Telerehabilitation for physical disabilities and movement impairment: A service evaluation in South West England.

RATIONALE, AIMS AND OBJECTIVES: Telerehabilitation was used to ensure continued provision of care during the COVID-19 pandemic, but there was a lack of guidance on how to use it safely and effectively for people with physical disabilities and movement impairment. In this service evaluation, we aimed to collate information on practitioner and patient experiences, challenges and facilitators, and examples of best practice to inform the development of an online toolkit and training package. METHODS: Guided discussions were carried out with 44 practitioners, 7 patients and 2 carers from five health and social care organisations in South West England, and analysed thematically. RESULTS: Practitioners and patients had positive experiences of telerehabilitation and were optimistic about its future use. Recognized benefits for people with physical disabilities included greater flexibility, reduced travel and fatigue, having appointments in a familiar environment and ease of involving family members. Challenges encountered were: technological (usability issues, access to technology and digital skills); difficulties seeing or hearing patients; the lack of 'hands-on' care; and safety concerns. Facilitators were supported by colleagues or digital champions, and family members or carers who could assist patients during their appointments. Key themes in best practice were: person-centred and tailored care; clear and open communication and observation and preparation and planning. Practitioners shared tips for remote physical assessments; for example, making use of patient-reported outcomes, and asking patients to wear bright and contrasting coloured clothing to make it easier to see movement. CONCLUSION: Telerehabilitation holds promise in health and social care, but it is necessary to share good practice to ensure it is safe, effective and accessible. We collated information and recommendations that informed the content of the Telerehab Toolkit (https://www.plymouth.ac.uk/research/telerehab), a practical resource for practitioners, patients and carers, with a focus on remote assessment and management of physical disabilities and movement impairment.

The Role of Cognitive Factors in Predicting Balance and Fall Risk in a Neuro-Rehabilitation Setting.

INTRODUCTION: There is a consistent body of evidence supporting the role of cognitive functions, particularly executive function, in the elderly and in neurological conditions which become more frequent with ageing. The aim of our study was to assess the role of different domains of cognitive functions to predict balance and fall risk in a sample of adults with various neurological conditions in a rehabilitation setting. METHODS: This was a prospective, cohort study conducted in a single centre in the UK. 114 participants consecutively admitted to a Neuro-Rehabilitation Unit were prospectively assessed for fall accidents. Baseline assessment included a measure of balance (Berg Balance Scale) and a battery of standard cognitive tests measuring executive function, speed of information processing, verbal and visual memory, visual perception and intellectual function. The outcomes of interest were the risk of becoming a faller, balance and fall rate. RESULTS: Two tests of executive function were significantly associated with fall risk, the Stroop Colour Word Test (IRR 1.01, 95% CI 1.00-1.03) and the number of errors on part B of the Trail Making Test (IRR 1.23, 95% CI 1.03-1.49). Composite scores of executive function, speed of information processing and visual memory domains resulted in 2 to 3 times increased likelihood of having better balance (OR 2.74 95% CI 1.08 to 6.94, OR 2.72 95% CI 1.16 to 6.36 and OR 2.44 95% CI 1.11 to 5.35 respectively). CONCLUSIONS: Our results show that specific subcomponents of executive functions are able to predict fall risk, while a more global cognitive dysfunction is associated with poorer balance.

Rehabilitation goals of people with spinal cord injuries can be classified against the International Classification of Functioning, Disability and Health Core Set for spinal cord injuries.

STUDY DESIGN: Cross-sectional study. OBJECTIVES: To establish whether inter-professional rehabilitation goals from people with non-traumatic spinal cord injury (SCI) can be classified against the International Classification of Functioning, Disability and Health (ICF) SCI Comprehensive and Brief Core Sets early postacute situation. SETTING: Neurological rehabilitation unit. METHODS: Rehabilitation goals of 119 patients with mainly incomplete and non-traumatic SCIs were classified against the ICF SCI Core Sets following established linking rules. RESULTS: A total of 119 patients generated 1509 goals with a mean (and s.d.) of 10.5 (9.1) goals per patient during the course of their inpatient rehabilitation stay. Classifying the 1509 rehabilitation goals against the Comprehensive ICF Core Set generated 2909 ICF codes. Only 69 goals (4.6%) were classified as 'not definable (ND)'. Classifying the 1509 goals against the Brief ICF Core Set generated 2076 ICF codes. However, 751(49.8%) of these goals were classified as 'ND'. In the majority of goals (95.7%), the ICF code description was not comprehensive enough to fully express the goals set in rehabilitation. In particular, the notion of quality of movement or specificity and measurability aspects of a goal (usually described with the criteria and acronyms SMART) could not be expressed through the ICF codes. CONCLUSION: Inter-professional rehabilitation goals can be broadly described by the ICF Comprehensive Core Set for SCI but not the Brief Core Set.

Goal setting in neurological rehabilitation: staff perspectives.

PURPOSE: The purpose of this study was to explore rehabilitation professionals' perspectives about goal setting, and more particularly, the use of two specific forms of goal setting used within the same setting; 'usual participation' and 'increased participation'. METHODS: A qualitative research approach was identified as being particularly pertinent for the aims of this study. Fifteen rehabilitation professionals representing five different professions and having experience of usual and increased participation goal setting approaches used in one Neurological Rehabilitation Unit participated in two focus groups. The focus group questions were designed to elicit staff views about goal setting generally, and to invite comparison regarding their experiences of using two goal setting approaches. The focus group transcripts were analysed according to thematic analysis principles. FINDINGS: Five themes were identified: the goal setting tools (including views about the folder developed for one form of goal setting); barriers to goal setting (including lack of time, professional group work patterns and lack of experience), the keyworker role (including prerequisites for effective keyworking); patient characteristics (disease, personality and expectations); and the nature of goals. CONCLUSIONS: Whilst the 'increased participation' mode of goal setting was seen as having the potential to allow patients a stronger voice within the goal setting process, both time and resources are required to ensure that this potential is fully realised.

Rehabilitation and MS.

Unfortunately, most people with MS will develop disability, which may or may not be permanent, at some point in their lives. Effective management of this is dependent on co-ordinated services that can be accessed by the person with MS in a timely and effective fashion. Neurological rehabilitation is a process of active change by which the person with MS acquires the knowledge and skills necessary for optimum physical, psychological and social function. It requires a dedicated multidisciplinary team with a clear understanding of the MS disease process, the mechanisms of disablement, and the skills to educate and treat people with disability so that they may participate fully in their chosen roles. This review considers the necessary components to the rehabilitation process and when such input may be most appropriate.

Vocational rehabilitation services for people with multiple sclerosis: what patients want from clinicians and employers.

BACKGROUND: The NSF for Long-term Neurological Conditions highlights the need for vocational rehabilitation services. Although the barriers to work for people with MS (pwMS) have been clearly identified, there has been little research that identifies the type of support required. OBJECTIVE: To identify what pwMS require from a vocational rehabilitation service in terms of content and service delivery. DESIGN OF STUDY: Four focus groups of pwMS, currently in employment, were convened. These were audio-taped and content analysed using a constant comparison method. RESULTS: People with MS identified two key needs; managing performance and managing expectations. Performance difficulties could be managed either by treating symptoms, by changing the environment, or by altering the demands of the job. PwMS highlighted the need for counselling to help them, and advocacy to help their employers have appropriate expectations. CONCLUSION: PwMS need support in the workplace in two distinct ways. First, by managing the interaction between the impairments caused by MS, the physical environment, and the demands imposed by the work. Second, by providing expert knowledge about the employment environment and the needs of employers, an awareness of the relevant legislation and counselling in supporting people to adapt, adjust and resolve complex issues.

Goal setting in neurological rehabilitation: patients' perspectives.

PURPOSE: Goal setting has been described as the core skill of rehabilitation professionals, but there is little information about patients understanding of goal setting. This study explored how in-patients with neurological impairments experienced two different types of goal setting and identified the issues that underpin individuals' experience of goal setting. METHOD: The study took place in a neurological rehabilitation unit in which two approaches to goal setting were being used that differed in the amount of patient involvement. A qualitative research design was adopted. Six focus groups were convened, three for participants experiencing usual participation and three for those with increased involvement in goal setting. A total of 28 participants (12 women, mean age 49 years) with a variety of deficits were recruited to the study over nine months. Thematic analysis was used to analyse the focus group transcripts. FINDINGS: Four themes were identified which impact on the ways in which in-patients make sense of goal setting: The rehabilitation process; personal response to goal setting; previous experience and disease limitations. CONCLUSIONS: Healthcare professionals working in rehabilitation need to explore patients' understandings of their disease and their experiences and expectations of goal setting to ensure goal setting is a meaningful activity.

Talking the talk on walking the walk: a 12-item generic walking scale suitable for neurological conditions?

BACKGROUND: The Multiple Sclerosis Walking Scale (MSWS-12) was developed to measure the impact of multiple sclerosis on walking. Many other disabling neurological conditions affect patients' ability to walk, and a generic measure of walking could provide valuable insights into patients' perceptions in clinical trials and epidemiological studies as well as routine clinical practice. OBJECTIVE: To evaluate the clinical usefulness and psychometric properties of the Walking Impact Scale (Walk-12), a modified version of the MSWS-12, in patients with neurological conditions. DESIGN: A prospective, observational study of 120 consecutive patients admitted for rehabilitation. The Walk-12 was used to measure the impact of neurological disability on walking. Traditional psychometric methods (data quality, scaling assumptions, targeting, reliability, validity and responsiveness) were used to assess the Walk-12. Transition questions were used on discharge to measure perception of change. Outcome was also measured using the timed walk test (TWT), Barthel Index (BI) and Functional Independence Measure (FIM). RESULTS: For the total group, missing data were few, scaling assumptions were satisfied, and internal consistency was 0.94. Correlations between the Walk-12 and TWT, BI and FIM motor score were moderate (r=-0.58, -0.26, -0.31). Responsiveness of the Walk-12 was high (effect size=1.12). Relationships between effect size and patients' and physiotherapists' opinion of change in walking demonstrated good concordance. Preliminary subgroup analyses indicate satisfactory psychometric properties across different neurological conditions; however, sample numbers in these analyses are small. CONCLUSIONS: In this sample of neurologically disabled patients the Walk-12 was clinically useful and satisfied standard psychometric criteria. This provides preliminary evidence that it may be suitable as a generic measure of walking ability.

Evaluating neurorehabilitation: lessons from routine data collection.

BACKGROUND: Clinical databases are being used increasingly to assess outcomes in healthcare services to provide evidence of clinical effectiveness in routine clinical practice. OBJECTIVES: To explore the benefits of a database for routine collection of clinical outcomes within an inpatient neurorehabilitation setting; determine the effectiveness of inpatient neurorehabilitation in a range of neurological conditions; and determine variables influencing change in functional outcome. METHODS: Over a nine year period, demographic and diagnostic characteristics were collected for the 1458 patients admitted consecutively to a neurorehabilitation unit. The level of function was measured on admission and discharge using the Barthel Index (BI) and Functional Independence Measure (FIM). Patient perception of rehabilitation benefit was evaluated using visual analogue scales (VAS). RESULTS: Of the 1413 patients (mean (SD) age 48 (14.8), range 16 to 87) whose length of stay was more than 10 days (mean 34 (24) range 10 to 184), 282 had stroke, 614 multiple sclerosis, 248 spinal cord injuries, 93 a neuromuscular condition, and 176 other brain pathology. Patients improved in functional ability as measured by both BI and the FIM motor subscale (effect sizes 0.93 to 1.44 and 1.01 to 1.48, respectively). VAS ratings demonstrated high levels of patient perceived benefit. Diagnosis, functional activity score on admission, and length of stay were significant predictors of functional gain, explaining 44% of the variability in the change scores. CONCLUSIONS: Systematic collection, analysis, and interpretation of standardised clinical outcomes data are feasible within routine clinical practice, and provide evidence that inpatient rehabilitation is effective in improving functional level in neurologically impaired patients. These data complement those of clinical trials and are useful in informing and developing clinical and research practice.

The reliability and validity of the Nottingham Extended Activities of Daily Living Scale in patients with multiple sclerosis.

OBJECTIVE: To investigate whether the Nottingham Extended Activities of Daily Living Scale (EADL) is reliable and valid for the assessment of disability in patients with multiple sclerosis (MS). DESIGN: Questionnaire measures were administered on two occasions four months apart. SUBJECTS: A total of 240 patients recruited through a randomized controlled trial of cognitive assessment and treatment in MS. MEASURES: The Nottingham EADL, Guys Neurological Disability Scale (GNDS) and SF-36 quality of life scale. RESULTS: The EADL items did not form a Guttman Scale (CR 0.8, CS 0.3). The EADL and its four subscales all had high internal consistency (alpha 0.72-0.94). Test-retest reliability was satisfactory (r(s) 0.81-0.90) with a mean difference in scores on the two occasions of 0.29. Factor analysis generally supported the subscale structure. There were significant but weak correlations with quality of life measures. CONCLUSIONS: The EADL shows promise for the assessment of disability in MS, but the range of items needs to be extended. Further evaluation of the scale seems warranted.

Integrated care pathways: outcome from inpatient rehabilitation following nontraumatic spinal cord lesion.

BACKGROUND: Integrated care pathways (ICPs) map the predicted course of an episode of patient care. They detail the expected interventions during the episode and document departures from the expected pathway (variance). This study describes the use of an ICP to audit the rehabilitation of patients with nontraumatic spinal cord injury admitted between 1997 and 1999. METHODS: The ICPs and outcomes of 85 patients with nontraumatic spinal cord injury admitted to the Neurorehabilitation Unit at the National Hospital for Neurology and Neurosurgery, Queen Square, London were analysed. Data extracted included diagnosis, level of the lesion and duration of stay. The numbers and categories of goals and the rates of goal achievement were extracted and the variance patterns analysed. RESULTS: An average of 28 patients were admitted each year. The level of disability on admission and the duration of stay decreased over the three-year period, while the average patient age increased from 48 to 54 years. None of these changes were statistically significant. On average each patient had three new goals set each week. Ninety per cent of all goals were achieved; this was not dependent on the category of goal. Sixteen patients (19%) accounted for 58% of all nonachieved goals. These patients tended to have acute-onset disability. The number of variances fell from 15 to 7 over the three-year period. CONCLUSIONS: The pathway enables monitoring of the rehabilitation process. As the Unit becomes more experienced there is a trend to shorter, more focused admissions with fewer variances. Specific groups of patients with particular needs can be identified. Future patients benefit from closure of the 'audit loop' and the implementation of clinical change based on information obtained from the ICP.

Evaluation of cognitive assessment in stroke rehabilitation.

OBJECTIVE: To assess the effect of cognitive assessment on the functional outcome of stroke patients and quality of life for both patients and their carers. DESIGN: A multicentre, single-blind, randomized controlled trial. SETTING AND PARTICIPANTS: Two hundred and twenty-eight stroke patients were recruited from hospital wards in three UK centres. INTERVENTIONS: Patients were screened for cognitive impairment and randomly allocated to either routine care (116 patients) or routine care plus a detailed cognitive assessment (112 patients). MAIN OUTCOME MEASURES: Outcome was assessed three and six months after recruitment by an independent assessor blind to the intervention on Extended ADL, Cognitive Failures Questionnaire, General Health Questionnaire-28 for patients and carers and Carer Strain Index. RESULTS: There was no significant difference between the two groups in patients' functional outcome, perceived cognitive ability, level of psychological distress or satisfaction with care. There was a trend for the assessment group to have lower levels of carer strain (p = 0.06). CONCLUSIONS: The provision of information about cognitive assessment in stroke rehabilitation may decrease carer strain.

Evaluation of cognitive assessment and cognitive intervention for people with multiple sclerosis.

OBJECTIVES: Cognitive problems in multiple sclerosis are common but any possible benefits of treatment remain uncertain. The aim of the study was to evaluate the benefits of providing a psychology service, including cognitive assessment and intervention, to patients with multiple sclerosis. METHOD: The study was a single blind randomised controlled trial. A total of 240 patients with clinically definite, laboratory supported, or clinically probable multiple sclerosis were recruited from an multiple sclerosis management clinic and assessed on a brief screening battery. They were randomised into three groups. The control group received no further intervention. The assessment group received a detailed cognitive assessment, the result of which was fed back to staff involved in the patients' care. The treatment group received the same detailed cognitive assessment and a treatment programme designed to help reduce the impact of their cognitive problems. Patients were followed up 4 and 8 months later on the general health questionnaire (GHQ-28), extended activities of daily living scale, SF-36, everyday memory questionnaire, dysexecutive syndrome questionnaire, and memory aids questionnaire. RESULTS: The three groups were compared on the outcome measures at 4 and 8 months after recruitment. There were few significant differences between the groups and those that occurred favoured the control group. Overall, the results showed no effect of the interventions on mood, quality of life, subjective cognitive impairment or independence. CONCLUSIONS: The study failed to detect any significant effects of cognitive assessment or cognitive intervention in this cohort of people with multiple sclerosis.

Occupational therapy for patients with Parkinson's disease.

BACKGROUND: Despite drug and surgical therapies for Parkinson's disease, patients develop progressive disability. The role of the occupational therapist is to support the patient and help them maintain their usual level of self-care, work and leisure activities for as long as possible. When it is no longer possible to maintain their usual activities, occupational therapists support individuals in changing and adapting their relationship with their physical and social environment to develop new valued activities and roles. OBJECTIVES: To compare the efficacy and effectiveness of occupational therapy with placebo or no interventions (control group) in patients with Parkinson's disease. SEARCH STRATEGY: Relevant trials were identified by electronic searches of MEDLINE, EMBASE, CINAHL, ISI-SCI, AMED, MANTIS, REHABDATA, REHADAT, GEROLIT, Pascal, LILACS, MedCarib, JICST-EPlus, AIM, IMEMR, SIGLE, ISI-ISTP, DISSABS, Conference Papers Index, Aslib Index to Theses, the Cochrane Controlled Trials Register, the CentreWatch Clinical Trials listing service, the metaRegister of Controlled Trials, ClinicalTrials.gov, CRISP, PEDro, NIDRR and NRR; and the reference lists of identified studies and other reviews were examined. SELECTION CRITERIA: Only randomised controlled trials (RCT) were included, however those trials that allowed quasi-random methods of allocation were allowed. DATA COLLECTION AND ANALYSIS: Data was abstracted independently by two authors and differences were settled by discussion. MAIN RESULTS: Two trials were identified with 84 patients in total. Although both trials reported a positive effect from occupational therapy, all of the improvements were small. The trials did not have adequate placebo treatments, used small numbers of patients and the method of randomisation and concealment of allocation was not specified in one trial. These methodological problems could potentially lead to bias from a number of sources reducing the strength of the studies further. REVIEWER'S CONCLUSIONS: Considering the significant methodological flaws in the studies, the small number of patients examined, and the possibility of publication bias, there is insufficient evidence to support or refute the efficacy of occupational therapy in Parkinson's disease. There does not appear to be a consensus as to the best practice in occupational therapy when treating people with Parkinson's disease. A survey of therapists is needed to determine what methods of occupational therapy are currently being used by therapists to treat Parkinson's disease, and whether there is a consensus as to 'best-practice'. Large well designed placebo-controlled RCTs are needed to demonstrate occupational therapy's effectiveness in Parkinson's disease. Outcome measures with particular relevance to patients, carers, occupational therapists and physicians should be chosen and the patients monitored for at least six months to determine the duration of benefit. The trials should be reported using CONSORT guidelines.