The Stanford Hall consensus statement for post-COVID-19 rehabilitation.

The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0-10. Substantial agreement (range 7.5-10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Reducing Intrathecal Baclofen Related Infections: Service Evaluation and Best Practice Guidelines.

OBJECTIVES: Intrathecal baclofen (ITB) pumps are an effective treatment for spasticity; however infection rates have been reported in 3-26% of patients in the literature. The multidisciplinary ITB service has been established at The National Hospital for Neurology and Neurosurgery, UCLH, Queen Square, London for over 20 years. Our study was designed to clarify the rate of infection in our ITB patient cohort and secondly, to formulate and implement best practice guidelines and to determine prospectively, whether they effectively reduced infection rates. METHODS: Clinical record review of all patients receiving ITB pre-intervention; January 2013-May 2015, and following practice changes; June 2016-June 2018. RESULTS: Four of 118 patients receiving ITB during the first time period (3.4%, annual incidence rate of infection 1.4%) developed an ITB-related infection (three following ITB pump replacement surgery, one after initial implant). Infections were associated with 4.2% of ITB-related surgical procedures. Three of four pumps required explantation. Following change in practice (pre-operative chlorhexidine skin wash and intraoperative vancomycin wash of the fibrous pocket of the replacement site), only one of 160 ITB patients developed infection (pump not explanted) in the second time period (0.6%, annual incidence rate 0.3%). The infection rate related to ITB surgical procedures was 1.1%. In cases of ITB pump replacement, the infection rate was reduced to 3.3% from 17.6%. CONCLUSIONS: This study suggests that a straightforward change in clinical practice may lower infection rates in patients undergoing ITB therapy.

Long-term employment outcomes following rehabilitation for significant neurological impairment in UK military personnel: a 3-year study.

BACKGROUND: Returning to employment is a major modifiable factor affecting long-term health in brain injury which neurological and vocational rehabilitation attempts to address. In military patients, little is known about long-term employability, whether employment is sustained and how they fare in civilian roles. METHODS: A telephone review was undertaken of every military patient having undergone inpatient neurorehabilitation between 2012 and 2014. This was compared to their employment outcomes one to three years post discharge. We further evaluated whether this employment was sustained over successive years in the same patients. Finally, we identify those rehabilitation interventions deemed most influential in improving employment outcomes in brain injury. RESULTS: During this period, an average of 57 (51-61) such patients were discharged each year. A review conducted by telephone successfully contacted 46% (43%-49% across cohorts) of all possible patients; 71.4% (64-81) returned to work increasing to 80.7% (76-85) including those training/actively seeking-work. Overall, 31.7% (24-40) returned to full-time military-in those leaving, 89.6% (85.4-90.9) were discharged for medical reasons. Severity of brain injury was unrelated to successful employment; 63.6%/78.6% had the same vocational outcome over two consecutive years while 36.3%/21.4% showed improved outcomes. DISCUSSION: Despite significant brain/neurological injury (graded by severity/Mayo Portland Adaptability Inventory 4), 80.7% (76-85) were working/training 2/3 years postdischarge from neurorehabilitation with 31.7% returning to full-time military role. Inability to continue within the military was not synonymous with inability to work. Return to work was independent of severity of brain/neurological injury and follow-up over consecutive years demonstrated sustained employment. The argument against inpatient neurorehabilitation has always been cost> This 3-year analysis reinforces that patients can and most likely will return to employment with all the benefits this brings to person/family/society. Vocational rehabilitation is therefore recommended for all brain/neurological injury.

Changing clinical patterns in rheumatoid arthritis management over two decades: sequential observational studies.

BACKGROUND: Rheumatoid arthritis (RA) treatment paradigms have shifted over the last two decades. There has been increasing emphasis on combination disease modifying anti-rheumatic drug (DMARD) therapy, newer biologic therapies have become available and there is a greater focus on achieving remission. We have evaluated the impact of treatment changes on disease activity scores for 28 joints (DAS28) and disability measured by the health assessment questionnaire scores (HAQ). METHODS: Four cross-sectional surveys between 1996 and 2014 in two adjacent secondary care rheumatology departments in London evaluated changes in drug therapy, DAS28 and its component parts and HAQ scores (in three surveys). Descriptive statistics used means and standard deviations (SD) or medians and interquartile ranges (IQR) to summarise changes. Spearman's correlations assessed relationships between assessments. RESULTS: 1324 patients were studied. Gender ratios, age and mean disease duration were similar across all cohorts. There were temporal increases in the use of any DMARDs (rising from 61% to 87% of patients from 1996-2014), combination DMARDs (1% to 41%) and biologic (0 to 32%). Mean DAS28 fell (5.2 to 3.7), active disease (DAS28 > 5.1) declined (50% to 18%) and DAS28 remission (DAS28 < 2.6) increased (8% to 28%). In contrast HAQ scores were unchanged (1.30 to 1.32) and correlations between DAS28 and HAQ weakened (Spearman's rho fell from 0.56 to 0.44). CONCLUSIONS: Treatment intensity has increased over time, disease activity has fallen and there are more remissions. However, these improvements in controlling synovitis have not resulted in comparable reductions in disability measured by HAQ. As a consequence the relationship between DAS28 and HAQ has become weaker over time. Although the reasons for this divergence between disease activity and disability are uncertain, focussing treatment entirely in suppressing synovitis may be insufficient.

Injury severity at presentation is not associated with long-term vocational outcome in British Military brain injury.

INTRODUCTION: Injury Severity Score (ISS) and GCS can be retrospective markers of injury severity, but if used by clinicians to decide on the treatment of acutely brain-injured casualties at the point of injury may potentially limit interventions on people who may ultimately survive with good functional outcomes. METHODS: ISS/GCS and long-term outcomes were reviewed by assessing all UK military neurorehabilitation patients with an operational/combat brain injury treated over 4 years (February 2008-July 2012) at Defence Medical Rehabilitation Centre (Headley Court). RESULTS: 34 participants from 9 operational tours of Iraq and Afghanistan were analysed. Overall, 44% of injuries were due to improvised explosive devices (IEDs) and 41% from gunshot wounds; 70.9% of injuries were penetrating wounds with the remainder due to blast/blunt trauma or combined injury. The primary injury was head/neck in 76.5%, although eight patients (23.4%) requiring neurorehabilitation were initially 'non-head injury'. Eight patients (26.5%) sustained more than 10 injuries, and 18 had between three and nine injuries. Eleven patients (32%) had an initial GCS of 3, and 16 (47%) had ISS of 75 (deemed 'unsurvivable'). All patients with ISS of 75 were long-term survivors. At 4 months after discharge, 47% (16) were fully independent, and a further 41% (14) were independent in own homes, but needed assistance with some activities, such as paying bills. Over three-quarters (27 patients, 79%) returned to full/part-time work, 11 of whom returned to military duties; 93% of 'unsurvivable' ISS, and 91% of patients with GCS of 3 were capable of returning/returned to work. In total, 7/11 casualties returning to military duties had major trauma ISS, and two were 'unsurvivable'. All seven casualties with both GCS 3 and ISS 75 survived and returned to independence (help with some activities). CONCLUSIONS: ISS/GCS at the point of injury does not reflect eventual outcome. IEDs/gunshots cause the greatest number of injuries and the highest incidence of brain injury. Brain injury should be considered in every battlefield casualty, irrespective of whether the head/neck/spinal cord was avoided. ISS should not be considered indicative or predictive of long-term prognosis/quality of life/employability as brain injury in this small cohort is both survivable and recoverable. It should not be used as a retrospective guide to alter treatment pathways, as there is poor correlation with long-term outcome. Subsequent neurorehabilitation should always be considered because survival, return to independence and full employment are very likely.