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Climatotherapy is the planned medical application of climatic factors for the improvement of functioning and prevention or treatment of diseases. Various climatic factors affect the physical and psychosocial functioning in persons with various health conditions including neuromuscular conditions, rheumatic diseases, and chronic respiratory illness. This systematic review is an evidence-based overview of the efficacy of the application of various climatotherapy on rehabilitation outcomes. A comprehensive literature search was conducted using medical/health science databases: PubMed, EMBASE, CINAHL, and Cochrane Library (from inception till May 2022). Two reviewers independently performed study selection, data extraction, and appraised study quality. Due to heterogeneity amongst included trials, a qualitative analysis provided the best evidence synthesis. Overall, 11 randomized controlled trials and 7 observational studies, which evaluated the impact of different climatic factors/conditions (such as warm/cold climate and high altitudes) on patient outcomes postrehabilitation interventions, were included. Most studies scored “low” on quality assessment due to methodological limitations. The findings suggest evidence for the beneficial effect of a warm climate in reducing disability and improved participation in patients with rheumatological, neuromuscular, and chronic respiratory conditions. Rehabilitation interventions conducted in warmer climate tends to enhance physical activity in some of these conditions. No data was available for adverse effects or associated care costs. Although the impact of climatic factors on rehabilitation outcomes is widely documented, high-quality research is sparse in this area. More methodologically robust studies are needed to build evidence for the use of climatotherapy to enhance rehabilitative care.

Prone positioning (PP) is becoming an important treatment modality for the management of COVID-19 related respiratory distress syndrome. The aim of this scoping review was to evaluate effectiveness and safety of awake PP in non-intubated patients with COVID-19 related acute respiratory distress at different care settings. The study was conducted during December 1, 2019 to August 30, 2020 using health science electronic databases and grey literature. A PRISMA flow diagram was used and finally 06 studies with 187 patients were included for review. Male patients were predominating with the mean age of approximately 55 years. Oxygenation was improved in 79.14% patients. One hundred fifty seven (83.95%) patients with COVID-19-related hypoxemic respiratory distress tolerated the procedure. Intubations required 25.41% of the patients or mechanical ventilation and 6(3.2%) patients expired. Number of patients in the reported studies could tolerate more than 3 hours of PP without a major side effect. Awake proning improved oxygenation of the patients suffering from COVID-19 related respiratory hypoxia in different care settings. Early instituted prone positioning may be an effective alternative method of treating COVID-19 related respiratory distress. Patient compliance and small size cohort studies are the limitations of this review. Multicenter controlled studies are warranted before conclusions are made about safety and the settings.

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<0.001, with large effect sizes). CONCLUSION: The mPSC is feasible to implement in an inpatient rehabilitation setting and community. It can identify relevant stroke-related problems, and hence facilitate targeted intervention.

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.

BACKGROUND: Many clinical interventions are trialled to manage medical complications following Traumatic Brain Injury (TBI). However, published evidence for the effects of those clinical interventions is limited. This article is an overview of common complications and their management from published systematic reviews in TBI. METHODS AND FINDINGS: A health science electronic database search for published systematic reviews for management of common complications in TBI was conducted in the last decade till 31st January 2021. Methodological quality and evidence were critically appraised using the Grading of Recommendations, Assessment, Development and Evaluations and Revised-Assessment of Multiple Systematic review tools. Overall, only six systematic reviews complied with search criteria, these evaluated fatigue, spasticity and post traumatic seizures (29 RCTs, 13 cohort studies, n = 5639 participants). No systematic reviews for other common TBI-related complications met criteria for this review. The included reviews varied from 'moderate to high' in methodological quality. The findings suggest beneficial treatment effect of anti-epileptic drugs (phenytoin/levetiracetam) compared with placebo in reducing early seizure incidence, but no significant benefit of phenytoin over levetiracetam, valproate, or neuroprotective agent for early or late posttraumatic seizures. There was 'limited' evidence for spasticity-related interventions, and 'insufficient' evidence of cardiorespiratory training on fatigue levels. CONCLUSIONS: Despite the high prevalence and associated functional impact of TBI-related complications, there is limited evidence to guide treating clinicians for management of common TBI complications. More robust studies are needed to build evidence in this population.

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.

Spasticity and motor recovery are both related to neural plasticity after stroke. A balance of activity in the primary motor cortex (M1) in both hemispheres is essential for functional recovery. In this study, we assessed the intracortical inhibitory and facilitatory circuits in the contralesional M1 area in four patients with severe upper limb spasticity after chronic stroke and treated with botulinum toxin-A (BoNT-A) injection and 12 weeks of upper limb rehabilitation. There was little to no change in the level of spasticity post-injection, and only one participant experienced a small improvement in arm function. All reported improvements in quality of life. However, the levels of intracortical inhibition and facilitation in the contralesional hemisphere were different at baseline for all four participants, and there was no clear pattern in the response to the intervention. Further investigation is needed to understand how BoNT-A injections affect inhibitory and facilitatory circuits in the contralesional hemisphere, the severity of spasticity, and functional improvement.© Copyright © 2020 Zoghi, Hafezi, Amatya, Khan and Galea.

The World Health Organization declared a pandemic due to the serious health risk posed by coronavirus disease (COVID-19). The number of infected cases is on the rise globally with escalating human, economic, and societal costs. Survivors of COVID-19 may experience a range of clinical, functional, and psychological impairments, resulting in disabilities. Many are amenable to rehabilitation intervention. The current focus of COVID-19 management is on public health measures and acute management. As patients transfer to subacute care or discharged to the community, rehabilitation services need to have a number of organizational and operational models in place to provide safe and effective care for patients and health professionals.There is need for global action by professional organizations in developing a structured rehabilitation approach for international response to disasters, including pandemics. This report proposes development of a "Rehabilitation Response Plan" to enable the International Society of Physical and Rehabilitation Medicine, to provide crucial leadership and governance role in liaison and coordination with the World Health Organization (and other stakeholders), to provide rehabilitation input during current and future pandemics. The key considerations include following categories: governance, coordination, communication, evaluation, and care continuum. These will strengthen rehabilitation, assist in the effective delivery of services, and provide advocacy and an international coordinated perspective.

OBJECTIVE: To evaluate the effectiveness and feasibility of an intensive technology-assisted inpatient enriched environmental programme for upper limb function. METHODS: Patients consecutively admitted to the rehabilitation unit randomly allocated to an intervention (enriched environmental programme, n = 46)) or a control group (usual ward activity, n = 46). Assessments were performed at baseline (T0), discharge (T1) and 3 months (T2) using validated measures. RESULTS: At T1, the enriched environmental group showed significant improvement in upper limb func-tion, compared with the control group: Action Research Arm Test (ARAT) "Total" (p = 0.002), and "Grip", "Pinch" and "Gross" subscales (p < 0.05 for all), with small effect size = 0.04-0.16. Most participants in the enriched environmental group had clinically significant improvement > 5.7 points on the ARAT "Total" compared with the control group (83% vs 44%, p < 0.001). Participants in the enriched environmental group were more involved in various forms of activities during waking hours. At T2, despite no significant between-group difference in ARAT scores, the majority of participants in the enriched environmental group maintained the improvement (> 5.7 points) on ARAT "Total" compared with the control group (91% vs 61%, p = 0.001). Both groups improved in other measures at both T1 and T2. CONCLUSION: An enriched environmental programme was feasible and effective in improving upper limb function and increasing the activity of patients during their inpatient subacute care.

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.

Spasticity and motor recovery are both related to neural plasticity after stroke. A balance of activity in the primary motor cortex (M1) in both hemispheres is essential for functional recovery. In this study, we assessed the intracortical inhibitory and facilitatory circuits in the contralesional M1 area in four patients with severe upper limb spasticity after chronic stroke and treated with botulinum toxin-A (BoNT-A) injection and 12 weeks of upper limb rehabilitation. There was little to no change in the level of spasticity post-injection, and only one participant experienced a small improvement in arm function. All reported improvements in quality of life. However, the levels of intracortical inhibition and facilitation in the contralesional hemisphere were different at baseline for all four participants, and there was no clear pattern in the response to the intervention. Further investigation is needed to understand how BoNT-A injections affect inhibitory and facilitatory circuits in the contralesional hemisphere, the severity of spasticity, and functional improvement.

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.

There is a strong consensus among humanitarian response authorities for a need for global action by professional organizations to work toward developing a structured approach to provide a coordinated international response during sudden-onset disasters. The aim of this report was to develop a Disaster Rehabilitation Response Plan to enable International Society of Physical and Rehabilitation Medicine to provide leadership and governance role in liaison/coordination with the WHO emergency medical team initiative and other relevant stakeholders to provide rehabilitation input during sudden-onset disasters. The proposed plan uses a "three-tier approach": tier 1, immediate disaster response at a national/international level; tier 2, organization and deployment of rehabilitation personnel; and tier 3, rehabilitation management of disaster survivors and community reintegration. The International Society of Physical and Rehabilitation Medicine (and its subcommittee, the Disaster Rehabilitation Committee), categorized in the tier 2, could provide central leadership role working for the rehabilitation subcluster within the WHO emergency medical team initiative (tier 1) and support in coordination, preparation, and management of rehabilitation teams and/or members for deployment to sudden-onset disasters. The Disaster Rehabilitation Committee could also contribute to advocacy, training, and accreditation processes for rehabilitation professionals. The challenge ahead is commitment of countries worldwide to develop comprehensive rehabilitation-inclusive approach to ensure effective delivery of services to communities at risk.

BACKGROUND: There are limited evidence of instrumented measures of gait and balance to determine the functional effects of botulinum toxin injections (BoNT-A) in spasticity after stroke. OBJECTIVE: To evaluate the functional changes in gait and balance following upper limb and lower limb BoNT-A in persons with stroke. METHODS: A pre-post prospective study of 35 stroke patients with upper and/or lower limb spasticity after focal treatment with BoNT-A. Assessments were at baseline (T0), 6-weeks (T1) and 12-weeks (T2), using validated subjective and objective physical activity measures. RESULTS: After BoNT-A injections, significant improvements in most measures of impairments, activity and participation domains were found at T1 (p < 0.05, effect sizes (r) = 0.5-0.9). There was a significant increase in low intensity physical activity (at T1) and sedentary time reductions at both follow-up periods. Instrumented gait/balance measures showed a significant increase in cadence and turn velocity, but no changes in sway measures were found using posturography. Improvements in most outcome measures were maintained at 12-weeks. CONCLUSION: BONT-A improved scores in most clinical measures but only in some of the objective gait/balance and physical activity measures. Further robust studies should utilize a larger sample size to better determine the benefits of BoNT-A for stroke-related spasticity.

The aim of this commentary is to discuss the rehabilitation perspective in the recently published Cochrane Review "Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews" by Amatya, Khan & Galea1, under the direct supervision of Multiple Sclerosis and Rare Diseases of the CNS group. This Cochrane Corner is produced in agreement with "NeuroRehabilitation" by Cochrane Rehabilitation.

BACKGROUND: Multiple sclerosis (MS) is a major cause of chronic, neurological disability, with a significant long-term disability burden, often requiring comprehensive rehabilitation. OBJECTIVES: To systematically evaluate evidence from published Cochrane Reviews of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS (pwMS), to improve patient outcomes, and to highlight current gaps in knowledge. METHODS: We searched the Cochrane Database of Systematic Reviews up to December 2017, to identify Cochrane Reviews that assessed the effectiveness of organised rehabilitation interventions for pwMS. Two reviewers independently assessed the quality of included reviews, using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) tool, and the quality of the evidence for reported outcomes, using the GRADE framework. MAIN RESULTS: Overall, we included 15 reviews published in the Cochrane Library, comprising 164 randomised controlled trials (RCTs) and four controlled clinical trials, with a total of 10,396 participants. The included reviews evaluated a wide range of rehabilitation interventions, including: physical activity and exercise therapy, hyperbaric oxygen therapy (HBOT), whole-body vibration, occupational therapy, cognitive and psychological interventions, nutritional and dietary supplements, vocational rehabilitation, information provision, telerehabilitation, and interventions for the management of spasticity. We assessed all reviews to be of high to moderate methodological quality, based on R-AMSTAR criteria.Moderate-quality evidence suggested that physical therapeutic modalities (exercise and physical activities) improved functional outcomes (mobility, muscular strength), reduced impairment (fatigue), and improved participation (quality of life). Moderate-quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains

Introduction/Background: Sudden-onset disasters (SODs) result in increased number of survivors with complex and long-term disabling injuries, including traumatic brain injury (TBI) that warrants comprehensive specialist rehabilitation. This presentation highlights the minimum technical standards required for specialised TBI rehabilitation teams and their integration into WHO Emergency Medical Teams (EMTs) to facilitate comprehensive management of TBI survivors in disaster settings. Material and method: A team of medical rehabilitation physicians from the Royal Melbourne Hospital conducted a comprehensive review of literature for TBI management, based on the WHO core-guidelines for ‘Minimum technical standards and recommendations for rehabilitation for EMTs’. These were endorsed by a specialist TBI expert panel in the Asia-Pacific region. Results: Comprehensive rehabilitation programs improve functional outcomes and quality of life of TBI survivors. It is recommended that specialised TBI care teams need to be embedded into EMTs for disaster response and management for early diagnosis, management and social reintegration. This guidance documents the minimum standards for deployment of TBI specialist rehabilitation teams in the context of SODs, including: skill requirements, team configuration and profile, professional competencies for management of TBI and complications, list of required equipment and consumables, information management/dissemination. Conclusion: TBI rehabilitation should commence from the early response phase in SODs by accredited rehabilitation professionals to minimise complications and disability. Integration of specialised TBI rehabilitation professionals into EMTs for disaster response will improve functional outcomes of survivors.

Introduction/Background: An estimated 80% of persons with disability (PwD) live in low- and middle-income countries (LMICs), with significant burden of disease and subsequent disability. The WHO Global Disability Action Plan 2014–2021 (GDAP), provides a list of specific actions and metrics for the empowerment of PwD, including strengthening/extending rehabilitation, assistive-technology, support services, and community-based rehabilitation. The aim of this study was to identify potential barriers for implementation of the GDAP in LMICs. Material and method: The Flying Faculty rehabilitation team from the Royal Melbourne Hospital, Australia conducted intensive workshops at medical/academic institutions in LMICs for healthcare professionals from various local Physical Medicine and Rehabilitation (PM&R) facilities. A modified Delphi method identified challenges for future implementation to address gaps identified. Results: Despite differences in the healthcare system and practices in LMICs, the challenges reported in four countries, at both macro (governmental/policy makers) and micro levels (community/social/individual) were similar. Common strategies were implemented to address challenges: limited knowledge of disability services, PM&R workforce, guidelines and accreditation standards; coordination amongst healthcare sectors; social issues; data and research; legislation and political commitment. Support of potential facilitators were: need for strong leadership; advocacy of disability-inclusive development; investment in infrastructure/human resources; coordination/partnerships in healthcare sector; and research. Conclusion: Disability care and rehabilitation is an emerging priority in LMICs to address the needs of people with disability. The GDAP framework provides guidance to facilitate access and strengthen PM&R services.

Introduction/Background: Despite the prevalence of disability in low-and-middle income countries (LMICs), the clinical skills of rehabilitation workforce are not well described. We report health professionals’ perspectives on clinical skills in austere settings and identify context-specific gaps for workforce capacity. Material and method: An exploratory-descriptive, cross-sectional, pilot survey of healthcare professionals working in rehabilitation in hospital and community settings conducted in Pakistan, Morocco, Nigeria and Malaysia. A situational-analysis survey-tool captured cross-sectional assessment of clinical skills required in various rehabilitation settings. Participant responses were coded in a line-by-line process, and clustered into common terms based on International Classification of Functioning, Disability and Health (ICF) framework to classify skill-categories in target domains. Results: Survey respondents (n = 532) from Pakistan 248, Nigeria 159, Morocco 93 and Malaysia 32 completed the survey. The participants were: physiotherapists (52.8%), nurses (8.8%), speech and occupational therapists (8.5%, 5.3%), other medical doctors (5.5%), rehabilitation physicians (3.8%), and prosthetist/orthotists (1.5%). The 10 most commonly used clinical skills reported were prescription of physical activity and medications, transfer-techniques, daily-living activities, allied health interventions, patient/carer education, comprehensive patient-care, diagnosis/screening, behaviour/cognitive interventions, referrals, assessments and collaboration. Most responses linked with ICF categories in activities/participation, and personal factors. Conclusion: The survey tool identified task shifting amongst healthcare professionals. The core skills and gaps reflected general rehabilitation practice, rather than discipline-specific skills.

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.

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.

Introduction/Background: Pain can be a significant long-term problem for a substantial proportion of persons with multiple sclerosis (pwMS). The aim of this study was to examine the course and impact of chronic pain over a span of 10-years. Material and method: A longitudinal, cross-sectional study assessed pwMS residing in the community at seven and ten years using validated measures: Visual Analogue Scale; Numerical Rating Scale; Chronic Pain Grade (CPG); Assessment of Quality of Life and the Carer Strain Index (CSI). Results: Mean age of the participants (n = 70) was 59.8 ± 9 years (range: 39–74 years) and majority (70%) were female. The findings show that over 10-year period, majority report bilateral lower limb dysesthesia (40%), mixed pain (35.2%) and widespread pain (17.1%). There was a significant deterioration in quality of life (QoL) in those with more severe CPG. Almost half of the participants (44%) required care either from a private carer/family or institution. The carers (n = 13) reported higher carer strain (mean CSI = 5.2), with over half reporting sleep disturbance, inconvenience, physical strains, family and personal constraints. Although fear of taking medications and side effects were common barriers to treatment for pain, there was an increase in the use of pharmacological treatment and healthcare services, mainly neurologists and general practitioners over time. Conclusion: This study demonstrates that persistent chronic pain is a significant issue over time in pwMS, with clinical and health implications, poorer QoL, and increased healthcare utilisation. Greater awareness of chronic pain in pwMS and interdisciplinary approach is required to improve long-term patient outcomes and well-being.

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-byline 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. Key words: disability; rehabilitation