Prolonged disorders of consciousness: identification using the UK FIM + FAM and cohort analysis of outcomes from a UK national clinical database.

PURPOSE: 1: To determine whether Total UK FIM + FAM scores can identify patients in VS/MCS. 2: Using the identified cut-off points, to examine outcomes from specialist rehabilitation. METHODS: Part 1: Retrospective analysis of a consecutive clinical cohort (n = 388) presenting to a single specialist PDOC evaluation programme 2007-2021. FIM + FAM scores were analysed by PDOC diagnosis to define cut-off points for vegetative (VS) and minimally conscious states (MCS). Part 2: Multicentre cohort analysis of prospectively-collected clinical outcomes data from the UK Rehabilitation Outcomes Collaborative database of adults in PDOC registered 2011-2020 (n = 2384 in 68 centres). RESULTS: Cut-off points of ≤31 and 32-35 in FIM + FAM total scores respectively identified patients in VS/MCS-Minus and MCS-Plus. Approximately 365 PDOC patients are admitted to specialist rehabilitation units in England each year. By discharge, 43% have emerged into consciousness and demonstrate a wide range of disability. A few reached full independence, but the majority remained severely dependent. Nevertheless, those who emerged generated mean net life-time savings of over £436,000 (£400 million for this cohort). CONCLUSION: In absence of a dedicated PDOC registry, FIM + FAM scores can identify patients in VS/MCS at population level. Identifying those who emerge and providing timely rehabilitation generates cost-savings well-exceeding the cost of the evaluation/rehabilitation programme.Implications for rehabilitationThe UK National Health Service currently collects no systematic data to identify patients in PDOC, so we have no accurate information on how many patients there are, where they are managed or what their outcomes are.In the absence of more direct data, total FIM + FAM scores of < =31 and 32-35 respectively can be used to identify patients in vegetative and minimally conscious states.Of the 365 or so patients admitted to specialist rehabilitation units per year, 43% emerge into consciousness leaving about 150 patients per year in PDOC states that are likely to be permanent.Identifying those who emerge and providing timely rehabilitation generates cost-savings that pay for the entire PDOC evaluation/rehabilitation programme many times over.

Ultrasound image guided injection of botulinum toxin for the management of spasticity: A Delphi study to develop recommendations for a scope of practice, competency, and governance framework.

Objective: To establish a scope of practice, competency (through education) and governance framework for ultrasound image guided injection of botulinum toxin in the management of spasticity. Design: Delphi study. Setting: International, web-based survey. Participants: A purposively selected multidisciplinary (physicians, physiotherapists, occupational therapists) panel of experts (n=15) in the use of ultrasound image guided injection of botulinum toxin for management of spasticity. Panel members were predominantly based in the UK (11/15). Interventions: In round 1, open-ended questions were posed relating to potential scope of practice for 'ultrasound imaging in spasticity management'; (specifically relating to ultrasound image guided injection of Botulinum Toxin) education/competency and governance considerations. In round 2, respondents were asked to rate their level of agreement with the statements generated. Outcome measures: 5-point Likert scale used for rating the statements. Threshold for consensus agreement was set at 70% or above. Results: Three different scopes of practice relating to ultrasound imaging in spasticity management were accepted. The primary scope of practice was the use of ultrasound imaging to guide safe and accurate delivery of botulinum toxin. Relating to this primary scope, 7 competency requirements were agreed relating to areas including image optimization and interpretation, needle visualization and safety. A singular, broad governance statement was generated. Conclusion: Relating specifically to guided injection of botulinum toxin for management of spasticity, we present a scope of practice, competency, and governance framework. These are integrated within a framework approach to provide a mechanism for increased patient access to accurate, safe, and effective focal spasticity treatment. The framework supports focused training routes, greater inter-profession communication and wider clinical community engagement in spasticity management using this modality.

The Leg Activity measure, a new measure of passive and active function and impact on quality of life; informing goal setting and outcome evaluation in leg spasticity.

PURPOSE: Application of the Leg Activity measure in acquired brain injury spasticity intervention to identify areas for goal setting prior to treatment, document the treatments applied and evaluate outcome. METHODS: A prospective cohort from three specialist spasticity management centres was used. Primary outcome measures were, Leg Activity Measure, Modified Ashworth Scale and Goal Attainment Scaling - light. Measurement was completed at baseline, 6 and 12 weeks. The Leg-Therapy recording Schedule was used to record physical therapy intervention. RESULTS: Participants (n = 64) included had a mean age of 51 (18-84) years, half (n = 32) were men. Significant changes were demonstrated over the 12-week period in MAS (Xr2 = 35.4; p < 0.001), the Leg Activity passive function scale (Xr2 = 32.2; p < 0.001) (e.g., improved ease of dressing, hygiene) and Leg Activity impact on quality of life scale (Xr2 = 32.2; p < 0.001). No change was identified in the Leg Activity active function scale. Goal achievement was demonstrated at 6 weeks and further improved at 12 weeks (Xr2 = 65.7; p < 0.001) and was associated with change in the relevant scale. Physical interventions were captured at each time-point. DISCUSSION: Significant gains in passive-function and quality-of-life were recorded by the Leg Activity measure scales at 6 weeks, and at 12 weeks post-injection in the context of on-going physical treatment, primarily by self-management.Implications for rehabilitationThe Leg Activity measure is able to detected changes in passive function and impact on quality of life.Measurement of change in active function is also likely to be detected, but was not seen in the cohort studied.The Leg Activity measure was effective in this study in identifying problem areas to enable setting of treatment goals and planning of treatment intervention.

Psychometric evaluation of the leg activity measure (LegA) for outcome measurement in people with brain injury and spasticity.

PURPOSE: The aim of this study is to evaluate the properties of the Leg Activity measure according to COnsensus-based Standards for the selection of health Measurement INstruments. METHOD: Participants were assessed at baseline, one day, 6 weeks and 12 weeks, following treatment for leg spasticity with botulinum toxin and physical interventions. RESULTS: In stage 1, 64 participants were recruited to evaluate the initial psychometric properties of Leg Activity measure. In stage 2, 100 additional participants were recruited, to evaluate the scaling properties. Total sample of 164 participants was used. Construct validity was supported for "passive function", "active function" and "impact on quality of life". Cronbach's alpha was 0.86, 0.97 and 0.87 respectively for the scales. Item level test-retest agreement ranged from 91-97% (Kappa 0.75-0.95). Following treatment for spasticity (n = 64), the Leg Activity measure "passive function" and "impact on life" scales were responsive to change. Principal components analysis confirmed the constructs and a unidimensional Rasch Partial Credit Model was subsequently established for each scale. Transformation to an interval scale was achieved. Using the ordinal-to-interval conversion tables, parametric statistical analysis may be used. CONCLUSION: The study provides support for the Leg Activity measure being valid, reliable and responsive.Implications for rehabilitationThe Leg Activity measure is the only published self-report measure in the current literature that addresses passive and active function as well as impact on quality of life, of the paretic leg in a comprehensive manner.The initial evaluation of Leg Activity measure psychometric properties, in relation to the COnsensus-based Standards for the selection of health Measurement INstruments checklist and Medical Outcomes Trust Quality Criteria, supports its measurement properties for clinical and research use.The Leg Activity measure as a valid, reliable and responsive tool for the evaluation of treatment in leg spasticity including condition specific (spasticity) quality-of-life.