Multi‐disciplinary rehabilitation for acquired brain injury in adults of working age

Background. Evidence from systematic reviews demonstrates that multi-disciplinary rehabilitation is effective in the stroke population, in which older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults has not been established, perhaps because this scenario presents different methodological challenges in research. Objectives. To assess the effects of multi-disciplinary rehabilitation following ABI in adults 16 to 65 years of age. Search methods. We ran the most recent search on 14 September 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic+Embase (OvidSP), Web of Science (ISI WOS) databases, clinical trials registers, and we screened reference lists. Selection criteria. Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation versus routinely available local services or lower levels of intervention; or trials comparing an intervention in different settings, of different intensities or of different timing of onset. Controlled clinical trials were included, provided they met pre-defined methodological criteria. Data collection and analysis. Three review authors independently selected trials and rated their methodological quality. A fourth review author would have arbitrated if consensus could not be reached by discussion, but in fact, this did not occur. As in previous versions of this review, we used the method described by Van Tulder 1997 to rate the quality of trials and to perform a 'best evidence' synthesis by attributing levels of evidence on the basis of methodological quality. Risk of bias assessments were performed in parallel using standard Cochrane methodology. However, the Van Tulder system provided a more discriminative evaluation of rehabilitation trials, so we have continued to use it for our primary synthesis of evidence. We subdivided trials in terms of severity of brain injury, setting and type and timing of rehabilitation offered. Main results. We identified a total of 19 studies involving 3480 people. Twelve studies were of good methodological quality and seven were of lower quality, according to the van Tulder scoring system. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most individuals made a good recovery when appropriate information was provided, without the need for additional specific interventions. For moderate to severe injury, 'strong evidence' showed benefit from formal intervention, and 'limited evidence' indicated that commencing rehabilitation early after injury results in better outcomes. For participants with moderate to severe ABI already in rehabilitation, 'strong evidence' revealed that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' suggested that continued outpatient therapy could help to sustain gains made in early post-acute rehabilitation. The context of multi-disciplinary rehabilitation appears to influence outcomes. 'Strong evidence' supports the use of a milieu-oriented model for patients with severe brain injury, in which comprehensive cognitive rehabilitation takes place in a therapeutic environment and involves a peer group of patients. 'Limited evidence' shows that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but studies serve to highlight the particular practical and ethical restraints imposed on randomisation of severely affected individuals for whom no realistic alternatives to specialist intervention are available. Authors' conclusions. Problems following ABI vary. Consequently, different interventions and combinations of interventions are required to meet the needs of patients with different problems. Patients who present acutely to hospital with mild brain injury benefit from follow-up and appropriate information and advice. Those with moderate to severe brain injury benefit from routine follow-up so their needs for rehabilitation can be assessed. Intensive intervention appears to lead to earlier gains, and earlier intervention whilst still in emergency and acute care has been supported by limited evidence. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation benefit from access to out-patient or community-based services appropriate to their needs. Group-based rehabilitation in a therapeutic milieu (where patients undergo neuropsychological rehabilitation in a therapeutic environment with a peer group of individuals facing similar challenges) represents an effective approach for patients requiring neuropsychological rehabilitation following severe brain injury. Not all questions in rehabilitation can be addressed by randomised controlled trials or other experimental approaches. For example, trial-based literature does not tell us which treatments work best for which patients over the long term, and which models of service represent value for money in the context of life-long care. In the future, such questions will need to be considered alongside practice-based evidence gathered from large systematic longitudinal cohort studies conducted in the context of routine clinical practice

The effects of the dopamine agonist rotigotine on hemispatial neglect following stroke

Hemispatial neglect following right-hemisphere stroke is a common and disabling disorder, for which there is currently no effective pharmacological treatment. Dopamine agonists have been shown to play a role in selective attention and working memory, two core cognitive components of neglect. Here, we investigated whether the dopamine agonist rotigotine would have a beneficial effect on hemispatial neglect in stroke patients. A double-blind, randomized, placebo-controlled ABA design was used, in which each patient was assessed for 20 testing sessions, in three phases: pretreatment (Phase A1), on transdermal rotigotine for 7-11 days (Phase B) and post-treatment (Phase A2), with the exact duration of each phase randomized within limits. Outcome measures included performance on cancellation (visual search), line bisection, visual working memory, selective attention and sustained attention tasks, as well as measures of motor control. Sixteen right-hemisphere stroke patients were recruited, all of whom completed the trial. Performance on the Mesulam shape cancellation task improved significantly while on rotigotine, with the number of targets found on the left side increasing by 12.8% (P = 0.012) on treatment and spatial bias reducing by 8.1% (P = 0.016). This improvement in visual search was associated with an enhancement in selective attention but not on our measures of working memory or sustained attention. The positive effect of rotigotine on visual search was not associated with the degree of preservation of prefrontal cortex and occurred even in patients with significant prefrontal involvement. Rotigotine was not associated with any significant improvement in motor performance. This proof-of-concept study suggests a beneficial role of dopaminergic modulation on visual search and selective attention in patients with hemispatial neglect following stroke

Truncated spectral regularization for an ill-posed non-linear parabolic problem

summary:It is known that the nonlinear nonhomogeneous backward Cauchy problem $u_t(t)+Au(t)=f(t,u(t))$, $0\leq t<\tau$ with $u(\tau )=\phi$, where $A$ is a densely defined positive self-adjoint unbounded operator on a Hilbert space, is ill-posed in the sense that small perturbations in the final value can lead to large deviations in the solution. We show, under suitable conditions on $\phi$ and $f$, that a solution of the above problem satisfies an integral equation involving the spectral representation of $A$, which is also ill-posed. Spectral truncation is used to obtain regularized approximations for the solution of the integral equation, and error analysis is carried out with exact and noisy final value $\phi$. Also stability estimates are derived under appropriate parameter choice strategies. This work extends and generalizes many of the results available in the literature, including the work by Tuan (2010) for linear homogeneous final value problem and the work by Jana and Nair (2016b) for linear nonhomogeneous final value problem

Spasticity management with botulinum toxin:A comparison of UK physiotherapy and rehabilitation medicine injectors

Background/Aims: To compare patient outcomes following botulinum toxin (BoNT) injection by either physiotherapy or rehabilitation medicine (medical) professionals over a 3-year period. Methods: A retrospective, observational cohort study was conducted in a specialised rehabilitation service providing spasticity management including BoNT injection and physical therapy (group therapy, individual therapy, self-exercise, and physical management programmes). Individualised goals were established before treatment using goal attainment scaling (GAS) by the multidisciplinary team. The Arm Activity measure (ArmA) was used to evaluate upper limb function and the Modified Ashworth Scale (MAS) used to evaluate spasticity. Findings: A total of 262 patients were injected. Mean GAS T-score after treatment for the group was 50.2 ± 6.7. GAS T-score for physiotherapy injectors (n=214 (82% of participants)) was 50.2 ± 6.4 and for rehabilitation medicine injectors (n=48 (18%)) 50.3 ± 7.9. No significant differences were identified in terms of goal achievement, upper limb passive function, or spasticity reduction between physiotherapy and rehabilitation medicine injectors. Differences were identified at both baseline (physiotherapist mean 49.7; rehabilitation medicine mean 46.6) and follow-up for active function (physiotherapist mean=49.7; rehabilitation medicine mean=47.8) (ArmA active function subscale; p=0.03). No reportable adverse effects were recorded. No difference in the complexity of injection (such as complex clinical presentation, anticoagulation, or technical difficulty) between the injector groups was identified. Conclusions: Clinical outcomes were comparable between physiotherapy and rehabilitation medicine injectors. No difference in side effect profile or complexity of injection was identified. In this cohort, injection of BoNT by a physiotherapist was as effective in terms of GAS as that undertaken by a rehabilitation medicine physician. </jats:sec

Reward sensitivity predicts dopaminergic response in spatial neglect

Available online 18 September 2018.It has recently been revealed that spatial neglect can be modulated by motivational factors including anticipated monetary reward. A number of dopaminergic agents have been evaluated as treatments for neglect, but the results have been mixed, with no clear anatomical or cognitive predictors of dopaminergic responsiveness. Given that the effects of incentive motivation are mediated by dopaminergic pathways that are variably damaged in stroke, we tested the hypothesis that the modulatory influences of reward and dopaminergic drugs on neglect are themselves related. We employed a single-dose, double-blind, crossover design to compare the effects of Co-careldopa and placebo on a modified visual cancellation task in patients with neglect secondary to right hemisphere stroke. Whilst confirming that reward improved visual search in this group, we showed that dopaminergic stimulation only enhances visual search in the absence of reward. When patients were divided into REWARD-RESPONDERs and REWARD-NON-RESPONDERs, we found an interaction, such that only REWARD-NONRESPONDERs showed a positive response to reward after receiving Co-careldopa, whereas REWARD-RESPONDERs were not influenced by drug. At a neuroanatomical level, responsiveness to incentive motivation was most associated with intact dorsal striatum. These findings suggest that dopaminergic modulation of neglect follows an ‘inverted U’ function, is dependent on integrity of the reward system, and can be measured as a behavioural response to anticipated reward.This study was directly supported by the NIHR Biomedical Research Centre at Imperial College London and a HEFCE Clinical Senior Lectureship Award to PM. D.S. acknowledges support from the Spanish Ministry of Economy and Competitiveness (MINECO), through the 'Severo Ochoa' Programme for Centres/Units of Excellence in R&D (SEV-2015-490) and project grants PSI2016-76443-P from MINECO and PI-2017-25 from the Basque Government