Statement of the Rehabilitation Medicine Society of Australia and New Zealand for the therapeutic use of botulinum toxin A in spasticity management.

The Rehabilitation Medicine Society of Australia and New Zealand advocates the safe, effective and evidence-based use of botulinum toxin type A for spasticity management. The process requires appropriate training, alongside considerable knowledge and skills, to maximise efficacy. The processes before and after injection contribute to effectiveness. The gold standard of managing spasticity is for assessment by a multidisciplinary specialist team, deriving patient-centric goals, and designing an injection protocol to match these goals. The patient and/or carers are considered part of the decision-making team. Postinjection therapy and measurement of goal achievement are highly recommended as part of the wider holistic approach to management. The Society believes treatment failures can be minimised by following clear clinical guidelines.

Early rehabilitation after hospital admission for road trauma using an in-reach multidisciplinary team: a randomised controlled trial.

OBJECTIVE: To investigate the impact of an in-reach rehabilitation team for patients admitted after road trauma. DESIGN: Randomised control trial of usual care versus early involvement of in-reach rehabilitation team. Telephone follow-up was conducted by a blind assessor at three months for those with minor/moderate injuries and six months for serious/severe injuries. SETTING: Four participating trauma services in New South Wales, Australia. SUBJECTS: A total of 214 patients admitted during 2012-2015 with a length of stay of at least five days. INTERVENTION: Provision of rehabilitation services in parallel with ward based therapy using an in-reach team for the intervention group. The control group could still access the ward based therapy (usual care). MAIN MEASURES: The primary outcome was acute length of stay. Secondary outcomes included percentage requiring inpatient rehabilitation, function (Functional Independence Measure and Timed Up and Go Test), psychological status (Depression Anxiety and Stress Score 21), pain (Orebro Musculoskeletal Pain Questionnaire) and quality of life (Short Form-12 v2). RESULTS: Median length of stay in acute care was 13 days (IQR 8-21). The intervention group, compared to the control group, received more physiotherapy and occupational therapy sessions (median number of sessions 16.0 versus 11.5, P=0.003). However, acute length of stay did not differ between the intervention and control groups (median 15 vs 12 days, P=0.37). There were no significant differences observed in the secondary outcomes at hospital discharge and follow-up. CONCLUSION: No additional benefit was found from the routine use of acute rehabilitation teams for trauma patients over and above usual care.

Subacute casemix classification for stroke rehabilitation in Australia. How well does AN-SNAP v2 explain variance in outcomes?

OBJECTIVE: We sought the best predictors for length of stay, discharge destination and functional improvement for inpatients undergoing rehabilitation following a stroke and compared these predictors against AN-SNAP v2. METHOD: The Oxfordshire classification subgroup, sociodemographic data and functional data were collected for patients admitted between 1997 and 2007, with a diagnosis of recent stroke. The data were factor analysed using Principal Components Analysis for categorical data (CATPCA). Categorical regression analyses was performed to determine the best predictors of length of stay, discharge destination, and functional improvement. RESULTS: A total of 1154 patients were included in the study. Principal components analysis indicated that the data were effectively unidimensional, with length of stay being the most important component. Regression analysis demonstrated that the best predictor was the admission motor FIM score, explaining 38.9% of variance for length of stay, 37.4%.of variance for functional improvement and 16% of variance for discharge destination. CONCLUSION: The best explanatory variable in our inpatient rehabilitation service is the admission motor FIM. AN- SNAP v2 classification is a less effective explanatory variable. This needs to be taken into account when using AN-SNAP v2 classification for clinical or funding purposes.

Interrater reliability of functional status scores for patients transferred from one rehabilitation setting to another.

OBJECTIVE: To report the interrater reliability of FIM total score, FIM motor subscore, and FIM cognitive subscore from scoring that occurred in routine clinical practice in 2 closely linked inpatient rehabilitation services in Sydney, Australia. DESIGN: A natural-experiment blind clinical interrater reliability cohort study of the FIM across 2 rehabilitation units. SETTING: This study is set in 2 inpatient rehabilitation units immediately adjacent to each other in southwestern Sydney, New South Wales, Australia. PARTICIPANTS: All patients (N=143) who were transferred between the 2 rehabilitation units between August 2006 and October 2007 were included in the study. INTERVENTION: Discharge FIMs were scored by the first unit and an admission FIM was scored independently by the second unit within a few days. The FIM scores were analyzed for agreement and systematic bias. MAIN OUTCOME MEASURE: Intraclass correlation coefficients, kappa statistic, weighted kappa statistic, and Bland-Altman plots were used. RESULTS: There were 143 sets of scores identified. The range of differences between the 2 FIM totals was -32 to 50, between the FIM motor subscores was -22 to 43, and between the FIM cognitive subscores was -14 to 21. Bland-Altman plots demonstrated poor agreement. Few FIM totals were perfectly matched. The intraclass correlation coefficients ranged from .872 for the FIM total to .830 for the cognitive subscales. Values for kappa ranged from -.007 (FIM motor subscore) to .123 (FIM cognitive subscore). Values for weighted kappa ranged from .465 (FIM cognitive subscore) to .521 (FIM total). CONCLUSIONS: There was no systematic scoring bias evident. Intraclass correlation coefficients were high, but tests of agreement demonstrated poor agreement. These findings have implications for the use of the FIM and any patient classification or funding system based on the FIM, especially if poor levels of agreement were found in the presence of all staff being FIM credentialed and standardization of methods of assessment. This study indicates that further investigation of agreement of both FIM totals and FIM item scores in the clinical setting is warranted.