.73, p <0.01)., Conclusion: The NPCNA provides a simple measure of care needs in total care hours, as well as a timetable of care from which a care package can be directly planned and costed. It has potential use, therefore, as an instrument that can demonstrate directly the effectiveness of rehabilitation in reducing the cost of continuing care in the community.

Objective: To establish whether a Barthel score derived by translation from the motor items of the Functional Independence Measure (FIM) would equate to the directly scored measure., Design: Conversion criteria for motor item scores on the FIM scale to Barthel scores were first developed. To test these criteria, 40 consecutive patients were assessed for Barthel and FIM scores by the multidisciplinary team who were unaware of the conversion criteria. The derived Barthel score was compared with the directly scored Barthel Index., Results: A very high degree of correlation was observed between total scores of the direct and derived Barthel (Spearman's rho = 0.99), which is highly significant, and no significant differences were seen between scores for any of the individual items (Wilcoxon signed rank test). Item by item analysis across the study population was undertaken to confirm the conversion criteria. Absolute agreement between the two methods ranged from 75 to 100% and kappa values from 0.53 to 1.0., Conclusions: This study demonstrates that a Barthel Index can be derived from the motor items of the FIM and there is a good agreement with the directly assessed Barthel score. Although a larger study may help to delineate the exact conversion criteria for one item, the current system provides an accurate and usable translation of the total score and serves as a major step towards achieving a common language in outcome measurement for rehabilitation.

Despite the problems posed by diversity of condition and the lack of agreement among researchers over what outcome to measure, there is now increasingly robust evidence for the effectiveness of rehabilitation in brain-injured populations. Meta-analysis has demonstrated clearly that stroke units provide a better outcome than management on a general medical ward, at the level of survival, discharge destination and dependency. The extent of this advantage may be summarized in the following terms. For every 100 patients treated in a stroke unit, four deaths and two institutional admissions are avoided, and five patients are discharged home. This benefit appears to arise from a combination of good-quality acute management and the coordinated input of a multidisciplinary team. Therapy programmes are shown to be of benefit and intensive therapy programmes of somewhat greater benefit. Smaller numbers and heterogeneity among the head-injured population tend to confound randomized controlled trial designs, but there is no good reason to suppose that brain injury resulting from trauma should be less responsive to similar good management principles than that arising from stroke. In any event, we have progressed to a stage where the weight of evidence supports the notion that rehabilitation is effective, and nontreatment controls are ethically no longer acceptable. It is time now to unravel the threads of rehabilitation and consider which are the critical components. There are still many opportunities for comparison of different models for delivery of care, and the existing evidence for these is discussed.

Background: Disability scores, such as the Functional Independence Measure (FIM) and Barthel Index, have been shown to correlate with care needs but cannot be used to assess them directly, as they do not indicate the number of people required to help with a task, nor the time taken. The Northwick Park Dependency Score (NPDS) is an ordinal scale that can be used to assess impact on nursing time. It takes 3-5 minutes to complete. Together with a short set of additional questions, it may be used directly to assess care needs in the community and to facilitate discharge planning., Aims: To develop and evaluate the NPDS for use in a rehabilitation setting., Methods: (1) DEVELOPMENT: Following a survey of existing instruments, tasks were selected on the basis of their impact on nursing time and divided into Basic Care Needs (BCN) and Special Nursing Needs (SNN). Cut-off points were devised to reflect the number of helpers needed and time taken. Following evaluation of the NPDS version 5, minor changes were made to produce version 6 which was re-evaluated on a smaller scale. (2) EVALUATION: Inter-rater and intra-rater reliability were tested in a cohort of 23 inpatients using five senior nurses. Analysis included assessment of degree of association, significant differences, absolute agreement, and agreement +1 level. Although there is no gold standard, the BCN section should correlate inversely with independently assessed Barthel scores. Re-evaluation of version 6 was undertaken using the same method of analysis in a cohort of 21 patients using three senior nurses., Results: On initial evaluation inter-rater reliability testing showed an excellent level of association in total composite score between each pair of nurses (rho = 0.73-0.92, p <0.01) and agreement +1 level for individual items ranged from 73 to 100%. Significant disagreements were in six items. On re-evaluation following minor modification, high levels of association were still seen for total BCN, SNN and composite scores both between and within raters, with very satisfactory levels of agreement for individual items. The BCN section of the NPDS showed good inverse correlation with Barthel scores (rho = 0.91, p <0.01)., Conclusion: The NPDS is simple and practical to use in a busy setting. It is shown to be reliable and valid in its assessment of nursing dependency on the ward. Its translation into a directly costable measure of continuing care needs in the community now requires evaluation.

Objective: To ascertain which standardized instruments are currently most commonly used as outcome measures for rehabilitation in routine clinical practice in the UK., Design: The study used a postal questionnaire which was sent out to members of two major societies of rehabilitation professionals in the UK., Results: Of 182 rehabilitation centres represented by respondents, 140 (77%) collected at least one standardized measure and 42 did not. Principal reasons for not recording measures were lack of time and not knowing what to collect. As had been anticipated, a very wide range of different measures were used by different centres, however some clear favourites emerged including the 10 m Walk, the Motricity Index and the Nine-hole Peg Test. One hundred and twenty-three centres used one or more global disability measure of which the commonest were the Barthel index or one of its modifications and the functional Independence Measure (FIM) and/or Functional Assessment Method (FAM). Among units that used handicap or extended activities of daily living (EADL) scales, the Nottingham EADL, the London Handicap Scale and the General Health Questionnaire (GHQ-22 or 12) were most popular. Outside neurorehabilitation, the Harold Wood/Stanmore mobility grades were used by 10/18 amputee rehabilitation centres and the Health Assessment Questionnaire (HAQ) was used by 15/48 units providing musculoskeletal rehabilitation., Conclusions: It is clear that no one measure is suitable in all settings and services, but the most popular measures from this survey may reasonably form the basis for a 'basket of recommended instruments' that may help to guide units wishing to collect outcome data but not knowing which to choose.