Scope, context and quality of telerehabilitation guidelines for physical disabilities: a scoping review.

OBJECTIVE: To identify the available guidance and training to implement telerehabilitation movement assessments for people (adults and children) with a physical disability, including those recovering from COVID-19. DESIGN: Rapid scoping review. INCLUDED SOURCES AND ARTICLES: PubMed, CINAHL, PsychInfo, Cochrane, Embase, Web of Science, PEDro, UK Health Forum, WHO, National Archives and NHS England were searched using the participant-concept-context framework from 2015 to August 2020. Primary studies that recruited individuals with physical disabilities and guidance documents aimed at providers to implement movement-related telerehabilitation were included. RESULTS: 23 articles (11 primary research studies, 3 systematic reviews and 9 guidance documents) were included out of 7857 that were identified from the literature search. Two main issues were found: (1) telerehabilitation guidance (from both research studies and guidance documents) was not specific to movement-related assessment and (2) most primary research studies provided neither guidance nor training of movement-specific assessment to practitioners. Of the COVID-19 related guidance, two articles reported COVID-19 management that only referred to identifying COVID-19 status without references to specific movement-related guidance. CONCLUSIONS: Telerehabilitation guidance and training have existed pre-COVID-19, yet the lack of specific movement-related information and provider support is surprising. This gap must be addressed to optimise effective implementation of remote assessments for those with physical disabilities. REVIEW REGISTRATION: Open Science Framework: osf.io/vm6sp.

A consensus process to agree best practice for managing physical wellbeing in people with a prolonged disorder of consciousness.

BACKGROUND: Current practice for physical wellbeing of people in a Prolonged Disorder of Consciousness (PDOC) is variable. A scoping literature review identified no agreed standard of care for physical management of those in a PDOC. This study addressed this deficit using a consensus process applied using nominal group technique. AIM: The aims of this project were to promote best practice for physical management in PDOC, by identifying consensus for: 1) a pathway of care; and 2) current best practice recommendations. DESIGN: A consensus process using nominal group technique. SETTING: Representation from national, purposively selected, rehabilitation services assessing and managing people in a PDOC in the UK. POPULATION: The population to whom the consensus process relates are people in a PDOC, requiring physical management. METHODS: An initial meeting with selected clinical experts from national centres was conducted to set terms of reference. A consensus meeting using nominal group technique (N.=33) then followed. Experts were initially asked to review systematic review findings reproduced as statements. Following systematic refinement, they were then asked to vote on the importance and relevance of statements. RESULTS: Following the nominal group process, 25 initial recommendations were refined to 19, which expressed the principles of physical management for people with a Prolonged Disorder of Consciousness. Statements are grouped into "acute-care" (6-recommendations), "postacute care" (10-recommendations) and "long-term care" (3-recommendations). Across the participants, agreement with the final recommendation statements ranged from 100-61% (N.=33-20), 15 of the statements were supported by 85% or more experts (N.=29). In addition, a clinical pathway of care, incorporating the recommendation principles was produced (agreement from 28 experts, 83%). CONCLUSIONS: The recommendations provide a basis for standardising current practice. They provide a standard against which care, and effectiveness can be evaluated. An accessible guideline document is planned for publication to enable implementation into practice, supported by online resources. CLINICAL REHABILITATION IMPACT: Recommendations have been produced under the headings of "acute care," "postacute care" and "long-term care." In addition, a pathway for provision of care interventions has been identified for the physical management of people in a prolonged disorder of consciousness.

Minimum data set to measure rehabilitation needs and health outcome after major trauma: application of an international framework.

BACKGROUND: Measurement of long term health outcome after trauma remains non-standardized and ambiguous which limits national and international comparison of burden of injuries. The World Health Organization (WHO) has recommended the application of the International Classification of Function, Disability and Health (ICF) to measure rehabilitation and health outcome worldwide. No previous poly-trauma studies have applied the ICF comprehensively to evaluate outcome after injury. AIM: To apply the ICF categorization in patients with traumatic injuries to identify a minimum data set of important rehabilitation and health outcomes to enable national and international comparison of outcome data. DESIGN: A mixed methods design of patient interviews and an on-line survey. SETTING: An ethnically diverse urban major trauma center in London. POPULATION: Adult patients with major traumatic injuries (poly-trauma) and international health care professionals (HCPs) working in acute and post-acute major trauma settings. METHODS: Mixed methods investigated patients and health care professionals (HCPs) perspectives of important rehabilitation and health outcomes. Qualitative patient data and quantitative HCP data were linked to ICF categories. Combined data were refined to identify a minimum data set of important rehabilitation and health outcome categories. RESULTS: Transcribed patient interview data (N.=32) were linked to 234 (64%) second level ICF categories. Two hundred and fourteen HCPs identified 121 from a possible 140 second level ICF categories (86%) as relevant and important. Patients and HCPs strongly agreed on ICF body structures and body functions categories which include temperament, energy and drive, memory, emotions, pain and repair function of the skin. Conversely, patients prioritised domestic tasks, recreation and work compared to HCP priorities of self-care and mobility. Twenty six environmental factors were identified. Patient and HCP data were refined to recommend a 109 possible ICF categories for a minimum data set. CONCLUSIONS: The comprehensive measurement of health outcomes after trauma is important for patients, health professionals and trauma systems. An internationally applied ICF minimum data set will standardize the language used and concepts measured after major trauma to enable national and international comparison of outcome data. CLINICAL REHABILITATION IMPACT: A minimum ICF data set for trauma will standardize rehabilitation language and provide a minimum dataset to capture outcome in trauma systems to enable comparison and service improvement.

A qualitative description of falls in a neuro-rehabilitation unit: the use of a standardised fall report including the International Classification of Functioning (ICF) to describe activities and environmental factors.

PURPOSE: Falls are a recognised problem for people with long-term neurological conditions but less is known about fall risk in young adults. This study describes fallers' and falls' characteristics in adults less than 60 years old, in a neuro-rehabilitation unit. METHODS: This single-centre, longitudinal, observational study included 114 consecutive admissions to a UK neuro-rehabilitation unit over 20 months. The demographic and clinical characteristics of eligible patients included age, sex, diagnosis, hospital length of stay and the Functional Independence Measure (FIM). Falls were recorded prospectively in a fall report, using the activities and environmental domains of the International Classification of Functioning (ICF). RESULTS: A total of 34 (30%) patients reported a fall, with 50% experiencing more than one fall. The majority of falls (60%) occurred during the first 2 weeks, during day-time (90%) and during mobile activities (70%). Overall, falls rate (95% confidence interval) was 1.33 (1.04 to 1.67) per 100 d of patient hospital stay. Factors associated with increased falls included becoming a walker during admission or being cognitively impaired. There were no serious fall-related injuries. CONCLUSION: The first 2 weeks of admission is a high risk time for fallers, in particular those who become walkers or are cognitively impaired. Prevention policies should be put in place based on fall characteristics. Implications for Rehabilitation The ICF is a valuable instrument for describing subject and environmental factors during a fall-event. Falls are frequent events but do not usually cause serious injuries during inpatient rehabilitation. There is an increased fall risk for subjects with cognitive impairments or those relearning how to walk.

The risk of falling in young adults with neurological conditions: a systematic review.

PURPOSE: To review systematically the literature on fall risk factors for young patients affected by neurological disorders. METHOD: A systematic search of all primary research-based literature on risk factors for falls or fall characteristics in young adults (mean age <55 years) published prior to July 2012 was conducted using 11 databases. Studies that focused on fall risk screening tools, fear of falling or interventions for fall prevention were excluded. Two reviewers independently agreed on eligibility and methodological quality and extracted data. RESULTS: Twenty-three final studies were selected, including 21 observational studies; one randomised controlled trial and one qualitative study. An average of 50.2% of the 2776 total participants experienced at least one fall. Among the multiple risk factors studied, a reduced performance in balance and gait was consistently associated with falls, while the contribution of single physical and cognitive impairments was variable in different populations. Walking aids, wheelchair characteristics and environmental hazards are significant environmental risk factors. The heterogeneity of the assessment tools used to measure risk factors limited comparison across studies. CONCLUSION: Falling is a common problem among young patients affected by neurological disorders, although the risk of falling for a specific individual is difficult to predict and the risk of a severe fall-related injury has not yet been established. IMPLICATIONS FOR REHABILITATION: Young patients with impaired gait and balance or medium to severe motor disability appear to be at increased risk of falling. Patients who are relatively independent and still participating in challenging activities have an increased exposure to fall-risk. Walking aids, wheelchair characteristics and environmental hazards are significant environmental risk factors. These risk factors should be monitored closely in the young neurological population to help prevent falls.

Measuring acute rehabilitation needs in trauma: preliminary evaluation of the Rehabilitation Complexity Scale.

BACKGROUND: Injury severity, disability and care dependency are frequently used as surrogate measures for rehabilitation requirements following trauma. The true rehabilitation needs of patients may be different but there are no validated tools for the measurement of rehabilitation complexity in acute trauma care. The aim of the study was to evaluate the potential utility of the Rehabilitation Complexity Scale (RCS) version 2 in measuring acute rehabilitation needs in trauma patients. METHODS: A prospective observation study of 103 patients with traumatic injuries in a Major Trauma Centre. Rehabilitation complexity was measured using the RCS and disability was measured using the Barthel Index. Demographic information and injury characteristics were obtained from the trauma database. RESULTS: The RCS was closely correlated with injury severity (r=0.69, p<0.001) and the Barthel Index (r=0.91, p<0.001). However the Barthel was poor at discriminating between patients rehabilitation needs, especially for patients with higher injury severities. Of 58 patients classified as 'very dependent' by the Barthel, 21 (36%) had low or moderate rehabilitation complexity. The RCS correlated with acute hospital length of stay (r=0.64, p=<0.001) and patients with a low RCS were more likely to be discharged home. The Barthel which had a flooring effect (56% of patients classified as very dependent were discharged home) and lacked discrimination despite close statistical correlation. CONCLUSION: The RCS outperformed the ISS and the Barthel in its ability to identify rehabilitation requirements in relation to injury severity, rehabilitation complexity, length of stay and discharge destination. The RCS is potentially a feasible and useful tool for the assessment of rehabilitation complexity in acute trauma care by providing specific measurement of patients' rehabilitation requirements. A larger longitudinal study is needed to evaluate the RCS in the assessment of patient need, service provision and trauma system performance.

Does self-reported well-being of patients with Parkinson's disease influence caregiver strain and quality of life?

BACKGROUND: The impact of Parkinson's disease (PD) on the quality of life of both patients and their carers has not been well documented. OBJECTIVE: This study describes the health status of both PD patients and caregivers as measured on a generic measure of health status (SF-12), and then explores to what extent patient self-reported health, as measured on the disease-specific Parkinson's Disease Questionnaire (PDQ-39), is associated with carer strain and self-reported quality of life. METHODS: A postal survey was carried out of both patients and caregivers through local branches of Parkinson's UK. Questionnaire packs were sent to those on the database with a diagnosis of PD. The patient was asked to give the carer questionnaire to their main caregiver, if they had one. RESULTS: Results from the SF-12 suggests that PD has substantial adverse effects on both the physical and mental well-being of patients when compared with population norms. While carer physical health was not found to be substantially different from that of the general population, emotional health was lower than that of the general population. Furthermore, results suggest that the self-reported health status of PD patients is associated with higher levels of caregiver strain and poorer emotional health. CONCLUSION: PD impacts on both the well being of both patients and caregivers; the data provide evidence that the health status of the patient, in particular their physical health, has a significant impact on the well-being of their caregiver.

An unusual case of myocardial infarction.

POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, skin changes) syndrome is a rare haematological condition with a constellation of clinical features that can present to the clinician in a variety of ways. This case highlights how a seemingly uncomplicated myocardial infarction can herald the development of this rare haematological disorder. While knowledge of the pathophysiological mechanisms that underpin POEMS syndrome is developing, so too are the diagnostic and treatment strategies available to the clinician.

Outcome measurement in neurological disease.

PURPOSE OF REVIEW: Recent publications have focused on the possibilities that neuroscience offers patients in terms of restoring neurological function after trauma or disease. This review highlights the contribution that sophisticated outcome measurement techniques can make to the accurate evaluation of these. RECENT FINDINGS: Recent studies have focused on the role of patient-reported outcomes and their importance in the design of trials to evaluate interventions. Work is focusing on developing banks of measurement items that can be accessed using computers. Algorithms then minimize the number of items that need to be answered by an individual before an accurate measure is obtained, which can be accessed by patients. SUMMARY: Patient-reported outcomes, item banking, and computerized adaptive testing have the potential to change the way we evaluate outcome, placing individualized testing and meaningful outcome at the heart of both research and clinical care.

Trunk movement in Parkinson's disease during rising from seated position.

Parkinson's disease (PD) is associated with particular difficulties rising from a seated position. Little is known about the mechanisms of sit-to-stand in this condition. We sought to define trunk movement during sit-to-stand in a group of patients with PD. Six patients and seven normal volunteers were studied using a six camera ELITE motion analysis system (BTS, Milan, Italy), which permitted data collection in the coronal, sagittal, and transverse planes. Retroreflective markers were positioned along the spine at C7, T3, T6, T9, T12, L3, and the sacrum. Whole-trunk kinematics and the movement at the six different trunk markers were recorded during rising. PD patients have a significantly greater degree of trunk flexion than controls, showing a significant increase in angular velocity of the trunk in the sagittal plane. The total range of movement of trunk rotation was significantly smaller in the PD group, but lateral movement in the trunk was greater than normal. These data suggest that patients with early PD compensate for their difficulties rising from a chair by generating greater trunk flexion at higher angular velocity, thus developing greater forward momentum. This process results in a decrease in the duration of the unstable transitional phase of sit-to-stand, allowing PD patients to reach the upright position as easily and safely as possible. Small rotational movements are an effective way to maintain the centre of mass within the base of support during sit-to-stand. This mechanism appears to be denied to the PD patients who may use increased movements in the coronal plane as an alternative strategy.