Lindsay McLellan

A randomised controlled trial of a home based exercise programme to reduce the risk of falling among people with Parkinson’s disease

Objective: To evaluate the effectiveness of a personalised home programme of exercises and strategies for repeat fallers with Parkinson’s disease (PD). Method: Patients with a confirmed diagnosis of idiopathic PD, independently mobile, living at home in the community, experiencing more than one fall in the previous 12 months and with intact gross cognitive function were invited to participate in this randomised controlled trial. Usual care was compared with a personalised 6 week, home based exercise and strategy programme. The primary outcomes were rates of falling at 8 weeks and 6 months. Whether participants had repeat fallen, nearly fallen or experienced injurious falls were also examined. Functional Reach, the Berg Balance Test, PD Self-assessment Scale and the Euro Quol were rated by a blinded assessor. Results: Participants were randomised to the exercise (n = 70) and control (n = 72) groups. There was a consistent trend towards lower fall rates in the exercise group at both 8 weeks and 6 months and lower rates of injurious falls needing medical attention at 6 months. Lower rates of repeat near falling were evident for the exercise group at 8 weeks (p = 0.004) and 6 months (p = 0.007). There was a positive effect of exercises at 6 months on Functional Reach (p = 0.009) and quality of life (p = 0.033). No significant differences were found on other secondary outcomes measures. Conclusion: There was a trend towards a reduction in fall events and injurious falls with a positive effect of exercises on near falls and quality of life.

Generic health status measures are unsuitable for measuring health status in severely disabled people

Objectives: To assess the perceived health status of disabled people. Design: Perceived health status was evaluated with the Short Form 36 Health Survey (SF-36) and the Nottingham Health Profile as part of a needs assessment project exploring systematic differences in unmet needs for rehabilitation as perceived by disabled people, carers and professional staff. Disabled participants completed these health status questionnaires, as part of a face-to-face interview in participants’ own homes. Subjects: Ninety-two disabled people aged 16–65, recruited into the study from two disability registers. Outcome measures: The Office of Population Censuses and Surveys (OPCS) Disability Severity Scale, Nottingham Health Profile, SF-36. Results: Ninety-six disabled people took part in this study. Four were later excluded because of overwhelming communication difficulties. Median OPCS category was 8 (interquartile range 6–9.75). The pain and physical mobility domains of the Nottingham Health Profile were not completed by 46/92 participants (50%) because many questions referred to activities that these people could not perform, particularly walking. The physical functioning domain of the SF-36 showed severe floor effects. It was not therefore possible to use these measures to test the effectiveness of services provided to disabled people, particularly in the areas of physical functioning and pain. Conclusions: There is a continued need to develop and test instruments that can measure the outcomes of rehabilitation in severely disabled populations.

Met and unmet needs reported by severely disabled people in southern England.

Purpose : To examine the met and unmet needs for rehabilitation of disabled people living in the community in Southern England. Method : A cross sectional interview study of people with a primary physical disability, aged 16-65. Disabled people were randomly selected from two existing disability registers, which comprised disabled people who had been identified by community rehabilitation services as being in need of regular surveillance by formal assessment of their care needs. A new semi-structured needs assessment questionnaire was developed and validated for the study (the Southampton Needs Assessment Questionnaire, SNAQ). Level of disability was examined with the OPCS Disability and Severity Scales. Results : Ninety three disabled people participated. Their median (IQR) OPCS score was 8 (6-10). Participants reported a median (IQR) of three unmet needs (2-7). The most prevalent unmet needs were for adaptations, equipment, physiotherapy and wheelchairs, rather than unmet needs for intellectual and social fulfilment. Conclusions : Disabled people who were already in touch with community rehabilitation services continued to express unmet needs for further services. Meeting the more basic needs relating to peoples housing, equipment, physiotherapy and wheelchairs may enable them to be more independent and fulfilled in other areas of their lives.

The Southampton Needs Assessment Questionnaire (SNAQ): a valid tool for assessing the rehabilitation needs of disabled people

Objective: To validate the Southampton Needs Assessment Questionnaire (SNAQ) for use with disabled people during face-to-face interviews. Design: The SNAQ was designed to be used in a cross-sectional survey of disabled people with a physical disability with a follow-up study one year later. Content and criterion validity was examined using 32 disabled people who took part in the pilot study. Construct validity and internal reliability was examined using data from 93 disabled people who took part in the main survey. Responsiveness of the questionnaire was evaluated using the data gathered during a follow-up study of 77 people had taken part in the original study. Outcome measures: The OPCS Disability Severity Scales (OPCS) and the Functional Independence Measure (FIM) were used to measure level of disability of participants, the Nottingham Health Profile (NHP) and the UK version of the SF-36 to examine perceived health status. Participants: People with a primary physical disability, aged 16–65, randomly selected from two disability registers in southern England. Main results: Content and criterion validity were established. Construct validity and internal reliability of the SNAQ was good. Inter-rater reliability was not tested since only one researcher conducted the interviews. Test–retest reliability was not formally tested because of the probability that participants would learn from the first needs assessment questionnaire and that different results on a retest occasion could arise from this. The SNAQ was sensitive in picking up changes over time. Conclusion: The SNAQ has shown good validity (content, coverage and construct), internal reliability, sensitivity and responsiveness. Further studies are needed to define the consequences of meeting or not meeting the rehabilitation needs of disabled people. Inter-rater reliability remains to be established.

A review of behavioural assessment scales for monitoring recovery in and after coma with pilot data on a new scale of visual awareness

Abstract The monitoring of behavioural events during and after coma is important in determining the nature and pace of recovery, in detecting early signs of deterioration, in the evaluation of coma stimulation and other rehabilitation programmes, and in identifying the persistent vegetative state. There are a number of difficulties in constructing objective, reliable, valid measures of significant behavioural events which are also easy to administer by the bedside. This paper reviews the many behavioural scales which have been developed in the search for quantifiable data on recovery, and presents some pilot data on a new scale of visual awareness.

The Subjective Index of Physical and Social Outcome: its usefulness in a younger stroke population

Studies on stroke subjects that aim to improve their well-being or community support have not been shown to be effective when measures of disability and handicap have been employed. This paper illustrates the usefulness of the Subjective Index of Physical and Social Outcome (SIPSO) with young adults following a stroke. The study comprised a cross-sectional survey of people (57% male; 39% female; median age 55.7) with a stroke (1–10 years ago), aged 18–65, recruited via NHS stroke registers and young stroke groups (response rate 53%). The SIPSO was incorporated into a postal needs-assessment questionnaire. Median SIPSO score: 24.5 (IQR 17–32). The SIPSO internal reliability: ICC 0.91 (95% CI, 0.90–0.92), item to total SIPSO correlations ranged from 0.52–0.83. The SIPSO construct validity was good: those with poorer employment, mobility and sex-life outcomes had lower SIPSO scores than those with better outcomes; there was no association between age and SIPSO scores, SIPSO scores were not significantly different for men and women. Test–retest reliability was good. The SIPSO had excellent reliability and validity properties in his population. Further work on its responsiveness needs to be carried out. The measurement of personal experience of integration can be a vital basis for effective clinical care.

To what extent are the needs of severely disabled people met by community rehabilitation services? A follow-up study

Purpose : To evaluate which needs of disabled people would be met over a one year follow-up period and to examine which factors would be predictive of identifying those people who had more needs met from those who had fewer needs met. Method : A follow-up study of a cohort of community dwelling disabled people (aged 16-65) from two NHS Health Districts in Southern England with contrasting patterns of rehabilitation provision, who had participated in a cross-sectional interview study one year previously which had assessed their met and unmet needs. The Southampton Needs Assessment Questionnaire was used to examine needs. Disability was evaluated with the OPCS Disability and Severity Scales and perceived health status with the SF-36. Results : Participation rate at follow-up was 92%. Of the 300 baseline unmet needs reported by 69 of the 77 participants 33% had been met at follow-up. People whose disability had increased more and/or whose mental health status had improved more had greater percentages of their baseline needs met. There was a non-significant trend for smaller percentages of baseline needs to be met in Basingstoke than in Southampton. Conclusions : At ground level, disabled peoples views were taken into account, to some extent, in the provision of rehabilitation services. This input should be made at a higher level, in the overall shaping of services.

Can patients in coma following traumatic head injury learn simple tasks

Abstract Initial observations that patients in coma showed a variety of responses when a cloth was placed over their faces generated a study investigating whether these patients could learn to remove the cloth. A method of backward chaining was used to teach the patients. Three experiments are reported. In the first study, five patients learned to remove the cloth while still in coma. In the second study, patients with a much lower Glasgow Coma Scale (GCS) score underwent the same procedure and all three removed the cloth while still in coma. The third experiment aimed to develop this procedure and two patients were trained to carry out other tasks using the same backward chaining technique. Both carried out the tasks while still in coma. The results of the study demonstrate that patients in coma following traumatic head injury developed increasingly reliable responses to specific stimuli. The theoretical and practical implications of these results are discussed.

The role of the SMART and WHIM in behavioural assessment of disorders of consciousness: clinical utility and scope for a symbiotic relationship

ABSTRACT As the prevalence and incidence of disorders of consciousness (DoC) increase, researchers and clinicians are tasked with developing best practice assessment techniques. Neurobehavioural assessment remains the most clinically available method of measuring consciousness. Neuroimaging and other physiological measurements are demonstrating promise in supporting this assessment but many of these techniques require further research and are not widely available in sub-acute and long-term care settings. No study to date has explored in-depth complementary use of multiple neurobehavioural assessments in aiding beside assessment of consciousness. This paper describes and proposes complementary use of two commonly used standardised neurobehavioural assessments. The Sensory Modality Assessment and Rehabilitation Technique (SMART) and the Wessex Head Injury Matrix (WHIM) both have specific aims and play an important role in behavioural assessment across the care continuum. This paper proposes that when used together appropriately these two assessments promote best practice and strengthen behavioural assessment of consciousness by providing increased opportunities to capture awareness. Further research into use of more than one neurobehavioural tool is highlighted as an important area of inquiry for this heterogeneous population not only in clinical practice but also in research.

A score of zero

The patient with a head injury may have a variety of impairments which interact to cause functional limitation. There may be deficits in everyday skills, ranging from self-care tasks to those tasks which require differing degrees of alertness, information processing, planning and execution. Even when the patient is capable of using these skills independently of each other, e.g. of planning an activity without having to execute it, head-injured patients are frequently unable to integrate skills, that is to say to select and use the skills sequentially to solve real-life problems. The sequelae of head injury were described in Chapter 9.