Disability and rehabilitation
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Review
Traumatic brain injury: classification of initial severity and determination of functional outcome.
The aim of the present manuscript is to review current methods for classifying initial severity and final outcome in traumatic brain injury (TBI) and to suggest a direction and form of further research. ⋯ Future research in TBI outcome, particularly in rehabilitation medicine, should focus on determinants of outcome, identifying those patients who will have the greatest chance of benefiting from intensive rehabilitation programmes. More research is needed to determine the long-term functional outcome in TBI, the long-term socio-economic costs, and the influence of behavioural problems on family cohesion. Finally, validation of outcome measures is required in the TBI-population; the relative value of various outcome measures needs to be determined, and the usefulness and applicability of measures for health related quality of life in TBI should be established.
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Reflex sympathetic dystrophy (RSD) is a complex and poorly-understood condition characterized by: (a) pain and altered sensation; (b) motor disturbance and soft tissue change; (c) vasomotor and autonomic changes; and (d) psychosocial disturbance. Neurological symptoms typically do not conform to any particular pattern of nerve damage. Many different names have been ascribed to this condition and most recently the term 'complex regional pain syndrome' has been coined to emphasize the complex interaction of somatic, psychological and behavioural factors. ⋯ This review article describes the clinical features which may present as part of the condition, and the patho-physiology and pre-disposing factors so far identified. The evidence for effectiveness of different interventions is presented and a treatment approach outlined for inter-disciplinary management. While RSD is traditionally associated with pain in the extremities, the possibility is raised that the same process may underlie chronic pain syndromes affecting more central structures, such as testicular or pelvic pain.
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This commentary provides both theoretical and practical insights into the concept of community-based rehabilitation (CBR) and its application in developing countries. In doing so it explores current practices in CBR and the debate surrounding them, namely the ethical question and how this may impact on future CBR. The main argument in this account is that disability is a development issue; with widespread poverty, inequality and violation of human rights, and should be addressed within the broader context of community development which may include strategies such as CBR. ⋯ This background emphasizes that new directions in CBR need to be put in place in order to maximize the realization of the ultimate goal: the greatest participation for disabled people in all spheres of life. Effective rehabilitation programmes should allow people with disability to have greater control in the nature of their rehabilitation and that the role of professionals and other stakeholders is one of allies and resources in the rehabilitation process. Moreover, the participation of community members in the rehabilitation policy should be assured.
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To review the published literature concerning the treatment of painful conditions using devices that deliver electrical stimulation to nervous structures. The review briefly surveys the results obtained using surface electrodes ("TENS") as well as implanted devices. ⋯ TENS has proved to be remarkably safe, and provides significant analgesia in about half of patients experiencing moderate predictable pain. Implanted devices can be more effective, but they carry a risk of device failure, implant infection or surgical complication, and are reserved for the more severe intractable chronic pains. The main implanted devices used clinically are the spinal cord stimulator and the deep brain stimulator.
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This paper provides a review of the current concepts of complex regional pain syndrome (CRPS) and current diagnostic criteria are presented. Etiology and pathophysiological mechanisms of painful disorders, previously addressed as reflex sympathetic dystrophy (RSD) remain doubtful. ⋯ The supposition of a sympathetic hyperactivity in the development of this syndrome could not be confirmed. Up to now no diagnostic test that would be specific for the diagnosis of CRPS is available. The diagnosis relies on clinical findings and the exclusion of conditions that could account for the degree of pain and dysfunction. Pain relief and functional restoration are the primary goals of all therapeutic intervention and should start as early as possible.