Telerehabilitation for people with physical disabilities and movement impairment: development and evaluation of an online toolkit for practitioners and patients.

PURPOSE: Telerehabilitation has increasingly been used since the COVID-19 pandemic but with limited guidance available on undertaking physical assessments using remote methods. We aimed to provide such guidance by developing a Telerehab Toolkit, an online information and training resource for practitioners, patients, and carers on telerehabilitation for people with physical disabilities and movement impairment. MATERIALS AND METHODS: Development and evaluation of the toolkit were informed by the Knowledge to Action framework and took place iteratively in two phases-knowledge creation and action. Information was collated from various sources including literature review, online survey, service evaluation, and focus group discussions. The toolkit has been evaluated using think-aloud interviews, e-mail and social media feedback from users, and analytics data on user engagement with the website. RESULTS: The Telerehab Toolkit focuses on remote physical assessments, and contains information on technology, digital skills, remote assessment tools, information governance, and safety for telerehabilitation. Resources include top tips from practitioners and patients, how-to guides, checklists, videos, and links to evidence. CONCLUSIONS: The Telerehab Toolkit has been well-received by practitioners, healthcare students, patients, and carers, is being disseminated widely, and is freely available (www.plymouth.ac.uk/research/telerehab). IMPLICATIONS FOR REHABILITATIONTelerehabilitation has been increasingly used since the COVID-19 pandemic, but with limited guidance and training for practitioners on undertaking safe and effective remote physical assessments.The Telerehab Toolkit has been developed iteratively using the Knowledge to Action framework; it is a free online resource for practitioners and patients with specific guidance on telerehabilitation for physical disabilities and movement impairment.It is anticipated that the resource will help to improve the knowledge, skills, and confidence of the current and future rehabilitation workforce.

A simple intervention for disorders of consciousness- is there a light at the end of the tunnel?

Sleep is a physiological state necessary for memory processing, learning and brain plasticity. Patients with disorders of consciousness (DOC) show none or minimal sign of awareness of themselves or their environment but appear to have sleep-wake cycles. The aim of our study was to assess baseline circadian rhythms and sleep in patients with DOC; to optimize circadian rhythm using an intervention combining blue light, melatonin and caffeine, and to identify the impact of this intervention on brain function using event related potentials. We evaluated baseline circadian rhythms and sleep in 17 patients with DOC with 24-h polysomnography (PSG) and 4-hourly saliva melatonin measurements for 48 h. Ten of the 17 patients (5 female, age 30-71) were then treated for 5 weeks with melatonin each night and blue light and caffeine treatment in the mornings. Behavioral assessment of arousal and awareness [Coma recovery scale-revised (CRS-R)], 24-h polysomnography and 4-hourly saliva melatonin measurements, oddball mismatch negativity (MMN) and subject's own name (SON) experiments were performed twice at baseline and following intervention. Baseline sleep was abnormal in all patients. Cosinor analysis of saliva melatonin results revealed that averaged baseline % rhythmicity was low (M: 31%, Range: 13-66.4%, SD: 18.4). However, increase in % Melatonin Rhythm following intervention was statistically significant (p = 0.012). 7 patients showed improvement of CRS-R scores with intervention and this was statistically significant (p = 0.034). All the patients who had improvement of clinical scores also had statistically significant improvement of neurophysiological responses on MMN and SON experiments at group level (p = 0.001). Our study shows that sleep and circadian rhythms are severely deranged in DOC but optimization is possible with melatonin, caffeine and blue light treatment. Clinical and physiological parameters improved with this simple and inexpensive intervention. Optimization of sleep and circadian rhythms should be integrated into rehabilitation programs for people with DOC.

Psychometric analysis of the Glasgow Coma Scale and its sub-scale scores in a national retrospective cohort of patients with traumatic injuries.

OBJECTIVES: To determine the psychometric validity, using Rasch analysis, of summing the three constituent parts of the Glasgow Coma Scale (GCS). DESIGN: National (registry-based) retrospective study. SETTING: England and Wales. PATIENTS: All individuals who sustained a traumatic injury and were: admitted for more than three days; required critical care resources; transferred for specialist management; or who died from their injuries. MAIN OUTCOMES AND MEASURES: Demographic information (i.e., age at time of injury, and sex), item sub-scores of the first available GCS (either completed by the attending paramedics or on arrival to hospital), injury severity as denoted by the Injury Severity Scale (ISS), and outcome (survival to hospital discharge or 30-days post-injury, whichever is earliest). RESULTS: 321,203 cases between 2008 and 2017. 55.9% were male, the median age was 62.7 years (IQR 44.2-80.8), the median ISS was 9 (IQR 9 to 17), and 6.6% were deceased at 30 days. The reliability statistics suggest that when the extreme scores (i.e. 3 and 15) are accounted for, that there is only sufficient consistency to support the separation of injuries into 3 broad categories, e.g. mild, moderate and severe. As extreme scores don't impact Rasch item calibrations, subsequent analysis was restricted to the 48,417 non-extreme unique cases. Overall fit to the Rasch model was poor across all analyses (p < 0.0001). Through a combination of empirical evidence and clinical reasoning, item response categories were collapsed to provide a post-hoc scoring amendment. Whilst the modifications improved the function of the individual items, there is little evidence to support them meaningfully contributing to a total score that can be interpreted on an interval scale. CONCLUSION AND RELEVANCE: The GCS does not perform in a psychometrically robust manner in a national retrospective cohort of individuals who have experienced a traumatic injury, even after post-hoc correction.

Prolonged disorders of consciousness: A response to a "critical evaluation of the new UK guidelines."

BACKGROUND: In 2020, The London Royal College of Physicians published "Prolonged disorders of consciousness following sudden-onset brain injury: national clinical guidelines". In 2021, in the journal Brain, Scolding et al. published "a critical evaluation of the new UK guidelines". This evaluation focussed on one of the 73 recommendations in the National Clinical Guidelines. They also alleged that the guidelines were unethical. CRITICISMS: They criticised our recommendation not to use activation protocols using fMRI, electroencephalography, or Positron Emission Tomography. They claim these tests can (a) detect 'covert consciousness', (b) add predictive value and (c) should be part of routine clinical care. They also suggest that our guideline was driven by cost considerations, leading to clinicians deciding to withdraw treatment at 72 h. EVIDENCE: Our detailed review of the evidence confirms the American Academy of Neurology Practise Guideline (2018) and the European Academy of Neurology Guideline (2020), which agree that insufficient evidence supports their approach. ETHICS: The ethical objections are based on unwarranted assumptions. Our guideline does not make any recommendations about management until at least four weeks have passed. We explicitly recommend that expert assessors undertake ongoing surveillance and monitoring; we do not suggest that patients be abandoned. Our recommendation will increase the cost We had ethicists in the working party. CONCLUSION: We conclude the "critical evaluation" fails to provide evidence for their criticism and that the ethical objections arise from incorrect assumptions and unsupported interpretations of evidence and our guideline. The 2020 UK national guidelines remain valid.

Telerehabilitation for People With Physical Disabilities and Movement Impairment: A Survey of United Kingdom Practitioners.

BACKGROUND: Telerehabilitation is a feasible and potentially effective alternative to face-to-face rehabilitation. However, specific guidance, training, and support for practitioners who undertake remote assessments in people with physical disabilities and movement impairment are limited. OBJECTIVE: The aims of this survey of United Kingdom-based health and social care practitioners were to explore experiences, assess training needs, and collate ideas on best practices in telerehabilitation for physical disabilities and movement impairment. The aim will be to use the findings to inform a practical tool kit and training package for telerehabilitation use. METHODS: UK rehabilitation practitioners were invited to complete an online questionnaire from November to December 2020. Opportunity and snowball sampling were used to recruit participants from professional and educational networks, special interest groups, and via social media. Closed questionnaire items were analyzed using descriptive statistics. Qualitative inductive analysis using NVivo was used for open responses. RESULTS: There were 247 respondents, of which 177 (72%) were physiotherapists and occupational therapists. Most (n=207, 84%) had used video-based consultations (typically supported by telephone and email), and the use of this method had increased in frequency since the COVID-19 pandemic. Practitioners perceived telerehabilitation positively overall and recognized benefits for patients including a reduced infection risk, convenience and flexibility, and reduced travel and fatigue. Common obstacles were technology related (eg, internet connection), practical (eg, difficulty positioning the camera), patient related (eg, health status), practitioner related (eg, lack of technical skills), and organizational (eg, lack of access to technology). Support from family members or carers was a major facilitator for successful remote consultations. Of the 207 respondents who had used video-based consultations, 103 (50%) had assessed physical impairments using this method, 107 (52%) had assessed physical function, and 121 (59%) had used patient-reported outcome measures. Although practitioners generally felt confident in delivering video-based consultations, they felt less proficient in undertaking remote physical assessments, expressing concerns about validity, reliability, and safety. Only 46 of the 247 (19%) respondents had received any training in telerehabilitation or video consultations, and some felt they were "feeling their way in the dark." Practitioners desired training and guidance on physical assessment tools suitable for remote use, when to use video-based consultations or alternative methods, governance issues, digital platforms, and signposting to digital skills training for themselves and their patients. CONCLUSIONS: In response to the COVID-19 pandemic, practitioners rapidly adopted telerehabilitation for people with physical disabilities and movement impairment. However, there are technical, practical, and organizational obstacles to overcome, and a clear need for improved guidance and training in remote physical assessments. The findings of this survey will inform the development of a tool kit of resources and a training package for the current and future workforce in telerehabilitation.

Beyond standard rehabilitation programmes: Working with people with MS for adequate goal setting and rehabilitation treatment evaluation.

Shared decision-making occurs when the decision is 'preference sensitive'. It consists of identifying the different treatment options (choice talk), considering the advantages and disadvantages of each option (option talk), and then supporting making the decision in the light of an individual's experiences and values (decision talk). It is most effective when working with an 'activated patient', that is, one who is prepared for the shared decision-making role. In rehabilitation, many decisions are preference sensitive. These decisions may be framed as 'goal setting'. Skilled clinicians can support patients to learn goal setting skills until the person has the skills to maintain health supporting behaviours most of the time, only seeing a clinical team at times of change or crisis. The steps in goal setting can be summarised as building empathy, creating a contract, identifying priorities, summarising the conversation, articulating the goal, defining actions, building coping plans, and then reviewing progress. Working with people with MS can extend beyond working with individuals to a consideration of what people with MS want from services. This can result in the co-production and co-design of services, as well as the identification of research priorities as exemplified by the James Lind Alliance.

Rasch analysis of the upper-limb subscale of the stroke rehabilitation assessment of movement (STREAM) tool in an acute stroke cohort Rasch analysis of the upper-limb subscale of the STREAM tool in an acute stroke population.

BACKGROUND: Stroke is a leading cause of disability worldwide. The most common impairment resulting from stroke is upper-limb weakness. OBJECTIVES: To determine the usefulness and psychometric validity of the upper-limb subscale of the STREAM in an acute stroke population. METHODS: Rasch Analysis, including unidimensionality assumption testing, determining model fit, and analysis of: reliability, residual correlations, and differential item functioning. RESULTS: 125 individuals were assessed using the upper-limb subscale of the Stroke Rehabilitation Assessment of Movement (STREAM) tool. Rasch analysis suggests the STREAM is a unidimensional measure. However, when scored using the originally proposed method (0-2), or using the response pattern (0-5) neither variant fit the Rasch model (p < 0.05). Although, the reliability was good (Person-Separation Index - 0.847 and 0.903, respectively). Correcting for the disordered thresholds, and thereby producing the new scoring pattern, led to substantial improvement in the overall fit (chi-square probability of fit - 22%), however, the reliability was slightly reduced (PSI - 0.806). CONCLUSIONS: The study proposes a new scoring method for the upper-limb subscale of the STREAM outcome measure in the acute stroke population.

The Trail Making test: a study of its ability to predict falls in the acute neurological in-patient population.

OBJECTIVE: To determine whether tests of cognitive function and patient-reported outcome measures of motor function can be used to create a machine learning-based predictive tool for falls. DESIGN: Prospective cohort study. SETTING: Tertiary neurological and neurosurgical center. SUBJECTS: In all, 337 in-patients receiving neurosurgical, neurological, or neurorehabilitation-based care. MAIN MEASURES: Binary (Y/N) for falling during the in-patient episode, the Trail Making Test (a measure of attention and executive function) and the Walk-12 (a patient-reported measure of physical function). RESULTS: The principal outcome was a fall during the in-patient stay ( n = 54). The Trail test was identified as the best predictor of falls. Moreover, addition of other variables, did not improve the prediction (Wilcoxon signed-rank P < 0.001). Classical linear statistical modeling methods were then compared with more recent machine learning based strategies, for example, random forests, neural networks, support vector machines. The random forest was the best modeling strategy when utilizing just the Trail Making Test data (Wilcoxon signed-rank P < 0.001) with 68% (± 7.7) sensitivity, and 90% (± 2.3) specificity. CONCLUSION: This study identifies a simple yet powerful machine learning (Random Forest) based predictive model for an in-patient neurological population, utilizing a single neuropsychological test of cognitive function, the Trail Making test.

What am I? A philosophical account of personhood and its applications to people with brain injury.

This article identifies the dilemma faced by clinical staff when asked to support the withdrawal of clinically assisted nutrition and hydration in a patient in a vegetative state. On the one hand, they are expected to treat the patient as a person in their daily interactions; on the other, they are asked to withdraw treatment on the grounds that it is futile, which may seem to run counter to treating people as persons. The article highlights that similar debates exist within the philosophical community about the nature of personhood and describes two philosophical accounts of personhood. The aim is to help clinicians articulate the reasons for their intuitions more clearly, and thus justify their beliefs.

Late recovery of awareness in prolonged disorders of consciousness -a cross-sectional cohort study.

PURPOSE: To detect any improvement of awareness in prolonged disorders of consciousness in the long term. METHODS: A total of 34 patients with prolonged disorders of consciousness (27 vegetative state and seven minimally conscious state; 16 males; aged 21-73) were included in the study. All patients were initially diagnosed with vegetative/minimally conscious state on admission to our specialist neurological rehabilitation unit. Re-assessment was performed 2-16 years later using Coma Recovery Scale-Revised. RESULTS: Although remaining severely disabled, 32% of the patients showed late improvement of awareness evidenced with development of non-reflexive responses such as reproducible command following and localization behaviors. Most of the late recoveries occurred in patients with subarachnoid hemorrhage (5/11, 45.5%). The ages of patients within the late recovery group (Mean = 45, SD = 11.4) and non-recovery group (Mean = 43, SD = 15.5) were not statistically different (p = 0.76). CONCLUSIONS: This study shows that late improvements in awareness are not exceptional in non-traumatic prolonged disorders of consciousness cases. It highlights the importance of long-term follow up of patients with prolonged disorders of consciousness, regardless of the etiology, age, and time passed since the brain injury. Long-term follow up will help clinicians to identify patients who may benefit from further assessment and rehabilitation. Although only one patient achieved recovery of function, recovery of awareness may have important ethical implications especially where withdrawal of artificial nutrition and hydration is considered. Implications for rehabilitation Long-term regular follow-up of people with prolonged disorders of consciousness is important. Albeit with poor functional outcomes late recovery of awareness is possible in both traumatic and non-traumatic prolonged disorders of consciousness cases. Recovery of awareness has significant clinical and ethical implications especially where withdrawal of artificial nutrition and hydration is considered.

The sink or SWIM hypothesis; a roadmap from pathology to work instability.

PURPOSE: Selecting the most appropriate health-related work outcome to evaluate an intervention can be fraught with difficulty. To aid clinicians in navigating this problem we have developed a model, which illustrates how pathology can affect specific measureable quantities, such as work instability. METHODS: Using a modified-Delphi procedure, a panel of experts met initially to analyze the content of 95 health-related work outcome measures and organize the identified areas of measurement into a coherent model, complemented by a narrative review of the literature. This initial model underwent two rounds of stakeholder-based feedback, the results of which were incorporated in the final expert panel meeting to produce the States-traits Work Instability Model (SWIM). RESULTS: The States-traits Work Instability Model (SWIM) illustrates how changes to an individual's physical and psychological states and traits might affect their work-related performance, well-being and self-efficacy. Moreover, each concept utilized in the model was specifically selected as it represents a measurable quantity, for which there are tools available. CONCLUSION: The SWIM is arguably the first holistic model of work that is based on both the clinical realities of vocational rehabilitation, sociological research, and is born from analyzing the basis of practical measurements. Implications for Rehabilitation Work Instability • Work instability has multiple causes many of which are amenable to intervention • The model clarifies the measureable domains of vocational rehabilitation interventions, which is of particular benefit for services working with people with disability at work who are struggling to remain in work • The model conceptualizes how the potential areas for intervention may be related based on evidence available in the literature.

The psychological impact of prolonged disorders of consciousness on caregivers: a systematic review of quantitative studies.

OBJECTIVE: Systematic review of the nature, frequency and severity of psychological experiences of people who have a close relationship with a person with a prolonged disorder of consciousness. DATA SOURCES: Cochrane Library, Web of Science, PsycINFO, PubMed, Embase®, MEDLINE®, Allied and Complementary Medicine™, were searched from inceptions until December 2016 with additional hand searching of reference lists of included articles. REVIEW METHODS: Studies were included that used quantitative methodologies and psychological measures to investigate experiences. The PRISMA statement was followed with inclusion criteria set a priori. A data synthesis summarized psychological constructs studied. RESULTS: A total of 18 studies (ranging between n = 16-487 participants) met the inclusion criteria with 15 of 18 studies focused on the primary caregiver. A total of 23 standardized psychological measures were identified to assess four primary psychological constructs: Loss and grief, psychological wellbeing changes, burden and use of coping strategies. CONCLUSIONS: Small sample sizes, limited variables and reliance on observational methods affected quality. Caregivers do find ways to manage independently, but some exhibit clinically significant psychological distress that does not change over time alone and may get worse.

The experience of transitioning from relapsing remitting to secondary progressive multiple sclerosis: views of patients and health professionals.

PURPOSE: The majority of people with multiple sclerosis (pwMS) initially present with discreet periods of relapses followed by partial remission of symptoms (RRMS). Over time, most pwMS transition to secondary progressive MS (SPMS), characterized by a gradual accumulation of disability. This study aimed to explore the experiences, coping and needs associated with transitioning from RRMS to SPMS. METHOD: Data were collected via semi-structured interviews with nine pwMS and seven specialist MS health professionals (HPs). Thematic analysis was used to analyze the data. RESULTS: Four major themes were identified: "Is this really happening?"; "Becoming a reality"; "A life of struggle"; and "Brushing oneself off and moving on." Findings suggested a process of moving from uncertainty towards confirmation of one's diagnostic label. Being reclassified with SPMS served as a turning point for many, and was accompanied by a range of cognitive, emotional and behavioral responses. The value of adequate information and support surrounding the transition, and the potential benefit of education and support for health professionals in relation to the transition were indicated. CONCLUSIONS: Understanding pwMS' experiences of the transition is essential if clinicians are to provide pwMS with appropriate support during the transition. Implications for Rehabilitation The timing and delivery of preparatory education for patients about the transition to SPMS should be carefully considered. Sufficient information and follow-up support following the reclassification of SPMS is crucial but sometimes lacking. The importance of sensitive communication of the reclassification of SPMS was highlighted. MS Specialist health professionals may potentially benefit from training and support around communication of the reclassification of SPMS. Given the potential negative psychological impact of the transition, the psychological wellbeing of the patients during the transition to SPMS should be monitored and responded to appropriately.

Systematic Review of Health-Related Work Outcome Measures and Quality Criteria-Based Evaluations of Their Psychometric Properties.

OBJECTIVE: To examine the state of psychometric validation in the health-related work outcome literature. DATA SOURCES: We searched PubMed, PubMed Central, CINAHL, Embase (plus Embase Classic), and PsycINFO from inception to January 2016 using the following search terms: stroke, multiple sclerosis, epilepsy, spinal cord injury, brain injury, musculoskeletal disease, work, absenteeism, presenteeism, occupation, employment, job, outcome measure, assessment, work capacity evaluation, scale, and questionnaire. STUDY SELECTION: From the 22,676 retrieved abstracts, 597 outcome measures were identified. Inclusion was based on content analysis. There were 95 health-related work outcome measures retained; of these, 2 were treated as outliers and therefore are discussed separately. All 6 authors individually organized the 93 remaining scales based on their content. DATA EXTRACTION: A follow-up search using the same sources, and time period, with the name of the outcome measures and the terms psychometric, reliability, validity, and responsiveness, identified 263 unique classical test theory psychometric property datasets for the 93 tools. An assessment criterion for psychometric properties was applied to each article, and where consensus was not achieved, the rating delivered by most of the assessors was reported. DATA SYNTHESIS: Of the articles reported, 18 reporting psychometric data were not accessible and therefore could not be assessed. There were 39 that scored <20% of the maximum achievable score, 106 scored between 20% and 40%, 82 scored between 40% and 60%, 15 scored between 60% and 80%, and only 1 scored >80%. The 3 outcome measures associated with the highest scoring datasets were the Sheehan Disability Scale, the Fear Avoidance Beliefs Questionnaire, and the assessment of the Subjective Handicap of Epilepsy. Finally, only 2 psychometric validation datasets reported the complete set of baseline psychometric properties. CONCLUSIONS: This systematic review highlights the current limitations of the health-related work outcome measure literature, including the limited number of robust tools available.

Functional near infrared spectroscopy as a probe of brain function in people with prolonged disorders of consciousness.

Near infrared spectroscopy (NIRS) is a non-invasive technique which measures changes in brain tissue oxygenation. NIRS has been used for continuous monitoring of brain oxygenation during medical procedures carrying high risk of iatrogenic brain ischemia and also has been adopted by cognitive neuroscience for studies on executive and cognitive functions. Until now, NIRS has not been used to detect residual cognitive functions in patients with prolonged disorders of consciousness (pDOC). In this study we aimed to evaluate the brain function of patients with pDOC by using a motor imagery task while recording NIRS. We also collected data from a group of age and gender matched healthy controls while they carried out both real and imagined motor movements to command. We studied 16 pDOC patients in total, split into two groups: five had a diagnosis of Vegetative state/Unresponsive Wakefulness State, and eleven had a diagnosis of Minimally Conscious State. In the control subjects we found a greater oxy-haemoglobin (oxyHb) response during real movement compared with imagined movement. For the between group comparison, we found a main effect of hemisphere, with greater depression of oxyHb signal in the right > left hemisphere compared with rest period for all three groups. A post-hoc analysis including only the two pDOC patient groups was also significant suggesting that this effect was not just being driven by the control subjects. This study demonstrates for the first time the feasibility of using NIRS for the assessment of brain function in pDOC patients using a motor imagery task.

Measuring arm function early after stroke: is the DASH good enough?

OBJECTIVE: Despite a growing call to use patient-reported outcomes in clinical research, few are available for measuring upper limb function post-stroke. We examined the Disabilities of the Arm, Shoulder and Hand (DASH) to evaluate its measurement performance in acute stroke. In doing so, we compared results from traditional and modern psychometric methods. METHODS: 172 people with acute stroke completed the DASH. Those with upper limb impairments completed the DASH again at 6 weeks (n=99). Data (n=271) were analysed using two psychometric paradigms: traditional psychometric (Classical Test Theory, CTT) analyses examined data completeness, scaling assumptions, targeting, reliability and responsiveness; Rasch Measurement Theory (RMT) analyses examined scale-to-sample targeting, scale performance and person measurement. RESULTS: CTT analyses implied the DASH was psychometrically robust in this sample. Data completeness was high, criteria for scaling assumptions were satisfied (item-total correlations 0.55-0.95), targeting was good, internal consistency reliability was high (Cronbach's α=0.99) and responsiveness was clinically moderate (effect size=0.51). However, RMT analyses identified important limitations: scale-to-sample targeting was suboptimal, 4 items had disordered response category thresholds, 16 items exhibited misfit, 3 pairs of items had high residual correlations (>0.60) and 84 person fit residuals exceeded the recommended range. CONCLUSIONS: RMT methods identified limitations missed by CTT and indicate areas for improvement of the DASH as an upper limb measure for acute stroke. Findings, similar to those identified in multiple sclerosis, highlight the need for scales to have strong conceptual underpinnings, with their development and modification guided by sophisticated psychometric methods.

Stroke rehabilitation: long-term rehabilitation after stroke.

Many stroke survivors, despite improvements in mortality and morbidity, remain dependent on others for everyday activities. People with stroke need access to effective specialist multidisciplinary rehabilitation services that are organised and integrated within the whole system of health and social care. They also commonly come under the care of generalists in various clinical contexts, including intercurrent illness. This Clinical Medicine Concise Guideline abstracts key recommendations from the National Institute for Health and Care Excellence Clinical Guideline 162 on stroke rehabilitation of particular relevance to clinicians in general medicine, to inform their front-line practice and promote liaison and collaboration with the specialist service.

Deontological and utilitarian ethics: a brief introduction in the context of disorders of consciousness.

PURPOSE: The aims of this paper are to discuss three different ethical frameworks; to briefly consider some of the philosophical positions concerning the nature of personhood. Clear consideration of these issues demonstrates the complexity of decision making in persisting disorders of consciousness. METHOD: Three different ethical frameworks, Kantian deontology, act utilitarianism and rule utilitarianism, are described and three different accounts of personhood are presented and analysed. RESULTS: These result in very different approaches to the management of patients in permanent vegetative states (PVSs), making it possible to argue for withdrawal of clinically assisted nutrition and hydration in all cases, considering the issues on a case by case basis or continuing to treat all patients whatever their wishes. CONCLUSIONS: These results explain why doctors often have different views on how to treat patients in PVS, particularly with regard to the withdrawal of clinically assisted nutrition and hydration. Understanding such issues may help clinicians articulate more clearly the reasons for their intuitions surrounding the management of patients in PVSs. Implications for Rehabilitation Patients with persisting disorders of consciousness pose significant dilemmas for clinicians and family members. Utilitarianism is a consequentialist theory, that is, it is concerned with the outcome of our actions to determine their morality. It is the concept that the right action is the one that will result in "the greatest amount of good for the greatest number". Deontological ethics suggests that there are certain sorts of acts that are wrong in themselves independent of the result of such actions. Personhood can be approached from a variety of perspectives including biological, relational, religious and psychological. Understanding different ethical frameworks, and the nature of personhood, may help clinicians articulate more clearly the reasons for their intuitions.

A rehabilitation unit at night: environmental characteristics of patient rooms.

PURPOSE: The aim of this study was first of all to investigate the sound, light, temperature and humidity levels in a rehabilitation ward and to establish whether the measured levels were within the recommended levels or not; secondly to explore influence of the type of the patient rooms on obtained measurements. METHODS: Measurements of environmental characteristics were recorded on three non-consecutive nights by data loggers in a 12-bedded residential neurological rehabilitation unit for patients with disorders of consciousness. The obtained measurements were compared with the recommendations of the World Health Organization and the Society of Light and Lighting. RESULTS: Recordings were within recommended levels for light and humidity overnight. Average noise levels were above the recommended levels. There were abrupt increases of light and noise levels which were high enough to cause sleep fragmentation. Mean temperature levels were higher than recommended. CONCLUSIONS: Our results indicated that the patients are at risk of disturbed sleep for the duration of their stay in rehabilitation unit. Exposure to generally high noise levels, as well as the sudden increases of noise and light intensities can prevent reaching restful night-time sleep and may negatively impact on rehabilitation process due to impaired memory, learning and well-being. Implications for Rehabilitation Standards for ward based hospital environments to minimize sleep disturbance exist and can be used to examine the environmental characteristics of patients' rooms in different healthcare settings including rehabilitation units. This study shows that measurements of environmental factors were not always within the recommended levels in the rehabilitation unit and presence of abrupt increase of noise and light levels are likely to cause sleep disturbance of patients. Assessment of current practice, education and training of night staff to raise awareness on importance of sleep and environmental factors and development of strategies are required in order to improve quality of sleep in rehabilitation settings.