Goal-setting and attainment in prolonged disorders of consciousness - development of a structured approach.

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.

Multidisciplinary care for Guillain-Barré syndrome.

BACKGROUND: Guillain-Barré syndrome (GBS) can be a significant cause of new long-term disability, which is thought to be amenable to multidisciplinary care. However, the evidence base of its effectiveness is unclear. AIM: The aim of this systematic review is to assess the effectiveness of multidisciplinary care in adults with GBS, the types of approaches that are effective (setting, type, intensity) and the outcomes that are affected. METHODS: The search strategy comprised: The Cochrane Neuromuscular Disease Group Specialized Register and the Cochrane Central Register of Controlled Trials; MEDLINE, EMBASE, AMED, PEDro, LILACS and CINAHL (up to May 2010). Selected studies included randomized and controlled clinical trials that compared multidisciplinary care in GBS with a control (routine local service, lower level of intervention); or studies that compared multidisciplinary care in different settings or at different levels of intensity of therapy. Best evidence synthesis was based on methodological quality. Three observational studies were also reported but they make limited contribution to evidence base synthesis. RESULTS: No randomized or controlled clinical trials were identified. Evidence from three low-quality observational studies provide some support for improved disability in the short term (6 months) with high intensity rehabilitation; and for improved participation and quality of life. CONCLUSION: The gaps in existing research should not be interpreted as ineffectiveness of multidisciplinary care in GBS. Appropriate and methodologically robust study designs, responsive outcome measures; and more research in the setting, type and intensity of rehabilitation are needed.

Botulinum toxin assessment, intervention and after-care for upper limb hypertonicity in adults: international consensus statement.

Upper limb spasticity affecting elbow, wrist, and finger flexors can be safely and effectively reduced with injections of botulinum toxin type-A (BoNT-A). It has been best studied in adults in the context of post-stroke spasticity. The clinical benefits include reduction in pain and deformity, improvement in washing and dressing the upper limb, and a reduction in caregiver burden (Class I evidence, recommendation level A). Some patients show improvement in function performed by active movement of the affected upper limb (Class III evidence, recommendation C), but predicting and measuring this is difficult, and further research is needed. An individually based approach to treatment and outcome measurement is preferred (Class IV, recommendation U). More research is needed to resolve many unknown issues of assessment and treatment, using research methods appropriate to the question.

Multiple sclerosis rehabilitation outcomes: analysis of a national casemix data set from Australia.

OBJECTIVE: To examine the outcomes of inpatient rehabilitation for persons with multiple sclerosis (pwMS), using the Australian Rehabilitation Outcomes Centre (AROC) database. METHOD: Deidentified data from the AROC database were analyzed for all rehabilitation admissions during 2003-2007, using four classes for functional level. The outcomes included Functional Independence Measure (FIM) scores and efficiency, hospital length of stay (LOS), and discharge destination. RESULTS: Of 1010 case episodes, 70% were women, admitted from home (n = 851) and discharged into the community (n = 890), and 97% (n = 986) were in the higher three classes for functional level (classes 216, 217, and 218). Majority of the more disabled pwMS were treated in the public hospital system, with a longer LOS compared with private facilities (P < 0.001). The FIM for classes 216-218 showed significant functional improvement during the admission (P < 0.001), and those in higher classes showed less change (likely due to higher FIM admission scores). FIM efficiency was significantly higher in class 217 than other classes (P < 0.001). The year-on-year trend was toward reducing hospital LOS and FIM efficiency, but these did not reach significance (P = 0.107, P = 0.634). CONCLUSION: The AROC data set is useful for describing rehabilitation outcomes for pwMS. However, additional information needs to be collected to evaluate nature of services provided and service implications.

Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy.

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 STRATEGY: 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.

Rehabilitation interventions for foot drop in neuromuscular disease.

BACKGROUND: "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. OBJECTIVES: To conduct a systematic review of randomised trials of treatment for footdrop resulting from neuromuscular disease. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group Trials Register (July 2005), MEDLINE (January 1966 to July 2005), EMBASE (January 1980 to July 2005), AMED (January 1985 to July 2005) and CINAHL databases (January 1982 to July 2005). SELECTION CRITERIA: Randomised and quasi-randomised trials of physical, orthotic and surgical treatments for footdrop 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, orthotics, surgery and pharmacological therapy. The primary outcome measure was ability to walk whilst secondary outcome measures included dorsiflexor torque and strength, measures of 'activity' and 'participation' and adverse effects. DATA COLLECTION AND ANALYSIS: Methodological quality was evaluated by two authors using the van Tulder criteria. Three studies with altogether 139 participants were included in the review. Heterogeneity of the studies precluded pooling the data. MAIN RESULTS: Early surgery did not significantly affect walking speed in a trial including 20 children with Duchenne muscular dystrophy. 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, (95% CI -8.18 to 2.42). In a trial with altogether 26 participants with Charcot-Marie-Tooth disease (hereditary motor and sensory neuropathy), long-term strength training significantly increased walking speed on a 6 metre timed walk (MD -0.70 seconds, 95% CI -1.17 to -0.23) but not on a 50 metre timed walk (MD -1.9 seconds, 95% CI -4.09 to 0.29). In a trial of a 24-week strength training programme in 28 participants with myotonic dystrophy, there was no significant change in walking speed on either a 6 or 50 metre walk. AUTHORS' CONCLUSIONS: Using the primary outcome of ability to walk, only one study demonstrated a positive effect and that was an exercise programme for people with Charcot-Marie-Tooth disease. Surgery was not significantly effective in children with Duchenne Muscular Dystrophy. More evidence generated by methodologically sound trials is required.

Multidisciplinary rehabilitation for adults with multiple sclerosis.

BACKGROUND: Multidisciplinary rehabilitation (MD) is an important component of symptomatic and supportive treatment for Multiple sclerosis (MS), but evidence base for its effectiveness is yet to be established. OBJECTIVES: To assess the effectiveness of organized MD rehabilitation in adults with MS. To explore rehabilitation approaches that are effective in different settings and the outcomes that are affected. SEARCH STRATEGY: The sources used included: Cochrane Central Register of Controlled Trials "CENTRAL", MEDLINE (1966- 2005), CINAHL (1982- 2005), PEDro (1990- 2005), EMBASE (1988- 2005), the Cochrane Rehabilitation and Related Therapies Field trials Register and the National Health Service National Research Register (NRR). SELECTION CRITERIA: Randomized and controlled clinical trials that compared MD rehabilitation with routinely available local services or lower levels of intervention; or trials comparing interventions in different settings or at different levels of intensity. DATA COLLECTION AND ANALYSIS: Three reviewers selected trials and rated their methodological quality independently. A 'best evidence' synthesis based on methodological quality was performed. Trials were grouped in terms of setting and type of rehabilitation and duration of patient follow up. MAIN RESULTS: Eight trials (7 RCTs; 1 CCT) (747 participants and 73 caregivers) were identified. Seven RCTs scored well and one CCT scored poorly on the methodological quality assessment. There was 'strong evidence' that despite no change in the level of impairment, inpatient MD rehabilitation can produce short-term gains at the levels of activity (disability) and participation for patients with MS. For outpatient and home-based rehabilitation programmes there was 'limited evidence' for short-term improvements in symptoms and disability with high intensity programmes, which translated into improvement in participation and quality of life. For low intensity programmes conducted over a longer period there was strong evidence for longer-term gains in quality of life; and also limited evidence for benefits to carers. Although some studies reported potential for cost-savings, there is no convincing evidence regarding the long-term cost-effectiveness of these programmes. It was not possible to suggest best 'dose' of therapy or supremacy of one therapy over another. This review highlights the limitations of RCTs in rehabilitation settings and need for better designed randomized and multiple centre trials. AUTHORS' CONCLUSIONS: MD rehabilitation programmes do not change the level of impairment, but can improve the experience of people with MS in terms of activity and participation. Regular evaluation and assessment of these persons for rehabilitation is recommended. Further research into appropriate outcome measures, optimal intensity, frequency, cost and effectiveness of rehabilitation therapy over a longer time period is needed. Future research in rehabilitation should focus on improving methodological and scientific rigour of clinical trials.

Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries.

OBJECTIVES: To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability. SUBJECTS AND SETTING: Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury. METHODS: Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: "low" (NPDS<10 (n=83)); "medium" (NPDS10-24 (n=112)); "high" (NPDS>24 (n=102)). RESULTS: Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in "weekly cost of care" was greatest in the high dependency group at pound639 per week (95% CI 488 to 789)), as compared with the medium (pound323/week (95% CI 217 to 428)), and low (pound111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups. CONCLUSIONS: The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients.

The Depression Intensity Scale Circles (DISCs): a first evaluation of a simple assessment tool for depression in the context of brain injury.

OBJECTIVE: To assess the validity, responsiveness, and test-retest reliability of DISCs (Depression Intensity Scale Circles) as a simple screening tool for depression in patients with cognitive or communicative deficits following acquired brain injury. DESIGN: Cohort analysis of consecutive patients entered into an integrated care pathway for screening and management of depression in the context of rehabilitation. SETTING: Regional neurological rehabilitation service in the UK. PARTICIPANTS: 114 patients with complex disabilities caused by acquired brain injury (mean (SD) age, 42.8 (14.5) years). MAIN OUTCOME MEASURES: DISCs (a graphic rating scale depicting six circles with increasing proportion of dark shading), Numbered Graphic Rating Scale (NGRS), Yale single question ("Do you often feel sad or depressed"), Beck Depression Inventory-II (BDI-II), DSM-IV criteria for depression. RESULTS: At initial assessment the DISCs correlated with total BDI-II scores (Spearman rho = 0.66, p < 0.001), NGRS (rho = 0.87, p<0.001), and DSM-IV (rho = 0.59, p<0.001). A DISCs score > or =2 identified depression (major or minor) according to DSM-IV criteria with 60% sensitivity, 87% specificity, 75% positive predictive value, and 77% negative predictive value. Test-retest reliability after 24 hours (n = 66) showed "excellent" level of agreement (weighted kappa = 0.84). In 45 patients who received intervention for depression, the DISCs showed a significant change in response to treatment (Wilcoxon; p<0.001). CONCLUSIONS: DISCs had acceptable convergent validity, reliability, and responsiveness as a simple graded tool for screening and assessment of depression in patients with complex disabilities following acquired brain injury. It warrants further investigation in patients with more profound language and cognitive deficits for which it is primarily intended.

Multi-disciplinary rehabilitation for acquired brain injury in adults of working age.

BACKGROUND: Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, where older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults is not yet established, perhaps because there are different methodological challenges. OBJECTIVES: To assess the effects of multi-disciplinary rehabilitation following ABI in adults, 16 to 65 years. To explore approaches that are effective in different settings and the outcomes that are affected. SEARCH STRATEGY: We used a wide range of sources including: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1983-2004), PsycLIT (1967-2004), AMED, the National Research Register 2004 and ISI Science Citation Index (1981-2004). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation with either routinely available local services or lower levels of intervention; or trials comparing intervention in different settings or at different levels of intensity. Quasi-randomised and quasi-experimental designs were also included, providing they met pre-defined methodological criteria. DATA COLLECTION AND ANALYSIS: Trials were selected by two authors independently, and their methodological quality rated, again by two independent authors. A third reviewer arbitrated when disagreements could not be resolved by discussion. A 'best evidence' synthesis was performed by attributing levels of evidence, based on methodological quality. Trials were sub-divided in terms of severity of ABI and the setting and type of rehabilitation offered. MAIN RESULTS: Ten trials were identified of good methodological quality and four of lower quality. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most patients make a good recovery with provision of appropriate information, without additional specific intervention. For moderate to severe injury, there is 'strong evidence' of benefit from formal intervention. For patients with moderate to severe ABI already in rehabilitation, there is strong evidence that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' that continued outpatient therapy can help to sustain gains made in early post-acute rehabilitation. There is 'limited evidence' that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but the studies serve to highlight the particular practical and ethical restraints on randomisation of severely affected individuals for whom there are no realistic alternatives to specialist intervention. AUTHORS' CONCLUSIONS: Problems following ABI vary; different services are required to suit the needs of patients with different problems. Patients presenting acutely to hospital with moderate to severe brain injury should be routinely followed up to assess their need for rehabilitation. Intensive intervention appears to lead to earlier gains. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation should have access to out-patient or community-based services appropriate to their needs. Those with milder brain injury benefit from follow-up, and appropriate information and advice. Not all questions in rehabilitation can be addressed by traditional research methodologies. There are important questions still to be answered and future research should employ the most appropriate methodology.

Exercise for people with peripheral neuropathy.

BACKGROUND: Peripheral neuropathies are a wide range of diseases affecting the peripheral nerves. Demyelination or axonal degeneration gives rise to a variety of symptoms including reduced or altered sensation, pain, muscle weakness and fatigue. Secondary disability arises and this may result in adjustments to psychological and social function. Exercise therapy, with a view to developing strength and stamina, forms part of the treatment for people with peripheral neuropathy, particularly in the later stages of recovery from acute neuropathy and in chronic neuropathies. OBJECTIVES: The primary objective was to examine the effect of exercise therapy on functional ability in the treatment of people with peripheral neuropathy. In addition, secondary outcomes of muscle strength, endurance, broader measures of health and well being, as well as unfavourable outcomes were examined. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register (July 2002 and updated February 2004) and MEDLINE (from January 1966 to June 2004), EMBASE (from January 1980 to June 2004), CINAHL (from January 1982 to July 2002) and LILACS (from January 1982 to July 2002) electronic databases. Bibliographies of all selected randomised controlled trials were checked and authors contacted to identify additional published or unpublished data. SELECTION CRITERIA: Any randomised or quasi-randomised controlled trial comparing the effect of exercise therapy with no exercise therapy or drugs or an alternative non-drug treatment on functional ability (or disability) in people with peripheral neuropathy at least eight weeks after randomisation was included. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected eligible studies, rated the methodological quality and extracted data. MAIN RESULTS: Only one trial fully met the inclusion criteria. An additional two trials assessed outcomes less than eight weeks after randomisation and were also included. Methodological quality was poor for several criteria in each study. Data used in the three studies could not be pooled due to heterogeneity of diagnostic groups and outcome measures. The results of the included trials failed to show any effect of strengthening and endurance exercise programmes on functional ability in people with peripheral neuropathy. However, there is some evidence that strengthening exercise programmes were moderately effective in increasing the strength of tested muscles. REVIEWERS' CONCLUSIONS: There is inadequate evidence to evaluate the effect of exercise on functional ability in people with peripheral neuropathy. The results suggest that progressive resisted exercise may improve muscle strength in affected muscles.

Does reducing spasticity translate into functional benefit? An exploratory meta-analysis.

BACKGROUND: Spasticity and loss of function in an affected arm are common after stroke. Although botulinum toxin is used to reduce spasticity, its functional benefits are less easily demonstrated. This paper reports an exploratory meta-analysis to investigate the relationship between reduced arm spasticity and improved arm function. METHOD: Individual data from stroke patients in two randomised controlled trials of intra-muscular botulinum toxin were pooled. The Modified Ashworth Scale (elbow, wrist, fingers) was used to calculate a "Composite Spasticity Index". Data from the arm section of the Barthel Activities of Daily Living Index (dressing, grooming, and feeding) and three subjective measures (putting arm through sleeve, cleaning palm, cutting fingernails) were summed to give a "Composite Functional Index". Change scores and the time of maximum change were also calculated. RESULTS: Maximum changes in both composite measures occurred concurrently in 47 patients. In 26 patients the improvement in spasticity preceded the improvement in function with 18 showing the reverse. There was a definite relationship between the maximum change in spasticity and the maximum change in arm function, independent of treatment (rho = -0.2822, p = 0.0008, n = 137). There was a clear relationship between the changes in spasticity and in arm function in patients treated with botulinum toxin (Dysport) at 500 or 1000 units (rho = -0.5679, p = 0.0090, n = 22; rho = -0.4430, p = 0.0018, n = 47), but not in those treated with placebo or 1500 units. CONCLUSIONS: Using a targeted meta-analytic approach, it is possible to demonstrate that reducing spasticity in the arm is associated with a significant improvement in arm function.

Traumatic brain injury.

PURPOSE: Traumatic brain injury (TBI) leading to severe disability is fortunately rare, but when it occurs, the effect on patients and their families can be devastating. ISSUE: In the UK at the current time, there are insufficient specialist rehabilitation services to cater for the case-load and many patients receive their care in general wards. CONCLUSION: This educational article outlines the principles of management of severe TBI from a practical clinical viewpoint, reviews briefly the evidence for effectiveness of rehabilitation and offers an approach to consistent outcome measurement.

Standardized outcome assessment in brain injury rehabilitation for younger adults.

PURPOSE: To explore possible candidates for a common outcome measure for brain injury rehabilitation in younger adults. METHOD: Patients recovering from brain injury pass through several different stages of rehabilitation, illustrated by the 'Slinky model'. Outcome measures used to assess progress must not only meet scientific criteria for validity and reliability--they must be practical to use in a clinical setting and relevant to the rehabilitation goals at each stage. Within most major rehabilitation settings, the commonest goals focus on reducing disability or dependency. Among the most widely used measures in the UK are the Barthel Index, the Functional Independence Measure (FIM) and the extended Functional Assessment Measure (FIM + FAM). The relationship between these instruments is discussed. CONCLUSION: No single outcome measure is suitable for all brain injury rehabilitation, but by taking these most widely used measures and understanding the relationship between them, we already have a potential common language in disability measurement between the majority of rehabilitation centres in the UK and beyond. These instruments, however, have clear floor and ceiling effects and further work is needed to agree common measures for rehabilitation intervention that falls outside the sensitivity range of these three scales.

Development of an integrated care pathway for the management of hemiplegic shoulder pain.

PURPOSE: To improve clinical management of patients with hemiplegic shoulder pain through development of an evidence-based multidisciplinary integrated care pathway (ICP), and to use this to audit quality of care against predefined standards. METHODS: The ICP was developed by a team of medical, paramedical and nursing staff. The evidence base was established through a systematic literature review supplemented by clinical consensus to ensure best practice where scientific evidence was lacking. Following development, performance was assessed against standards in a cohort of stroke patients with hemiplegia (n = 32) consecutively admitted to a regional unit providing in-patient rehabilitation for young patients with complex disabilities. RESULTS: Performance showed improvements in assessment and documentation of pain and in initial care, including analgesia and application of positioning/handling protocols. However, review and response to continuing or changing symptoms were poorly documented. Changes to the ICP were introduced to improve this. CONCLUSIONS: Principal benefits have been to raise awareness of shoulder pain, to educate staff and prompt management in line with recommended best practice, but strong leadership is essential to ensure continuity in clinical practice. Future research is needed to establish whether improved quality of care offsets the substantial investment of staff time in ICP development.

Reflex sympathetic dystrophy--a complex regional pain syndrome.

Reflex sympathetic dystrophy (RSD) is a complex and poorly-understood condition characterized by: (a) pain and altered sensation; (b) motor disturbance and soft tissue change; (c) vasomotor and autonomic changes; and (d) psychosocial disturbance. Neurological symptoms typically do not conform to any particular pattern of nerve damage. Many different names have been ascribed to this condition and most recently the term 'complex regional pain syndrome' has been coined to emphasize the complex interaction of somatic, psychological and behavioural factors. Diagnostic criteria have been proposed by the International Association for the Study of Pain, but are still subject to debate. This review article describes the clinical features which may present as part of the condition, and the patho-physiology and pre-disposing factors so far identified. The evidence for effectiveness of different interventions is presented and a treatment approach outlined for inter-disciplinary management. While RSD is traditionally associated with pain in the extremities, the possibility is raised that the same process may underlie chronic pain syndromes affecting more central structures, such as testicular or pelvic pain.

Can brain-injured patients participate in an aerobic exercise programme during early inpatient rehabilitation?

OBJECTIVE: We investigated the capacity of brain-injured patients to participate in an aerobic exercise programme early after injury. DESIGN: Retrospective analysis of exercise achievements in patients participating in a randomized controlled trial. SETTING AND SUBJECTS: Ninety patients participated in an exercise training programme on a cycle ergometer at four inpatient neurological rehabilitation units for younger patients. At intake, impairments and function were rated on: Motricity Index, Ashworth Scale, Berg Balance Scale, Barthel Index and Functional Independence Measure. INTERVENTIONS: Patients cycled for up to 30 minutes three times weekly for 24-36 sessions over 12 weeks. MAIN OUTCOME MEASURES: Exercise performance was measured by: (a) number of sessions to achieve a cycling time of 30 minutes, (b) overall mean cycling time per session over 24 sessions and (c) mean time per session cycling at >60% of age predicted maximum heart rate (HR max) over 24 sessions. RESULTS: Fifty-five patients completed 24 sessions. Thirty-five withdrew, largely for logistic reasons, before completing training; they were significantly less disabled than the 55 who remained. Forty-four of the 55 patients trained for an average of at least 20 minutes per session, 18 training at >60% HR max for this time. There were no differences in performance on the three exercise parameters between two groups of patients with baseline Barthel scores of < or = 12 and > or = 13. CONCLUSIONS: Brain-injured patients with a range of disabilities have the capacity to participate in an exercise programme during early inpatient rehabilitation, though some may take longer to achieve adequate intensity of aerobic exercise.