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.

Problems following ABI vary. Consequently, different interventions and combinations of interventions are required to meet the needs of patients with different problems. Patients who present acutely to hospital with mild brain injury benefit from follow-up and appropriate information and advice. Those with moderate to severe brain injury benefit from routine follow-up so their needs for rehabilitation can be assessed. Intensive intervention appears to lead to earlier gains, and earlier intervention whilst still in emergency and acute care has been supported by limited evidence. The balance between intensity and cost-effectiveness has yet to be determined. Patients discharged from in-patient rehabilitation benefit from access to out-patient or community-based services appropriate to their needs. Group-based rehabilitation in a therapeutic milieu (where patients undergo neuropsychological rehabilitation in a therapeutic environment with a peer group of individuals facing similar challenges) represents an effective approach for patients requiring neuropsychological rehabilitation following severe brain injury. Not all questions in rehabilitation can be addressed by randomised controlled trials or other experimental approaches. For example, trial-based literature does not tell us which treatments work best for which patients over the long term, and which models of service represent value for money in the context of life-long care. In the future, such questions will need to be considered alongside practice-based evidence gathered from large systematic longitudinal cohort studies conducted in the context of routine clinical practice.

Editorial group: Cochrane Injuries Group Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 12, 2015.

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

The provision and maintenance of prostheses in 100 trans-femoral amputees and 73 trans-tibial amputees were retrospectively analysed over a 10-year period. The aim of the study was to analyse the prosthetic episodes, i.e., the need for maintenance, repairs and replacements to a trans-femoral and a trans-tibial prosthesis and frequency of new sockets prescribed over the same period of use by established adult amputees. The study showed that the trans-femoral amputees needed 0.96 new prostheses, 3.27 new sockets, 2.31 major repairs, 3.36 component changes and 21.85 minor repairs. Younger trans-femoral amputees aged less than 60 years needed 1.1 new prostheses, 3.15 new sockets, 2.06 major repairs, 4.23 component changes and 20.49 minor repairs. Younger trans-femoral amputees needed significantly more changes of prosthetic components (p ¼ 0.04). The associated study on 73 trans-tibial amputees showed that they needed 1.4 new prosthesis, 2.9 new sockets, 3.2 major repairs and 14.1 minor repairs over the same 10-year period. The introduction and prescription of modular prosthesis as opposed to conventional limbs used earlier has possibly allowed components to be easily replaced thus reducing the need to replace a whole new prosthesis.