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Developments in Neurological Rehabilitation

Developments in Neurological Rehabilitation. Prof. Anthony B Ward North Staffordshire Rehabilitation Centre University Hospital of North Staffordshire Stoke on Trent. U.H.N.S. Rehabilitation. Process of active change to use all means aimed at:

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Developments in Neurological Rehabilitation

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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 • 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. Neurological Rehabilitation • Developments in specialised rehabilitation • Concepts • Services • Developments in rehabilitation of neurological disorders • Effectiveness of interventions • Measurement • Technological developments

  5. Neurological Rehabilitation • Developments in specialised rehabilitation • Concepts • Services • Developments in rehabilitation of neurological disorders • Effectiveness of interventions • Measurement • Technological developments

  6. Rehabilitation Medicine • Teamwork • Clinical effectiveness • Outcomes • Identification • Measurement • Cost-utility • Cost-effectiveness

  7. International Classification of Functioning, Disability & Health The Current Framework of Functioning & Disability (ICF) Use of ICF in Clinical Practice Address pathology Alter impairments Improve activity & functioning Optimise appropriate participation World Health Organisation. International Classification of Functioning, Disability and Health: ICF: Geneva: WHO; 2001.

  8. Neurological Rehabilitation • Developments in specialised rehabilitation • Concepts • Services • Developments in rehabilitation of neurological disorders • Effectiveness of interventions • Measurement • Technological developments

  9. Neurological Rehabilitation Services • Criteria for admission • Field of competence (service & specialist) • Range of service delivery • Teamwork issues • Acute settings • Rehab programmes in post-acute facilities • Longer term programmes • Rehabilitation in the community • Skilled nursing facilities • Vocational rehabilitation 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

  10. Neurological Rehabilitation in Acute Settings • 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 Shiel A, et al. Clinical Rehabilitation 1999 Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in Europe. 2007

  11. Neurological Rehabilitation in Acute Settings • 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 Didier JP.2004 McLellan DL. 1991 Krauth C. 2005 Verplancke D, et al. 2005 Fjaertoft H, et al. 2005 Shiel A, et al. 1999

  12. Ward A B, et al, In press. Jnl Rehabilitation Med

  13. Ward A B, et al, In press. Jnl Rehabil Med

  14. Neurological Rehabilitation • Developments in specialised rehabilitation • Concepts • Services • Developments in rehabilitation of neurological disorders • Effectiveness of interventions • Measurement • Technological developments

  15. Example Spasticity Management

  16. Is Early Intervention Useful? Yes • 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 Verplancke D, Salisbury C, Snape S, Jones P, Ward AB, Clinical Rehabil 2005 Ward AB, Javaid S. European Journal Neurology 2007

  17. Is Patients’ Function Helped by Early Intervention? Maybe No • 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

  18. 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?

  19. 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 Outcomes - Tom

  20. Neurological Rehabilitation • Developments in specialised rehabilitation • Concepts • Services • Developments in rehabilitation of neurological disorders • Effectiveness of interventions • Measurement • Technological developments

  21. 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

  22. OutcomeMeasures • 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)

  23. Northwick Park Care Dependency Score • Time to care & number of carers • Prospective care needs • Cost of care Turner-Stokes L, Nyein K, Halliwell D. Clinical Rehabilitation 1999

  24. 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

  25. 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

  26. Goal Attainment Scale (GAS) 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. • Allows individualisation of realistic and feasible goals for patient needs & expectations1 • 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 attainment2, 3 • More clinically meaningful & sensitive than global measures (BI)3

  27. Neurological Rehabilitation • Developments in specialised rehabilitation • Concepts • Services • Developments in rehabilitation of neurological disorders • Effectiveness of interventions • Measurement • Technological developments

  28. New Developments • Therapeutic assistance • Mobility aids • Electronic assistive technology • Communication aids • Environmental aids • Neurological prostheses & modulation • Robotics • Telerehabilitation

  29. Progress? • Early treatment to prevent learned non-use • Combining treatments for a better effect • Concentrating on functional outcomes

  30. Lokomat® Driven Gait Orthosis • Max voluntary isometric muscle force • Inter - & intra - rater reliability demonstrated • Valuable tool in rehabilitation process Bolliger M, et al. Journal of Neuroengineering & Rehabilitation 2008; 5: 23.

  31. ActiGait® Burridge J, et al. Jnl Rehabil Med. 2007

  32. 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.

  33. Sacral Root Stimulator

  34. Communication Aids

  35. Electronic Assistive Technology Devices to reduce dependence & care

  36. Vocational Rehabilitation • Cost-effectiveness • $1 spent on rehab produces up to $17 benefit1 • 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.

  37. 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

  38. Thank You

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