Rehabilitation medicine in palliative care of chronic neurological conditions.

BACKGROUND: People living with long-term neurological conditions (LTNC) often require palliative care. Rehabilitation medicine specialists often coordinate the long-term care of these patients. OBJECTIVE: The aim of the present review was to undertake systematic literature searches to identify the evidence on palliative care for people with LTNC to guide rehabilitation medicine specialists caring for these patients in the UK. METHODS: We searched for evidence for (1) discussion of end of life, (2) planning for end-of-life care, (3) brief specialist palliative care interventions, (4) support for family and carers, (5) training of rehabilitation medicine specialists in palliative care, and (6) commissioning of services. The databases searched were MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database and Health Technology Assessment Database. Evidence was assimilated using a simplified version of the Grading of Recommendations Assessment, Development and Evaluation method. RESULTS: We identified 2961 records through database searching for neurological conditions and 1261 additional records through database searches for specific symptoms. We removed duplicate records and conference presentations. We screened 3234 titles and identified 330 potentially relevant abstracts. After reading the abstracts we selected 34 studies for inclusion in the evidence synthesis. CONCLUSIONS: From the evidence reviewed we would like to recommend that we move forward by establishing a closer working relationship with specialists in palliative care and rehabilitation medicine and explore the implications for cross-specialty training.

Clinicians' perspectives on decision making in lower limb amputee rehabilitation.

OBJECTIVE: Decision making within amputee rehabilitation includes the assessment of whether a patient is suitable for a prosthesis and if so, what components to provide. This study seeks to increase understanding about clinicians' perspectives on what factors influence these decisions. METHOD: One-to-one semi-structured interviews were completed with 23 experienced clinicians at their place of work at 4 UK amputee rehabilitation centres. Thematic analysis using a theoretical, semantic approach was used to identify key themes from the data. RESULTS: Four key themes were identified: estimating outcome; difficulties predicting outcome; patient choice and barriers to prescribing. There was variation in the importance placed on each theme between individual clinicians and services, with factors such as budget and risk aversion acting as barriers to prescribing. Only one of the 4 centres used formal prescribing guidelines. CONCLUSION: The results highlight the difficulties clinicians experience in estimating outcome and suggest inequity of prosthetic provision in the UK, with variation in the provision of high cost items. The development of national prescription guidelines is suggested to improve equality of prosthetic provision.

Can simple clinical tests predict walking ability after prosthetic rehabilitation?

OBJECTIVE: To investigate whether simple clinical measures can predict walking ability after lower limb prosthetic rehabilitation. DESIGN: Prospective observational study. SUBJECTS: Ninety five adults who were assessed as suitable for lower limb prosthetic rehabilitation by the multidisciplinary team. METHODS: Information regarding baseline clinical factors (amputation details, comorbidities, physical ability, mood and cognitive ability) was collected prior to provision of the prosthesis. Backward step linear regression was used to identify factors predictive of performance on the Timed Up and Go test following rehabilitation. RESULTS: Seventy one participants were able to complete this walking test and were included in the final analysis. The backward step regression model had an adjusted R2 of 0.588 and comprised 6 factors: age (p = 0.002), gender (p = 0.027), level of amputation (p = 0.000), presence of contracture (p = 0.088), ability to stand on one leg (p = 0.062) and Trail Making Tests A + B (p = 0.047), a test of cognitive flexibility. Cause of amputation (dysvascular or non-dysvascular) was not an independent predictor of walking outcome. CONCLUSION: These results indicate that simple clinical assessments completed prior to prosthetic provision can be used to predict mobility outcome. These findings need to be validated in a larger population across other amputee rehabilitation services and if confirmed could easily be incorporated into routine clinical practice.

Predicting walking ability following lower limb amputation: a systematic review of the literature.

OBJECTIVE: To investigate factors that predict walking with a prosthesis after lower limb amputation. DESIGN: Systematic literature review. METHODS: A computer-aided literature search of MEDLINE, EMBASE, CINAHL and the Cochrane Library was performed to identify studies published up to August 2007 that investigated factors that predicted walking ability after lower limb amputation. RESULTS: A total of 57 studies were selected. Predictors of good walking ability following lower limb amputation include cognition, fitness, ability to stand on one leg, independence in activities of daily living and pre-operative mobility. Longer time from surgery to rehabilitation and stump problems are predictors of poor outcome. The impact of the cause of amputation on walking varies between studies. In general, unilateral and distal amputation levels, and younger age were predictive of better walking ability. Sex probably does not have a significant influence on walking ability. CONCLUSION: The heterogeneity of methods and outcome measures used in the identified studies make comparison difficult and, in part, explains conflicting conclusions in relation to predictive factors. Further investigation of predictive factors is needed to estimate walking potential more accurately and guide targeting of modifiable factors to optimize outcome after lower limb amputation.