Stroke Telerehabilitation in Calabria: A Health Technology Assessment

Introduction: Telerehabilitation (TR) is defined as a model of home service for motor and cognitive rehabilitation, ensuring continuity of care over time. TR can replace the traditional face-to-face approach as an alternative method of delivering conventional rehabilitation and applies to situations where the patient is unable to reach rehabilitation facilities or for low-income countries where outcomes are particularly poor. For this reason, in this study, we sought to demonstrate the feasibility and utility of a well-known TR intervention on post-stroke patients living in one of the poorest indebted regions of Italy, where the delivery of rehabilitation services is inconsistent and not uniform.Materials and Methods: Nineteen patients (13 male/6 female; mean age: 61.1 ± 8.3 years) with a diagnosis of first-ever ischemic (n = 14) or hemorrhagic stroke (n = 5), who had been admitted to the intensive rehabilitation unit (IRU) of the Institute S. Anna (Crotone, Italy), were consecutively enrolled to participate in this study. After the discharge, they continued the motor treatment remotely by means of a home-rehabilitation system. The entire TR intervention was performed (online and offline) using the Virtual Reality Rehabilitation System (VRRS) (Khymeia, Italy). All patients received intensive TR five times a week for 12 consecutive weeks (60 sessions, each session lasting about 1h).Results: We found a significant motor recovery after TR protocol as measured by the Barthel Index (BI); Fugl-Meyer motor score (FM) and Motricity Index (MI) of the hemiplegic upper limbs.Conclusions: This was the first demonstration that a well-defined virtual reality TR tool promotes motor and functional recovery in post-stroke patients living in a low-income Italian region, such as Calabria, characterized by a paucity of specialist rehabilitation services.

Acquired brain injury and serious criminal offenders: An argument to expand the court's therapeutic jurisdiction

<p>Brain injury is a debilitating mental impairment. It can cause aggression, impulsivity, and other socially challenging behaviours, including criminal offending. This is largely a consequence of damage to the frontal lobes, the part of the brain that facilitates selfregulation and emotional control. Remedying this requires specialist rehabilitation, preferably in dedicated facilities. However, rather than being in such facilities, a disproportionate number of brain injured New Zealanders are in prison, often for violent or sexual offences. By contrast, other mentally impaired offenders, such as the intellectually disabled and mentally ill, are not kept in prison but instead transferred to the health jurisdiction to receive treatment or care. This raises a question as to why brain injured offenders do not receive the same therapeutic response by our criminal justice system. This paper explores that question by examining the current legislative framework for diverting mentally impaired offenders into healthcare through therapeutic dispositions on sentencing. It demonstrates the inadequacy of this framework for violent or sexual offenders with brain injury by showing how the gateway definitions of “intellectual disability” and “mental disorder” exclude that condition. It then explores the appropriateness of imprisoning serious offenders with brain injury by examining whether their detention breaches the state’s statutory obligations, and argues that the status quo violates both the Corrections Act 2004 and the New Zealand Bill of Rights Act 1990. Finally, in recognition of the current exclusion of brain injured offenders from therapeutic dispositions, and the potential illegality of their detention in prison, this paper argues for an expansion of the court’s therapeutic jurisdiction and examines mechanisms to achieve this.</p>

Acquired brain injury and serious criminal offenders: An argument to expand the court's therapeutic jurisdiction

<p>Brain injury is a debilitating mental impairment. It can cause aggression, impulsivity, and other socially challenging behaviours, including criminal offending. This is largely a consequence of damage to the frontal lobes, the part of the brain that facilitates selfregulation and emotional control. Remedying this requires specialist rehabilitation, preferably in dedicated facilities. However, rather than being in such facilities, a disproportionate number of brain injured New Zealanders are in prison, often for violent or sexual offences. By contrast, other mentally impaired offenders, such as the intellectually disabled and mentally ill, are not kept in prison but instead transferred to the health jurisdiction to receive treatment or care. This raises a question as to why brain injured offenders do not receive the same therapeutic response by our criminal justice system. This paper explores that question by examining the current legislative framework for diverting mentally impaired offenders into healthcare through therapeutic dispositions on sentencing. It demonstrates the inadequacy of this framework for violent or sexual offenders with brain injury by showing how the gateway definitions of “intellectual disability” and “mental disorder” exclude that condition. It then explores the appropriateness of imprisoning serious offenders with brain injury by examining whether their detention breaches the state’s statutory obligations, and argues that the status quo violates both the Corrections Act 2004 and the New Zealand Bill of Rights Act 1990. Finally, in recognition of the current exclusion of brain injured offenders from therapeutic dispositions, and the potential illegality of their detention in prison, this paper argues for an expansion of the court’s therapeutic jurisdiction and examines mechanisms to achieve this.</p>

Tackling multimorbidity: staff perceptions of the transition from single-condition rehabilitation to a specialist-generalist model

Background/aims The Healthy and Active Rehabilitation Programme is a specialist-generalist approach to targeting multimorbidity, which was developed through reconfiguring single-condition rehabilitation pathways. This project examined staff perceptions of the transition from specialist rehabilitation, to delivering this new model. Methods A total of 18 staff from the Healthy and Active Rehabilitation Programme (eight nurses, seven exercise instructors, two physiotherapists, one occupational therapist) participated in three focus groups, generating three key themes: apprehension, confidence growth, and integrated working. Results Despite initial apprehension around the Healthy and Active Rehabilitation Programme's impact on the existing service, the service users, and their clinical roles, staff developed confidence in the service and in their broader roles. Integrated working within the Healthy and Active Rehabilitation Programme has enhanced their awareness of the wider rehabilitation team, and provides valuable peer support. Conclusions This project provides valuable information for single-condition rehabilitation services that are considering delivery of specialist-generalist care to help target multimorbidity.

Opioid Prescriptions in Chronic Pain Rehabilitation. A Prospective Study on the Prevalence and Association between Individual Patient Characteristics and Opioids

While against recommendations, long-term opioid therapy (LTOT) for chronic pain is common. This study aimed to describe the prevalence of opioid prescriptions and to study the association of patient characteristics (demographics, pain characteristics, anxiety, depressive symptoms and pain coping) with future LTOT. The sample included N = 1334 chronic musculoskeletal pain patients, aged 18–65, who were assessed for Interdisciplinary Multimodal Pain Rehabilitation (IMMR) in Swedish specialist rehabilitation. Prescriptions were tracked across a two-year target period after assessment. In total, 9100 opioid prescriptions were prescribed to 55% of the sample (Mmedian = 6, IQR = 14). Prediction of LTOT was analyzed separately for those who did (24%) and did not (76%) receive IMMR. The odds of receiving opioids was similar for these subsamples, after controlling for differences in baseline characteristics. In both samples, there were significant associations between patient characteristics and future opioid prescriptions. Dysfunctional pain coping was a unique predictor of LTOT in those who received IMMR while pain intensity and depressive symptoms were unique predictors in those who did not receive IMMR. The results underscore that opioid treatment is common among patients in chronic pain rehabilitation and relates to pain and psychological factors. Understanding in detail why these factors relate to opioid prescription patterns is an important future study area as it is a prerequisite for better management and fundamental for preventing overuse.

Protecting the Health Service and Managing the COVID-19 Pandemic Surge: The Unintended Impact of Service Reconfiguration on the Specialist Rehabilitation Service at a Regional Teaching Hospital

As part of the UK National Health Service (NHS) preparations to manage the impact of the COVID-19 pandemic on hospital services, clinical guidelines that emphasized the expansion of the acute care capacity in managing the anticipated surge in COVID-19 cases were implemented. Clinical wards were reconfigured and routine face-to-face outpatient clinics were suspended. Some of the changes include workforce and facilities reorganization. One of the changes implemented at the Hull University Teaching Hospitals NHS Trust (HUTHT), was the relocation of the Complex Rehabilitation Ward from its 15- bed base in the Queen’s Centre for Oncology to a repurposed 12-bed surgical ward within the main Castle Hill Hospital (CHH) building in March 2020. Methods: A comparative review of the admissions and outcome measures data (admission diagnosis; referral source; PCAT: Patient Categorization Tool; LOS: Length of Stay; Bed occupancy and discharge destinations) over a 4-month period (March-June 2020) was undertaken and compared to retrospective data from a corresponding 4-month (March-June 2019) period in the previous year to determine the impact of the ward relocation on the delivery of specialist rehabilitation to patients with complex needs during the pandemic episode. Results: A reduction in total number of admitted patients (n=28 in 2019; n=18 in 2020) with reduced bed occupancy from 99% in 2019 to 72% in 2020 despite a reduction in bed base was noted following the ward relocation. A shorter length of stay with a mean of 29 days was noted following relocation of the ward while an increase in patient complexity as demonstrated by the PCAT scores was observed. The proportion of patients achieving a home discharge destination as opposed to other residential care facilities increased, accounting for 89% among discharged patients. Conclusion: This review demonstrated some of the impact of the measures implemented to combat the 1st wave of the coronavirus pandemic, specifically the relocation of the specialist inpatient rehabilitation ward in a tertiary hospital setting. Though a higher proportion of the admitted patients had increased complexity, a shorter length of stay with a significant proportion of the patients achieving a home discharge destination were observed following ward-relocation in 2020 compared to a similar quarter in 2019. The findings also reflected a reduction in bed occupancy despite reduced bed base capacity. Though there is a noted reduction in duration of stay in hospital and a greater proportion the patients achieved a home discharge destination, this was achieved with a compromise on the rehabilitation process due to the constraints of the new ward environment. Significant impact in the quality of the therapy programmes delivered was observed. The longer-term impact of this will need to be monitored. This review highlights the need for consideration of specialist rehabilitation as part of the acute response planning process in pandemic and mass casualty events.

A Proposal for Multidisciplinary Tele-Rehabilitation in the Assessment and Rehabilitation of COVID-19 Survivors

A global pandemic of a new highly contagious disease called COVID-19 resulting from coronavirus (severe acute respiratory syndrome (SARS)-Cov-2) infection was declared in February 2020. Though primarily transmitted through the respiratory system, other organ systems in the body can be affected. Twenty percent of those affected require hospitalization with mechanical ventilation in severe cases. About half of the disease survivors have residual functional deficits that require multidisciplinary specialist rehabilitation. The workforce to deliver the required rehabilitation input is beyond the capacity of existing community services. Strict medical follow-up guidelines to monitor these patients mandate scheduled reviews within 12 weeks post discharge. Due to the restricted timeframe for these events to occur, existing care pathway are unlikely to be able to meet the demand. An innovative integrated post-discharge care pathway to facilitate follow up by acute medical teams (respiratory and intensive care) and a specialist multidisciplinary rehabilitation team is hereby proposed. Such a pathway will enable the monitoring and provision of comprehensive medical assessments and multidisciplinary rehabilitation. This paper proposes that a model of tele-rehabilitation is integrated within the pathway by using digital communication technology to offer quick remote assessment and efficient therapy delivery to these patients. Tele-rehabilitation offers a quick and effective option to respond to the specialist rehabilitation needs of COVID-19 survivors following hospital discharge.

Enabling people with communication and cognitive impairments to provide feedback on service satisfaction: development and reliability testing of an adapted pictorial questionnaire

Introduction/aims Evaluation of patient satisfaction with health services is mandatory within the UK, but patients with communication difficulties are often excluded by their inability to complete written questionnaires. This study examines the test–retest reliability and agreement of an adapted, pictorial patient satisfaction questionnaire, based on the Talking Mats technique. Methods A total of 26 participants, who had a range of communication impairments resulting from brain injury, completed two questionnaires while in specialist rehabilitation: a standard written and adapted pictorial questionnaire, at two time points to evaluate test–retest reliability. Agreement between the two questionnaire formats was also examined. Results Test–retest reliability in overall scores between Time 1 and 2 was substantial for both the adapted pictorial questionnaire (k=0.72 [95% confidence interval 0.388, 0.76]) and the standard written questionnaire (ϰ=0.78 [95% confidence interval 0.74, 0.82]). Overall agreement between the two techniques was ϰ=0.76 (95% confidence interval 0.73, 0.79). Eighty-six per cent of questions for patients with aphasia showed at least ‘moderate’ agreement between the two questionnaire types compared with only 67% in participants with cognitive communication disorder. Conclusions The adapted pictorial questionnaire is a reliable tool for people with brain injury who have aphasia, enabling some patients to provide service satisfaction feedback who would have otherwise been excluded using a written questionnaire.