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Objective: To assess the long-term functional, psychosocial and participation outcomes in an Australian cohort of non-Hodgkin lymphoma (NHL) survivors. Methods: A cross-sectional sample of adult NHL survivors at the Peter MacCallum Cancer Centre (between 2015 and 2020), participated by completing validated questionnaires. A series of analyses described their current level of function, psychosocial well-being, and participation. Results: Of 129 participants (mean (M) ± standard deviation (SD) age: 62.5 ± 8.8 years), the majority (58%) had aggressive NHL and grade III–IV (72%), with time since diagnosis of 4.6 ± 1.2 years. Participants reported ongoing issues after completion of treatment: fatigue (63%), bladder dysfunction (61%), cognitive impairment (53%), and NHL-related pain (46%). Most made good functional recovery (M ± SD) (Functional Independent Measure-Motor: 79.5 ± 8.2), reported minimal change in their negative emotional states, and NHL-specific quality of life (QoL) (Functional Assessment of Cancer Therapy–Lymphoma: 133.5 ± 22.1). Participants were “well” adjusted to community living (Community Integration Measure: 42.2 ± 7.4) and satisfied with their current life (Satisfaction with Life Scale: 26.3 ± 6.0). Factors significantly associated with the poorer current level of function were: age at diagnosis < 60 years, time since NHL diagnosis > 4.5 years, and aggressive NHL type. Conclusion: Despite good functional recovery and adjustment in the community, NHL survivors report the presence of ongoing residual impairments and cognitive issues, which requires long-term rehabilitation-inclusive management. LAY ABSTRACT This cross-sectional study evaluated functional and psychosocial outcomes in non-Hodgkin lymphoma (NHL) survivors. Most patients made a good functional recovery and reported minimal change in their negative emotional states and quality of life after they were discharged. Patients reported satisfaction with their current life and were “well” adjusted to community living after NHL treatment. However, many reported ongoing issues, specifically fatigue, bladder dysfunction, cognitive impairment, and NHL-related pain. Those below 60 years of age when diagnosed, with time since NHL of over 4.5 years, and with aggressive and advanced NHL grades were associated with a poorer current level of function. These findings suggest that, despite patients’ potential adjustment to disability over time (response-shift phenomenon), many patients with NHL need long-term rehabilitation-inclusive management of ongoing disability and psychosocial issues in the community post-discharge.

Objective: To examine the responsiveness of the International Classification of Functioning, Disability and Health (ICF) Clinical Functioning Information Tool (ClinFIT) in routine clinical practice in an Australian context. Methods: A prospective observational study with consecutive recruitment of inpatients at a tertiary rehabilitation facility. The assessments were at admission (T0), discharge (T1) and 3-month postdischarge (T2), using the following questionnaires: ClinFIT, Functional Independence Measure (FIM) and European Quality of Life (EQ-5D-5L). Extension Indices (EI) were calculated for the ClinFIT set, and responsiveness measured as a change in scores over time. The association between FIM and ClinFIT scores was explored. Results: Participants (n = 91, mean age 66.8±13.0 years, 52% male, 48% following stroke) reported ≥ 1 issue related to ClinFIT categories. ClinFIT total raw scores improved significantly across all health conditions compared with T0 (median (interquartile range): 196 (110, 228)) at both T1: 69 (37, 110); p < 0.001 and T2: 46.5 (20.8, 77); p < 0.001, with a medium effect size (r = 0.61 for both). There were significant changes in EI in the entire ClinFIT set from T0 to T1, and from T0 to T2 (p < 0.001 for both), with small to medium effect sizes. Analyses confirmed significant correlation in improvements between ClinFIT and FIM scores. Conclusion: ClinFIT is useful in evaluating patient functioning and can detect changes in functioning over time and across different health conditions. LAY ABSTRACT Regular patient evaluation and clinical assessment is needed to maximize positive outcomes from rehabilitation intervention. This prospective study assessed the responsiveness of the International Classification of Functioning, Disability and Health (ICF) – Clinical Functioning Information Tool (ClinFIT) for the assessment of functioning in an inpatient rehabilitation facility in Australia. Overall, 91 patients with different health conditions (majority with stroke) were assessed at admission, discharge, and at 3 months after discharge, using the ClinFIT set, and compared with another routinely used instruments, the Functional Independence Measure (FIM). The findings showed that the ClinFIT set is useful in evaluating patients’ functioning over time across different health conditions.

Objective: To assess the utility of the modified Post-Stroke Checklist (mPSC) to identify impairments and care needs of patients with stroke (PwS) in an inpatient rehabilitation setting. Methods: Prospective observational design with consecutive admission of PwS (n = 44) at a tertiary rehabilitation facility. The post-stroke checklist was administered at hospital discharge (T1) and 3 months post-discharge (T2). Furthermore, validated questionnaires assessed function and participation, including the Clinical Functioning Information Tool (ClinFIT) on admission (T0), T1 and T2. Results: Participants’ mean age was 67.7 years (standard deviation; SD) 14.6), 58% of participants were female, and the mean length of inpatient stay was 32.7 days (SD 22.4). At T1, 80% and at T2 only 60% of participants reported ≥1 stroke-related problem (mean 5.3 (SD 3.3) and 3.6 (SD 2.8), respectively). Half of participants were referred to physiotherapy/occupational therapy, and 36% to specialist clinics following discharge. The most prevalent problems included: life after stroke (62.2%), fatigue (55.6%), activities of daily living, and mobility (51.1% each). Compared with T1, at T2 there was an observed reduction in all mPSC items, except pain and incontinence. Participants showed improved function at T1 and T2 (Extension Index, ClinFIT set), from T0 to T1 and T0 to T2 (p

Objective: To critically appraise published clinical practice guidelines (CPGs) for brain tumours, and to synthesize evidence-based recommendations from a rehabilitation perspective. Methods: A comprehensive literature search included: health science databases, CPG clearinghouse/developer websites, and grey literature up to March 2018. All brain tumour CPGs that reported systematic methods for evidence search, and clearly defined recommendations supporting evidence for rehabilitation interventions were included. Three authors independently selected potential CPGs and assessed their methodological quality using the Appraisal of Guidelines, Research and Evaluation (AGREE-II) Instrument. Recommendations from included CPGs were categorized from a rehabilitation perspective. Results: Of the 11 CPGs identified, only 2, developed by the National Institute for Health and Clinical Excellence (NICE) and the Australian Cancer Network (ACN), included rehabilitation components for the management of brain tumours. Both CPGs were of moderate quality. The recommendations reported were generic, and only the ACN guidelines provided detailed recommendations for rehabilitation interventions. Both guidelines recommend a comprehensive multi-disciplinary care approach. Detailed comparison, however, was not possible due to inconsistent recommendations, making it difficult to summarize rehabilitative care. Conclusion: Despite rehabilitation being an integral component of the management of brain tumours, only a limited number of CPGs have incorporated recommendations for specific rehabilitation interventions. In order to improve clinical outcomes in this population future CPGs should incorporate rehabilitation interventions.

Objective: To evaluate existing evidence from published systematic reviews for the effectiveness of rehabilitation interventions in patients with lymphoma. Data sources: A comprehensive literature search was conducted using medical/health science databases up to 1 October 2020. Bibliographies of pertinent articles, journals and grey literature were searched. Data extraction and synthesis: Two reviewers independently selected and reviewed potential reviews for methodological quality and graded the quality of evidence for outcomes using validated tools. Any discrepancies were resolved by final group consensus. Results: Twelve systematic reviews (n = 101 studies, 87,132 patients with lymphoma) evaluated 3 broad categories of rehabilitation interventions (physical modalities, nutrition and complementary medicine). Most reviews were of moderate-to-low methodological quality. The findings suggest: moderate-quality evidence for exercise programmes for improved fatigue and sleep disturbance; low-quality evidence for exercise therapy alone and qigong/tai chi for improved symptoms and overall quality of life, and an inverse association between sunlight/ultraviolet radiation exposure and incidence of non-Hodgkin’s lymphoma; and very low-quality evidence for beneficial effects of yoga for sleep disturbances. Association between physical activity and lymphoma risk is indistinct. Conclusion: Despite a range of rehabilitation modalities used for patients with lymphoma, high-quality evidence for many is sparse. Beneficial effects of exercise programmes were noted for fatigue, psychological symptoms and quality of life. More research with robust study design is required to determine the effective rehabilitation approaches.

Objective: To determine the effectiveness of multidisciplinary rehabilitation in improving functional and psychological outcomes in person with multiple trauma. Date sources: A comprehensive literature review was conducted using medical and health science electronic databases up to February 2019. Data extraction: Two independent reviewers selected studies, extracted data and assessed study quality using the Critical Appraisal Skills Programme (CASP) checklists and Grading of Recommendations, Assessment, Development and Evaluations (GRADE). Data synthesis: One randomized controlled trial, 1 clinical controlled trial and 4 observational studies (1 with 2 reports) were included. Qualitative analysis was used to synthesize the evidence due to the heterogeneity of included trials. The quality of the studies varied (CASP approach); the majority were of “low quality”. The findings suggest “very low to moderate” evidence (GRADE) for the effectiveness of multidisciplinary rehabilitation in improving functional ability and participation. The majority of studies (n = 6) reported functional improvements after multidisciplinary rehabilitation in the short-term. Conclusion: The lack of “high-quality” evidence for multidisciplinary rehabilitation in improving outcomes following trauma highlights gaps in the available evidence, signifying the need for more robust studies.

Missing (Commentary)

Objective: To evaluate evidence from published systematic reviews of clinical trials to determine the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in stroke population. Methods: The Cochrane Library, MEDLINE, CINAHL, EMBASE, and PubMed were searched for systematic reviews up to 15 January 2019. Three authors independently screened the reviews and assessed the methodological quality, using Assessment of Multiple Systematic Reviews (AMSTAR) appraisal tool. Quality of evidence for outcomes evaluated within the reviews was appraised with Grade of Recommendation, Assessment, Development and Evaluation (GRADE) tool. Results: Twelve reviews (n = 9,117 participants) evaluated the effectiveness of rTMS on motor and non-motor (aphasia, depression, dysphagia and cognition) functions. The rTMS protocols applied and outcomes measured were diverse amongst the selected reviews. The findings suggest beneficial effect of rTMS with: “moderate quality” evidence for dysphagia and hemineglect, “low to moderate quality” evidence for motor function (upper limb function, daily activities), and “low quality” evidence for aphasia and post-stroke depression. Conclusion: Despite widespread use of rTMS, high-quality evidence for its routine use for the treatment of stroke survivors is lacking. Further studies are required to establish differential roles of various protocols and long-term effects of rTMS in the stroke population.

Objective: To identify implementation and process issues that influence the implementation of an advance care planning (ACP) programme in rehabilitation settings. Methods: An ACP programme was established in an inpatient tertiary rehabilitation setting in Victoria, Australia. Rehabilitation patients with chronic illnesses were recruited and the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework used. Pre-implementation measures included: patient medical record audit of ACP discussions; and barriers and facilitators analyses. Implementation interventions were staff group educational sessions and clinical process changes. Further medical record audit was carried out to review the number of ACP conversations performed and re-evaluate ACP barriers. Results: A total of 180 consecutive inpatients were recruited for pre- (n = 90) and post- (n = 90) implementation groups. The majority of the pre-implementation cohort were female (51%), mean age 64.2 years (standard deviation 16.4 years) and had low rates of ACP discussions (n = 9, 10%). Major ACP barriers included: lack of staff education programme, and insufficient knowledge to conduct ACP. There was a significant increase in ACP conversations performed (n = 21, 23.3%) between both groups; however, staff reported limited time and skills to perform discussions. Conclusion: This ACP programme is feasible, but needs robust process evaluation and longer term follow-up to assess the impact of outcomes in public hospital settings on care quality.

Objective: Despite the prevalence of disability in low-and middle-income countries, the clinical skills of the rehabilitation workforce are not well described. We report health professionals’ perspectives on clinical skills in austere settings and identify context-specific gaps in workforce capacity. Methods: A cross-sectional pilot survey (Pakistan, Morocco, Nigeria, Malaysia) of health professionals’ working in rehabilitation in hospital and community settings. A situational-analysis survey captured assessment of clinical skills required in various rehabilitation settings. Responses were coded in a line-by-line process, and linked to categories in domains of the International Classification of Functioning, Disability and Health (ICF). Results: Respondents (n = 532) from Pakistan 248, Nigeria 159, Morocco 93 and Malaysia 32 included the following: physiotherapists (52.8%), nurses (8.8%), speech (5.3%) and occupational therapists (8.5%), rehabilitation physicians (3.8%), other doctors (5.5%) and prosthetist/orthotists (1.5%). The 10 commonly used clinical skills reported were prescription of: physical activity, medications, transfer-techniques, daily-living activities, patient/carer education, diagnosis/screening, behaviour/cognitive interventions, comprehensive patient-care, referrals, assessments and collaboration. There was significant overlap in skills listed irrespective of profession. Most responses linked with ICF categories in activities/participation and personal factors. Conclusion: The core skills identified reflect general rehabilitation practice and a task-shifting approach, to address shortages of health workers in low-and middle-income countries.

Objective: To identify potential barriers and facilitators for implementation of the World Health Organization Global Disability Action Plan (GDAP) in Nigeria and compare these with other low- and middle-income countries. Methods: A rehabilitation team from the Royal Melbourne Hospital, Parkville, Australia, conducted intensive workshops at medical/academic institutions in Nigeria for healthcare professionals from various local Physical Medicine and Rehabilitation facilities. A modified Delphi method identified challenges for person with disability, using 3 GDAP objectives. Findings were compared with similar exercises in Madagascar, Pakistan and Mongolia. Results: Despite differences in the healthcare system and practice, the challenges reported in Nigeria were similar to those in other 3 low- and middle-income countries, at both macro (governmental/policymakers) and micro levels (community/social/individual). Common challenges identified were: limited knowledge of disability services, limited Physical Medicine and Rehabilitation workforce, guidelines and accreditation standards; coordination amongst healthcare sectors; social issues; data and research; legislation and political commitment. Common potential facilitators included: need for strong leadership; advocacy of disability-inclusive development; investment in infrastructure/human resources; coordination/partnerships in healthcare sector; and research. Conclusion: Disability care is an emerging priority in low- and middle-income countries to address the needs of people with disability. The challenges identified in Nigeria are common to most low- and middle-income countries. The GDAP framework can facilitate access and strengthen Physical Medicine and Rehabilitation services.

With increasing frequency of natural disasters, there has been greater focus recently on the importance and role of rehabilitation services in disaster management. In past disasters, rehabilitative needs were often neglected, with emphasis on acute response plans focused on saving lives and treating acute injuries. There was a lack of, or inadequate, rehabilitation-inclusive disaster response plans and rehabilitation services in many disaster-prone developing countries. The World Health Organization (WHO) Emergency Medical Team (EMT) initiative recognizes rehabilitation as an integral part of medical response and patient-centred care in disaster settings. Current developments under this initiative include: the development of minimum standards for rehabilitation in emergencies to allow rapid, professional, coordinated medical response by both national and international EMTs. These guidelines ensure that EMTs deliver effective and coordinated patient care during disasters and continuum of care beyond their departure. The aim is to strengthen national capacity, foster an environment of self-empowerment of EMTs and local health services, and work in rehabilitation within defined coordination mechanisms in disaster-affected areas. A brief overview of rehabilitation in natural disasters, highlighting current developments, challenges; and gaps in the implementation of WHO guidelines for Minimum Standards for Rehabilitation in Emergencies is discussed in order to improve care for victims of future disasters.

Objective: To provide an update on disability and rehabilitation in Mongolia, and to identify potential barriers and facilitators for implementation of the World Health Organization (WHO) Global Disability Action Plan (GDAP). Methods: A 4-member rehabilitation team from the Royal Melbourne Hospital conducted an intensive 6-day workshop at the Mongolian National University of Medical Sciences, for local healthcare professionals (n = 77) from medical rehabilitation facilities (urban/rural, public/private) and non-governmental organizations. A modified Delphi method (interactive sessions, consensus agreement) identified challenges for rehabilitation service provision and disability education and attitudes, using GDAP objectives. Results: The GDAP summary actions were considered useful for clinicians, policy-makers, government and persons with disabilities. The main challenges identified were: limited knowledge of disability services and rehabilitation within healthcare sectors; lack of coordination between sectors; geo-topographical issues; limited skilled workforces; lack of disability data, guidelines and accreditation standards; poor legislation and political commitment. The facilitators were: strong leadership; advocacy of disability-inclusive development; investment in local infrastructure/human resources; opportunities for coordination and partnerships between the healthcare sector and other stakeholders; research opportunities; and dissemination of information. Conclusion: Disability and rehabilitation is an emerging priority in Mongolia to address the rights and needs of persons with disabilities. The GDAP provides guidance to facilitate access and strengthen rehabilitation services.