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Complex regional pain syndrome (CRPS) is a debilitating, painful condition in a limb associated with sensory, motor, autonomic, skin and bone abnormalities. Pain is typically the leading symptom, but is often associated with limb dysfunction and psychological distress. Prompt diagnosis and early treatment is required to avoid secondary physical problems related to disuse of the affected limb and the psychological consequences of living with undiagnosed chronic pain. UK guidelines have recently been developed for diagnosis and management in the context of primary and secondary care.1 The purpose of this concise guideline is to draw attention to these guidelines. Information in this article has been extracted from the main document and adapted to inform the management of CRPS as it presents to physicians in the course of their daily practice.

Depression is increasingly recog- nised as a common sequel to acquired brain injury and the use of antidepressant medication in this context has increased markedly over recent years. However, these drugs are not without side effects - some of them serious - and they should not be used without proper evalua- tion and monitoring. This set of concise guidance was developed jointly by the British Society of Rehabilitation Medicine, the British Geriatrics Society and the Royal College of Physicians, to guide clinicians working with people who have brain injury of any cause (ie stroke, trauma, anoxia, infection etc). The guidance covers (a) screening and assessment of depression in the context of brain injury, (b) issues to consider and discuss with the patient and their family before starting treatment, and (c) proper treatment planning and evaluation - including planned withdrawal at the end of treatment.

National Service Frameworks (NSFs) set out standards for health and social care provided by the NHS and social services in England. The latest in this series--the NSF for Long Term Conditions--was published recently. This editorial discusses some of the challenges for its development and implementation.

The national clinical guidelines for Rehabilitation following acquired brain injury were developed by a multidisciplinary working party convened by the British Society of Rehabilitation Medicine, and are published in collaboration with the Royal College of Physicians (2003). They have been produced to complement the National Institute of Clinical Excellence head injury guidelines, and to address the medium- to longer-term needs of patients with acquired brain injury and of their families/carers. This article serves as an introduction to make physicians aware of the guidelines, and to highlight in particular the advice to doctors in the acute services regarding early discharge and referral to rehabilitation.

Economic evaluation assists in healthcare planning to make sure that limited resources are used in the optimal way by comparing the costs of alternative interventions over a broad range of parameters including physical health, social and psychological benefits etc. The recently published guidelines, Rehabilitation following acquired brain injury: national clinical guidelines, 1 make wide-ranging recommendations. Given the current dearth of rehabilitation services in the UK, their implementation will require significant investment, so it is pertinent to consider the evidence for the cost-effectiveness of rehabilitation. A central theme of post-acute rehabilitation is early, targeted intervention to restore independent function. If effective, this should lead to cost benefits in terms of reduced length of stay in hospital and reduced needs for long-term care in the community. Similarly, effective vocational rehabilitation should increase the opportunity for return to work or alternative employment, such that the individual ideally becomes financially self-supporting. On the other hand, rehabilitation itself imposes a cost. More intensive programmes may in theory produce even faster results, but they cost more. Eventually a balance must be struck between the expense of providing the programme and the likely cost savings achieved. The evidence for costeffectiveness may be gleaned from studies which have included formal economic analysis, or from secondary analysis of studies which have recorded outcomes that can be costed, such as length of stay, return to work etc. Comparative research in the field of complex disability following acquired brain injury (ABI) poses several major challenges to traditional research methodologies: i There is marked heterogeneity with respect to the patient group, the intervention and setting, and to the outcomes that are relevant at each stage of recovery.

Botulinum toxin (BTX) is a powerful neurotoxin which blocks cholinergic transmission at the neuromuscular junction. Judiciously applied, it can reduce local muscle overactivity while maintaining the strength in other muscles. To date BTX has not been licensed for use in spasticity in the UK and the literature pertaining to clinical practice is still relatively scant. However, controlled trials have provided evidence of the effectiveness of BTX both in reducing spasticity itself and in achieving functional gain. The guidance given here to clinicians involved in the management of spasticity covers the types of patient suitable for treatment using BTX, the appropriate dosage, and the necessary follow-up procedures and documentation.

Patients who remain in a prolonged disorder of consciousness following profound brain injury present a complex array of clinical and ethical challenges to those who care for them. Diagnosis is often difficult and may change over time as patients recover awareness, requiring repeated skilled

Long-term neurological conditions (LTNCs) comprise a diverse set of conditions resulting from injury or disease of the nervous system that will affect an individual for life. Some 10 million people in the UK are living with a neurological condition which has a significant impact on their lives, and they make up 19% of hospital admissions. These guidelines build on the Quality Requirements in the National Service Framework for Long-term (Neurological) Conditions to explore the interaction between specialist neurology, rehabilitation and palliative care services, and how they may best work together to provide long-term support for people with LTNCs and the family members who care for them. The guidelines also provide some practical advice for other clinicians when caring for someone with an LTNC, and outline indications for specialist referral. This article provides a brief summary. Full details of the methods and literature evaluation, as well as tools for implementation, are available in the full guideline.

New commissioning arrangements in the NHS require the identification of 'complex specialised' (CS) services, as distinct from more 'general' or 'district specialist' (DS) rehabilitation services, to determine differential cost-tariffs. In this cross-sectional postal survey representing 49 inpatient neurological rehabilitation services in the UK, no clear service characteristics that distinguished CS services (n = 20) from DS services (n = 29) could be identified. On the other hand, the Rehabilitation Complexity Scale (RCS) demonstrated clear differences between the two types of service, in terms of the complexity of case mix and of the rehabilitation inputs provided. District specialist services reported a median RCS score of 7 (interquartile range (IQR) 6-8), whereas CS services reported higher scores (median 9 (IQR 7-11)) (Mann-Whitney z = -9.3, p < 0.0001). Carrying a caseload in which 50% of patients had total RCS scores > or = 9 appeared to be a sensitive and specific indicator of a CS service. This study represents the first reported use of the RCS. Feedback regarding the utility of the tool was generally favourable, although other more detailed instruments are likely to be required to distinguish complexity at the very top end of the scale. As NHS services tackle the challenges posed by Payment by Results for management of patients with complex needs, it is suggested that this approach may have application in other fields of clinical practice.

This article reports a parallel survey of consultants working in the fields of neurology, rehabilitation and palliative medicine, and explores the interface between the three specialties in providing services for people with long-term neurological conditions. There was general agreement with respect to the core contributions offered by each specialty. However, there were also important areas of overlap which highlight the need for collaborative working practice, and for clinicians to respect the expertise of others in related areas. The survey highlighted a general shortfall in service provision for both palliative care and rehabilitation services for people with long-term neurological conditions, particular in the community. There was also a marked lack of coordination between services. Perhaps not surprisingly, each specialty reported greater ease of access to services within their own field, which further emphasises the need to work closely together.

This study evaluated a new six-point ordinal scale for measuring pain intensity. Seventy- two participants aged between 23 and 87 years rated the intensity of 'present pain' as well as remembered episodes of 'severe' and 'mild' pain on the scale of pain intensity (SPIN), a 10 cm visual analogue scale (VAS) and a 0-10 numeric scale, in random order. Retesting followed an intervening assessment. Participants' comments on the scales were analysed thematically. Spearman's correlation between scales all exceeded 0.78 (p

Infective endocarditis (IE) is a life-threatening disease with substantial morbidity and mortality which affects individuals with underlying structural cardiac defects who develop bacteraemia, often as a result of dental, gastrointestinal, genitourinary, respiratory or cardiac invasive/surgical procedures. Prompt recognition of the clinical diagnosis by a wide variety of medical personnel, early involvement of specialist cardiologists, cardiac surgeon and a microbiologist, and prompt treatment with the most appropriate antimicrobial agents offer the greatest chance of improving the outcome for these patients. The guidance given here to clinicians involved in the management of patients with IE briefly covers diagnosis, antibiotic prophylaxis, medical treatment and the indications for surgery.