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Biomedical subjects

L Turner-Stokes

Publications and source records attributed to L Turner-Stokes.

At least 19 recordsLinked to original sources
PubMed2006

Efficiency of specialist rehabilitation in reducing dependency and costs of continuing care for adults with complex acquired brain injuries.

OBJECTIVES: To examine functional outcomes from a rehabilitation programme and to compare two methods for evaluating cost efficiency of rehabilitation in patients with severe complex disability. SUBJECTS AND SETTING: Two hundred and ninety seven consecutive admissions to a specialist inpatient rehabilitation unit following severe acquired brain injury. METHODS: Retrospective analysis of routinely collected data, including the Functional Independence Measure (FIM), Barthel Index, and Northwick Park Dependency Score and Care Needs Assessment (NPDS/NPCNA), which provides a generic estimation of dependency, care hours. and weekly cost of continuing care in the community. Patients were analysed in three groups according to dependency on admission: "low" (NPDS<10 (n=83)); "medium" (NPDS10-24 (n=112)); "high" (NPDS>24 (n=102)). RESULTS: Mean length of stay (LOS) 112 (SD 66) days. All groups showed significant reduction in dependency between admission and discharge on all measures (paired t tests: p<0.001). Mean reduction in "weekly cost of care" was greatest in the high dependency group at pound639 per week (95% CI 488 to 789)), as compared with the medium (pound323/week (95% CI 217 to 428)), and low (pound111/week (95% CI 42 to 179)) dependency groups. Despite their longer LOS, time taken to offset the initial cost of rehabilitation was only 16.3 months in the high dependency group, compared with 21.5 months (medium dependency) and 38.8 months (low dependency). FIM efficiency (FIM gain/LOS) appeared greatest in the medium dependency group (0.25), compared with the low (0.17) and high (0.16) dependency groups. CONCLUSIONS: The NPDS/NPCNA detected changes in dependency potentially associated with substantial savings in the cost of ongoing care, especially in high dependency patients. Floor effects in responsiveness of the FIM may lead to underestimation of efficiency of rehabilitation in higher dependency patients.

Activities of Daily Living↗
PubMed2005

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, where older adults predominate. However, the evidence base for the effectiveness of rehabilitation following acquired brain injury (ABI) in younger adults is not yet established, perhaps because there are different methodological challenges. OBJECTIVES: To assess the effects of multi-disciplinary rehabilitation following ABI in adults, 16 to 65 years. To explore approaches that are effective in different settings and the outcomes that are affected. SEARCH STRATEGY: We used a wide range of sources including: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966-2004), EMBASE (1988-2004), CINAHL (1983-2004), PsycLIT (1967-2004), AMED, the National Research Register 2004 and ISI Science Citation Index (1981-2004). SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing multi-disciplinary rehabilitation with either routinely available local services or lower levels of intervention; or trials comparing intervention in different settings or at different levels of intensity. Quasi-randomised and quasi-experimental designs were also included, providing they met pre-defined methodological criteria. DATA COLLECTION AND ANALYSIS: Trials were selected by two authors independently, and their methodological quality rated, again by two independent authors. A third reviewer arbitrated when disagreements could not be resolved by discussion. A 'best evidence' synthesis was performed by attributing levels of evidence, based on methodological quality. Trials were sub-divided in terms of severity of ABI and the setting and type of rehabilitation offered. MAIN RESULTS: Ten trials were identified of good methodological quality and four of lower quality. Within the subgroup of predominantly mild brain injury, 'strong evidence' suggested that most patients make a good recovery with provision of appropriate information, without additional specific intervention. For moderate to severe injury, there is 'strong evidence' of benefit from formal intervention. For patients with moderate to severe ABI already in rehabilitation, there is strong evidence that more intensive programmes are associated with earlier functional gains, and 'moderate evidence' that continued outpatient therapy can help to sustain gains made in early post-acute rehabilitation. There is 'limited evidence' that specialist in-patient rehabilitation and specialist multi-disciplinary community rehabilitation may provide additional functional gains, but the studies serve to highlight the particular practical and ethical restraints on randomisation of severely affected individuals for whom there are no realistic alternatives to specialist intervention. AUTHORS' CONCLUSIONS: Problems following ABI vary; different services are required to suit the needs of patients with different problems. Patients presenting acutely to hospital with moderate to severe brain injury should be routinely followed up to assess their need for rehabilitation. Intensive intervention appears to lead to earlier gains. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation should have access to out-patient or community-based services appropriate to their needs. Those with milder brain injury benefit from follow-up, and appropriate information and advice. Not all questions in rehabilitation can be addressed by traditional research methodologies. There are important questions still to be answered and future research should employ the most appropriate methodology.

Adolescent↗
PubMed2005

The Depression Intensity Scale Circles (DISCs): a first evaluation of a simple assessment tool for depression in the context of brain injury.

OBJECTIVE: To assess the validity, responsiveness, and test-retest reliability of DISCs (Depression Intensity Scale Circles) as a simple screening tool for depression in patients with cognitive or communicative deficits following acquired brain injury. DESIGN: Cohort analysis of consecutive patients entered into an integrated care pathway for screening and management of depression in the context of rehabilitation. SETTING: Regional neurological rehabilitation service in the UK. PARTICIPANTS: 114 patients with complex disabilities caused by acquired brain injury (mean (SD) age, 42.8 (14.5) years). MAIN OUTCOME MEASURES: DISCs (a graphic rating scale depicting six circles with increasing proportion of dark shading), Numbered Graphic Rating Scale (NGRS), Yale single question ("Do you often feel sad or depressed"), Beck Depression Inventory-II (BDI-II), DSM-IV criteria for depression. RESULTS: At initial assessment the DISCs correlated with total BDI-II scores (Spearman rho = 0.66, p < 0.001), NGRS (rho = 0.87, p<0.001), and DSM-IV (rho = 0.59, p<0.001). A DISCs score > or =2 identified depression (major or minor) according to DSM-IV criteria with 60% sensitivity, 87% specificity, 75% positive predictive value, and 77% negative predictive value. Test-retest reliability after 24 hours (n = 66) showed "excellent" level of agreement (weighted kappa = 0.84). In 45 patients who received intervention for depression, the DISCs showed a significant change in response to treatment (Wilcoxon; p<0.001). CONCLUSIONS: DISCs had acceptable convergent validity, reliability, and responsiveness as a simple graded tool for screening and assessment of depression in patients with complex disabilities following acquired brain injury. It warrants further investigation in patients with more profound language and cognitive deficits for which it is primarily intended.

Adult↗
PubMed2004

Exercise for people with peripheral neuropathy.

BACKGROUND: Peripheral neuropathies are a wide range of diseases affecting the peripheral nerves. Demyelination or axonal degeneration gives rise to a variety of symptoms including reduced or altered sensation, pain, muscle weakness and fatigue. Secondary disability arises and this may result in adjustments to psychological and social function. Exercise therapy, with a view to developing strength and stamina, forms part of the treatment for people with peripheral neuropathy, particularly in the later stages of recovery from acute neuropathy and in chronic neuropathies. OBJECTIVES: The primary objective was to examine the effect of exercise therapy on functional ability in the treatment of people with peripheral neuropathy. In addition, secondary outcomes of muscle strength, endurance, broader measures of health and well being, as well as unfavourable outcomes were examined. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register (July 2002 and updated February 2004) and MEDLINE (from January 1966 to June 2004), EMBASE (from January 1980 to June 2004), CINAHL (from January 1982 to July 2002) and LILACS (from January 1982 to July 2002) electronic databases. Bibliographies of all selected randomised controlled trials were checked and authors contacted to identify additional published or unpublished data. SELECTION CRITERIA: Any randomised or quasi-randomised controlled trial comparing the effect of exercise therapy with no exercise therapy or drugs or an alternative non-drug treatment on functional ability (or disability) in people with peripheral neuropathy at least eight weeks after randomisation was included. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected eligible studies, rated the methodological quality and extracted data. MAIN RESULTS: Only one trial fully met the inclusion criteria. An additional two trials assessed outcomes less than eight weeks after randomisation and were also included. Methodological quality was poor for several criteria in each study. Data used in the three studies could not be pooled due to heterogeneity of diagnostic groups and outcome measures. The results of the included trials failed to show any effect of strengthening and endurance exercise programmes on functional ability in people with peripheral neuropathy. However, there is some evidence that strengthening exercise programmes were moderately effective in increasing the strength of tested muscles. REVIEWERS' CONCLUSIONS: There is inadequate evidence to evaluate the effect of exercise on functional ability in people with peripheral neuropathy. The results suggest that progressive resisted exercise may improve muscle strength in affected muscles.

Exercise Therapy↗
PubMed2004

Does reducing spasticity translate into functional benefit? An exploratory meta-analysis.

BACKGROUND: Spasticity and loss of function in an affected arm are common after stroke. Although botulinum toxin is used to reduce spasticity, its functional benefits are less easily demonstrated. This paper reports an exploratory meta-analysis to investigate the relationship between reduced arm spasticity and improved arm function. METHOD: Individual data from stroke patients in two randomised controlled trials of intra-muscular botulinum toxin were pooled. The Modified Ashworth Scale (elbow, wrist, fingers) was used to calculate a "Composite Spasticity Index". Data from the arm section of the Barthel Activities of Daily Living Index (dressing, grooming, and feeding) and three subjective measures (putting arm through sleeve, cleaning palm, cutting fingernails) were summed to give a "Composite Functional Index". Change scores and the time of maximum change were also calculated. RESULTS: Maximum changes in both composite measures occurred concurrently in 47 patients. In 26 patients the improvement in spasticity preceded the improvement in function with 18 showing the reverse. There was a definite relationship between the maximum change in spasticity and the maximum change in arm function, independent of treatment (rho = -0.2822, p = 0.0008, n = 137). There was a clear relationship between the changes in spasticity and in arm function in patients treated with botulinum toxin (Dysport) at 500 or 1000 units (rho = -0.5679, p = 0.0090, n = 22; rho = -0.4430, p = 0.0018, n = 47), but not in those treated with placebo or 1500 units. CONCLUSIONS: Using a targeted meta-analytic approach, it is possible to demonstrate that reducing spasticity in the arm is associated with a significant improvement in arm function.

Activities of Daily Living↗
PubMed2002

Reflex sympathetic dystrophy--a complex regional pain syndrome.

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. Diagnostic criteria have been proposed by the International Association for the Study of Pain, but are still subject to debate. 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.

Humans↗
PubMed2002

Traumatic brain injury.

PURPOSE: Traumatic brain injury (TBI) leading to severe disability is fortunately rare, but when it occurs, the effect on patients and their families can be devastating. ISSUE: In the UK at the current time, there are insufficient specialist rehabilitation services to cater for the case-load and many patients receive their care in general wards. CONCLUSION: This educational article outlines the principles of management of severe TBI from a practical clinical viewpoint, reviews briefly the evidence for effectiveness of rehabilitation and offers an approach to consistent outcome measurement.

Brain Injuries↗
PubMed2002

Development of an integrated care pathway for the management of hemiplegic shoulder pain.

PURPOSE: To improve clinical management of patients with hemiplegic shoulder pain through development of an evidence-based multidisciplinary integrated care pathway (ICP), and to use this to audit quality of care against predefined standards. METHODS: The ICP was developed by a team of medical, paramedical and nursing staff. The evidence base was established through a systematic literature review supplemented by clinical consensus to ensure best practice where scientific evidence was lacking. Following development, performance was assessed against standards in a cohort of stroke patients with hemiplegia (n = 32) consecutively admitted to a regional unit providing in-patient rehabilitation for young patients with complex disabilities. RESULTS: Performance showed improvements in assessment and documentation of pain and in initial care, including analgesia and application of positioning/handling protocols. However, review and response to continuing or changing symptoms were poorly documented. Changes to the ICP were introduced to improve this. CONCLUSIONS: Principal benefits have been to raise awareness of shoulder pain, to educate staff and prompt management in line with recommended best practice, but strong leadership is essential to ensure continuity in clinical practice. Future research is needed to establish whether improved quality of care offsets the substantial investment of staff time in ICP development.

Adult↗
PubMed2002

Standardized outcome assessment in brain injury rehabilitation for younger adults.

PURPOSE: To explore possible candidates for a common outcome measure for brain injury rehabilitation in younger adults. METHOD: Patients recovering from brain injury pass through several different stages of rehabilitation, illustrated by the 'Slinky model'. Outcome measures used to assess progress must not only meet scientific criteria for validity and reliability--they must be practical to use in a clinical setting and relevant to the rehabilitation goals at each stage. Within most major rehabilitation settings, the commonest goals focus on reducing disability or dependency. Among the most widely used measures in the UK are the Barthel Index, the Functional Independence Measure (FIM) and the extended Functional Assessment Measure (FIM + FAM). The relationship between these instruments is discussed. CONCLUSION: No single outcome measure is suitable for all brain injury rehabilitation, but by taking these most widely used measures and understanding the relationship between them, we already have a potential common language in disability measurement between the majority of rehabilitation centres in the UK and beyond. These instruments, however, have clear floor and ceiling effects and further work is needed to agree common measures for rehabilitation intervention that falls outside the sensitivity range of these three scales.

Brain Injuries↗
PubMed2001

Accuracy of prediction of walking for young stroke patients by use of the FIM.

BACKGROUND AND PURPOSE: Clinical prediction of walking outcome after a stroke is essential for effective discharge planning. However, its accuracy has hardly been explored. This study took place in a regional unit admitting patients with complex neurological disabilities for specialist inpatient rehabilitation. The aim was to compare predicted outcome (goal score) with achieved outcome (discharge score) on the seven-point locomotion subscale of the Functional Independence Measure (FIM), to evaluate its precision and identify factors influencing accuracy. METHOD: Admission, goal and discharge scores were analysed retrospectively for 141 subjects (90 M; 51 F) admitted consecutively to the Unit with median age 54 years (range 15-68 years) with median length of stay 13.6 weeks (range 3-35 weeks). RESULTS: Ninety subjects (64%) gained from two to six points; 50 subjects (35%) gained one point or showed no change. One patient deteriorated by two points. Excluding patients admitted with the highest score (FIM level 7), the overall level of agreement between predicted and discharge scores was moderate (weighted kappa 0.47). Prediction was accurate to +/- 1 point in 113 subjects (80%). Overprediction by > or = 2 points occurred in 16 subjects (11%) and underprediction by > or = 2 points in 12 subjects (9%). Analysis of the most-disabled cohort, admitted with FIM levels 1 or 2 scores, revealed a higher sensitivity for predicting 'independence' (FIM levels 5-7) (78%) than 'dependence' (FIM levels 1-4) (65%). Accuracy was not affected by age, gender or side of stroke. Inaccurate predictions were associated with lower admission FIM level scores (p = -0.26; p = 0.002) and a greater length of stay (p = 0.36; p < 0.001). Subjects with quadriplegia were more likely to have inaccurate outcome predictions made than those with hemiplegia (p = 0.025) and those with neglect were more likely to have inaccurate outcome predictions made than those without neglect (p = 0.017). CONCLUSION: Further investigation into clinical prediction and the variables which confound accuracy is needed for effective planning.

Adolescent↗
PubMed2001

Can brain-injured patients participate in an aerobic exercise programme during early inpatient rehabilitation?

OBJECTIVE: We investigated the capacity of brain-injured patients to participate in an aerobic exercise programme early after injury. DESIGN: Retrospective analysis of exercise achievements in patients participating in a randomized controlled trial. SETTING AND SUBJECTS: Ninety patients participated in an exercise training programme on a cycle ergometer at four inpatient neurological rehabilitation units for younger patients. At intake, impairments and function were rated on: Motricity Index, Ashworth Scale, Berg Balance Scale, Barthel Index and Functional Independence Measure. INTERVENTIONS: Patients cycled for up to 30 minutes three times weekly for 24-36 sessions over 12 weeks. MAIN OUTCOME MEASURES: Exercise performance was measured by: (a) number of sessions to achieve a cycling time of 30 minutes, (b) overall mean cycling time per session over 24 sessions and (c) mean time per session cycling at >60% of age predicted maximum heart rate (HR max) over 24 sessions. RESULTS: Fifty-five patients completed 24 sessions. Thirty-five withdrew, largely for logistic reasons, before completing training; they were significantly less disabled than the 55 who remained. Forty-four of the 55 patients trained for an average of at least 20 minutes per session, 18 training at >60% HR max for this time. There were no differences in performance on the three exercise parameters between two groups of patients with baseline Barthel scores of < or = 12 and > or = 13. CONCLUSIONS: Brain-injured patients with a range of disabilities have the capacity to participate in an exercise programme during early inpatient rehabilitation, though some may take longer to achieve adequate intensity of aerobic exercise.

Adolescent↗
PubMed2001

Clinical standards for specialist community rehabilitation services in the UK.

OBJECTIVE: To develop a set of clinical standards for specialist community rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services. DESIGN AND METHODS: The proposed set of standards was adapted from the previously published standards for inpatient services, by a working party of the British Society for Rehabilitation Medicine (BSRM). Consensus was then achieved by an iterative consultation process in five rounds. A postal survey was conducted on behalf of the BSRM amongst its consultant members providing community rehabilitation services in the UK, who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability. RESULTS: Fifty consultants who ran specialist community rehabilitation services agreed to participate, of whom 29 (58%) actually responded. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Twenty-five (89%) felt the standards were helpful and 26 (93%) felt that they covered the main aspects of specialist community rehabilitation services: 23 (79%) found them at least partially applicable to their own service. CONCLUSIONS: Proposed clinical standards have been developed for specialist community rehabilitation services in the UK. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

Community Health Services↗
PubMed2000

Clinical standards for inpatient specialist rehabilitation services in the UK.

OBJECTIVE: To develop a set of clinical standards for specialist inpatient rehabilitation services in the UK and to undertake a preliminary survey of consultants who provide those services. DESIGN: The proposed set of standards was developed by group consensus followed by an iterative consultation process. A postal survey was conducted on behalf of the British Society for Rehabilitation Medicine (BSRM) amongst its consultant members in the UK (n = 163), who were asked to assess their services in relation to these standards, and to comment on the standards themselves, their usefulness and applicability. RESULTS: The response rate was 61%, of which 81 respondents ran an inpatient rehabilitation service. Overall, the standards appeared to be acceptable to most, and mainly struck the right level, being attained by the majority of services. Specific suggestions were incorporated into the revised standards. Further work is required to establish agreed outcomes that are systematically measured and recorded: only half the respondents (50%) routinely recorded a standardized outcome measure, and only a quarter (26%) routinely reviewed patients to record long-term outcome. CONCLUSIONS: Clinical standards have been developed for specialist inpatient rehabilitation services in the UK. The BSRM proposes to adopt these standards for a test period of 2-3 years in the first instance. It is likely that they will require further refinement with time, and modification is required to adapt them to different subspecialities and settings.

Guideline Adherence↗
PubMed2000

Can young severely disabled stroke patients regain the ability to walk independently more than three months post stroke?

OBJECTIVE: To investigate the acquisition of ability to walk independently in young severely disabled stroke patients unable to walk three months after onset. SETTING: A regional rehabilitation unit providing post-acute neurorehabilitation mainly for patients aged 16-65 years. SUBJECTS AND METHODS: A retrospective analysis of records was undertaken for 152 stroke patients admitted consecutively over a three-year period. All had a combination of physical, cognitive and language impairments; male/female 98/54; median age 54 (IQR 47-60) years. MAIN OUTCOME MEASURES: Time taken from stroke onset to regain the ability to walk safely and independently at least 5 metres around the hospital bay. RESULTS: Seventy-five (49%) regained the ability to walk independently between 3 and 11 months post onset. Patients with cognitive impairments and neglect took longer to walk. Time from stroke onset to admission was longer in patients who did not walk (median 16.3 weeks), than in those who regained walking (median 12.7 weeks; p = 0.009). Independent positive associations were found between the time taken to walk and time from onset to referral for rehabilitation (p = 0.55; p < 0.001), and time from acceptance to admission (p = 0.30; p = 0.008). CONCLUSION: With intensive specialist input, significant numbers of severely disabled young stroke patients can regain independent walking many months after onset, though late walkers may follow a slower recovery course. These results argue for investment in appropriate rehabilitation for these patients. Waiting list delays may prolong rehabilitation and potentially compromise cost effectiveness.

Activities of Daily Living↗
PubMed1999

Three-dimensional motion analysis of upper limb movement in the bowing arm of string-playing musicians.

OBJECTIVES: To explore the role of three-dimensional movement analysis in defining patterns of joint movement while bowing on different stringed instruments, and its potential for future use by the clinician in the study of musculoskeletal problems in musicians. DESIGN AND METHODS: A protocol was developed for analysis of bowing arm movements using the MacReflex 3-D analysis system- including definition of marker sites, positioning of the musician within the calibrated area and standardised bowing sequences. This protocol was then used to determine whether the system was sensitive to differences between instrument types and to variation in bowing style and technique between individual players. The ranges of movement in the shoulder, elbow and wrist were compared between instrument groups in a cohort of 39 asymptomatic string players. RESULTS: The system gave reproducible results on repeated testing, and demonstrated clear differences between instruments, as well as stylistic differences between players. Range of shoulder movement increased progressively towards the upper register of the cello, while decreasing on the violin. Maximum elevation of the shoulder was significantly greater on the cello (P<0.001), while elbow flexion, and therefore range, was consistently greater on the violin. CONCLUSIONS: Clear and reproducible differences in style and technique were demonstrated between individuals. The increased range of shoulder movement in the upper register of the 'cello may contribute to the greater prevalence of neck and shoulder symptoms among 'cellists. Further study is required to establish whether different musculoskeletal symptoms produce characteristic patterns which could help in diagnosis and development is required to make the system feasible for routine use. RELEVANCE: Musculoskeletal problems are common among musicians. Different instruments and playing positions make different demands on joints and may contribute to the variance in reported incidence of musculoskeletal symptoms among violinists and cellists. Three-dimensional analysis may prove helpful in the future for the diagnosis of different musculoskeletal syndromes in string players, or for identifying movement patterns which could exacerbate repetitive strain injuries. However, as this is the first application of the technique in this complex area, preliminary work was required to establish feasibility and to obtain data on normal players.

Arm↗
PubMed1999

Effectiveness of brain injury rehabilitation.

Despite the problems posed by diversity of condition and the lack of agreement among researchers over what outcome to measure, there is now increasingly robust evidence for the effectiveness of rehabilitation in brain-injured populations. Meta-analysis has demonstrated clearly that stroke units provide a better outcome than management on a general medical ward, at the level of survival, discharge destination and dependency. The extent of this advantage may be summarized in the following terms. For every 100 patients treated in a stroke unit, four deaths and two institutional admissions are avoided, and five patients are discharged home. This benefit appears to arise from a combination of good-quality acute management and the coordinated input of a multidisciplinary team. Therapy programmes are shown to be of benefit and intensive therapy programmes of somewhat greater benefit. Smaller numbers and heterogeneity among the head-injured population tend to confound randomized controlled trial designs, but there is no good reason to suppose that brain injury resulting from trauma should be less responsive to similar good management principles than that arising from stroke. In any event, we have progressed to a stage where the weight of evidence supports the notion that rehabilitation is effective, and nontreatment controls are ethically no longer acceptable. It is time now to unravel the threads of rehabilitation and consider which are the critical components. There are still many opportunities for comparison of different models for delivery of care, and the existing evidence for these is discussed.

Behavior Therapy↗