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A more balanced perspective The BBC’s Panorama programme The Mind Reader: Unlocking My Voice broadcast on 13 November 2012 provided important insights into the devastating experience of patients who live in vegetative or minimally conscious states and the families who support them. It also provided useful information on the use of functional magnetic resonance imaging (fMRI) to explore evidence of localised brain activity that might indicate underlying awareness. However, the programme failed to distinguish clearly between the two states and gave the impression that 20% of patients in a vegetative state show cognitive responses on fMRI. This claim needs to be clarified and put into perspective. There are important differences between the two states. Patients in a vegetative state have no discernible awareness of self and no cognitive interaction with their environment. Patients in a minimally conscious state show evidence of interaction through localising or discriminating behaviours, although such interactions occur inconsistently. It is clinically important to make this distinction, for prognostic reasons and because some evidence suggests that patients in a minimally conscious state experience symptoms (such as pain) in a manner indistinguishable from non-brain injured patients.1 2 The programme presented two patients said to be in a “vegetative state” who showed evidence of cognitive interaction on assessment using fMRI in Ontario, Canada. The clinical methods used for the original diagnosis …

Background and Purpose This paper aimed to select studies evaluating botulinum toxin (BoNT) intervention applied for upper-limb spasticity and from these identify outcome measures that are a) applicable in the hemiparetic upper limb and b) include evaluation of functional outcome in the context of everyday real-life activities. Methods A systematic search was used to identify peer-reviewed papers evaluating BoNT intervention for focal spasticity management in the upper limb. From these papers, outcome evaluation methods were identified, which attempted to capture ‘active function’ improvement (functional use of the hand and/or arm) or passive function improvement (care for the affected limb, for example to maintain hygiene and dress or support the arm). Results The search yielded 411 studies. Seventy papers were identified following a final review of the abstracts as potentially including evaluation of functional outcome (active and/or passive function). Following the review of the papers, a total of 22 studies contained specific methods for evaluating functional outcome in the upper limb. Discussion Three different patient-focused methods to evaluate functional outcome following focal spasticity intervention using BoNT have been identified: 1) use of patient report of upper-limb items (including the Leeds Adult Spasticity Impact Scale and the Disability Assessment Scale), 2) use of a composite measure of function incorporating functional items and 3) Goal Attainment Scaling. None of these methods fully address evaluation of functional outcome in this context but may go some way to recording these improvements. An alternative or complementary measure, recently published, is the Arm Activity Measure for evaluation of active and passive function in this context. The Arm Activity Measure addresses active and passive function changes from the perspective of patients and carers and has been developed for application in this context. Copyright © 2013 John Wiley & Sons, Ltd.

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.

To describe the extended Rehabilitation Complexity Scale (RCS-E) and its factor structure, and to determine whether it provides added value over the RCS-version 2 to identify patients with highly complex rehabilitation needs.A cohort analysis of prospectively-collected routine clinical data from 331 patients with complex neurological disabilities undergoing inpatient rehabilitation in a tertiary specialist neurorehabilitation unit in the UK. RCS-E and RCS-v2 scores were recorded in parallel by the multi-disciplinary team (MDT) at fortnightly intervals, alongside the Northwick Park nursing (NPDS) and therapy (NPTDA) dependency scales, capturing nursing care and therapy interventions in staff hours/week.Very strong correlations were found between total RCS-v2 and RCS-E scores (ρ = 0.954); the RCS-E "Carenursing" subscale and care/nursing hours/week (ρ = 0.838, p0.001); and the RCS-E "Therapy" subscale and total therapy hours/week (p = 0.697, p0.001). The RCS-E showed better discrimination for complex therapy needs than the RCS-v2, but not for complex care/nursing needs. The RCS-E factor structure was similar to the RCS-v2, with moderate internal consistency overall, separating into two distinct dimensions ("Nursing/medical care + Equipment" and "Therapy").The RCS-E provides an equivalent measure of complexity to the RCS-v2, but offers added value in identifying patients with highly complex therapy and equipment needs.

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 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.

Background Guillain-Barre syndrome is a significant cause of new long-term disability, which is thought to be amenable to multidisciplinary care, but the evidence base for its effectiveness is unclear. Objectives To assess the effectiveness of multidisciplinary care in adults with Guillain-Barre syndrome, especially the types of approaches that are effective (settings, intensity) and the outcomes that are affected. Search methods We searched the Cochrane Neuromuscular Disease Group Specialized Register (20 May 2010), The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2010, Issue 2), MEDLINE (1966 to May 2010), EMBASE (1980 to May 2010), CINAHL (1982 to May 2010), AMED (1985 to May 2010), PEDro (1982 to May 2010) and LILACS (1982 to May 2010). We checked the bibliographies of papers identified and contacted their authors and known experts in the field seeking published and unpublished trials. Selection criteria Randomised and controlled clinical trials that compared multidisciplinary care in Guillain-Barre syndrome with either routinely available local services or lower levels of intervention, or studies that compared multidisciplinary care in different settings or at different levels of intensity. Studies of ‘other designs’ (such as observational studies) were included only in the Discussion since such studies could only be of limited contribution to the best evidence synthesis. Data collection and analysis We performed a 'best evidence' synthesis based on methodological quality. Main results No randomised controlled trials or controlled clinical trials were identified. We summarised the results of three observational studies in the Discussion section of this review. Authors' conclusions In the absence of randomised controlled trials or controlled clinical trials, the 'best' evidence to date comes from three 'very low quality' observational studies. These provide some support for improved disability in the short term (less than 6 months) with high intensity inpatient multidisciplinary rehabilitation; and for improved quality of life, as measured by a reduction in handicap (participation). These conclusions are tentative and the gap in current research should not be interpreted as proof that multidisciplinary care is ineffective. Further research is needed into appropriate study designs; outcome measurement; caregiver needs; and the evaluation of optimal settings, type, intensity or frequency and cost-effectiveness of multidisciplinary care in the Guillain-Barre syndrome population.

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

Objective: To examine the dimensionality of the Zarit Burden Interview in a sample of carers of adults with acquired brain injury. Design: A cross-sectional UK survey using postal questionnaires. Participants: A sample of 222 carers; 43 men (19.4%) and 179 women (80.6%); mean age 54 years. Types of brain injury included traumatic brain injury (49.5%), stroke (25.9%), brain infection (17.3%), hypoxia (4.1%), and “other” (3.2%). Methods: Exploratory and confirmatory factor analysis and Rasch analysis. Results: Unidimensionality was tested using confirmatory factor analysis, which showed a poor fit. The underlying structure of the Zarit Burden Interview was explored using principal components analysis and varimax rotation. This revealed 3 factors, although 1 comprised only 2 items. The 2 major factors identified were personal strain and role strain. They were then examined using Rasch analysis, which identified 2 brief and reliable unidimensional scales. There was no evidence of differential item functioning for different types of carer/brain injury. Conclusion: The Zarit Burden Interview is a promising measure for the assessment of burden in carers of people with an acquired brain injury. It offers 2 reliable, brief subscales of personal strain and role strain for this purpose. However, it remains for these 2 brief subscales to be validated clinically in future research.

The objective of this study was to explore methods examining patient complexity and therapy interventions in relation to functional outcomes from an inpatient multiple sclerosis (MS) rehabilitation program. Retrospective and prospective data for 24 consecutive inpatients at a tertiary rehabilitation facility assessed (i) impairment/disability - Expanded Disability Status Scale, Neurological Impairment Set, (ii) complexity of intervention - Rehabilitation Complexity Scale, Northwick Park Therapy Dependency Assessment (NPTDA), the type and duration of therapy, (iii) Function - Barthel Index (BI), functional independence measure (FIM), (iv) hospital length of stay, discharge destination. The mean length of stay was 20 days (SD=15.7); male : female ratio was 10 : 14; 11 (46%) had Expanded Disability Status Scale scores more than 6.5, and all discharged to community. Over one-half had 'moderate-severe' scores for fatigue, and deficits in motor function and mood that resulted in significant functional limitation. Rehabilitation Complexity Scale scores showed substantial complexity with two-thirds requiring specialized nursing. The NPTDA score (median 22 interquartile range 20-23) showed moderate dependency on admission in the following domains: physical, cognitive and psychosocial programs and preparing for discharge. The mean physiotherapy and occupational therapy received was 45.76 and 24.04 min/day, respectively. Functional gains from admission to discharge for FIM and BI were significant (P

Despite a range of factors being proposed in research literature to be key to 'work-ability', agreed definitions and boundaries of this concept are lacking. This review sought to identify and clarify key factors thought to contribute to individual work-ability, then compare these against existing measures of work-ability for people with injury.A literature search was undertaken based on principles of systematic review. MEDLINE, AMED, Scopus and Web of Science databases were searched. All potentially relevant articles were obtained and, if they met inclusion criteria, evaluated for quality. The search was expanded and repeated to identify currently available measures of work-ability for people with injury. These measures were then compared against components from the first search.Thirty-four articles were obtained from the first search, and 23 provided information about factors that contribute to work-ability. Six broad categories were identified: physical, psychological, cognitive, social/behavioural, workplace factors, and factors outside the workplace. The follow-up search identified 10 measures. No one measure captured all six identified categories.Components contributing to work-ability go beyond the ability to perform particular work tasks. Measures intended to be used to inform vocational rehabilitation arguably need to consider all these factors to maximise likelihood of a sustainable return to work.

La torsione del testicolo e stata inizialmente descritta da Delasiauve nel 1840 (Delasiauve 1840). Il primo caso di torsione di un testicolo completamente sceso e stato riportato da Langton nel 1881 (Williamson 1976). Nel 1893, Nash ha descritto la prima detorsione manuale del testicolo (Nash 1893). Curling (1857) ha citato un caso riportato da Rosenmerkel di Monaco, che ha detorto un criptorchidismo e lo ha fissato nello scroto con una sutura attraverso la tunica dartos (Noske et al. 1998). Defontaine ha descritto il primo caso di riparazione operatoria di una torsione intrascrotale nel 1893 (Sparks 1971). Mosby ha descritto la prima torsione sopravaginale nel 1897 (Taylor 1897).

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 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.

To apply Rasch analysis to the Beck Depression Inventory-II (BDI-II) responses of a mixed neurorehabilitation sample to determine its suitability for assessing depression among this group.Three hundred and fifteen in-patients undergoing post-acute specialist in-patient rehabilitation at the Regional Rehabilitation Unit (RRU) of Northwick Park Hospital in North London were administered the Beck Depression Inventory. All patients were administered the BDI-II by a clinical psychologist using a large print version and taking as much time as patients required. Rasch analysis was completed using the RUMM2020 software. Where disordered thresholds were identified item rescoring was undertaken. Each item was also examined for Differential Item Functioning. Where misfit to model expectations was identified items were removed in an iterative fashion. The effect of any deletion upon person estimates was examined. Specific tests of unidimensionality were undertaken at each iterative phase.Rescoring was necessary before Items 1-4, 6, 8-12, 20 and 21 showed ordered thresholds. Three items failed to satisfy model expectations - items 16 (changes in sleeping pattern), 18 (changes in appetite) and 21 (loss of interest in sex) and were deleted - after which good overall fit to the Rasch model was observed. The three items deleted affected person estimates in a significant way such that the 21 item version in this group of patients may be biased because of multidimensionality.The BDI-II in a sample of patients undergoing neurorehabilitation satisfies unidimensional Rasch model expectations in an 18-item format. Some disordering of response categories was evident, but this evidence requires replication before any common rescoring option should be considered.

Title. Work sampling: a quantitative analysis of nursing activity in a neuro-rehabilitation setting. Aim. The aim of this investigation was to establish the distribution and proportion of nursing activity represented by patient-related care activities (direct and indirect), and other nursing activities (unit-related and personal) within one inpatient neurological rehabilitation unit. Background. A set of tools has been developed for estimating the care/nursing hours required for direct hands-on patient care in hospital rehabilitation settings. However, to apply this information to estimate the actual staffing requirements in relation to a given caseload, it is necessary to know the proportion of nursing workload assigned to other activities and how this may vary throughout the day. Method. A work sampling study was conducted during 2004. A snapshot of nursing activity was recorded at 5-minute intervals from 06·00 to 23·55 spread over 2 weeks, with one session from 06·00 to 15·25 and the second from 15·30 to 23·55. Results. A total of 8883 nursing activities were observed and recorded over 126 hours and categorized as follows: 4060 (46%) direct patient care, 2218 (25%) indirect patient care, 874 (10%) unit-related and 1731 (19%) personal time. The proportions of direct care fluctuated throughout the day, with direct care activities mainly concentrated in early mornings and to a lesser extent evenings. Conclusion. Direct patient care accounted for less than half of the nursing activity in a rehabilitation setting. Estimates of staffing requirement must also take account of the time required for indirect care and non-patient related activity.

Objective: To evaluate clinimetric properties of the Rehabilitation Complexity Scale (RCS) in a neurorehabilitation inpatient sample. Design: An observational cohort analysis in a tertiary specialist setting. Subjects: 179 consecutive patients (mean age 44.5(sd15) years, Males:Females 110:69) with complex neurological disabilities, mainly following acquired brain injury. Methods: Repeat RCS ratings of the level of care, nursing, therapy and medical interventions were examined for dimensionality, repeatability, consistency, and responsiveness; and compared with the Northwick Park Nursing and Therapy Dependency Scales (NPDS and NPTDA), the Functional Independence Measure (FIM) and Barthel Index, recorded at the start and end of treatment. Results: Test-retest reliability confirmed the RCS to be repeatable (Kappa 0.93-0.96) and moderately responsive to changes in levels of intervention over the course of the programme, suggesting the need for serial evaluation. Coefficient-alpha was 0.76 and item-total correlations all >0.50, with moderate-high loadings on the first principal component. Factor analysis showed two clear factors (‘Nursing/medical care’, and ‘Therapies’). The RCS demonstrated good convergent and discriminant validity with the NPDS and NPTDA, but some ceiling effect. FIM motor and Barthel scores correlated well with basic care and nursing scores (Spearman rho -0.65 to -0.79), but less well with therapy (rho -0.26) and medical (rho -0.28 to -0.33) scores. Conclusion: In this cohort, the RCS provided a reliable, valid and moderately responsive profile of rehabilitation interventions, separating into two main subscales. It usefully identified medical and therapy inputs not captured by the FIM and BI, which are commonly used to define case complexity in rehabilitation.

"Foot drop" or "Floppy foot drop" is the term commonly used to describe weakness or contracture of the muscles around the ankle joint. It may arise from many neuromuscular diseases.To conduct a systematic review of randomised trials for the treatment of foot drop resulting from neuromuscular disease.In this update, we searched the Cochrane Neuromuscular Disease Group Trials Register (April 2009), MEDLINE (January 1966 to April 24 2009), EMBASE January 1980 to April 24 2009), CINAHL (January 1982 to May 6 2009), AMED (January 1985 to April 24 2009), the British Nursing Index (January 1985 to January 2008) and Royal College of Nursing Journal of Databases (January 1985 to January 2008).Randomised and quasi-randomised trials of physical, orthotic and surgical treatments for foot drop resulting from lower motor neuron or muscle disease and related contractures were included. People with primary joint disease were excluded. Interventions included a 'wait and see' approach, physiotherapy, orthoses, surgery and pharmacological therapy. The primary outcome measure was quantified ability to walk whilst secondary outcome measures included range of movement, dorsiflexor torque and strength, measures of activity and participation, quality of life and adverse effects.Methodological quality was evaluated by two authors using the van Tulder criteria. Four studies with a total of n = 152 participants were included in the update to the original review. Heterogeneity of the studies precluded pooling the data.Early surgery did not significantly affect walking speed in a trial including 20 children with Duchenne muscular dystrophy. Both groups deteriorated during the 12 months follow-up. After one year, the mean difference (MD) of the 28 feet walking time was 0.00 seconds (95% confidence interval (CI) -0.83 to 0.83) and the MD of the 150 feet walking time was -2.88 seconds, favouring the control group (95% CI -8.18 to 2.42). Night splinting of the ankle did not significantly affect muscle force or range of movement about the ankle in a trial of 26 participants with Charcot-Marie-Tooth disease. Improvements were observed in both the splinting and control groups. In a trial of 26 participants with Charcot-Marie-Tooth disease and 28 participants with myotonic dystrophy, 24 weeks of strength training significantly improved six-metre timed walk in the Charcot-Marie-Tooth group compared to the control group (MD 0.70 seconds, favouring strength training, 95% CI 0.23 to 1.17), but not in the myotonic dystrophy group (MD -0.20 seconds, favouring the control group, 95% CI -0.79 to 0.39). No significant differences were observed for the 50 metre timed walk in the Charcot-Marie-Tooth disease group (MD 1.90 seconds, favouring the training group, 95% CI -0.29 to 4.09) or the myotonic dystrophy group (MD -0.80 seconds, favouring the control group, 95% CI -5.29 to 3.69). In a trial of 65 participants with facioscapulohumeral muscular dystrophy, 26 weeks of strength training did not significantly affect ankle strength. After one year, the mean difference in maximum voluntary isometric contraction was -0.43 kg, favouring the control group (95%CI -2.49 to 1.63) and the mean difference in dynamic strength was 0.44 kg, favouring the training group (95%CI -0.89 to 1.77).Only one study, involving people with Charcot-Marie-Tooth disease, demonstrated a statistically significant positive effect of strength training. No effect of strength training was found in people with either myotonic dystrophy or facioscapulohumeral muscular dystrophy. Surgery had no significant effect in children with Duchenne muscular dystrophy and night splinting of the ankle had no significant effect in people with Charcot-Marie-Tooth disease. More evidence generated by methodologically sound trials is required.

"Foot drop" or "Floppy foot drop" is the term commonly used to describe weakness or contracture of the muscles around the ankle joint. It may arise from many neuromuscular diseases.

Objective: Botulinum toxin is known to relieve upper limb spasticity, which is a disabling complication of stroke. We examined its effect on quality of life and other person-centred perspectives. Design: A multi-centre, randomized, double-blind, placebocontrolled study. Patients: Ninety-six patients were randomized (mean age 59.5 years) at least 6 months post-stroke. Mean time since stroke was 5.9 years. Methods: Patients received either botulinum toxin type A or placebo into the affected distal upper limb muscles on 2 occasions, 12 weeks apart. Assessment was undertaken at baseline, 8, 12, 20 and 24 weeks. The primary outcome measure was the Assessment of Quality of Life scale (AQoL). Secondary outcome assessments included Goal Attainment Scaling (GAS), pain, mood, global benefit, Modified Ashworth Scale (MAS), disability and carer burden. Results: The groups did not differ significantly with respect to quality of life, pain, mood, disability or carer burden. However, patients treated with botulinum toxin type A had significantly greater reduction in spasticity (MAS) (p < 0.001), which translated into higher GAS scores (p < 0.01) and greater global benefit (p < 0.01). Conclusion: Although no change in quality of life was demonstrated using the AQoL, botulinum toxin type A was found to be safe and efficacious in reducing upper limb spasticity and improving the ability to achieve personal goals.

As their differential needs are unknown and to inform service planning, this study (a) examined experiences of caring for adults with acquired brain injury (ABI) and (b) compared these with carers of adults with dementia.Cross-sectional postal survey. ABI carer experiences were compared with those of a previously studied group of dementia carers using equivalent instruments.Family carers (n = 222) of adults with ABI: TBI (49%), strokes (26%), brain infections (18%) and other (7%) completed validated questionnaires assessing physical dependency and psychological problems of those cared for and carers' own perceived burden, quality-of-life and mental health.Carer burden, quality-of-life and mental health were worse for ABI carers, but were not predicted by gender, relationship, injury type, physical dependency or cognitive problems in either ABI or dementia carers. Behavioural problems of those cared for varied between the two groups and affected carers differently. Aggressive problems significantly predicted greater burden, poor quality-of-life and mental health in ABI carers, whereas passivity/low mood significantly predicted greater burden and worse quality-of-life in dementia carers.This study revealed different experiences of caring for younger adults with ABI vs. older adults with dementia, thereby supporting targeted development of services to sustain families affected by these conditions.

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.

Background Multiple sclerosis is a neurological disease that frequently affects adults of working age, resulting in a range of physical, cognitive and psychosocial deficits that impact on workforce participation. Although, the literature supports vocational rehabilitation (VR) approaches in persons with multiple sclerosis (pwMS), the evidence for its effectiveness is yet to be established. Objectives To evaluate the effectiveness of VR programs compared to alternative programs or care as usual on return to work, workability and employment in pwMS; to evaluate the cost effectiveness of these programs. Search strategy Electronic searches included: Cochrane Central Register of Controlled Trials "CENTRAL" 2008 issue 3, MEDLINE (PubMed) (1966- 2008), EMBASE (1988- 2008), CINAHL (1982- 2008), PEDro (1990- 2008), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register. Selection criteria Randomized and controlled clinical trials, including before - after controlled trials, that compare VR rehabilitation with alternative intervention such as standard or a lesser form of intervention or waitlist controls. Data collection and analysis Two reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis was performed, based on methodological quality. Trials were grouped in terms of type and setting of VR programs. Main results Two trials (one RCT and one CCT) (total 80 participants) met the review criteria. Both trials scored poorly on the methodological quality assessment. There was 'insufficient evidence' for VR programs for (a)'competitive employment', in altering rates of job retention, changes in employment, improvement in rates of re-entry into the labour force; (b) for altering 'work ability' by improving participants' confidence in the accommodation request process, or employability maturity or job seeking activity. No evidence could be assimilated for changes in proportions of persons in supported employment or on disability pensions, nor for cost-effectiveness. Authors' conclusions There was inconclusive evidence to support VR for pwMS. However, the review highlights some of the challenges in providing VR for pwMS. Clinicians need to be aware of vocational issues, and to understand and manage barriers for maintaining employment. Proactive and timely VR programs should incorporate practical solutions to deal with work disability, workplace accommodation and educate employers, and the wider community. Liaison with policy makers is imperative for government initiatives that encourage work focused VR programs. Future research in VR should focus on improving methodological and scientific rigour of clinical trials; on the development of appropriate and valid outcome measures; and on cost effectiveness of VR programs.

The Beck Depression Inventory-II (BDI-II) is widely used for assessing depression in neurorehabilitation. Given the concern that the somatic items might be misleading, we examined its factor structure in 353 inpatients. Exploratory factor analysis was undertaken to compare two- to five-factor solutions. Confirmatory factor analysis was then used to test the best exploratory solutions for goodness of fit on a subsample. Both provided strong support for a general depression factor and two specific factors, one somatic and one cognitive/affective. The BDI-II provides a meaningful score of overall depression, and it can also yield two subscores—one measuring somatic symptoms and the other measuring psychological symptoms of depression. To avoid confusing the common symptoms of neurological disability with depression in neurorehabilitation, clinicians need to consider all three scores carefully. (JINS, 2009, 15, 142–147.)

"Foot drop" or "Floppy foot drop" is the term commonly used to describe weakness or contracture of the muscles around the ankle joint. It may arise from many neuromuscular diseases.

Purpose. The UK Functional Assessment Measure (UK FIMþFAM) is a widely used outcome measure in brain injury rehabilitation. An Extended Activities of Daily Living (EADL) module was included in its original development, but has never been formally evaluated. This study evaluated its scoring accuracy and reliability using vignettes (short clinical scenarios). Method. A set of vignettes was developed and tested by a panel of experienced UK FIMþFAM trainers to derive ‘gold standard’ scores. To evaluate scoring accuracy, these were subsequently compared with scores made by 12 rehabilitation professionals; first individually, and then together in four multi-disciplinary (MD) teams to reflect clinical practice. Scoring was repeated after 1 month. Inter-rater and intra-rater reliability were evaluated for both individual and MD team scores using weighted Cohen’s kappa statistics. Results. Agreement with ‘gold standard scores’ was excellent, ranging from kw ¼ 0.88–0.97 (individuals) and kw ¼ 0.93– 1.00 (MD teams). Inter-rater agreement was good to excellent, ranging from k ¼ 0.68–0.92 (individuals) and k ¼ 0.74–1.00 (MD teams). Test–retest agreement was excellent, ranging from kw ¼ 0.92–1.00 (individuals) and kw ¼ 0.89–0.99 (MD teams). Conclusion. This vignette-based study demonstrated high levels of scoring accuracy and reliability for the EADL items of the UK FIMþFAM. Further testing in real-life situations is now warranted.

La torsion du testicule est une urgence frequente. Le diagnostic est clinique et le traitement consiste en une detorsion chirurgicale et une fixation bilaterale en urgence. Dans les cas douteux, il est imperatif d’avoir une tres forte suspicion, et les erreurs de prise en charge doivent se faire dans un sens plutot agressif que conservateur. Une orchidopexie homo et controlaterale doit etre effectuee avec des sutures non resorbables pour prevenir une recidive de la torsion. Les taux de sauvegarde du testicule sont correles a la duree et au degre de la torsion. L’hypofertilite apres torsion est bien connue mais n’a probablement pas d’importance clinique. La torsion du testicule reste une urgence chirurgicale en deca de 48 h de symptomatologie persistante. En presence d’une induration scrotale ligneuse, la torsion du testicule n’est plus une urgence au dela de 24 h de symptomatologie persistante. Les patients presentant un tableau clinique de torsion subaigue intermittente ou recidivante, et ceux ayant deja perdu un testicule par torsion, traumatisme ou tumeur, doivent probablement subir une orchidopexie. Les torsions d’annexes testiculaires peuvent etre traitees de facon conservatrice et n’ont pas de consequence clinique en dehors du fait qu’elles doivent etre differenciees de la torsion du testicule.

To explore the role of Botulinum Toxin type A (BoNT-A) in the management of the spastic hemiplegic shoulder and identify the common achievable goals for treatment.Set in a regional spasticity management service in the UK, a prospective observational cohort study was undertaken. Patients (n = 16) were receiving BoNT-A (Dysport) injection and concurrent therapy for spasticity of the shoulder girdle or proximal upper limb following stroke/other acquired brain injury. Mean age 54.5 (SD 15.7) years. Mean time since injury: 15.7 months. Functional goals for intervention were determined through agreement with the patient or their carers using Goal Attainment Scaling (GAS). Evaluation of spasticity (Modified Ashworth Scale), pain (numbered graphic rating scale) and three standard passive function tasks (washing, dressing and positioning) were also undertaken.Sixteen weeks post-injection, significant improvements were identified in spasticity (Z = -3.535, p0.0001), pain (Z = -1.942, p = 0.052) and passive function (Z = -3.172, p = 0.002). GAS scores had improved in all but one subject, with goals either achieved or over-achieved.BoNT-A injection of the proximal upper limb, with combined therapy, produced a reduction in spasticity, improvement in passive function and pain. Management of upper limb spasticity should include evaluation and, if necessary treatment, of the shoulder girdle and proximal musculature.

Background Joint replacements are common procedures and treatment of choice for those with intractable joint pain and disability arising from arthropathy of the hip or knee. Multidisciplinary rehabilitation is considered integral to the outcome of joint replacement. Objectives To assess the evidence for effectiveness of multidisciplinary rehabilitation on activity and participation in adults following hip or knee joint replacement for chronic arthropathy. Search methods We searched the Cochrane Musculoskeletal Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and CINAHL up to September 2006. Selection criteria Randomised controlled trials (RCTs) that compared organised multidisciplinary rehabilitation with routine services following hip or knee replacement, and included outcome measures of activity and participation in accordance with the International Classification of Functioning, Health and Disability (ICF). Data collection and analysis Four authors independently extracted data and assessed methodological quality of included trials. Main results Five trials (619 participants) met the inclusion criteria; two addressed inpatient rehabilitation (261 participants) and three (358 participants) home-based settings. There were no trials addressing outpatient centre-based programmes. Pooling of data was not possible due to differences in study design and outcomes used. Methodological assessment showed all trials were of low quality. For inpatient settings early commencement of rehabilitation and clinical pathways led to more rapid attainment of functional milestones (disability) (Functional Independence Measure (FIM) transfer WMD 0.5, 95% CI 0.15, 0.85, number needed to treat to benefit (NNTB) = 6, FIM ambulation WMD 1.55 (95%CI 0.96, 2.14), NNTB = 3), shorter hospital stay, fewer post-operative complications and reduced costs in the first three to four months. Home-based multidisciplinary care improved functional gain (Oxford Hip Score (OHS) WMD at 6 months -7.00 (95%CI -10.36, -3.64), NNT = 2 and quality of life (QoL) and reduced hospital stay in the medium term (six months). No trials addressed longer-term outcomes following hip replacement only. Authors' conclusions Based on the heterogeneity and the low quality of the included trials that precluded pooled meta-analysis, there is silver level evidence that following hip or knee joint replacement, early multidisciplinary rehabilitation can improve outcomes at the level of activity and participation. The optimal intensity, frequency and effects of rehabilitation over a longer period and associated social costs need further study. Future research should focus on improving methodological and scientific rigour of clinical trials, and use of standardised outcome measures, so that results can be pooled for statistical analysis.

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.

Spinal cord injury (SCI) is a lifelong condition affecting over 40,000 people in the UK. When an individual with established SCI is admitted to hospital for a procedure or because of illness, hospital teams need to manage both the acute condition and the spinal cord injury. These guidelines aim to assist in their assessment and management to avoid the common problems of hospital-acquired morbidity in this potentially vulnerable group of people. Key steps are: gaining an understanding of the common patho-physiological consequences of SCI; listening to the person and their family who are often expert in managing the condition; and maintaining close contact with the individual's regular team/specialist spinal cord injury centre.

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 paper explores the tensions between politics and payment in providing affordable services that satisfy the public demand for patient-centred care.The two main approaches taken by the UK Government to curtail the spiralling costs of healthcare have been to focus development in priority areas and to cap spending through the introduction of a fixed-tariff episode-based funding system. The National Service Framework for Long Term Neurological Conditions embraces many laudable principles of person-centred management, but the 'one-size-fits all' approach to reimbursement potentially cuts right across these. A series of tools have been developed to determine complexity of rehabilitation needs that will support the development of banded tariffs. A practical approach is also offered to demonstrate the cost-efficiency of rehabilitation services for people with complex needs, and help to ensure that they are not excluded from treatment because of their higher treatment costs.Whilst responding to public demand for person-centred care, we must recognize the current financial pressure on healthcare systems. Clinicians will have greater credibility if they routinely collect and share outcomes that demonstrate the economic benefits of intervention, as well the impact on health, function and quality of life.

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.

The Memory and Behavior Problems Checklist-1990R (MBPC-1990R) is a carer-rated measure of (a) problem behaviours and (b) corresponding carer reaction. Although originally developed and validated for dementia, its items are relevant to acquired brain injury (ABI). This study evaluated its validity in this population.Cross-sectional study.In a national postal survey carried out to inform service planning, 222 family carers of adults with TBI (49%), strokes (26%), infections (18%), other (7%) completed the MBPC-1990R, Head Injury Behaviour Scale (HIBS), Barthel Index (BI), Northwick Park Dependency Score (NPDS), Carer Burden Interview (CBI), WHOQOL-BREF and GHQ-28.MBPC-1990R problems correlated well with HIBS problems (r = 0.70), as did MBPC-1990R carer reaction with HIBS distress (r = 0.78) and CBI (r = 0.73) scores, indicating good convergent validity. Discriminant validity was inferred from absent/weak correlations between MBPC-1990R problems and both BI (r = -0.02) and NPDS (r = 0.24); likewise between MBPC-1990R carer reaction and WHOQOL-BREF physical, psychological, social, environmental sub-scales (r = -0.32 to -0.41) and GHQ-28 scores (r = 0.35). Factor analysis revealed excessive, cognitive, aggressive and passive/low mood sub-scales, which showed good internal consistency and varied across ABI groups.The MBPC-1990R is supported as a measure of problem behaviours and carer reaction in ABI. Further validation in ABI groups is recommended.

Title. Northwick Park Care Needs Assessment: adaptation for inpatient neurological rehabilitation settings Aim. This paper is a report of a study to establish which timings and assumptions of the Northwick Park Dependency Scale and Care Needs Assessment are appropriate to the inpatient rehabilitation setting and which, if any, require adjustment. Background. Cost-effective provision of nursing care relies on being able to adjust staffing levels in accordance with patient dependency. The Northwick Park Dependency Scale and Care Needs Assessment enables direct assessment of nursing care needs in community settings. Method. An observational study was conducted in 2004 to record the time taken to complete direct nursing care interventions in a rehabilitation ward and to compare these times with simultaneously recorded time-estimates provided by the Care Needs Assessment. A total of 1168 nursing interactions were timed for 50 care episodes. Results. There was considerable variation in the time taken for each nursing intervention, depending on overall patient dependency and the number of nurses required. Although there was good correlation between observed care times and those estimated by the Care Needs Assessment, observation confirmed that most interventions took substantially less time than the estimates. There was also a very different pattern of care in hospital compared with the community, with shorter, more frequent interactions as nurses distribute their time between different patients, and activities other than direct patient care. Conclusion. The Northwick Park Care Needs Assessment tool already has widespread application in other countries and its continued use for estimating community care needs remains relevant. The tool, once fully developed, will have the potential to contribute to international rehabilitation nursing workforce planning and research.