Developments in Neurological Rehabilitation

Prof. Anthony B WardNorth 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:

– 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

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 ofclinical activity

Neurological Rehabilitation

• Developments in specialised rehabilitation– Concepts– Services

• Developments in rehabilitation of neurological disorders– Effectiveness of interventions– Measurement– Technological developments

• Developments in specialised rehabilitation– Concepts– Services

• Developments in rehabilitation of neurological disorders– Effectiveness of interventions– Measurement– Technological developments

Neurological Rehabilitation

Teamwork

Clinical effectiveness

Outcomes•Identification•Measurement

Cost-utility

Cost-effectiveness

Rehabilitation Medicine

Health condition (disorder or disease)

Body Functions and Structures

Activities Participation

Environmental Factors

Personal Factors

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

• Developments in specialised rehabilitation– Concepts– Services

• Developments in rehabilitation of neurological disorders– Effectiveness of interventions– Measurement– Technological developments

Neurological Rehabilitation

► 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 pressNSF Long Term Conditions. 2005 London. TSO. www.dh.gov.longtermnsf

Vocational Assessment & Rehabilitation after Acquired Brain Injury. 2004. BSRM/RCP/JobCentrePlus

• 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 1999Gutenbrunner C, Ward AB, Chamberlain MA. White Book on PRM in

Europe. 2007

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

Neurological Rehabilitation in Acute Settings

Didier JP.2004 McLellan DL. 1991Krauth C. 2005 Verplancke D, et al. 2005Fjaertoft H, et al. 2005 Shiel A, et al. 1999

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•Interact with 1o 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

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

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

• Developments in specialised rehabilitation – Concepts– Services

• Developments in rehabilitation of neurological disorders– Effectiveness of interventions– Measurement– Technological developments

Neurological Rehabilitation

Example

Spasticity Management

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

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

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?

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

• Developments in specialised rehabilitation – Concepts– Services

• Developments in rehabilitation of neurological disorders– Effectiveness of interventions– Measurement– Technological developments

Neurological Rehabilitation

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

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

CareNorthwick Park Care Dependency Score

• Quality of life

EQ5D, SF36

Patient satisfaction (VAS/Likert)

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

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

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

Goal Attainment Scale (GAS)

• 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

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: 2434.

• Developments in specialised rehabilitation – Concepts– Services

• Developments in rehabilitation of neurological disorders– Effectiveness of interventions– Measurement– Technological developments

Neurological Rehabilitation

New Developments

• Therapeutic assistance• Mobility aids• Electronic assistive technology

– Communication aids– Environmental aids

• Neurological prostheses & modulation• Robotics• Telerehabilitation

Early treatment to prevent learned non-use

Combining treatments for a better effect

Concentrating on functional outcomes

Progress?

• 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.

Lokomat® Driven Gait Orthosis

Burridge J, et al. Jnl Rehabil Med. 2007

ActiGait®

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.

Sacral Root Stimulator

Communication Aids

Electronic Assistive Technology

Devices to reduce dependence & care

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.

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

Thank You