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This article has two aims. Firstly, to describe how UKROC tools (which are mandated for use in every specialist inpatient neurorehabilitation unit in England: Standard Contract for Specialist Rehabilitation, NHS England, 2013) can be used to assess the level of need for neuropsychological intervention. We identify patients with a neuropsychological need using items from the UKROC data set. The methods and rationale for item selection is outlined here. This could be replicated by neuropsychologists locally to plan adequate neuropsychology services or highlight unmet need. Secondly, we have used these methods to assess the need for neuropsychological services across England over the last five years, using national UKROC data (N=26,484 episodes of care). The results indicate 62–75 per cent per cent of case episodes in specialist neurorehabilitation units in England, between 2014 and 2019, could be classified as having a neuropsychological need. We conclude this provides evidence to suggest neuropsychologists should be adequately funded to provide a service to every specialist neurorehabilitation unit in the UK and should be considered an essential part of any specialist inpatient neurorehabilitation team. We discuss the importance of considering this level of need at the national policy level.

National guidelines provide advice for end-of-life care in patients with prolonged disorders of consciousness (PDOC). Following a Supreme Court judgment in July 2018, updated guidelines set out requirements to ensure that decisions to withdraw clinically assisted nutrition and hydration (CANH) are made responsibly in the absence of a mandatory application to the court. This retrospective 8-year cohort analysis of prospectively collected clinical data examines the experience and lessons learned from implementing the guidelines in the 80 PDOC patients who have died in one tertiary centre since 2014. It also reports performance against the standards for elective withdrawal of CANH outside of court since July 2018. CANH was withdrawn in 39/80 (49%) of the patients, over half of whom were already imminently dying. Even in a centre where patients are referred for this purpose, elective CANH withdrawal is comparatively rare (just 14 patients since 2018). The requirements were met in all cases.

Background Many Intensive Care Unit (ICU) survivors suffer from a multi- system disability, termed the post-intensive care syndrome. There is no current national coordination of either rehabilitation pathways or related data collection for them. In the last year, the need for tools to systematically identify the multidisciplinary rehabilitation needs of severely affected COVID-19 survivors has become clear. Such tools offer the opportunity to improve rehabilitation for all critical illness survivors through provision of a personalised Rehabilitation Prescription (RP). The initial development and secondary refinement of such an assessment and data tools is described in the linked paper. We report here the clinical and workforce data that was generated as a result. Methods Prospective service evaluation of 26 acute hospitals in England using the Post-ICU Presentation Screen (PICUPS) tool and the RP. The PICUPS tool comprised items in domains of a) Medical and essential care, b) Breathing and nutrition; c) Physical movement and d) Communication, cognition and behaviour. Results No difference was seen in total PICUPS scores between patients with or without COVID-19 (77 (IQR 60-92) vs. 84 (IQR 68-97); Mann-Whitney z = −1.46, p = 0.144. A network analysis demonstrated that requirements for physiotherapy, occupational therapy, speech and language therapy, dietetics and clinical psychology were closely related and unaffected by COVID-19 infection status. A greater proportion of COVID-19 patients were referred for inpatient rehabilitation (13% vs. 7%) and community-based rehabilitation (36% vs.15%). The RP informed by the PICUPS tool generally specified a greater need for multi-professional input when compared to rehabilitation plans instituted. Conclusions The PICUPS tool is feasible to implement as a screening mechanism for post-intensive care syndrome. No differences are seen in the rehabilitation needs of patients with and without COVID-19 infection. The RP could be the vehicle that drives the professional interventions across the transitions from acute to community care. No single discipline dominates the rehabilitation requirements of these patients, reinforcing the need for a personalised RP for critical illness survivors.

PURPOSE: 1: To determine whether Total UK FIM + FAM scores can identify patients in VS/MCS. 2: Using the identified cut-off points, to examine outcomes from specialist rehabilitation.METHODS: Part 1: Retrospective analysis of a consecutive clinical cohort (n = 388) presenting to a single specialist PDOC evaluation programme 2007-2021. FIM + FAM scores were analysed by PDOC diagnosis to define cut-off points for vegetative (VS) and minimally conscious states (MCS). Part 2: Multicentre cohort analysis of prospectively-collected clinical outcomes data from the UK Rehabilitation Outcomes Collaborative database of adults in PDOC registered 2011-2020 (n = 2384 in 68 centres).RESULTS: Cut-off points of ≤31 and 32-35 in FIM + FAM total scores respectively identified patients in VS/MCS-Minus and MCS-Plus. Approximately 365 PDOC patients are admitted to specialist rehabilitation units in England each year. By discharge, 43% have emerged into consciousness and demonstrate a wide range of disability. A few reached full independence, but the majority remained severely dependent. Nevertheless, those who emerged generated mean net life-time savings of over £436,000 (£400 million for this cohort).CONCLUSION: In absence of a dedicated PDOC registry, FIM + FAM scores can identify patients in VS/MCS at population level. Identifying those who emerge and providing timely rehabilitation generates cost-savings well-exceeding the cost of the evaluation/rehabilitation programme.Implications for rehabilitationThe UK National Health Service currently collects no systematic data to identify patients in PDOC, so we have no accurate information on how many patients there are, where they are managed or what their outcomes are.In the absence of more direct data, total FIM + FAM scores of

Objective: To describe the development of the Spasticity-related Quality of Life 6-Dimensions instrument (SQoL-6D) and its sensitivity to clinical change (responsiveness). Design: Multicentre, prospective, longitudinal cohort study at 8 UK sites (NCT03442660). Patients: Adults (n = 104) undergoing focal treatment of upper limb spasticity. Methods: No condition-specific health-related quality of life tool is available for upper-limb spasticity of any aetiology. The SQoL-6D was developed to fulfil this need, designed to complement the Upper Limb Spasticity Index (which incorporates the Goal Attainment Scaling evaluation of upper limb spasticity [GASeous] tool) with targeted standardised measures. The 6 dimensions of the SQoL-6D (score range 0–4) map onto common treatment goal areas identified in upper-limb spasticity studies. A Total score (0–100) provides overall spasticity-related health status. To assess responsiveness, the SQoL-6D, Global Assessment of Benefit scale and ”GASeous” were administered at enrolment and 8 weeks. Results: Significant differences in mean SQoL-6D Total score change and effect sizes across patients rating ”some benefit” (0.51) and ”great benefit” (0.88) supported responsiveness. Conclusion: The SQoL-6D is a promising new measure of health status in upper limb spasticity, that enables systematic assessment of the impact of this condition in relation to patients’ priority treatment goals. A psychometric evaluation of SQoL-6D is presented separately. LAY ABSTRACT Upper-limb spasticity is a condition in which muscles become ”tight”, restricting use of the arm and hand. Questionnaires have been developed to assess a person’s quality of life, but are not specifically designed to assess the impact of spasticity on a person. The Spasticity-related Quality of Life 6-Dimensions instrument (SQoL-6D) was created to address this deficiency. The development of the SQoL-6D is described here, along with analysis of its responsiveness to ensure that the SQoL-6D detects changes in spasticity symptoms following treatment (as reported by patients using other questionnaires). These analyses showed that the SQoL-6D captured changes in the burden of spasticity for people with this problem. Other technical psychometric properties of the SQoL-6D are reported in the companion paper available in this issue

Objective: Psychometric evaluation of the Spasticity-related Quality of Life 6-Dimensions instrument (SQoL-6D). Design: A clinimetric evaluation conducted in a multicentre, prospective, longitudinal cohort study at 8 UK sites. Patients: Adult patients (n=104) undergoing focal treatment of upper-limb spasticity. Methods: The SQoL-6D was administered in the clinic at enrolment and at 8 weeks, then 1–4 days later at home to assess test-retest reliability. Results: The SQoL-6D demonstrated adequate construct validity and unidimensionality of the scale, allowing the calculation of a Total score. Cronbach’s alpha (0.74) supported the internal consistency reliability, while the intraclass correlation coefficient supported test-retest reliability (0.82). Correlation coefficients with established instruments supported convergent validity, while significant differences between known-groups (of differing clinical severity) in SQoL-6D Total score confirmed its sensitivity to both cross-sectional and longitudinal differences. Conclusion: The SQoL-6D is a promising new measure to assess health status for patients with upper-limb spasticity of any aetiology. Further investigation and exploration of the allocation of weights to convert the SQoL-6D to a health-related quality of life utility index, are required. Lay Abstract In upper-limb spasticity, the use of the arm and hand become restricted due to “tight” muscles. Although questionnaires to assess a person’s quality of life have been developed, they do not specifically assess the impact of upper-limb spasticity. To address this deficiency, the Spasticity-related Quality of Life 6-Dimensions (SQoL-6D) questionnaire was developed (see also the companion “development” paper available in this issue). To test that the SQoL-6D works as expected, it was completed by 104 people living with spasticity and compared with other questionnaires they completed. The results show that the SQoL-6D questions are relevant to people with spasticity. The answers were reliable when the SQoL-6D was repeated, and differences in the burden of spasticity between people grouped by the severity of their condition were captured accurately. The SQoL-6D is a promising new measure to assess aspects of quality of life in people living with spasticity.

PURPOSE: Hemiplegic shoulder pain (HSP) is a common but heterogeneous complication of acquired brain injury. Integrated care pathways (ICPs) can support clinical decision-making, prompting timely intervention to improve quality of care. This 18-year cohort analysis of clinical data presents outcomes from an ICP for management of HSP in an inpatient rehabilitation unit.MATERIALS & METHODS: Consecutive data were extracted for all eligible patients admitted between 2000-2018 (n = 333). Patients were categorised according to presentation pattern ("Floppy-subluxed" (59%), "Painful-stiff" (21%) or Mixed/not categorised(20%)) to help guide early management. Pain was assessed using the Shoulder-Q with pain ratings/10 in three domains: rest, night-time and movement. Patients with pain reduction ≥3 points in any domain were designated 'responders'.RESULTS: Mean baseline pain scores were 4.7 (95%CI 4.5,5.0). They were higher on movement (6.1(5.8,6.3)) than at rest (4.7(4.3, 5.0)) or at night (5.7(5.2,5.9)). Pain reduced significantly in all three domains (p CONCLUSION: These high pain-response rates compare favourably to the literature (14-27%), suggesting that this stratified and integrated approach to HSP guides more effective management in this heterogeneous clinical presentation.Implications for RehabilitationTwo-thirds of the patients demonstrated a clinically-significant reduction in pain when managed using the integrated care pathway. These results compare favourably with pain resolution rates of well under one-third cited in the literature and suggest that the integrated care pathway leads to reduced pain and improved patient outcomes.Hemiplegic shoulder pain can result from a range of different clinical problems. The diversity of presentation and the range of required treatments are confirmed in this 18-year cohort analysis.Heterogeneity in presentation of HSP poses a challenge for both management and the evaluation of outcome. The results of this study suggest that a stratified approach helps to guide more effective management.

Purpose: To evaluate functional outcomes, care needs and cost-efficiency of specialist rehabilitation for a multi-centre cohort of inpatients with spinal cord injury (SCI)-comparison based on age and aetiology.Methods and materials: Retrospective analysis of prospectively collected data from the UK Rehabilitation Outcomes Collaborative (UKROC) national clinical database from 2012-2019. Adults with SCI admitted for a rehabilitation programme in levels 1 and 2 specialist rehabilitation Units in England, were included if they had valid UK Functional Assessment Measure (UK FIM + FAM) and Northwick Park Dependency Scale (NPDS) scores recorded on admission and discharge (n = 2506 of 3321 admissions).Results: Approximately 425 patients were admitted yearly. 1344(56%) patients were under 65. 736(29%) had traumatic aetiology. Older and Traumatic SCI patients were more likely to have cervical cord damage (X2, p < 0.001). There was a significant improvement in all parameters of functional independence (UK FIM + FAM) (p < 0.001), with the reduction in dependency and care costs (NPDS/NPCNA) (p < 0.001). 1817(72.5%) patients were discharged home. Mean care-costs savings were £25 500/year per patient. Year-on-year trends showed admissions with increasing age, higher complexity and dependency with corresponding increasing episode costs (ANOVA p < 0.001). However, the time taken to offset the cost of rehabilitation did not change significantly (ANOVA p = 0.57).Conclusions: Specialist rehabilitation services provide effective and cost-efficient rehabilitation for patients with spinal cord injury.Implications for RehabilitationApproximately a third of patients who access specialist inpatient rehabilitation following spinal cord injury (SCI) in England are managed in the Specialist Level 1 and 2 neuro-rehabilitation units, rather than in the eight designated national SCI Centres.Despite admitting progressively more complex and dependent patients over eight years, these specialist rehabilitation units continue to provide highly cost-efficient care.The mean annual savings amount to £25,500 per patient. With a mean admission rate of 425 patients, this would generate total savings in excess of £10 million per year for the cohort.Specialist rehabilitation services play an important, but under-recognised, role in the spinal cord injury care pathway.

The aim of this study is to evaluate the properties of the Leg Activity measure according to COnsensus-based Standards for the selection of health Measurement INstruments.Participants were assessed at baseline, one day, 6 weeks and 12 weeks, following treatment for leg spasticity with botulinum toxin and physical interventions.In stage 1, 64 participants were recruited to evaluate the initial psychometric properties of Leg Activity measure. In stage 2, 100 additional participants were recruited, to evaluate the scaling properties. Total sample of 164 participants was used. Construct validity was supported for "passive function", "active function" and "impact on quality of life". Cronbach's alpha was 0.86, 0.97 and 0.87 respectively for the scales. Item level test-retest agreement ranged from 91-97% (Kappa 0.75-0.95). Following treatment for spasticity (The study provides support for the Leg Activity measure being valid, reliable and responsive.Implications for rehabilitationThe Leg Activity measure is the only published self-report measure in the current literature that addresses passive and active function as well as impact on quality of life, of the paretic leg in a comprehensive manner.The initial evaluation of Leg Activity measure psychometric properties, in relation to the COnsensus-based Standards for the selection of health Measurement INstruments checklist and Medical Outcomes Trust Quality Criteria, supports its measurement properties for clinical and research use.The Leg Activity measure as a valid, reliable and responsive tool for the evaluation of treatment in leg spasticity including condition specific (spasticity) quality-of-life.

Homer's Odyssey, one of the major Greek epic poems, tells the story of the hero Odysseus (or Ulysses in Roman versions) and his journey home to his wife Penelope. An epic poem is a long, narrative poem that is usually about heroic deeds and events that are significant to the culture of the poet. In keeping with this classic storytelling style, we describe the journey that the Upper Limb International Spasticity Study (ULIS) program has taken. The program was started in 2008 and has encountered a number of trials and obstacles along the way. This article sets out the history of development through its 10-year “Odyssey.” We use the benefit of hindsight to discuss how conducting large-scale, international observational studies can inform and influence routine practice in an area as diverse and complex as spasticity rehabilitation. We focus on the clinical pearls found within the now extensive ULIS dataset and how continually building upon the insights from each study can provide a real impetus for change.

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.

Background Patients who have had prolonged stays in intensive care have ongoing rehabilitation needs. This is especially true of COVID-19 ICU patients, who can suffer diverse long-term ill effects. Currently there is no systematic data collection to guide the needs for therapy input for either of these groups nor to inform planning and development of rehabilitation services. These issues could be resolved in part by the systematic use of a clinical tool to support decision-making as patients progress from the Intensive Care Unit (ICU), through acute hospital care and onwards into rehabilitation. We describe (i) the development of such a tool (the Post-ICU Presentation Screen (PICUPS)) and (ii) the subsequent preparation of a person-centred Rehabilitation Prescription (RP) to travel with the patient as they continue down the care pathway. Methods PICUPS development was led by a core group of experienced clinicians representing the various disciplines involved in post-ICU rehabilitation. Key constructs and item-level descriptors were identified by group consensus. Piloting was performed as part of wider clinical engagement in 26 acute hospitals across England. Development and validation of such a tool requires clinimetric analysis, and this was based on classical test theory. Teams also provided feedback about the feasibility and utility of the tool. Results Initial PICUPS design yielded a 24-item tool. In piloting, a total of 552 records were collated from 314 patients, of which 121 (38.5%) had COVID-19. No obvious floor or ceiling effects were apparent. Exploratory factor analysis provided evidence of uni-dimensionality with strong loading on the first principal component accounting for 51% of the variance and Cronbach’s alpha for the full-scale score 0.95 – although a 3-factor solution accounted for a further 21%. The PICUPS was responsive to change both at full scale- and item-level. In general, positive responses were seen regarding the tool’s ability to describe the patients during their clinical course, engage and flag the relevant professionals needed, and to inform what should be included in an RP. Conclusions The PICUPS tool has robust scaling properties as a clinical measure and is potentially useful as a tool for identifying rehabilitation needs as patients step down from ICU and acute hospital care.

To determine differences in rehabilitation gains made by people with an acquired brain injury undergoing staged community-based brain injury rehabilitation (SCBIR) at different times between injury and admission.Retrospective cohort analysis of routinely collected demographic and rehabilitation data from clients admitted to SCBIR service 2011-2017 (n=92). Outcome measures: Mayo-Portland Adaptability Inventory-4 (MPAI-4) and UK Functional Assessment Measure (UK FIM+FAM) collected on admission and annually thereafter until discharge. Analysis was stratified by time since injury on admission: 'Early' (1 year (n=36)), 'Middle' (1-2 years (n=34)) and 'Late' (2 years (n=22)). Between-group differences were tested using bootstrapped one-way ANOVA. Within-group differences were tested using paired T tests.Total cohort made significant gains in MPAI-4 and UK FIM+FAM total and all subscales (p = .001). Early group made greatest change in all subscales of both outcome measures (p .01). Middle cohort improved significantly in all subscales (p .02) excluding MPAI-4 Adjustment. Late cohort still made statistically significant gains in all UK FIM+FAM subscales (p .05) and MPAI-4 Participation (p .01). Item level changes are presented.More than 2 years after injury, people are able to make improvements in participation and functional independence following SCBIR.

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.

Background/Aims: UK national clinical guidelines recommend assessment of patients in prolonged disorders of consciousness in specialist centres. Working in these centres can be challenging, but little is currently published about what staff experience or how best to support them. We explored the views of health care professionals working with prolonged disorders of consciousness patients in one specialist rehabilitation unit. Methods: Six focus groups were run with allied health professionals, medical and nursing staff in discipline-specific groups to explore the rewards and challenges of working with patients in prolonged disorders of consciousness, and what staff felt they needed to assist them. Transcribed data were analysed using thematic analysis. Findings: Five positive themes emerged: seeing change, supporting families, quality of the team and clinical input, work complexity and its personal impact. Three negative themes were identified: dealing with death and ‘living death’, dealing with family expectations and distress, and the negative professional and personal impact on staff. In terms of what would assist staff, three themes emerged: greater support with family communication, additional prolonged disorders of consciousness-specific training and further development of assessments of awareness. Conclusions: Staff recommendations on what would assist them could be used to inform the development of high-quality approaches to assessment and care in prolonged disorders of consciousness.

Background/Aims: To compare patient outcomes following botulinum toxin (BoNT) injection by either physiotherapy or rehabilitation medicine (medical) professionals over a 3-year period. Methods: A retrospective, observational cohort study was conducted in a specialised rehabilitation service providing spasticity management including BoNT injection and physical therapy (group therapy, individual therapy, self-exercise, and physical management programmes). Individualised goals were established before treatment using goal attainment scaling (GAS) by the multidisciplinary team. The Arm Activity measure (ArmA) was used to evaluate upper limb function and the Modified Ashworth Scale (MAS) used to evaluate spasticity. Findings: A total of 262 patients were injected. Mean GAS T-score after treatment for the group was 50.2 ± 6.7. GAS T-score for physiotherapy injectors (n=214 (82% of participants)) was 50.2 ± 6.4 and for rehabilitation medicine injectors (n=48 (18%)) 50.3 ± 7.9. No significant differences were identified in terms of goal achievement, upper limb passive function, or spasticity reduction between physiotherapy and rehabilitation medicine injectors. Differences were identified at both baseline (physiotherapist mean 49.7; rehabilitation medicine mean 46.6) and follow-up for active function (physiotherapist mean=49.7; rehabilitation medicine mean=47.8) (ArmA active function subscale; p=0.03). No reportable adverse effects were recorded. No difference in the complexity of injection (such as complex clinical presentation, anticoagulation, or technical difficulty) between the injector groups was identified. Conclusions: Clinical outcomes were comparable between physiotherapy and rehabilitation medicine injectors. No difference in side effect profile or complexity of injection was identified. In this cohort, injection of BoNT by a physiotherapist was as effective in terms of GAS as that undertaken by a rehabilitation medicine physician.

BACKGROUND: Goal-classification of person-centred goals, using Goal Attainment Scaling for leg spasticity treatment.METHODS: The study was conducted in two phases: phase I, a retrospective review to evaluate categories of goal set in routine clinical practice. Findings were used to design a goal classification system. Phase II, a multi-centre study to confirm the goal categories. Goals set (n = 270) were analysed from data collected at three centres in the UK (one centre for phase I). Goal categories were mapped onto the domains of the World Health Organisation, International Classification of Functioning Disability and Health.RESULTS: One hundred and twenty seven participants were recruited in two cohorts: phase I: 63; phase II: 64. Goal categories using both cohorts were assigned to two domains, each subdivided into three key goal categories: Domain 1: body structure impairment 121 (44%): (a) pain/discomfort 34 (12%), (b) involuntary movements 20 (7%), and (c) range of movement/contracture prevention 67 (25%). Domain 2: activity function 149 (56%): (a) passive function (ease of caring for the affected limb) n = 89 (33%), (b) active function (transfers) 26 (10%), and (c) active function (mobility) 27 (10%), other n = 7 (3%).CONCLUSIONS: Patients individual leg spasticity goals can be grouped into six categories and two domains, which will assist clinicians, patients and cares in setting and evaluating goals in practice. Implications for Rehabilitation Six goal areas used in clinical goal setting for leg spasticity management were identified, under the two domains: (1) body structure impairment: pain, involuntary movements, and range of movement and (2) activities/function: passive function (ease of caring), active function - transfers or standing and active function - mobility. Categorisation of goals is consistent on repeated evaluation and across different clinical services. Using clinical goals for leg spasticity treatment is an effective method to identify treatment priorities.

Objectives: To determine whether the UK Functional Assessment Measure (UK FIM+FAM) fits the Rasch model in stroke patients with complex disability and, if so, to derive a conversion table of Rasch-transformed interval level scores. Methods: The sample included a UK multicentre cohort of 1,318 patients admitted for specialist rehabilitation following a stroke. Rasch analysis was conducted for the 30-item scale including 3 domains of items measuring physical, communication and psychosocial functions. The fit of items to the Rasch model was examined using 3 different analytical approaches referred to as ”pathways”. Results: The best fit was achieved in the pathway where responses from motor, communication and psychosocial domains were summarized into 3 super-items and where some items were split because of differential item functioning (DIF) relative to left and right hemisphere location (χ2 (10) = 14.48, p = 0.15). Re-scoring of items showing disordered thresholds did not significantly improve the overall model fit. Conclusion: The UK FIM+FAM with domain super-items satisfies expectations of the unidimensional Rasch model without the need for re-scoring. A conversion table was produced to convert the total scale scores into interval-level data based on person estimates of the Rasch model. The clinical benefits of interval-transformed scores require further evaluation.

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.

Application of the Leg Activity measure in acquired brain injury spasticity intervention to identify areas for goal setting prior to treatment, document the treatments applied and evaluate outcome.A prospective cohort from three specialist spasticity management centres was used. Primary outcome measures were, Leg Activity Measure, Modified Ashworth Scale and Goal Attainment Scaling - light. Measurement was completed at baseline, 6 and 12 weeks. The Leg-Therapy recording Schedule was used to record physical therapy intervention.Participants (Significant gains in passive-function and quality-of-life were recorded by the Leg Activity measure scales at 6 weeks, and at 12 weeks post-injection in the context of on-going physical treatment, primarily by self-management.Implications for rehabilitationThe Leg Activity measure is able to detected changes in passive function and impact on quality of life.Measurement of change in active function is also likely to be detected, but was not seen in the cohort studied.The Leg Activity measure was effective in this study in identifying problem areas to enable setting of treatment goals and planning of treatment intervention.

Aims: To develop a structured goal-set for use in programs for the assessment and management of prolonged disorders of consciousness (PDOC).Methods: A retrospective analysis of goals from a consecutive cohort of patients (n = 162) admitted to a specialist in-patient PDOC program in the UK from 2007 to 2018. Overall goal attainment was examined with Goal Attainment Scaling (GAS) using the GAS-Light method. Rates of individual goal-setting and achievement were examined for both standardized objectives (n = 2959) and personalized goals (n = 661). Goal statements from the personalized goals were independently reviewed and mapped to the domains of the existing structured objective set to identify any missing goal areas.Results: Mean outcome GAS T-scores were 47.2 (95% CI: 46.7, 47.6) and 47.7 (95% CI: 46.7, 48.8), respectively, for the standardized and personally set goals. These were closely correlated (r = 0.482, p < .001) with no significant difference between them. Analysis of goal achievement within each domain identified goals that were/were not likely to be achieved. An initial structured set of 20 standardized objectives in 12 domains was expanded and re-organized to produce a final-structured goal-set of 36 objectives in 18 domains.Conclusions: Developed through real-life clinical practice, this first published structured goal-set for PDOC programs now requires testing in other services/settings.

Supplemental Digital Content is Available in the Text., Objectives: To evaluate cost-efficiency of rehabilitation following severe traumatic brain injury (TBI) and estimate the life-time savings in costs of care. Setting/Participants: TBI patients (n = 3578/6043) admitted to all 75 specialist rehabilitation services in England 2010–2018. Design: A multicenter cohort analysis of prospectively collated clinical data from the UK Rehabilitation Outcomes Collaborative national clinical database. Main Measures: Primary outcomes: (a) reduction in dependency (UK Functional Assessment Measure), (b) cost-efficiency, measured in time taken to offset rehabilitation costs by savings in costs of ongoing care estimated by the Northwick Park Dependency Scale/Care Needs Assessment (NPDS/NPCNA), and (c) estimated life-time savings. Results: The mean age was 49 years (74% males). Including patients who remained in persistent vegetative state on discharge, the mean episode cost of rehabilitation was £42 894 (95% CI: £41 512, £44 235), which was offset within 18.2 months by NPCNA-estimated savings in ongoing care costs. The mean period life expectancy adjusted for TBI severity was 21.6 years, giving mean net life-time savings in care costs of £679 776/patient (95% CI: £635 972, £722 786). Conclusions: Specialist rehabilitation proved highly cost-efficient for severely disabled patients with TBI, despite their reduced life-span, potentially generating over £4 billion savings in the cost of ongoing care for this 8-year national cohort.

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