E. Diane Playford

Areas of consensus and controversy about goal setting in rehabilitation: a conference report

Objective: To consider clinical issues surrounding goal setting in neurological rehabilitation, and to identify priorities for future research. Participants: Twenty-four rehabilitation professionals were invited to attend because they had taught or published on the topic of goal setting. In addition two patient groups were represented. Evidence: (1) The results of a systematic literature review, (2) presentations given during the two-day conference by investigators working within the field of goal setting, (3) questions and statements from conference attendees during open discussion, (4) a report initially formulated by a panel composed of four of the conference attendees, and then circulated to all attendees for comment, (5) views of the conference attendees gathered using a modified Delphi technique. Consensus: There were significant areas of consensus about goal setting. The Delphi studies highlighted and confirmed these areas of general agreement with consensus that goal setting is a core component of the rehabilitation process, and that goals should be specific, ambitious, relevant and time limited, with incremental steps that lead to progressive achievement. It was also agreed that that goal setting has a major impact on the relationship between patient and professional, with the availability of professional time and expertise being key to the success of the process. Controversy: Areas in which there was more controversy centred on the evaluation of goal achievement and the benefits of ambitious rather than achievable goals. The need for patient-centred goal setting was recognized, although it was felt at times that there were conflicts that prevented this being attainable.

Systematic review of paramedical therapies for Parkinson's disease

We evaluated the efficacy of physiotherapy, occupational therapy, and speech and language therapy in Parkinsons disease by synthesizing six Cochrane systematic reviews. All randomised, controlled trials examining the efficacy of a paramedical therapy versus control intervention and all those comparing the efficacy of two forms of active therapy in Parkinsons disease were included. Trials were identified by searching biomedical databases, reference lists, hand searching, and contacting investigators. The main outcome measures were quality of life, speech intelligibility, activities of daily living, and individual measures of motor and speech impairment. We identified 16 physiotherapy randomised controlled trials (399 patients), two occupational therapy trials (84 patients), and five speech and language therapy for dysarthria trials (154 patients). None of these studies examined nonpharmacological swallowing therapy for dysphagia. We were unable to perform meta‐analysis of the results because the trials used heterogeneous therapy methods and outcome measures. The trials also had marked methodological flaws that could have introduced bias. In summary, we failed to find conclusive evidence of benefit for any form of paramedical therapy sufficient to recommend them in routine clinical practice. However, this lack of evidence is not proof of a lack of effect. Further large pragmatic randomised controlled trials are required to determine the effectiveness of paramedical therapies in Parkinsons disease.

Should patients participate in clinical decision making? An optimised balance block design controlled study of goal setting in a rehabilitation unit

Objectives: The recent National Service Framework for Long Term Conditions recommends that patients participate more in decision making about their care. However, few protocols exist to support this. One potentially useful method is goal setting, but little has been done to evaluate the added value of increasing patient participation in this way. Therefore, this study examined the impact of an increased participation goal setting protocol in a neurorehabilitation setting. Design: The study was an AB optimised balance block design with each block lasting 3 months, over an 18 month period. Setting and participants: Patients (n = 201) were recruited from an inpatient neurological rehabilitation unit. Interventions: Patients (n = 100) recruited in phase A were involved in “usual practice” goal setting. Patients (n = 101) recruited in phase B were involved in “increased participation” goal setting, which included a protocol to help them define and prioritise their own goals. Main outcome measures: Patients’ perceptions of the relevance of goal setting and their autonomy within the process; the number, type and outcome of goals; and level of functional ability. Results: Phase B patients (“increased participation”) set fewer goals, of which significantly more were participation related. These patients perceived the goals to be more relevant, and expressed greater autonomy and satisfaction with goal setting. There were no differences in functional outcomes between the groups. Conclusion: This study has shown that patients prefer increased participation in the goal setting process over standard procedures, perceiving their goals as more relevant and rehabilitation more patient centred despite the absence of functional gains. Effective patient centred care can be realised by using structures that help support patients to identify and communicate their priorities. As such, our findings suggest patients would benefit from greater participation in this aspect of clinical decision making.

A survey of goal-setting methods used in rehabilitation

Objectives. This survey provides a description of the goal-setting methods that are currently being used in community and inpatient rehabilitation centers across the United Kingdom. Given current policy, emphasis was placed on finding out how much patient involvement in the goal-setting process exists, concentrating on how such involvement may be facilitated. Design. A postal survey design was used to access a large sample size over a broad geographical area. The questionnaire was piloted at a British Society for Rehabilitation Medicine (BSRM) meeting; subsequently, some response categories were expanded. The questionnaire was approved by the BSRM Research and Clinical Standards committee. Questionnaires were coded to track responses from individuals. The received data were anonymized and analyzed using a statistics package for social science (SPSS) database. Subjects. Members of the BSRM were selected for this survey because this represents one of the most comprehensive listings of rehabilitation services in the United Kingdom. Results. The survey had a 60% response rate. A problem-orientated approach to goal setting was most commonly reported, with rehabilitation teams defining, formulating, and evaluating the goals. Patients were supplied with limited information about goal setting during their rehabilitation admission, although 60% of respondents reported giving patients a copy of their goals. Thirty percent of respondents used goals as a measure of rehabilitation effectiveness. Standardized goal-setting measures were not commonly used. Conclusion. These data demonstrate that individual disciplines tend to discuss potential goals with their patients during treatment sessions and then formulate goals on the basis of the discussion. There is scope to develop and refine the approach to goal setting so the patients have more opportunities to engage in the goal-setting process.

The vestibular control of balance after stroke

Objectives: To examine vestibular control of balance in those who recovered the ability to stand after middle cerebral artery (MCA) stroke. Methods: Sixteen patients with MCA stroke were compared with 10 age matched controls. Two additional patients were studied with isolated corticospinal tract lesions, one each at the level of the pons and medulla. Vestibular evoked postural responses were obtained using galvanic vestibular stimulation (GVS) while patients stood with their eyes closed and head facing forwards, equally loading both legs. The GVS response was characterised by measuring the amplitude of the stimulus evoked lateral forces acting through each leg and the lateral displacement of the axial skeleton. Results: Lateral displacement and net lateral force following GVS were significantly larger after stroke. Unlike controls, the lateral forces in the stroke group were asymmetrical, being enhanced on the side of the non-paretic limb and small on the side of the paretic limb. The degree of GVS evoked asymmetry correlated with corticospinal damage assessed using transcranial magnetic stimulation. A similar asymmetrical response was seen in the patient with the pontine lesion but not the patient with the medullary lesion. Conclusions: MCA stroke may disrupt corticobulbar projections to brainstem output pathways involved in vestibular control of balance. These projections are either collaterals of the corticospinal tract or lie close to that tract and terminate in the pons/upper medulla. This hypothesis accounts for the association between corticospinal tract damage and GVS response asymmetry, and the lack of GVS evoked asymmetry with corticospinal lesions below the rostral medulla.

Outcome Measurement in Stroke A Scale Selection Strategy

Background and Purpose— Evaluating the impact of new treatments requires the use of reliable, valid, and responsive outcome measures. However, given the wide range of instruments currently available, it is not always straightforward for healthcare professionals to select the most appropriate tool. In this review, we propose a potential approach to scale selection. Methods— In designing a new study of the impact of a robotic device in stroke rehabilitation, we developed a three-stage scale selection strategy. First, two guidance documents (Medical Outcome Trust and Food and Drug Administration PRO Guidance) were reviewed to identify key scale assessment criteria. Second, consideration was given at a theoretical level of the concepts and domains relevant to the goals our study. Third, a comprehensive literature search strategy and review were developed in conjunction with healthcare professionals and psychometricians. Identified scales were appraised regarding their psychometric properties and clinical content. Results— Forty-five measures were initially identified and appraised. From a clinical content perspective, none of the measures were considered to be sufficient on their own to capture all the important outcome domains in this study. However, 3 measures were identified that best met our review criteria: Stroke Rehabilitation Assessment of Movement, Chedoke Arm and Hand Inventory, and ABILHAND. After the final stage of scale appraisal, two further upper limb scales (Fugl-Meyer and Action Research Arm Test) were included based on clinical content and study design issues. Conclusions— Our three-stage review process appears to be a potentially useful approach for evidence-based scale selection in stroke rehabilitation studies.

Does neurorehabilitation have a role in relapsing-remitting multiple sclerosis?

Abstract.Patients with relapsing-remitting multiple sclerosis (RR MS) often make incomplete recovery from disabling exacerbations, despite corticosteroid treatment. Inpatient rehabilitation has been shown to be valuable in progressive MS, but its role in RR MS is less clear. We evaluated the effect of rehabilitation in consecutive patients with RR MS admitted to a neurological rehabilitation unit. Outcome measures applied on admission and discharge included the Expanded Disability Status Scale (EDSS), the Barthel Index (BI) and the Functional Independence Measure (FIM), as well as a visual analogue scale (VAS) of the patients’ perception of rehabilitation impact. Confounding factors including the timing of steroid therapy and re-admissions were also examined. RR patients showed considerable improvement following rehabilitation, with a median change of –0.5 on EDSS, +4 on BI and +12 on FIM (mean change of –0.8 EDSS, +4.5 BI and +15.6 FIM points; effect sizes of –1.01, 0.97 and 0.86, respectively), which was significantly greater than other MS subtypes. RR patients rated their admissions highly (median VAS 8.9, interquartile range 7.5–9.9), and the VAS scores correlated modestly with disability measures (Spearman’s rho = –0.42, 0.31 and 0.24 versus EDSS, BI and FIM, respectively; p = 0.007–0.040). Repeat admissions and the timing of steroid treatment did not have a significant effect on outcome. This suggests that inpatient rehabilitation is useful in RR MS, particularly in patients with incomplete recovery from relapses who have accumulated moderate to severe disability.

Cognitive dysfunction after isolated brain stem insult. An underdiagnosed cause of long term morbidity

Cognitive dysfunction adversely influences long term outcome after cerebral insult, but the potential for brain stem lesions to produce cognitive as well as physical impairments is not widely recognised. This report describes a series of seven consecutive patients referred to a neurological rehabilitation unit with lesions limited to brain stem structures, all of whom were shown to exhibit deficits in at least one domain of cognition. The practical importance of recognising cognitive dysfunction in this group of patients, and the theoretical significance of the disruption of specific cognitive domains by lesions to distributed neural circuits, are discussed.

A systematic review of research undertaken in vocational rehabilitation for people with multiple sclerosis

Objective: The National Service Framework (NSF) for Long-Term Neurological Conditions (LTNC) highlights the need for vocational rehabilitation (VR) services in quality requirement 6. As a part of a review of this requirement, an extensive literature review was undertaken to identify, review and report on all relevant research undertaken in the area of employment for people with multiple sclerosis (MS). Data sources: A systematic review of the English language literature for studies under the headings: multiple sclerosis and employment, unemployment, vocational rehabilitation, occupational health, job and work adjustment. The following databases were systematically searched AMED (1985 to Feb 2010), CINAHL (1982 to Feb 2010), PsycINFO (1806 to Feb 2010), EMBASE (1974 to Feb 2010), Medline (1950 to Feb 2010) and PubMed (1950 to Feb 2010). Data extraction and study selection: Four hundred and sixty-two papers were identified. This number was reduced removing the duplicates, non-English, not reporting research, not primarily about MS and not primarily about work which left 89 papers reviewed. Conclusion: The body of evidence reviewed gives clear indicators as to what the barriers to working with MS are and what is required for a VR service to meet the often complex needs of people with MS. Further research is needed to identify the efficacy of different models of VR, and their cost-effectiveness, and particularly for means of identifying and measuring the effectiveness of interventions that support work retention. Implications for Rehabilitation Factors that lead to unemployment for people with MS are clearly defined in the literature. Much of the published literature in this area has a qualitative methodology, which is not reflected in large systematic reviews such as Cochrane reviews. Vocational rehabilitation approaches that could benefit people with MS are described in the literature. It is clear that further research is needed to evaluate the efficacy of vocational rehabilitation interventions and their cost-effectiveness.

Rehabilitation after stroke: summary of NICE guidance

Each year, about 150 000 people in the UK have a first or recurrent stroke.1 Despite UK health policies that place a great emphasis on reducing stroke (such as the National Stroke Strategy2) and improvements in mortality and morbidity, guidance is needed on access to and provision of effective rehabilitation services to maximise quality of life after stroke. This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on long term rehabilitation after stroke.3 NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations can be based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Organising rehabilitation and care for people with stroke Rehabilitation may take place in a variety of settings—in hospital, in outpatient clinics, in the community, and in individuals’ own homes. ### Planning and delivering stroke rehabilitation To ensure the safety of the person with stroke while maintaining a patient centred approach, key processes need to be in place. These processes include assessment on admission …