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Botulinum toxins, such as abobotulinumtoxinA, are used to treat spasticity (muscle overactivity) in arm muscles. Spasticity in shoulder muscles occurs in many patients following a stroke. Shoulder spasticity can be painful and limit limb movement. This paper compares the results from patients who did and those who did not receive abobotulinumtoxinA injections in shoulder muscles (among other arm muscles) in 2 studies. In both studies, the results showed that more patients receiving treatment in shoulder muscles chose pain as a key goal for treatment and had reduced pain following treatment compared with patients not treated in the shoulder. In addition, patients receiving shoulder injections showed further improvement in arm movement compared with those not receiving shoulder injections. Overall, these results suggest that abobotulinumtoxinA treatment in shoulder muscles may improve outcomes for patients with arm spasticity involving the shoulder.

OBJECTIVE: To investigate the scaling properties of the Patient Categorisation Tool (PCAT) as an instrument to measure complexity of rehabilitation needs.DESIGN: Psychometric analysis in a multicentre cohort from the UK national clinical database.PATIENTS: A total of 8,222 patents admitted for specialist inpatient rehabilitation following acquired brain injury.METHODS: Dimensionality was explored using principal components analysis with Varimax rotation, followed by Rasch analysis on a random sample of n = 500.RESULTS: Principal components analysis identified 3 components explaining 50% of variance. The partial credit Rasch model was applied for the 17-item PCAT scale using a "super-items" methodology based on the principal components analysis results. Two out of 5 initially created super-items displayed signs of local dependency, which significantly affected the estimates. They were combined into a single super-item resulting in satisfactory model fit and unidimensionality. Differential item functioning (DIF) of 2 super-items was addressed by splitting between age groups (CONCLUSION: The PCAT has satisfied expectations of the unidimensional Rasch model in the current sample after minor modifications, and demonstrated acceptable reliability for individual assessment of rehabilitation complexity.

OBJECTIVE To determine whether the UK Functional Assessment Measure (UK FIM+FAM) fits the Rasch model in patients with complex disability following traumatic brain injury. DESIGN Psychometric evaluation including preliminary exploratory and confirmatory factor analyses followed by Rasch analysis. PARTICIPANTS A multicentre UK national cohort of 1,956 patients admitted for specialist rehabilitation following traumatic brain injury. RESULTS The suitability of the Partial Credit Model was confirmed by the likelihood-ratio test (χ2 (df86) =7,325.0, p

Objective: To identify psychometrically evaluated patient-reported outcome measures reflective of 'real-life' function (active and passive) for application following focal rehabilitation interventions in the lower limb after stroke or brain injury. Data sources: A literature search conducted in MEDLINE, CINAHL, Embase, Web of Science, PubMed, National Health Service National Research Register, MRC Clinical Trials directory, Database of Abstracts of Reviews of Effects (DARE), Google Scholar and the Cochrane Database of Systematic Reviews. Study selection: Interventional study designs using patient-reported outcome measures for outcome evaluation meeting the review objective. Data extraction: Evaluation of the psychometric properties used the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) process, by two independent reviewers reaching consensus, with adjudication by a third reviewer. Data synthesis: One-hundred and thirteen studies were identified following initial review of the abstracts, yielding 12 outcome measures. Eight measures were identified, which were relevant to real life functional performance. These were the Brain Injury Community Rehabilitation Outcome, Climbing Stairs Questionnaire, Human Activity Profile, Lower Extremity Functional Scale, Nottingham Extended ADL Index, Rivermead Mobility Index (RMI), Sickness Impact Profile, Stroke Impact Scale. Conclusions: All measures addressed active function, with none evaluating passive function. The RMI met most psychometric criteria, but may have a ceiling effect for high functioning patients.

OBJECTIVES To estimate and compare the costs of informal and formal care provided to adults with long term neurological conditions and to identify characteristics associated with these costs. DESIGN Cross-sectional postal questionnaire survey. PARTICIPANTS Family carers of 282 adults with sudden onset, progressive and stable/intermittent conditions were recruited through UK-wide voluntary organisations and neuroscience centres. METHODS Carers provided demographic and condition specific information about the adults cared for. Informal care was measured with the Caregiver Activity Survey and formal service use with the Client Service Receipt Inventory. Costs were calculated and regression analyses identified demographic and clinical characteristics associated with cost. RESULTS Annual informal care costs mean £82,620 (standard deviation 58,493) were 4 times higher than formal costs mean £18,117 (standard deviation 28,990). Caring for adults with sudden onset conditions and hidden/mixed impairments were both significantly associated with informal costs. Healthcare costs were significantly associated with having a sudden onset condition, greater dependency in activities of daily living and longer condition duration. Greater dependency was significantly associated with increased social care costs. CONCLUSIONS The cost of caring for adults with long term neurological conditions is largely borne by families. Both health and social costs are higher for more dependent patients, endorsing the importance of developing specialist rehabilitation services that reduce dependency.

Limited empirical information exists regarding botulinum toxin-A injector decision-making practices for adult upper limb post-stroke spasticity. The design of most studies prevents such an assessment, as injection sites and dosage are mandated by researcher protocols. This contrasts to usual injector practices, where individualized decision-making is the standard of care.Secondary data analysis from an Australian randomized controlled trial of 90 adults with upper limb post-stroke spasticity where experienced clinicians followed their standard clinical injecting practice rather than a mandated injection regimen.Clinicians were hypothesized to tailor their injection practices according to the subject's degree of spasticity and/or the type of functional gain desired. Hypothesis testing was conducted using non-parametric analysis.Muscle selection and botulinum toxin-A dosage were not significantly associated with spasticity severity or with patient-identified goals. Between-site differences in injection practices suggested that injector beliefs, rather than patient characteristics, were the dominant feature driving botulinum toxin-A injection strategy for post-stroke upper limb spasticity.This result looks into the "black box" of rehabilitation, revealing significant variation in injector beliefs. Findings suggest that further scientific work is required to maximize the efficacy of botulinum toxin-A injections in post-stroke upper limb spasticity management.

To examine the psychometric properties of the Northwick Park Dependency Scale (NPDS).Review of existing literature and psychometric analysis in relation to other standardized measures of disability in a large neurorehabilitation cohort.A regional post-acute specialist inpatient neurorehabilitation unit in London, UK.A total of 569 inpatients with complex neurological disabilities (350 males, 219 females; mean age 44.4 years).The NPDS, Barthel Index, Functional Independence and Functional Assessment measures.A database search found 5 studies that examined the psychometrics of the NPDS. These supported its validity and reliability. The present study added to these by evaluating the internal consistency, factor structure, discriminatory power and responsiveness to change during rehabilitation. The NPDS was found to have good internal consistency (α = 0.90), suggesting that it can reasonably be summed to a single total score. It discriminated among people with different levels of dependency and was responsive to change, particularly in the higher dependency groups.The NPDS is a psychometrically robust tool, providing a broader range of information on nursing needs than some other commonly-used disability measures. The Special Nursing Needs subscale provides clinically useful information, but its metric properties require further development, which is now underway.

Objective: To examine goal attainment scaling for evaluation of treatment for upper limb post-stroke spasticity with botulinum toxin-A. Design: Secondary analysis of a multi-centre double-blind, placebo-controlled randomized clinical trial. Setting: Six outpatient clinics in Australia. Participants: Patients (n = 90) completing per protocol 2 cycles of treatment/placebo. Mean age 54.5 (standard deviation 13.2) years. Mean time since stroke 5.9 (standard deviation 10.5) years. Interventions: Intramuscular botulinum toxin-A (Dysport ® 500–1000U) or placebo given at 0 and 12 weeks. Measurement points were baseline, 8 and 20 weeks. Main outcome measures: Individualized goal attainment and its relationship with spasticity and other person-centred measures – pain, mood, quality of life and global benefit. Results: A significant treatment effect was observed with respect to goal attainment (Mann-Whitney z = –2.33, p ≤ 0.02). Goal-attainment scaling outcome T-scores were highly correlated with reduction in spasticity (rho = 0.36, p = 0.001) and global benefit (rho = 0.45, p < 0.001), but not with other outcome measures. Goal-attainment scaling T-scores were lower than expected (median 32.4, interquartile range 29.6–40.6). Goals related to passive tasks were more often achieved than those reflecting active function. Qualitative analysis of goals nevertheless demonstrated change over a wide area of patient experience. Conclusion: Goal-attainment scaling provided a responsive measure for evaluating focal intervention for upper limb spasticity, identifying outcomes of importance to the individual/carers, not otherwise identifiable using standardized measures.

Objective: To compare goal attainment scaling (GAS) and standardized measures in evaluation of person-centred outcomes in neurorehabilitation. Design: A prospective cohort analysis from a tertiary inpatient neuro-rehabilitation service for younger adults with complex neurological disability. Subjects/patients: Consecutive patients (n = 164) admitted for rehabilitation following acquired brain injury (any cause) over 3 years. Mean age 44.8 (standard deviation 14.4) years. Diagnosis: 66% strokes, 18% trauma, 16% other. Male:female ratio 102:62. Methods: GAS-rated achievement of 1–6 patient-selected goals was compared with the Functional Assessment Measure (UK FIM+FAM), and Barthel Index (BI), rated on admission and discharge. Personal goals were mapped retrospectively to the FIM+FAM and International Classification of Functioning, Disability and Health (ICF). Results: Median (interquartile range; IQR) GAS T-scores were 50.0 (44.2–51.8) and moderately correlated with changes in FIM+FAM and BI (both rho 0.38 (p < 0.001)). Standardized response means were 2.2, 1.6 and 1.4 for GAS, FIM+FAM and BI, respectively. Of 667 personal goals set, 495 (74%) were fully achieved. Although 413 (62%) goals were reflected by changes in FIM+FAM, over one-third of goals were set in other areas. Conclusion: GAS appeared to be more responsive, and captured gains beyond the FIM+FAM, thus providing added value as an adjunct to outcome measurement in patients with complex disability.