The COVID-19 Yorkshire Rehabilitation Scale (C19-YRS): Application and psychometric analysis in a post-COVID-19 syndrome cohort.

As our understanding of the nature and prevalence of post-coronavirus disease 2019 (COVID-19) syndrome (PCS) is increasing, a measure of the impact of COVID-19 could provide valuable insights into patients' perceptions in clinical trials and epidemiological studies as well as routine clinical practice. To evaluate the clinical usefulness and psychometric properties of the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS) in patients with PCS, a prospective, observational study of 187 consecutive patients attending a post-COVID-19 rehabilitation clinic was conducted. The C19-YRS was used to record patients' symptoms, functioning, and disability. A global health question was used to measure the overall impact of PCS on health. Classical psychometric methods (data quality, scaling assumptions, targeting, reliability, and validity) were used to assess the C19-YRS. For the total group, missing data were low, scaling and targeting assumptions were satisfied, and internal consistency was high (Cronbach's α = 0.891). Relationships between the overall perception of health and patients' reports of symptoms, functioning, and disability demonstrated good concordance. This is the first study to examine the psychometric properties of an outcome measure in patients with PCS. In this sample of patients, the C19-YRS was clinically useful and satisfied standard psychometric criteria, providing preliminary evidence of its suitability as a measure of PCS.

The modified COVID-19 Yorkshire Rehabilitation Scale (C19-YRSm) patient-reported outcome measure for Long Covid or Post-COVID-19 syndrome.

BACKGROUND: The C19-YRS is the literature's first condition-specific, validated scale for patient assessment and monitoring in Post-COVID-19 syndrome (PCS). The 22-item scale's subscales (scores) are symptom severity (0-100), functional disability (0-50), additional symptoms (0-60), and overall health (0-10). OBJECTIVES: This study aimed to test the scale's psychometric properties using Rasch analysis and modify the scale based on analysis findings, emerging information on essential PCS symptoms, and feedback from a working group of patients and professionals. METHODS: Data from 370 PCS patients were assessed using a Rasch Measurement Theory framework to test model fit, local dependency, response category functioning, differential item functioning, targeting, reliability, and unidimensionality. The working group undertook iterative changes to the scale based on the psychometric results and including essential symptoms. RESULTS: Symptom severity and functional disability subscales showed good targeting and reliability. Post hoc rescoring suggested that a 4-point response category structure would be more appropriate than an 11-point response for both subscales. Symptoms with binary responses were placed in the other symptoms subscale. The overall health single-item subscale remained unchanged. CONCLUSION: A 17-item C19-YRSm was developed with subscales (scores): symptom severity (0-30), functional disability (0-15), other symptoms (0-25), and overall health (0-10).

Telerehabilitation for individuals with spinal cord injury in low-and middle-income countries: a systematic review of the literature.

STUDY DESIGN: Systematic review. OBJECTIVE: To systematically review the evidence for the effectiveness of telerehabilitation as an intervention for people with spinal cord injury (SCI) in low-and middle-income countries (LMICs). SETTING: Not applicable. METHODS: MEDLINE (Ovid), Embase (Ovid), Pubmed and Global Health databases were used to identify studies published between 1946-2020 meeting the following criteria: (1) patients with SCI diagnosis; (2) in LMIC; (3) an outcome measuring clinical functional ability, quality of life or all-cause mortality reduction. The risk of bias in studies was graded using revised Cochrane risk-of-bias tool in randomised trials (RoB 2) and risk-of-bias tool in non-randomised trials (ROBINS-I). Evidence levels were graded with Grading of Recommendations, Assessment, Development and Evaluations (GRADE). RESULTS: In total, 107 articles were identified from the initial search. After screening, five studies were included. Some significant improvements to quality of life and pressure ulcer management were observed, alongside some improvement in functional ability with suggested improvement to depression scores. Telerehabilitation alleviated participants' sense of social isolation, improved satisfaction scores and assisted them to remember techniques for SCI management. Telerehabilitation was valued by health professionals. There was no reduction in all-cause mortality. CONCLUSION: There is insufficient evidence to recommend telerehabilitation as an intervention to treat and manage SCI in LMICs, although there is an indication of potential patient benefit. Further research is required to better understand the causal mechanisms underpinning the use of telerehabilitation and establish its efficacy, in the context of resource-limited settings.

Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation.

BACKGROUND: There is currently very limited information on the nature and prevalence of post-COVID-19 symptoms after hospital discharge. METHODS: A purposive sample of 100 survivors discharged from a large University hospital were assessed 4 to 8 weeks after discharge by a multidisciplinary team of rehabilitation professionals using a specialist telephone screening tool designed to capture symptoms and impact on daily life. EQ-5D-5L telephone version was also completed. RESULTS: Participants were between 29 and 71 days (mean 48 days) postdischarge from hospital. Thirty-two participants required treatment in intensive care unit (ICU group) and 68 were managed in hospital wards without needing ICU care (ward group). New illness-related fatigue was the most common reported symptom by 72% participants in ICU group and 60.3% in ward group. The next most common symptoms were breathlessness (65.6% in ICU group and 42.6% in ward group) and psychological distress (46.9% in ICU group and 23.5% in ward group). There was a clinically significant drop in EQ5D in 68.8% in ICU group and in 45.6% in ward group. CONCLUSIONS: This is the first study from the United Kingdom reporting on postdischarge symptoms. We recommend planning rehabilitation services to manage these symptoms appropriately and maximize the functional return of COVID-19 survivors.

A pilot single-blind multicentre randomized controlled trial to evaluate the potential benefits of computer-assisted arm rehabilitation gaming technology on the arm function of children with spastic cerebral palsy.

OBJECTIVE: To evaluate the potential benefits of computer-assisted arm rehabilitation gaming technology on arm function of children with spastic cerebral palsy. DESIGN: A single-blind randomized controlled trial design. Power calculations indicated that 58 children would be required to demonstrate a clinically important difference. SETTING: Intervention was home-based; recruitment took place in regional spasticity clinics. PARTICIPANTS: A total of 15 children with cerebral palsy aged five to 12 years were recruited; eight to the device group. INTERVENTIONS: Both study groups received 'usual follow-up treatment' following spasticity treatment with botulinum toxin; the intervention group also received a rehabilitation gaming device. MAIN MEASURES: ABILHAND-kids and Canadian Occupational Performance Measure were performed by blinded assessors at baseline, six and 12 weeks. RESULTS: An analysis of covariance showed no group differences in mean ABILHAND-kids scores between time points. A non-parametric analysis of variance on Canadian Occupational Performance Measure scores showed a statistically significant improvement across time points (χ2 (2,15) = 6.778, p = 0.031), but this improvement did not reach minimal clinically important difference. Mean daily device use was seven minutes. Recruitment did not reach target owing to unanticipated staff shortages in clinical services. Feedback from children and their families indicated that the games were not sufficiently engaging to promote sufficient use that was likely to result in functional benefits. CONCLUSION: This study suggests that computer-assisted arm rehabilitation gaming does not benefit arm function, but a Type II error cannot be ruled out.

The case Conference Assessment Tool (cCAT): a new workplace-based assessment.

Rehabilitation medicine is an educational, problem-solving specialty that relies on excellent team communication, honest discussion with patients and their families, and collaborative goal setting. The case conference has been described as the technology of rehabilitation medicine because it encompasses all of these functions. Trainees should have the opportunity to develop skills in chairing case conferences through receipt of constructive feedback on their performance from their trainers. The aim of this project was to develop and evaluate the case Conference Assessment Tool (cCAT), a workplace-based assessment designed to score a trainee's performance on the key elements of chairing a case conference. Experienced rehabilitation medicine educational supervisors participated in a training workshop and then rated a series of simulated case conferences using the cCAT. Internal consistency was high (Cronbach's α =: 0.945) and interrater reliability was acceptable (intraclass correlation coefficient range 0.673-0.777). Following feedback from the workshops, a final version of the cCAT was developed. The cCAT has now been adopted as a workplace-based assessment for specialty trainees in rehabilitation medicine by the Training Board of the Joint Royal Colleges of Physicians. Further work will explore its utility for trainees in other specialties and in communication and leadership skill training for undergraduate students.

Home-based Computer Assisted Arm Rehabilitation (hCAAR) robotic device for upper limb exercise after stroke: results of a feasibility study in home setting.

BACKGROUND: Home-based robotic technologies may offer the possibility of self-directed upper limb exercise after stroke as a means of increasing the intensity of rehabilitation treatment. The current literature has a paucity of robotic devices that have been tested in a home environment. The aim of this research project was to evaluate a robotic device Home-based Computer Assisted Arm Rehabilitation (hCAAR) that can be used independently at home by stroke survivors with upper limb weakness. METHODS: hCAAR device comprises of a joystick handle moved by the weak upper limb to perform tasks on the computer screen. The device provides assistance to the movements depending on users ability. Nineteen participants (stroke survivors with upper limb weakness) were recruited. Outcome measures performed at baseline (A0), at end of 8-weeks of hCAAR use (A1) and 1 month after end of hCAAR use (A2) were: Optotrak kinematic variables, Fugl Meyer Upper Extremity motor subscale (FM-UE), Action Research Arm Test (ARAT), Medical Research Council (MRC) and Modified Ashworth Scale (MAS), Chedoke Arm and Hand Activity Inventory (CAHAI) and ABILHAND. RESULTS: Two participants were unable to use hCAAR: one due to severe paresis and the other due to personal problems. The remaining 17 participants were able to use the device independently in their home setting. No serious adverse events were reported. The median usage time was 433 minutes (IQR 250 - 791 min). A statistically significant improvement was observed in the kinematic and clinical outcomes at A1. The median gain in the scores at A1 were by: movement time 19%, path length 15% and jerk 19%, FM-UE 1 point, total MAS 1.5 point, total MRC 2 points, ARAT 3 points, CAHAI 5.5 points and ABILHAND 3 points. Three participants showed clinically significant improvement in all the clinical outcomes. CONCLUSIONS: The hCAAR feasibility study is the first clinical study of its kind reported in the current literature; in this study, 17 participants used the robotic device independently for eight weeks in their own homes with minimal supervision from healthcare professionals. Statistically significant improvements were observed in the kinematic and clinical outcomes in the study.

HEART Rate Variability Biofeedback for LOng COVID Dysautonomia (HEARTLOC): Results of a Feasibility Study.

Introduction: Post-COVID-19 syndrome, or Long Covid (LC) refers to symptoms persisting 12 weeks after the COVID-19 infection. LC comprises a wide range of dysautonomia symptoms, including fatigue, breathlessness, palpitations, dizziness, pain and brain fog. This study tested the feasibility and estimated the efficacy, of a Heart Rate Variability Biofeedback (HRV-B) programme via a standardised slow diaphragmatic breathing technique in individuals with LC. Methods: LC patients underwent a 4-week HRV-B intervention for 10 minutes twice daily for 4 weeks using the Polar H10 ECG (Electrocardiogram) chest strap and Elite HRV phone application. Outcome measures C19-YRSm (Yorkshire Rehabilitation Scale modified), Composite Autonomic Symptom Score (COMPASS-31), WHO Disability Assessment Schedule (WHODAS), EQ5D-5L (EuroQol 5 Dimensions) and Root Mean Square of Successive Differences between heartbeats (RMSSD) using a Fitbit device were recorded before and after the intervention. The study was pre-registered at clinicaltrials.gov NCT05228665. Results: A total of 13 participants (54% female, 46% male) completed the study with high levels of independent use of technology, data completeness and intervention adherence. There was a statistically significant improvement in C19YRS-m (P = .001), COMPASS-31 (P = .007), RMSSD (P = .047), WHODAS (P = .02) and EQ5D Global Health Score (P = .009). Qualitative feedback suggested participants could use it independently, were satisfied with the intervention and reported beneficial effects from the intervention. Conclusion: HRV-B using diaphragmatic breathing is a feasible intervention for LC. The small sample size limits generalisability. HRV-B in LC warrants further exploration in a larger randomised controlled study.

Community stroke rehabilitation helps patients return to work.

Around 150,000 people experience a stroke every year in the UK. Nearly one million people in England are living with the effects of a stroke; one third of whom are moderately to severely disabled. A quarter of stroke survivors are under the age of 65 meaning that many are in work and/or have responsibility for caring for children or elderly parents. With a comprehensive rehabilitation team, patients with more complex or severe disability can be rehabilitated in the community providing that the home environment can be suitably adapted. All patients will require regular review by their own doctor and some of these reviews will focus on standardised assessments of risk factors for stroke and implementation of appropriate secondary prevention. The GP has a role in identifying the emotional impact of stroke on the patient and the impact that the stroke has on relatives and carers. The core components of the community-based programme can be broadly defined as improving emotional wellbeing, communication, cognitive function and physical independence and supporting return to work. Antidepressants are effective in reducing emotional lability. Cognitive functions such as memory, attention, perception and planning are often affected by stroke. Assessment and treatment by the occupational therapy team and clinical psychologist can reduce the impact of these impairments. Speech and language therapy is instrumental in facilitating recovery as is training carers in supportive communication and providing aphasia-friendly information. NICE recommends that patients receive 45 minutes of each relevant therapy five times a week. Each therapy needs to be provided at an intensity that will produce a functional change. Most patients will be able to drive again if there is no significant visual field loss or uncontrolled epilepsy. Graded return to work programmes are more successful as people are gradually accustomed to the workplace.

The impact of COVID-19 on professional development for physiotherapists in Lagos, Nigeria.

Background: Continuous professional development is important to maintain standards of care in the healthcare sector. However, in Lagos, Nigeria, the additional burden of COVID-19 and limited resources may provide separate challenges for physiotherapists' continuous professional development (CPD). Objectives: To examine the availability and perceived quality of continuous professional development opportunities for physiotherapists working before and during the pandemic in Lagos, Nigeria. Method: A qualitative study was conducted with 10 conveniently sampled physiotherapists, recruited via email. Interviews took place via Zoom, and the video function was utilised. Data were collected via semi-structured interviews using a pilot tested interview, and was transcribed and analysed thematically. Results: The main method of workplace teaching pre-COVID-19 and during COVID-19 was bedside teaching (BT), which most participants received. Pre-COVID-19, the main barrier to receiving teaching was a lack of national guidelines providing specific details on CPD. During COVID-19, the main barrier was the difficulty of increased online teaching instead of teaching on real life patients. The main barriers for non-workplace CPD pre-COVID-19 were a lack of availability of learning opportunities and monetary cost of conferences. This was partially combatted by the increasing trend of online learning events during the pandemic, which increased access to non-workplace learning opportunities. Conclusion: Because of COVID-19, most CPD learning opportunities for physiotherapists in Lagos, Nigeria, were online, increasing overall accessibility. Adequate training to improve utilising online learning resources as well as specific guidelines for workplace physiotherapists CPD in Nigeria should be implemented and promoted to improve confidence and quality of care. Clinical implications: Key insight into the CPD experiences of physiotherapists currently working in Lagos, Nigeria, which can guide policies and improve clinical outcomes.

User experiences of pre-sleep sensory alpha brainwave entrainment for people with chronic pain and sleep disturbance.

Aim: To explore the user experiences of pre-sleep alpha entrainment via a smartphone-enabled audio or visual stimulation program for people with chronic pain and sleep disturbance. Materials & methods: Semi-structured interviews were held with 27 participants completing a feasibility study of pre-sleep entrainment use for 4 weeks. Transcriptions were subject to template analysis. Results: Five top-level themes generated from this analysis are presented. These report on participants' impressions of the pain-sleep relationship, their previous experiences of strategies for these symptoms, their expectations and their experience of use and perceived impact on symptoms of audiovisual alpha entrainment. Conclusion: Pre-sleep audiovisual alpha entrainment was acceptable to individuals with chronic pain and sleep disturbance and perceived to have symptomatic benefits.

In this study, people who had used an experimental treatment for chronic pain called alpha entrainment, which was delivered by audio (tones through headphones) or visual (flickering light) stimulation just before sleep each night for 4 weeks, were interviewed about their experiences. Analysis of the interview transcripts generated findings in five large areas: participants' impressions of the relationship between pain and sleep, previous strategies they had tried, expectations of using this intervention and their experiences of using it and how it affected their symptoms. Overall, participants found using this type of sensory stimulation last thing at night to be acceptable in a real-life setting, consistent with prior understanding, and many felt it to have benefits for sleep and pain symptoms with few side effects. Comfort of the equipment and having the choice of different types of stimulation were important. Further development should be guided by these user experiences.

A feasibility study of pre-sleep audio and visual alpha brain entrainment for people with chronic pain and sleep disturbance.

Introduction: Chronic pain and sleep disturbance are bi-directionally related. Cortical electrical activity in the alpha frequency band can be enhanced with sensory stimulation via the phenomenon of entrainment, and may reduce pain perception. A smartphone based programme which delivers 10 Hz stimulation through flickering light or binaural beats was developed for use at night, pre-sleep, with the aim of improving night time pain and sleep and thereby subsequent pain and related daytime symptoms. The aim of this study was to assess the feasibility and give an indication of effect of this programme for individuals with chronic pain and sleep disturbance. Materials and methods: In a non-controlled feasibility study participants used audio or visual alpha entrainment for 30 min pre-sleep each night for 4 weeks, following a 1 week baseline period. The study was pre-registered at ClinicalTrials.gov with the ID NCT04176861. Results: 28 participants (79% female, mean age 45 years) completed the study with high levels of data completeness (86%) and intervention adherence (92%). Daily sleep diaries showed an increase compared to baseline in total sleep time of 29 min (p = 0.0033), reduction in sleep onset latency of 13 min (p = 0.0043), and increase in sleep efficiency of 4.7% (p = 0.0009). Daily 0-10 numerical rating scale of average pain at night improved by 0.5 points compared to baseline (p = 0.027). Standardised questionnaires showed significant within-participant improvements in sleep quality (change in median Global PSQI from 16 to 12.5), pain interference (change in median BPI Pain Interference from 7.5 to 6.8), fatigue (change in median MFI total score from 82.5 to 77), and depression and anxiety (change in median HADS depression score from 12 to 10.5 and anxiety from 13.5 to 11). Discussion: Pre-sleep use of a smartphone programme for alpha entrainment by audio or visual stimulation was feasible for individuals with chronic pain and sleep disturbance. The effect on symptoms requires further exploration in controlled studies.

Physiotherapy in Madagascar: current challenges and opportunities for development.

PURPOSE: World Health Organisation's data show that low and middle-income countries have a higher prevalence of disabilities. Madagascar is the ninth poorest country in the world. This report aims to analyse the current difficulties faced by physiotherapists and physicians working in the hospital setting, and offer recommendations for how healthcare services can develop in the future. MATERIALS AND METHODS: Data were collected over the course of 3 months in the form of observational logs, interviews, and questionnaires. Interpreters were used in all interviews, and written questionnaires were translated from English to Malagasy. RESULTS: Thematic analysis of all data collected was completed with key themes emerging: difficult working conditions, including high patient volume and limited staff capacity or treatment space; limited recognition of physiotherapy as a profession, with no autonomy for physiotherapy staff; the low standard of clinical reasoning skills being used in practice; and variable levels of clinical competence, with little evidence of active continuing professional development or appropriate training specific to the needs of clinicians. CONCLUSIONS: The current practice of physiotherapy in Madagascar mirrors the challenge in low-income settings. This study highlights the ongoing needs of the profession, including increasing clinical reasoning skills, updating the physiotherapy curriculum, and further development of multidisciplinary teamwork.IMPLICATIONS FOR REHABILITATIONThere are approximately 300 physiotherapists in Madagascar serving 25.5 million people in a low-income country with a high prevalence of disability.Developing the core training skills of physiotherapists in areas such as clinical reasoning skills, improved multidisciplinary team working, and access to research will allow physiotherapists to deliver a higher level of patient-centred care focused on rehabilitation.Upskilling physiotherapists and improving rehabilitation standards will result in improved functioning and quality of life for people with disabilities.Developments in multidisciplinary team communication and working will lead to interprofessional respect, improved quality of work, and a focus on patient-centred care.

Use and evaluation of assistive technologies for upper limb function in tetraplegia.

CONTEXT: More than half of all spinal cord injuries (SCI) occur at the cervical level leading to loss of upper limb function, restricted activity and reduced independence. Several technologies have been developed to assist with upper limb functions in the SCI population. OBJECTIVE: There is no clear clinical consensus on the effectiveness of the current assistive technologies for the cervical SCI population, hence this study reviews the literature in the years between 1999 and 2019. METHODS: A systematic review was performed on the state-of-the-art assistive technology that supports and improves the function of impaired upper limbs in cervical SCI populations. Combinations of terms, covering assistive technology, SCI, and upper limb, were used in the search, which resulted in a total of 1770 articles. Data extractions were performed on the selected studies which involved summarizing details on the assistive technologies, characteristics of study participants, outcome measures, and improved upper limb functions when using the device. RESULTS: A total of 24 articles were found and grouped into five categories, including neuroprostheses (invasive and non-invasive), orthotic devices, hybrid systems, robots, and arm supports. Only a few selected studies comprehensively reported characteristics of the participants. There was a wide range of outcome measures and all studies reported improvements in upper limb function with the devices. CONCLUSIONS: This study highlighted that assistive technologies can improve functions of the upper limbs in SCI patients. It was challenging to draw generalizable conclusions because of factors, such as heterogeneity of recruited participants, a wide range of outcome measures, and the different technologies employed.

HEART rate variability biofeedback for long COVID symptoms (HEARTLOC): protocol for a feasibility study.

INTRODUCTION: Long COVID (LC), also known as post-COVID-19 syndrome, refers to symptoms persisting 12 weeks after COVID-19 infection. It affects up to one in seven people contracting the illness and causes a wide range of symptoms, including fatigue, breathlessness, palpitations, dizziness, pain and brain fog. Many of these symptoms can be linked to dysautonomia or dysregulation of the autonomic nervous system after SARS-CoV2 infection. This study aims to test the feasibility and estimate the efficacy, of the heart rate variability biofeedback (HRV-B) technique via a standardised slow diaphragmatic breathing programme in individuals with LC. METHODS AND ANALYSIS: 30 adult LC patients with symptoms of palpitations or dizziness and an abnormal NASA Lean Test will be selected from a specialist Long COVID rehabilitation service. They will undergo a 4-week HRV-B intervention using a Polar chest strap device linked to the Elite HRV phone application while undertaking the breathing exercise technique for two 10 min periods everyday for at least 5 days a week. Quantitative data will be gathered during the study period using: HRV data from the chest strap and wrist-worn Fitbit, the modified COVID-19 Yorkshire Rehabilitation Scale, Composite Autonomic Symptom Score, WHO Disability Assessment Schedule and EQ-5D-5L health-related quality of life measures. Qualitative feedback on user experience and feasibility of using the technology in a home setting will also be gathered. Standard statistical tests for correlation and significant difference will be used to analyse the quantitate data. ETHICS AND DISSEMINATION: The study has received ethical approval from Health Research Authority (HRA) Leicester South Research Ethics Committee (21/EM/0271). Dissemination plans include academic and lay publications. TRIAL REGISTRATION NUMBER: NCT05228665.

TEleRehabilitation Nepal (TERN) for People With Spinal Cord Injury and Acquired Brain Injury: A Feasibility Study.

BACKGROUND: Spinal Cord Injury (SCI) or Acquired Brain Injury (ABI) leads to disability, unemployment, loss of income, decreased quality of life and increased mortality. The impact is worse in Low-and Middle-Income Countries (LMICs) due to a lack of efficient long-term rehabilitative care. This study aims to explore the feasibility and acceptability of a telerehabilitation programme in Nepal. METHODS: Prospective cohort feasibility study in a community setting following discharge from a specialist rehabilitation centre in Nepal. Patients with SCI or ABI who had previously accessed specialist rehabilitation were connected to a specialist Multidisciplinary Team (MDT) in the centre through a video conference system for comprehensive remote assessments and virtual individualised interventions. Data were captured on recruitment, non-participation rates, retention, acceptability (via end-of-study in-depth interviews with a subset of participants) and outcome measures including the Modified Barthel Index (MBI), Depression Anxiety Stress Scale (DASS) and EuroQol-5D (EQ-5D), completed pre- and post-programme. RESULTS: 97 participants with SCI (n = 82) or ABI (n = 15) discharged from the centre during an 18-month period were approached and enrolled on the study. The telerehabilitation programme facilitated the delivery of support around multiple aspects of rehabilitation care, such as spasticity treatments and pain management. Outcome measures indicated a significant improvement in functional independence (P < .001), depression, anxiety and stress (P < .001) and quality of life (P < .001). Qualitative interviews (n = 18) revealed participants found the programme acceptable, valuing regular contact and input from MDT professionals and avoiding expensive and lengthy travel. CONCLUSION: This is the first study in Nepal to identify telerehabilitation as a feasible and acceptable approach to augment the provision of specialist rehabilitation. Future research is needed to assess the suitability of the programme for other conditions requiring specialist rehabilitation and determine the mechanisms underpinning improved outcomes for people with SCI or ABI. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04914650.

LOng COvid Multidisciplinary consortium Optimising Treatments and servIces acrOss the NHS (LOCOMOTION): protocol for a mixed-methods study in the UK.

INTRODUCTION: Long COVID, a new condition whose origins and natural history are not yet fully established, currently affects 1.5 million people in the UK. Most do not have access to specialist long COVID services. We seek to optimise long COVID care both within and outside specialist clinics, including improving access, reducing inequalities, helping self-management and providing guidance and decision support for primary care. We aim to establish a 'gold standard' of care by systematically analysing current practices, iteratively improving pathways and systems of care. METHODS AND ANALYSIS: This mixed-methods, multisite study is informed by the principles of applied health services research, quality improvement, co-design, outcome measurement and learning health systems. It was developed in close partnership with patients (whose stated priorities are prompt clinical assessment; evidence-based advice and treatment and help with returning to work and other roles) and with front-line clinicians. Workstreams and tasks to optimise assessment, treatment and monitoring are based in three contrasting settings: workstream 1 (qualitative research, up to 100 participants), specialist management in 10 long COVID clinics across the UK, via a quality improvement collaborative, experience-based co-design and targeted efforts to reduce inequalities of access, return to work and peer support; workstream 2 (quantitative research, up to 5000 participants), patient self-management at home, technology-supported monitoring and validation of condition-specific outcome measures and workstream 3 (quantitative research, up to 5000 participants), generalist management in primary care, harnessing electronic record data to study population phenotypes and develop evidence-based decision support, referral pathways and analysis of costs. Study governance includes an active patient advisory group. ETHICS AND DISSEMINATION: LOng COvid Multidisciplinary consortium Optimising Treatments and servIces acrOss the NHS study is sponsored by the University of Leeds and approved by Yorkshire & The Humber-Bradford Leeds Research Ethics Committee (ref: 21/YH/0276). Participants will provide informed consent. Dissemination plans include academic and lay publications, and partnerships with national and regional policymakers. TRIAL REGISTRATION NUMBER: NCT05057260, ISRCTN15022307.

RETurn to work After stroKE (RETAKE) Trial: protocol for a mixed-methods process evaluation using normalisation process theory.

OBJECTIVES: This mixed-method process evaluation underpinned by normalisation process theory aims to measure fidelity to the intervention, understand the social and structural context in which the intervention is delivered and identify barriers and facilitators to intervention implementation. SETTING: RETurn to work After stroKE (RETAKE) is a multicentre individual patient randomised controlled trial to determine whether Early Stroke Specialist Vocational Rehabilitation (ESSVR) plus usual care is a clinically and cost-effective therapy to facilitate return to work after stroke, compared with usual care alone. This protocol paper describes the embedded process evaluation. PARTICIPANTS AND OUTCOME MEASURES: Intervention training for therapists will be observed and use of remote mentor support reviewed through documentary analysis. Fidelity will be assessed through participant questionnaires and analysis of therapy records, examining frequency, duration and content of ESSVR sessions. To understand the influence of social and structural contexts, the process evaluation will explore therapists' attitudes towards evidence-based practice, competency to deliver the intervention and evaluate potential sources of contamination. Longitudinal case studies incorporating non-participant observations will be conducted with a proportion of intervention and usual care participants. Semistructured interviews with stroke survivors, carers, occupational therapists, mentors, service managers and employers will explore their experiences as RETAKE participants. Analysis of qualitative data will draw on thematic and framework approaches. Quantitative data analysis will include regression models and descriptive statistics. Qualitative and quantitative data will be independently analysed by process evaluation and Clinical Trials Research Unit teams, respectively. Linked data, for example, fidelity and describing usual care will be synthesised by comparing and integrating quantitative descriptive data with the qualitative findings. ETHICS AND DISSEMINATION: Approval obtained through the East Midlands-Nottingham 2 Research Ethics Committee (Ref: 18/EM/0019) and the National Health ServiceResearch Authority. Dissemination via journal publications, stroke conferences, social media and meetings with national Stroke clinical leads. TRIAL REGISTRATION NUMBER: ISRCTN12464275.

What reductions in dependency costs result from treatment in an inpatient neurological rehabilitation unit for people with stroke?

This paper examines the reductions in care costs that result from inpatient multidisciplinary rehabilitation for younger people with acquired brain injury. Thirty-five consecutive patients admitted following a stroke over one year were recruited to this observational study. Physical ability, dependency and potential community care costs were measured on admission and discharge. Fifty-one community-dwelling patients were transferred to rehabilitation from acute medical wards in a large teaching hospital; 35 met the inclusion criteria. After a median of 59 days of rehabilitation, 29 patients were discharged home and six to nursing homes. Patients made highly significant gains in physical ability (median Barthel index 50 to 64; p < 0.001). Dependency decreased; median calculated costs for care were reduced from pounds 1900 to pounds 1100 per week, a saving of pounds 868 per week. Total annualised care costs reduced from pounds 3,358,056 to pounds 1,807,208, a potential saving of pounds 1,550,848. The median time to repay rehabilitation costs was 21 weeks. Savings occurred in those with moderate and severe disability and they have the potential to continue to accrue for over 12 years. Similar results will probably be found for rehabilitation in other forms of acquired brain injury.

Trauma rehabilitation in a teaching hospital in Antananarivo, Madagascar: current provision and patients' perspectives.

Purpose: This study aims to describe the current provision of trauma rehabilitation in Antananarivo, Madagascar and explore the experiences and perspectives of users of this service in order to inform future research and service development.Material and methods: A qualitative study supplemented by a descriptive service review were applied in the central government hospital in Antananarivo. Registers in the rehabilitation department were analyzed for a 3 month period. Semi-structured interviews were conducted with a convenience sample of users of the rehabilitation service and were subject to thematic analysis.Results: One in six patients treated in the rehabilitation department has survived a traumatic injury, with limb injuries comprising the majority. Analysis of interviews with 10 adult patients, following traumatic injuries to the lower limbs (6), upper limbs (3) or polytrauma (1) generated seven broad themes: health seeking behavior, organization of services, clinical management, costs and financial impact, effect on function and role, psychological impact and societal attitudes.Conclusions: Financial constraints and impact on personal finances pervade the overall picture. The perspectives and experiences elucidated will inform future research into the development of context-specific models of care for people with trauma-related disabilities in Madagascar.Implications for rehabilitationPotentially treatable traumatic injury can have a profound effect on function and societal participation in Madagascar.Interventions to increase access to timely acute trauma care and rehabilitation are needed, and may include different models of financing and innovations to reduce materials costs and length of stay.A structured rehabilitation pathway must be integrated to the earliest stages of trauma care, including scrutinizing the use of prolonged immobilization.Consideration should be given to models of care which are financially and geographically accessible to the population.