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Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
Developments in Neurological Rehabilitation Prof. Anthony B Ward
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Developments in Neurological Rehabilitation Prof. Anthony B Ward

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  • 1. Developments in Neurological Rehabilitation Prof. Anthony B Ward North Staffordshire Rehabilitation Centre University Hospital of North Staffordshire Stoke on Trent U.H.N.S
  • 2. Rehabilitation <ul><li>Process of active change to use all means aimed at: </li></ul><ul><ul><li>Acquiring knowledge & skills necessary for optimal physical, psychological and social function </li></ul></ul><ul><ul><li>Reducing the impact of disabling and handicapping conditions </li></ul></ul><ul><ul><li>Enabling people with disabilities to achieve optimal participation </li></ul></ul><ul><li>WHO 1981 </li></ul>
  • 3. Neurological Rehabilitation <ul><li>Rehabilitation activity of people with impairments due to neurological health conditions </li></ul><ul><li>Delivered by Rehabilitation Medicine specialists & some Clinical Neurologists </li></ul><ul><li>Requires specific training – laid out in RM curriculum of Joint Royal Colleges of Physicians Training Board </li></ul><ul><li>Not a specialty </li></ul><ul><li>Neurorehabilitation does not describe the range of </li></ul><ul><li>clinical activity </li></ul>
  • 4. Rehabilitation Medicine <ul><li>An independent medical specialty </li></ul><ul><li>Concerned with the promotion of physical and cognitive functioning, activities (including behaviour), participation (including quality of life) and modifying personal and environmental factors. </li></ul><ul><li>Responsible for the prevention, diagnosis, treatments & rehabilitation management of people with disabling medical conditions and co-morbidity across all ages </li></ul>Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. 2007
  • 5. Neurological Rehabilitation <ul><li>Developments in specialised rehabilitation </li></ul><ul><ul><li>Concepts </li></ul></ul><ul><ul><li>Services </li></ul></ul><ul><li>Developments in rehabilitation of neurological disorders </li></ul><ul><ul><li>Effectiveness of interventions </li></ul></ul><ul><ul><li>Measurement </li></ul></ul><ul><ul><li>Technological developments </li></ul></ul>
  • 6. <ul><li>Developments in specialised rehabilitation </li></ul><ul><ul><li>Concepts </li></ul></ul><ul><ul><li>Services </li></ul></ul><ul><li>Developments in rehabilitation of neurological disorders </li></ul><ul><ul><li>Effectiveness of interventions </li></ul></ul><ul><ul><li>Measurement </li></ul></ul><ul><ul><li>Technological developments </li></ul></ul>Neurological Rehabilitation
  • 7. <ul><li>Teamwork </li></ul><ul><li>Clinical effectiveness </li></ul><ul><li>Outcomes </li></ul><ul><ul><li>Identification </li></ul></ul><ul><ul><li>Measurement </li></ul></ul><ul><li>Cost-utility </li></ul><ul><li>Cost-effectiveness </li></ul>Rehabilitation Medicine
  • 8. International Classification of Functioning, Disability & Health The Current Framework of Functioning & Disability (ICF) World Health Organisation. International Classification of Functioning, Disability and Health: ICF: Geneva: WHO; 2001. Use of ICF in Clinical Practice Address pathology Alter impairments Improve activity & functioning Optimise appropriate participation
  • 9. <ul><li>Developments in specialised rehabilitation </li></ul><ul><ul><li>Concepts </li></ul></ul><ul><ul><li>Services </li></ul></ul><ul><li>Developments in rehabilitation of neurological disorders </li></ul><ul><ul><li>Effectiveness of interventions </li></ul></ul><ul><ul><li>Measurement </li></ul></ul><ul><ul><li>Technological developments </li></ul></ul>Neurological Rehabilitation
  • 10. <ul><li>Acute settings </li></ul><ul><li>Rehab programmes in post-acute facilities </li></ul><ul><li>Longer term programmes </li></ul><ul><ul><li>Rehabilitation in the community </li></ul></ul><ul><ul><li>Skilled nursing facilities </li></ul></ul><ul><ul><li>Vocational rehabilitation </li></ul></ul>Neurological Rehabilitation Services <ul><li>Criteria for admission </li></ul><ul><li>Field of competence (service & specialist) </li></ul><ul><li>Range of service delivery </li></ul><ul><li>Teamwork issues </li></ul>Ward AB, et al. PRM in Acute Settings. Jnl Rehabilitation Medicine. In press NSF Long Term Conditions. 2005 London. TSO. www.dh.gov.longtermnsf Vocational Assessment & Rehabilitation after Acquired Brain Injury. 2004. BSRM/RCP/JobCentrePlus
  • 11. <ul><li>Concentrates therapy - therapy input associated with shorter hospital stays & improved outcomes </li></ul><ul><li>Right learning environment & right skill mix with trained doctors, nurses, therapists plus other team members </li></ul><ul><li>Optimises patients’ physical & social functioning </li></ul>Neurological Rehabilitation in Acute Settings Shiel A, et al. Clinical Rehabilitation 1999 Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. 2007
  • 12. <ul><li>Reduces complications </li></ul><ul><ul><li>Physical effects of initial physiological injury </li></ul></ul><ul><ul><li>Immobility, etc </li></ul></ul><ul><li>Identifies cognitive & emotional complications of TBI, even in absence of physical sequelae </li></ul><ul><li>Improves chances of independent living at home & return to work </li></ul>Neurological Rehabilitation in Acute Settings Didier JP.2004 McLellan DL. 1991 Krauth C. 2005 Verplancke D, et al. 2005 Fjaertoft H, et al. 2005 Shiel A, et al. 1999
  • 13. Ward A B, et al, In press. Jnl Rehabilitation Med Establishment Activity Advantages Limitations RM Beds in Acute Hospital (≡ Acute inpatient specialised team) Transfer of pts to RM beds in acute hospital <ul><li>Rapid transfer to </li></ul><ul><li>appropriate RM care </li></ul><ul><li>Early rehabilitation </li></ul><ul><li>principles </li></ul><ul><li>Requires adequate </li></ul><ul><li>numbers of </li></ul><ul><li>dedicated staff </li></ul><ul><li>Limited nos. of </li></ul><ul><li>beds and thus pts </li></ul><ul><li>Potential for bed- </li></ul><ul><li>blocking </li></ul><ul><li>Protect against </li></ul><ul><li>inappropriate </li></ul><ul><li>admissions </li></ul><ul><li>Difficult if staff </li></ul><ul><li>numbers inadequate </li></ul>Peripatetic Team ( ≡ Acute RM liaison team ) RM team working solely within acute hospital visits pts. under care of other specialists <ul><li>Consult on larger pt. </li></ul><ul><li>nos. & many </li></ul><ul><li>conditions </li></ul><ul><li>Good liaison team </li></ul><ul><li>with ac. ward staff </li></ul><ul><li>Identify patients </li></ul><ul><li>requiring I/P rehab </li></ul><ul><li>Education of naïve </li></ul><ul><li>family care-givers </li></ul><ul><li>I nteract with 1 o </li></ul><ul><li>care physician </li></ul><ul><li>Some staff not in </li></ul><ul><li>RM team </li></ul><ul><li>Least specialised </li></ul><ul><li>format </li></ul><ul><li>No clinical control </li></ul><ul><li>– pts under care of </li></ul><ul><li>other specialists </li></ul><ul><li>Deal at impairment </li></ul><ul><li>& activity level </li></ul><ul><li>Participation issues </li></ul><ul><li>not addressed </li></ul>
  • 14. Ward A B, et al, In press. Jnl Rehabil Med Establishment Activity Advantages Limitations RM Consultation to Acute Wards RM specialist from stand-alone RM centre visits pts. under care of other specialists <ul><li>Consult on larger </li></ul><ul><li>nos. of patients </li></ul><ul><li>with wide range of </li></ul><ul><li>conditions </li></ul><ul><li>Closer links </li></ul><ul><li>between RM and </li></ul><ul><li>acute specialists </li></ul><ul><li>When treating </li></ul><ul><li>nurses & therapists </li></ul><ul><li>within PRM team </li></ul><ul><li>No clinical control </li></ul><ul><li>– patients under </li></ul><ul><li>care of other </li></ul><ul><li>specialists </li></ul><ul><li>Time & expense to </li></ul><ul><li>be effective; need </li></ul><ul><li>to be on site </li></ul><ul><li>When treating </li></ul><ul><li>nurses & therapists </li></ul><ul><li>not within RM </li></ul><ul><li>team </li></ul>Acute RM Centre Rapid transfer of patients to fast-track facility in stand alone RM Centre <ul><li>Pt exposed at early </li></ul><ul><li>stage to total RM </li></ul><ul><li>team & facilities </li></ul><ul><li>RM specialist </li></ul><ul><li>team competence </li></ul><ul><li>in treating acute </li></ul><ul><li>conditions </li></ul><ul><li>Medically stable pts </li></ul><ul><li>Transfer back if pt </li></ul><ul><li>deteriorates </li></ul><ul><li>No formal contact </li></ul><ul><li>between PRM team </li></ul><ul><li>& acute specialists </li></ul><ul><li>Little or no service </li></ul><ul><li>for patients not </li></ul><ul><li>transferred </li></ul>
  • 15. <ul><li>Developments in specialised rehabilitation </li></ul><ul><ul><li>Concepts </li></ul></ul><ul><ul><li>Services </li></ul></ul><ul><li>Developments in rehabilitation of neurological disorders </li></ul><ul><ul><li>Effectiveness of interventions </li></ul></ul><ul><ul><li>Measurement </li></ul></ul><ul><ul><li>Technological developments </li></ul></ul>Neurological Rehabilitation
  • 16. Example <ul><li>Spasticity Management </li></ul>
  • 17.  
  • 18. Is Early Intervention Useful? <ul><li>Lower limb casting study in early severe brain injury (within two weeks) </li></ul><ul><ul><li>Prevention of contractures </li></ul></ul><ul><ul><ul><li>Active treatment with casting valuable </li></ul></ul></ul><ul><ul><ul><li>Additional BoNT-A valuable in pts with </li></ul></ul></ul><ul><ul><ul><ul><li>Diffuse axonal injury </li></ul></ul></ul></ul><ul><ul><ul><ul><li> GCS 6 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>4 limb spasticity at 10 days </li></ul></ul></ul></ul><ul><ul><li>Active function (sitting balance, transfers) at 12/52 </li></ul></ul><ul><ul><li>Safety </li></ul></ul><ul><ul><li>Better participation </li></ul></ul>Yes <ul><ul><ul><li>Verplancke D, Salisbury C, Snape S, Jones P, Ward AB, Clinical Rehabil 2005 </li></ul></ul></ul><ul><ul><ul><li>Ward AB, Javaid S. European Journal Neurology 2007 </li></ul></ul></ul>
  • 19. Is Patients’ Function Helped by Early Intervention? <ul><ul><li>Early post-stroke dose ranging study using ARAT </li></ul></ul><ul><ul><li>Subjects with no arm function & signs of abnormal muscle activity may functionally benefit from early flexor mm. BoNT-A </li></ul></ul><ul><ul><li>Early BoNT-A treatment may not be beneficial for individuals with functional recovery or without signs of abnormal m. activation </li></ul></ul><ul><ul><li>Larger doses had longer lasting effect </li></ul></ul><ul><ul><li>Quarter dose BoNT-A effects wore off within 2 months </li></ul></ul><ul><ul><ul><li>Cousins E, Ward A B, Roffe C, Pandyan A, Rimington L. Physical Therapy 2009 </li></ul></ul></ul>Maybe No
  • 20. Spasticity Management Plus <ul><li>Combined approach to newer technologies </li></ul><ul><li>Botulinum toxin </li></ul><ul><li>Intrathecal baclofen </li></ul><ul><li>Physical therapy </li></ul><ul><ul><li>Ward AB. European Journal of Neurology 2002; 9 (Suppl 1): 48-52. </li></ul></ul><ul><li>Functional electrical stimulation </li></ul><ul><ul><li>Burridge J, et al. Jnl Rehabil Med. 2007. </li></ul></ul><ul><li>Casting and splinting </li></ul>Is there evidence that a combination works better?
  • 21. Outcomes - Tom <ul><li>Patient </li></ul><ul><li>Walking </li></ul><ul><li>No carer required </li></ul><ul><li>Wife returned to work </li></ul><ul><li>Financial & social benefits </li></ul><ul><li>Patient self-esteem </li></ul><ul><li>Service </li></ul><ul><li>Treatment activity </li></ul><ul><li>Reduced care costs </li></ul><ul><li>No care required </li></ul><ul><li>Less benefit payments </li></ul><ul><li>Higher initial costs </li></ul>
  • 22. <ul><li>Developments in specialised rehabilitation </li></ul><ul><ul><li>Concepts </li></ul></ul><ul><ul><li>Services </li></ul></ul><ul><li>Developments in rehabilitation of neurological disorders </li></ul><ul><ul><li>Effectiveness of interventions </li></ul></ul><ul><ul><li>Measurement </li></ul></ul><ul><ul><li>Technological developments </li></ul></ul>Neurological Rehabilitation
  • 23. Measurement <ul><li>Functional status of individual </li></ul><ul><ul><li>Impairment </li></ul></ul><ul><ul><li>Activity </li></ul></ul><ul><ul><li>Participation </li></ul></ul><ul><ul><li>Quality of life </li></ul></ul><ul><li>Impact of disability on life of individual & family/carer </li></ul><ul><ul><li>Burden of care </li></ul></ul><ul><li>Effectiveness of process of care </li></ul><ul><ul><li>Service quality </li></ul></ul><ul><li>Cost-effectiveness </li></ul>
  • 24. Outcome Measures <ul><li>Impairment </li></ul><ul><ul><li>Goniometry, tone </li></ul></ul><ul><ul><li>Muscle power </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><li>Activity </li></ul><ul><ul><li>Dexterity </li></ul></ul><ul><ul><ul><li>A.R.A.T./ Frenchay 9HPT </li></ul></ul></ul><ul><ul><li>Mobility </li></ul></ul><ul><ul><ul><li>10 metre walk / 6 min walk </li></ul></ul></ul><ul><ul><ul><li>Stride length </li></ul></ul></ul><ul><ul><ul><li>Berg balance </li></ul></ul></ul><ul><li>Participation </li></ul><ul><ul><li>Goal setting </li></ul></ul><ul><ul><li>Occupational/Leisure </li></ul></ul><ul><ul><ul><li>Questionnaires </li></ul></ul></ul><ul><ul><li>Care </li></ul></ul><ul><ul><ul><li>Northwick Park Care Dependency Score </li></ul></ul></ul><ul><li>Quality of life </li></ul><ul><ul><li>EQ5D, SF36 </li></ul></ul><ul><ul><li>Patient satisfaction (VAS/Likert) </li></ul></ul>
  • 25. <ul><li>Time to care & number of carers </li></ul><ul><li>Prospective care needs </li></ul><ul><li>Cost of care </li></ul>Northwick Park Care Dependency Score Turner-Stokes L, Nyein K, Halliwell D. Clinical Rehabilitation 1999
  • 26. Northwick Park Care Dependency Score & Care Needs Assessment <ul><li>Cost-effective provision of nursing care relies on being able to adjust staffing levels in accordance with patient dependency </li></ul><ul><li>The NPDS & Care Needs Assessment enables direct assessment of nursing care needs in community settings </li></ul>Williams H, Harris R, Turner-Stokes L. 2007
  • 27. Process of Rehabilitation <ul><li>Goal Attainment Scale </li></ul><ul><ul><li>5-point prospective scale </li></ul></ul><ul><ul><ul><li>- 2 = patient’s state at start of study </li></ul></ul></ul><ul><ul><ul><li>- 1 = better than start, but goal not achieved </li></ul></ul></ul><ul><ul><ul><li>0 = goal achieved </li></ul></ul></ul><ul><ul><ul><li>+1 = goal exceeded </li></ul></ul></ul><ul><ul><ul><li>+2 = goal substantially exceeded </li></ul></ul></ul>
  • 28. Goal Attainment Scale (GAS) <ul><li>Allows individualisation of realistic and feasible goals for patient needs & expectations 1 </li></ul><ul><ul><li>Everyday activities, self-care or other targets </li></ul></ul><ul><ul><li>Meaningful and relevant to patient </li></ul></ul><ul><ul><li>Focus away from measuring disability to goal achievement </li></ul></ul><ul><li>Transfers heterogeneous goals into single numerical score </li></ul><ul><li>Measurement of change performed according to goal attainment 2, 3 </li></ul><ul><li>More clinically meaningful & sensitive than global measures (BI) 3 </li></ul>1. Royal College of Physicians. Spasticity in Adults: Management Using BT: National Guidelines. 2009. 2. Brock K, et al. Disabil. Rehabil. 2008; Nov 26 [epub]. 3. Ashford S, Turner-Stokes L. Physiotherapy Research Int. 2006; 11: 24  34.
  • 29. <ul><li>Developments in specialised rehabilitation </li></ul><ul><ul><li>Concepts </li></ul></ul><ul><ul><li>Services </li></ul></ul><ul><li>Developments in rehabilitation of neurological disorders </li></ul><ul><ul><li>Effectiveness of interventions </li></ul></ul><ul><ul><li>Measurement </li></ul></ul><ul><ul><li>Technological developments </li></ul></ul>Neurological Rehabilitation
  • 30. New Developments <ul><li>Therapeutic assistance </li></ul><ul><li>Mobility aids </li></ul><ul><li>Electronic assistive technology </li></ul><ul><ul><li>Communication aids </li></ul></ul><ul><ul><li>Environmental aids </li></ul></ul><ul><li>Neurological prostheses & modulation </li></ul><ul><li>Robotics </li></ul><ul><li>Telerehabilitation </li></ul>
  • 31. <ul><li>Early treatment to prevent </li></ul><ul><li>learned non-use </li></ul><ul><li>Combining treatments for a better </li></ul><ul><li>effect </li></ul><ul><li>Concentrating on functional </li></ul><ul><li>outcomes </li></ul>Progress?
  • 32. <ul><li>Max voluntary isometric muscle force </li></ul><ul><li>Inter - & intra - rater reliability demonstrated </li></ul><ul><li>Valuable tool in rehabilitation process </li></ul>Lokomat ® Driven Gait Orthosis Bolliger M, et al. Journal of Neuroengineering & Rehabilitation 2008; 5: 23.
  • 33. Burridge J, et al. Jnl Rehabil Med. 2007 ActiGait ®
  • 34. Botulinum Toxin and FES <ul><li>Long-term follow-up of patients using the ActiGait ® implanted drop-foot stimulator </li></ul><ul><li>Effective in improving distance & speed of walking </li></ul><ul><li>Well accepted by users </li></ul><ul><ul><li>Burridge JH, et al. Journal of Rehabilitation Medicine 2007; 39 (3): 212-218. </li></ul></ul><ul><ul><li>Burridge JH, et al. Journal of Rehabilitation Medicine 2008; 40 (10): 873-875. </li></ul></ul>
  • 35. Sacral Root Stimulator
  • 36. Communication Aids
  • 37. Electronic Assistive Technology Devices to reduce dependence & care
  • 38. Vocational Rehabilitation <ul><li>Cost-effectiveness </li></ul><ul><li>$1 spent on rehab produces up to $17 benefit 1 </li></ul><ul><li>Inclusion from outset of rehabilitation programmes </li></ul><ul><li>Needs resources & inter-agency cooperation </li></ul><ul><li>DH initiative </li></ul><ul><li>Impact on personal injury claims </li></ul>Didier JP. Collection de l’Académie Européenne de Médecine de Réadaptation. 2004. p476. Paris. Melin R. Fugl-Meyer AR. Jnl Rehabil. Med. 2003; 35 (6): 284-289. Krauth C, et al. Rehabilitation 2005; 44: pp e46-e56.
  • 39. Conclusion <ul><li>View on concepts & application of rehabilitation principles in people with impairments due to neurological health conditions </li></ul><ul><li>Describe some of the thinking of where rehabilitation is going </li></ul><ul><li>Technologies available </li></ul>
  • 40. Thank You

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