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

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