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Recent studies have shown a marked variation in the standards of healthcare for young people with disabilities in different regions of the UK and even within the same health district. Equity in the provision of healthcare is a fundamental principle of the NHS. However, this can only be measured against an agreed minimal standard of healthcare that serves as a benchmark for healthcare purchasers and providers. The aim of the present document is to develop a set of minimum standards of healthcare for children and adults with cerebral palsy (CP).The document was developed in two stages by a multi-professional and multi-disciplinary group of practitioners in the field of CP. Initially, members of the panel jointly formulated a statement of what they believed should be the minimal acceptable standards of healthcare in CP drawing on their own experience and the published scientific evidence. In the second stage the views of some of the relevant professional bodies and voluntary organizations on the draft statement were sought. The responses of these organizations were incorporated into the final document if agreed by the panel.Twenty-two recommendations were made. These were considered the minimum standards of care in a district general hospital. The emphasis was on the organisation and delivery of healthcare for children with CP. The statement is intended to stimulate debate especially in relation to the equity of service provision throughout the country and may be used to inform purchasers of healthcare. Similarly, it may also be useful to providers of healthcare as an audit tool.

Severe muscle spasticity is common in patients with neurological disease. It is often associated with pain and distressing spasms, and frequently leads to functional motor disability. Antispasticity drugs usually result in systemic adverse effects, and peripheral nerve blocks have some disadvantages such as sensory loss and painful dysaesthesiae. In recent years botulinum toxin type A (BT/A) has been advocated for the treatment of muscle spasticity. We studied, using a functional assessment scale, the effects of BT/A on the patients' symptoms and the functional disability due to spasticity in five children and eight adults who were referred for treatment. In 10 patients the treatment goals were achieved, and children generally had a better and more sustained response than adults. There were no adverse effects reported. The present study suggests that BT/A is safe and effective in improving the motor functional disability which is often associated with severe localized muscle spasticity.

Objective: To examine the attitudes of a rural community in southern India toward its disabled members. Design: Prospective cross-sectional study Method: One hundred and twenty randomly selected villagers around the town of Vellore in southern India were invited to take part in the study. The attitudes towards individuals with physical disabilities were examined using a modified version of the Scale of Attitudes Toward Disabled Persons (SADP). The questionnaire was administered in its original English format with simultaneous translation into Tamil. Results: Data were complete in 111 cases, 82% of whom showed a positive attitude toward people with disability. Gender and employment status did not appear to have an influence on whether the respondent regarded disabled people in a positive or negative way but most older individuals expressed prejudice and/or challenged the rights of disabled people to equal opportunities in education, employment and social integration. Further data analysis demonstrated that more subjects with than without a disabled family member supported the rights of disabled individuals to education, employment and social integration. By contrast, the items of SADP which described the personal attributes of disabled people did not discriminate between the two groups. Conclusion: The attitudes of the rural community studied toward people with disabilities were unrelated to the sex or educational status of the respondents but was influenced by their age. This suggests that older subjects in rural communities in developing countries should be the main target for educational programmes which promote positive images of disability.

An interdisciplinary outpatient rehabilitation clinic was set up to assess patients with severe and complex disabilities. The rehabilitation team consisted of a physician, a nurse, a community liaison occupational therapist, a community physiotherapist and a speech and language therapist. Each patient was assessed in the clinic for half a day. The patients' carers were encouraged to attend. A total of 25 consecutive new patients were studied. The findings of the study suggest that the range of therapeutic interventions carried out during the outpatient clinic visit were comparable to the standard model of care. To evaluate the effectiveness of this service in preventing hospital admissions the case histories of the study patients were presented to three consultants in rehabilitation medicine who were asked to give their management decision on each case, but were not told the objectives of the study. Analysis of the consultants' decisions showed that there was agreement between all consultants that five patients needed admission to hospital for evaluation or treatment and two out of the three physicians said that they would have admitted a further eight patients. In fact, none of our patients was admitted, which suggests that the model of outpatient multi disciplinary assessment service proposed here may reduce the need for admissions to hospital.

The use of phenol and alcohol nerve blocks in the treatment of localized muscle spasticity is well established. However, a number of questions relating to this procedure are still unanswered. This article presents experience of the effectiveness of chemical neurolysis in the treatment of severe lower limb muscle spasticity in 28 patients who had a total of 56 nerve blocks performed during a follow-up period of between four and 18 months.

The Barthel Index (BI) in its original format must be completed by a therapist. To overcome this disadvantage a self-administered version of the BI was designed, the modified Barthel Index (MBI). In the present study the MBI was validated against the original BI and also the Stanford Health Assessment Questionnaire (HAQ) in 33 patients with rheumatoid arthritis (RA). There was a close correlation between BI and MBI in eight out of the 10 items of the scale and in the overall score. Similarly, there was a good correlation between MBI and HAQ but only in patients with mild disability. Further analysis of data showed that the HAQ overestimated the degree of disability in patients with RA and may be less reliable than the MBI in measuring functional independence in these patients.

A significant proportion of hospital beds is usually occupied by patients awaiting placement, home adaptations or other care provisions by Social Services. Anecdotal evidence suggests that the number of 'acute bed-blockers' has fallen since the implementation of the Community Care Act (CCA). The aim of the present study was to examine the validity of this claim. Records of patients discharged from Southampton Rehabilitation Unit in the twelve months before and after the implementation of the CCA ( n = 72) were analysed. Contrary to previous reports, there was no difference in the overall length of hospital stay or the time patients spent awaiting discharge after they had achieved functional independence. The reasons for the inappropriate hospitalization were also similar in the two groups and were mainly due to shortage of residential care places for patients with disabilities and delays in the provision of equipment, services and home adaptations.

Different criteria are used to define the terms mid-stance (MST) and mid-swing (MSW) when describing the gait cycle. None of these definitions is universally accepted. This causes difficulties with the interpretation of gait analysis data and hinders the comparison between the different studies. The aim of the present study was to compare three definitions of MST and MSW by examining the gait of a group of healthy children.A prospective comparison of three commonly used definitions of the MST and MSW events of the gait cycle.The timing of the temporal, kinematic and kinetic MST and MSW of the gait cycle.Thirty healthy 8 - 10-year-old children were studied. There was no consistent correlation between the timing of the chosen definitions of MST and MSW. However, there was a tendency for the timing of the temporal and kinetic MST and MSW to occur, respectively, at approximately 30 and 80% of the gait cycle.The temporal definition of MST and MSW as the midpoints in time of the respective phases of the gait cycle appears to be more appropriate than other definitions. The use of this definition may prevent misunderstanding and permit comparison of the results of the different gait analysis studies.

Objective. To examine the correlation between an impairment-level and a functional-level assessment scale of aphasia.Design. Prospective, longitudinal study.Setting. A stroke rehabilitation unit.Subjects. Sixty-seven aphasic acute stroke patients who were undergoing a multi-disciplinary rehabilitation programme, including conventional speech and language therapy (SLT).Intervention. Patients were assessed on study entry and 4, 8, 12 and 24 weeks after the start of SLT. The language impairment was assessed with the Western Aphasia Battery (WAB) and the communicative functional limitation associated with aphasia was measured with the Communicative Effectiveness Index (CETI).Results. There was a statistically significant correlation between the two scales for all assessment periods (Pearson's r = 0.71; P

The correct research design is crucial in establishing whether treatments for complex neurological disorders are effective The effectiveness of botulinum toxin type A (BtxA) in reducing post-stroke muscle hypertonia and its complications has been demonstrated in adult patients in at least eight large randomised controlled trials (RCTs).1–8 The clinical benefits were reported when diverse treatment protocols and different dose schedules and injection techniques were used for the management of the same clinical indication. Nonetheless, some doubt as to the value of this treatment remain.9 What is the explanation for this apparent paradox? The contradiction may be explained by the inadequate design of these studies and the inherent difficulties with the interpretation of the results of RCTs of a drug treatment that is carried out in the context of rehabilitation for a person with chronic neurological disability. The WHO classification of functioning, disability, and health10 provides a useful framework for understanding the complex relation between the statistical significance and the clinical significance of a given treatment and helps to explain the complexity of rehabilitation research. A statistically significant change at the level of impairment (as a result of the intervention) may not alter the subject’s functional abilities or potential for social participation. The outcome of treatment with BtxA is clinically significant only if it results in the full or partial attainment of functional goals that are meaningful to the recipient of this treatment. An example of such outcomes is the achievement of safe walking and prevention of falls in a patient with dynamic foot equinus after BtxA injections into the calf muscles. Successful treatment reduces muscle …

The involuntary movements of the paretic arm during ambulation and other motor activities are known as associated upper limb reactions (ARs). ARs occur in 80% of stroke patients with spastic hemiplegia and often interfere with balance and safe mobilization. It is hypothesized that the treatment of localized muscle spasticity with botulinum toxin type A (BtxA) would abolish the ARs and improve balance and mobility.This hypothesis will need to be tested in a randomized controlled trial (RCT). The aim of the present pilot study is to obtain preliminary data to inform the design of a future RCT. Eight patients received a single injection of 500 units of BtxA (Dysport((R)) Ipsen, Ltd) into the biceps brachii of the paretic arm. The patients' balance and mobility were assessed before and 2, 4 and 6 weeks after treatment using observational gait analysis and other subjective assessment scales.There was a significant reduction of the ARs after treatment but this did not appear to improve the patients' balance or mobility as assessed by the clinicians. Interestingly, seven out of the eight patients reported improvement in their walking.The discrepancy between the observed and reported effects of treatment could be due to the poor sensitivity of the outcome measures used in this study.

Objective: Safe swallowing may be achieved in most patients with neurogenic dysphagia by manipulating the viscosity of ingested fluids. However, in clinical practice fluids are thickened using subjective judgement. This may lead to errors in the preparation of drinks to the prescribed viscosity. The aim of the present study is to examine whether the use of a viscometer improves the dietary management of dysphagic stroke patients. Study design: A randomized controlled study design was used. The speech and language therapist determined the optimal fluid thickness for each patient. The prescribed fluid viscosity for the study group was obtained using a viscometer. Patients in the control group received fluids prepared according to current practice, i.e. the amount of thickener required to produce the prescribed viscosity was judged subjectively by the nursing staff. The two methods of fluid thickening were used for seven consecutive days. Assessment was made blind to randomization. Main outcome measure: Pulmonary aspiration, assessed clinically and with pulse oximetry. If the patient did not drink all the fluid that was offered the residue was measured. Results: Ten patients in the study group ( n = 23) and nine in the control group ( n = 23) aspirated. The mean viscosity of fluids offered to patients in the control group was significantly higher than that of the study patients. There was a statistically significant correlation between the viscosity and the residual volume of fluid (Pearson's test: r = 0.7, p Conclusion: Manipulation of fluid thickness using objective measurements with a viscometer may improve the dietary management of dysphagic stroke patients.

Objective: To examine the factors which influence the length of hospitalization of stroke patients. Design: Analysis of the relative importance of 10 preselected variables on the length of hospital stay of all patients admitted with a clinical diagnosis of stroke. The data were collected prospectively. Setting: Two teaching hospitals serving the city of Southampton and southwest Hampshire, England (approximate population 450 000). Subjects: Forty-six consecutive stroke patients. Results: Data were complete on 38 patients. The mean and (median) length of hospital stay was 74.9 (80.5) days for men and 74.7 (73.5) for women. The mean age of women in the study sample was higher than that of men (73.2 vs 71.6). Patients who were less than 70 years of age stayed shorter periods in hospital than older subjects. Other factors associated with shorter hospitalization were a stroke type other than total anterior circulation infarct, a Barthel score of 12 or more on admission or at the time of discharge and a frequency of consultants' ward rounds of more than one per week. A delay in the provision of equipment and home adaptations and waiting for placement in a private nursing home were the best predictors of long hospital stays of stroke patients. Conclusions: Early liaison of rehabilitation staff with Social Services in order to secure the quick provision of environmental aids and adaptations or placement in residential care of stroke patients with a poor prognosis for functional recovery would probably reduce the unnecessary hospitalization of these patients.

Previous studies of speech dysfunction in patients with Parkinson's disease (PD) consisted of postal surveys, which rely on the subjective opinions of patients, or were primarily focused on the detailed assessment of impairments without addressing the disabilities resulting from them. Similarly, the impact of the communication disability on the patient's everyday life was not assessed. The aim of the present study was to examine the prevalence of verbal communication disability in these patients, using a validated objective measurement tool. A secondary aim was to establish the patients' awareness of their disability and its impact on their lifestyle. Verbal communication disability was examined in 48 patients with PD using a modified version of the Intelligibility of Dysarthric Speech Assessment Scale. Nearly two-thirds of patients had reduced intelligibility of speech but this was mild, causing no disability, in the majority of them. Two out of seven patients with severely or moderately severely reduced intelligibility of speech were unaware of their disability, and none of the patients reported that the speech difficulties interfered with their lifestyle. The study also identified some predictors of verbal communication disability in these patients.