Christopher WardChristopher WardProfessor & Consultant in Rehabilitation MedicineProfessor & Consultant in Rehabilitation Medicine

University of Nottingham School of Community Health Sciences University of Nottingham School of Community Health Sciences

Derby Hospitals Foundation TrustDerby Hospitals Foundation Trust

Neurological Rehabilitation Neurological Rehabilitation

in Practicein Practice

OutlineOutline

�� Key concepts in rehabilitationKey concepts in rehabilitation

�� Neurological rehabilitation in primary careNeurological rehabilitation in primary care�� Focus on longFocus on long--term and progressive term and progressive conditionsconditions

�� Local resources for neurological Local resources for neurological rehabilitation in primary carerehabilitation in primary care

�� Regional and national resources to support Regional and national resources to support service developmentservice development

Key concepts in rehabilitationKey concepts in rehabilitation

Rehabilitation: a definitionRehabilitation: a definition

�� ““The use of all possible means to minimise The use of all possible means to minimise the impact of disabling conditions on the impact of disabling conditions on autonomy autonomy and and participationparticipation””

AutonomyAutonomy

�� The ability to choose, and the opportunity The ability to choose, and the opportunity to live in accordance with oneto live in accordance with one’’s choicess choices

�� NB: Autonomy is possible with varying NB: Autonomy is possible with varying degrees of independence, and physical degrees of independence, and physical independence does not guarantee independence does not guarantee autonomyautonomy�� Cardol M et al Cardol M et al Beyond disability: Perceived participation in people with a Beyond disability: Perceived participation in people with a chronic disabling condition. chronic disabling condition. Clinical RehabilitationClinical Rehabilitation 2002;16:272002;16:27--35 35

Participation

Impairment

Activity

Environmental factors

Personal factors

World Health Organisation International

Classification of Functioning and

Health (ICF)

http://www3.who.int/icf/http://www3.who.int/icf/

icftemplate.cfmicftemplate.cfm

ParticipationParticipation in contextin context

The individual

+ the environment

Autonomy and participation

=

ICFICF--based rehabilitation assessment based rehabilitation assessment

��RReview pathology and impairment eview pathology and impairment

��EEnvironmental factors nvironmental factors

��PParticipation & personal factorsarticipation & personal factors

��AAutonomy utonomy

��IIndependence ndependence

��RRisk management & preventionisk management & prevention

Review pathology Environment?Participation?AutonomyIndependenceRisks/prevention?

Rehabilitation principles in Rehabilitation principles in

progressive conditionsprogressive conditions

�� PatientPatient-- and familyand family--centredcentred

�� Focus on the environment + individualFocus on the environment + individual

�� Focus on participationFocus on participation

�� ForwardForward--looking: looking: anticipation anticipation and and

prevention prevention of physical + social problemsof physical + social problems

�� Build rehab goals into care packagesBuild rehab goals into care packages

Neurological rehabilitation Neurological rehabilitation

in primary carein primary care

.. many of the .. many of the

solutions are easily solutions are easily

within our grasp..within our grasp..

�� Mrs P. (74) Mrs P. (74) –– right right hemiparesishemiparesisfollowing stroke 2 yrs ago following stroke 2 yrs ago -- can can stand but not walk stand but not walk

�� Enjoys reading, visiting Enjoys reading, visiting grandchildren grandchildren

�� HasnHasn’’t been out since April.t been out since April.

�� Losing weight, Losing weight, dysphagiadysphagia

�� Neck painNeck pain

�� IncontinentIncontinent

�� One other major problem?One other major problem?

Review pathology Environment?Participation?AutonomyIndependenceRisks/prevention?

‘‘Refer to neurologist?'Refer to neurologist?'

'Heading for a crisis''Heading for a crisis'

�� MrsMrs J age 37 J age 37 –– MS 15 yrsMS 15 yrs

�� PhysioPhysio: : ““worse and worseworse and worse”” -- resting resting splints to help her in standing splints to help her in standing -- right right arm tone arm tone increasing increasing

�� SSD OT: SSD OT: ‘‘she chooses to sit in low she chooses to sit in low settee settee –– ……house totally unsuitablehouse totally unsuitable…’…’

�� Specialist nurse: Husband not engaged Specialist nurse: Husband not engaged with rehabilitation goals with rehabilitation goals ––’’just wants to just wants to know about diseaseknow about disease--modifying drugsmodifying drugs’’

�� Care manager: Who can get young Care manager: Who can get young children to school? Application for children to school? Application for direct payments direct payments ‘‘to enable parentingto enable parenting’’rejectedrejected

Review pathology Environment?Participation?AutonomyIndependenceRisks/prevention?

MS across 22 yearsMS across 22 yearsMrs C. Mrs C.

�� EmploymentEmployment

�� ChildcareChildcare

�� MobilityMobility

�� Pain, Pain, spasticityspasticity

�� NutritionNutrition

�� Carer supportCarer support

�� Respite careRespite care

�� DementiaDementia

�� EndEnd--ofof--life decisionslife decisions

Review pathology Environment?Participation?AutonomyIndependenceRisks/prevention?

Local Resources for Neurological Local Resources for Neurological

Rehabilitation in Primary CareRehabilitation in Primary Care

Key Community Personnel Key Community Personnel

The family +The family +

�� GPGP

�� Care managerCare manager

�� Community MatronCommunity Matron

�� Community therapists (NHS, SSD)Community therapists (NHS, SSD)

�� Care workers (SSD, agencies)Care workers (SSD, agencies)

�� etcetc

InterInter--agency and agency and

interinter--disciplinary communication disciplinary communication

�� Explicit goals for all interventions Explicit goals for all interventions

(rehabilitation, not just care)(rehabilitation, not just care)

�� InterInter--professional joint working at all professional joint working at all

levelslevels

�� Confidentiality and trustConfidentiality and trust

�� PatientPatient--held recordsheld records

Specialist centres

Primary care

Secondary care

Social servicesOther agencies

RehabilitationCommunication

Group

Ward CD, Phillips MF, Smith S, Moran M. Multidisciplinary ApproaWard CD, Phillips MF, Smith S, Moran M. Multidisciplinary Approaches in ches in

Progressive Neurological Disease: Can we do better? Progressive Neurological Disease: Can we do better? Neurology in Practice Neurology in Practice

J J NeurolNeurol NeurosurgNeurosurg &Psychiatry 2003; 74: &Psychiatry 2003; 74: SupplSuppl 8iv8iv--12iv12iv

Rehabilitation medicine Rehabilitation medicine Rehabilitation medicine is Rehabilitation medicine is

�� a registered specialty providing a registered specialty providing

assessment and rehabilitation for adults assessment and rehabilitation for adults

with complex disabilities with complex disabilities

Rehabilitation Medicine consultants Rehabilitation Medicine consultants

�� are based in hospitals but with strong are based in hospitals but with strong

community linkscommunity links

�� work with specialist teamswork with specialist teams

Rehabilitation medicine Rehabilitation medicine

consultants are trained toconsultants are trained to

�� assess complex situationsassess complex situations

�� recognize psychological and social recognize psychological and social

factors factors

�� recognize the potential use of assistive recognize the potential use of assistive

technologiestechnologies

�� provide specific medical interventionsprovide specific medical interventions

British Society of British Society of

Rehabilitation MedicineRehabilitation Medicine

http://www.bsrm.co.uk/http://www.bsrm.co.uk/��

British Society of British Society of

Rehabilitation Rehabilitation MedicineMedicine

The Royal College of The Royal College of PhysiciansPhysicians

11 St Andrews Place11 St Andrews Place

London NW1 4LELondon NW1 4LE

Tel/fax 01992 638865Tel/fax 01992 638865

When are specialist When are specialist

neurological rehabilitation services neurological rehabilitation services

needed?needed?�� Specialist input only where needed (cost, Specialist input only where needed (cost,

distance from home, complexity of care)distance from home, complexity of care)

�� Specialist help required for:Specialist help required for:

�� Complex impairments (Complex impairments (spasticityspasticity))

�� Complex combinations of problems (Complex combinations of problems (egeg

cognitive + physical problems)cognitive + physical problems)

�� Technologies (Technologies (egeg seating, communication)seating, communication)

Neurological rehabilitation in Neurological rehabilitation in

primary careprimary care

Can you help? Can you help?

The British Society of Rehabilitation Medicine seeks The British Society of Rehabilitation Medicine seeks your your help in developing simple deskhelp in developing simple desk--top tools, top tools, adaptable to local conditions, to support GPs as adaptable to local conditions, to support GPs as

participants in neurological rehabilitationparticipants in neurological rehabilitation

contact contact c.d.ward@nottingham.ac.ukc.d.ward@nottingham.ac.uk

Regional and National Resources to Regional and National Resources to

Support Service Development Support Service Development

NSF for LongNSF for Long--term Conditionsterm Conditionswww.dh.gov.uk/longtermnsfwww.dh.gov.uk/longtermnsf

www.longtermconditions.csip.org.ukwww.longtermconditions.csip.org.uk

1.1. A person centred serviceA person centred service

2.2. Early recognition, prompt diagnosis and treatmentEarly recognition, prompt diagnosis and treatment

3.3. Emergency and acute careEmergency and acute care

4.4. Early and specialist rehabilitationEarly and specialist rehabilitation

5.5. Community rehabilitation and supportCommunity rehabilitation and support

6.6. Vocational rehabilitationVocational rehabilitation

7.7. Providing equipment and accommodationProviding equipment and accommodation

8.8. Providing personal care and supportProviding personal care and support

9.9. Palliative carePalliative care

10.10. Supporting family and carersSupporting family and carers

11.11. Caring for people with neurological conditions in hospitals Caring for people with neurological conditions in hospitals and other health and social care settingsand other health and social care settings

Participation, Environment

Risk management

Activity, Participation, Environment, Risk management

Environment

Activity, Participation, Environment, Risk management

Risk management

Aims of the Aims of the

Trent Neurosciences Network Trent Neurosciences Network http://http://www.tin.nhs.ukwww.tin.nhs.uk/local/local--networks/neurosciencesnetworks/neurosciences

�� Develop service modelDevelop service model

�� AccessAccess

�� PathwaysPathways

�� NSFNSF

�� Integrate care between primary & Integrate care between primary &

secondary/tertiary caresecondary/tertiary care

�� Agree standards Agree standards

In conclusion: four suggestionsIn conclusion: four suggestions

1.1. Build rehabilitation principles Build rehabilitation principles into all services at all levels into all services at all levels

2.2. Value and build on existing Value and build on existing services and services and connectivitiesconnectivities

3.3. Use regional and national Use regional and national resources to facilitate service resources to facilitate service improvementimprovement

4.4. Make use of local resources, Make use of local resources, egegrehabilitation medicine teamrehabilitation medicine team

Review pathology Environment?Participation?AutonomyIndependenceRisks/prevention?

c.d.ward@nottingham.ac.uk