The future of rehabilitation services in Great Britain

After reviewing the overall situation, this paper concludes with the following recommendations:

1. General: The field of disability and rehabilitation has been characterized, during the last 20 or 30 years in Great Britain, by a multiplicity of official reports of high quality. The need is not so much for the establishment of new principles, which are by now quite generally agreed, but for the sweeping away of old structures which impede the implementation of these policies.

2. Hospital services: The establishment of regional (i.e., subnational) hospital rehabilitation centres should be accelerated, with particular regard to geographical distribution. Evaluative research on the remedial therapies should be strongly encouraged, and the potential contribution of clinical psychology should be actively explored and exploited.

3. Community doctors: It should be formally recognized that overall responsibility for longterm chronic illness and disability for the patient living at home rests with the general practitioner (GP). There should be more efficient communication between GP and hospital, and the GP should have the opportunity (with the advice of specialists) to coordinate therapies and assessments for vocational and social help in the community. Within the primary health-care team, practical responsibility for advice and coordination should rest with one specialist paramedical worker.

4. Community services: Local (municipal) authority provision for the disabled should be mandatory, and basic minimum entitlements should be established. Exhortations by central government that local authorities should provide community care, hostels, or sheltered housing for the various groups whose institutionalization is deplored should be replaced by new methods of financing, to provide better geographical uniformity and ensure that policies are actually implemented. Though certain local authority services relevant to disability will always necessarily be separate from health services, those which are most specifically health-related (such as the supply of aids and appliances) should be administered within the health sector.

5. Aids and appliances: Many of the recommendations of the BMA Working Party (21) on aids and appliances remain to be implemented.

6. Vocational rehabilitation: Radical revision and simplification of the system of vocational rehabilitation and help should proceed as rapidly as possible, and the medical profession should take an active interest in this. Special services should be instituted for the training and vocational help of the handicapped school-leaver. All rehabilitation services (as distinct from retraining and placement services) would be placed within the health sector, within centres associated with hospitals.

7. Medical education: Important changes are required in medical education, at both the postgraduate and undergraduate levels.

8. In the longer-term: The increasing emphasis upon disability and rehabilitation is likely both to require quite fundamental changes in society's concepts of health and sickness, and to play an important part in the development of those changes.     

Beyond function: predicting participation in a rehabilitation cohort

OBJECTIVES: To monitor participation in a rehabilitation cohort and to identify determinants of change during a 12-month period posthospitalization following the onset of one of several major disabling conditions. DESIGN: Cohort study. SETTING: Postacute care rehabilitation settings. PARTICIPANTS: Adults (N=435) aged 18 years and older with complex medical, lower-extremity orthopedic, and major neurologic impairments. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: At 1-, 6-, and 12-month follow-ups, community participation and social and home participation were assessed by personal interviews using the Participation Measure for Post-Acute Care. Information on potential determinants was abstracted from the medical chart and by personal interview using standardized instruments. RESULTS: On average, rehabilitation patients achieved modest improvements in their levels of community participation during the first 6 months after acute hospitalization. In contrast, these same patients displayed a modest loss in social and home participation levels during the follow-up period. Activity limitations were the dominant factors that explained much of the variance in the extent of community participation achieved by patients. Personal and social environmental factors played a major role in predicting levels of social and home participation. CONCLUSIONS: The focus of rehabilitation interventions aimed at achieving posthospital participation requires careful consideration of the specific domain of participation that is being targeted.     

Commentary on: Community-based service delivery in rehabilitation: the promise and the paradox

The National Health Service was established in postwar Britain with the main aims of improving the health of the nation and providing free medical care when it was needed. Over the years the service has become increasingly involved in crisis intervention, rather than prevention. The ageing population has placed new demands on the service but the strength of family medicine, together with rehabilitation services, has formed the basis of good community-based rehabilitation. There is still the need to integrate the medically provided service with that of the social services.     

Inpatient cancer rehabilitation: a retrospective comparison of transfer back to acute care between patients with neoplasm and other rehabilitation patients

Alam E, Wilson RD, Vargo MM. Inpatient cancer rehabilitation: a retrospective comparison of transfer back to acute care between patients with neoplasm and other rehabilitation patients.

Objective

To determine whether patients with diagnoses of neoplasm undergoing acute rehabilitation differ from other patients in frequency of acute care transfer and type of medical complications.

Design

Retrospective cohort analysis.

Setting

Acute rehabilitation hospital located within an academic medical center.

Participants

Patients with diagnosis of neoplasm (n=40) and patients without neoplasm (n=253) requiring transfer were identified from a database of 2801 rehabilitation discharges over nearly a 4-year period.

Interventions

Not applicable.

Main Outcome Measures

Frequency of unplanned transfer and reasons for the transfer.

Results

Significant difference occurred in overall rate of transfer between patients with neoplasm (21%) and controls (9.7%; P<.001). When evaluated separately for type of neoplasm (with patients receiving corresponding type of rehabilitation as controls), a significantly higher rate of transfer to acute care was found for brain tumor (25% vs 12%; P=.004) and spinal cord neoplasms (23% vs 10%; P=.009), but statistical significance was not reached for other tumor types (12.5% vs 7.4%; P=.19). Patients with stroke with neoplasm as a comorbidity, analyzed separately, with the other patients with stroke as controls, had significantly higher risk of transfer (22% vs 10%; P=.012). Logistic regression analysis found an odds ratio (OR) of 2.5 for unplanned transfer among patients with diagnosis of neoplasm (OR=2.5 for malignancy; OR=2.4 for benign neoplasm). Patients with neoplasm had infection as the most common reason for transfer (28% of the neoplasm transfers vs 18% of other transfers; P=.01), whereas in the nonneoplasm group, cardiopulmonary factors predominated (12% of patients with tumor vs 31% of patients without tumor transfers; P<.001).

Conclusions

In the present sample, patients with neoplasm were more likely to require transfer than patients without neoplasm, although this pattern did not reach statistical significance for noncentral nervous system cases. Overall, patients with neoplasm appear more likely than those without neoplasm to have an infectious cause for unplanned transfer. Increased awareness of this difference may lead to improved medical management on rehabilitation units.     

Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab Study

Whiteneck GG, Gassaway J, Dijkers MP, Lammertse DP, Hammond F, Heinemann AW, Backus D, Charlifue S, Ballard PH, Zanca JM. Inpatient and postdischarge rehabilitation services provided in the first year after spinal cord injury: findings from the SCIRehab study.

Objective

To examine the amount and type of therapy services received in inpatient and postdischarge settings during the first year after spinal cord injury (SCI).

Design

Prospective observational longitudinal cohort design. Data were obtained from systematic recording of interventions by clinicians and from patient interview.

Setting

Inpatient and postdischarge rehabilitation programs.

Participants

Patients (N=493) with traumatic SCI admitted to 6 rehabilitation centers participating in the SCIRehab study.

Interventions

Not applicable.

Main Outcome Measures

Hours of therapy by physical therapy (PT), occupational therapy (OT), speech therapy, recreation therapy, psychology, social work/case management, and nursing education during initial inpatient rehabilitation and postdischarge up to the first anniversary of injury. Inpatient data were collected prospectively by the treating clinicians; postdischarge service data were collected by patient self-report during follow-up interviews.

Results

Of the total hours spent on these rehabilitation interventions during the first year after injury, 44% occurred after discharge from inpatient rehabilitation. Participants received 56% of their PT hours after discharge and 52% of their OT hours, but only a minority received any postdischarge services from other rehabilitation disciplines. While wide variation was found in the total hours of inpatient treatment across all disciplines, the variation in the total hours of postdischarge services was greater, with the interquartile range of postdischarge services being twice that of the inpatient services.

Conclusions

SCI rehabilitation is often given in a care continuum, with inpatient rehabilitation being only the beginning. Reductions in inpatient SCI rehabilitation length of stay are well documented, but the postdischarge services that may replace some inpatient treatment appear to be greater than previously reported. The availability and impact of postdischarge care should be studied in greater detail to capture the wide array of postdischarge services and outcomes.     

Providing instructional support for AAC service delivery in low- and middle-income (LAMI) countries

Purpose: The majority of individuals with disabilities live in low- and middle-income (LAMI) countries; typically these individuals receive limited, if any, communication rehabilitation services. The present study investigated the experiences of eight augmentative and alternative communication (AAC) professionals who had provided instructional support for AAC service delivery in LAMI countries.

Method: An online focus group was used to explore the training experiences of eight AAC professionals.

Result: A thematic analysis of the focus group discussion resulted in four major recommendations when providing training for AAC service delivery in LAMI countries: (a) investigate learner needs, (b) provide contextually relevant instructional content, (c) use engaging instructional activities and (d) assess the impacts of instructional activities.

Conclusion: The instructional recommendations of the focus group participants are discussed within a theoretical framework of recommended best practices in supporting adult learning. The information shared by the focus group participants will benefit others providing instructional support for AAC service delivery in LAMI countries.     

The ecology of medical care: access points to the health care system in Austria and other developed countries

Abstract

Objective: This study aimed to analyze the Austrian health care system using the ecology of care model. Our secondary aim was to compare data from Austria with those available from other countries.

Design: 3508 interviews employing a 30-item questionnaire related to the utilization of the health care system including demographic factors were conducted. Participants were chosen by a Random Digital Dialing procedure. Further, a literature review of studies of other countries use of the ecology of care model was conducted.

Main outcome measures: Austria has one of the highest utilization of health care services in any of the assessed categories. The comparison with the literature review shows that Austria has the highest utilization of specialists working in the outpatient sector as well as the highest hospitalization rates. Taiwan and Korea have comparable utilization patterns. Canada, Sweden, and Norway are countries with lower utilization patterns, and the U.S. and Japan are intermediate.

Conclusion: In Austria and similarly organized countries, high utilization of all health care services can be observed, in particular, the utilization of specialists and hospitalizations. The over-utilization of all levels of health care in Austria may be due to the lack of a clear demarcation line between the primary and secondary levels of care, and the presence of universal health coverage, which also allows for unrestricted and undirected access to all levels of care. Previous studies have shown that comparable countries lack the health benefits of a strong primary care system with its coordination function.

• Key points

• In Austria and similarly organized countries, there appears to be high utilization of health care in general, as well as with particular utilization of specialists and hospitalizations.

• The high utilization of all levels of care in Austria may be the result of competition, lack of a clear demarcation line between the primary and secondary level of care, and the presence of universal health coverage.

• Pathways between primary and secondary care should be strengthened as previous studies have shown that comparable countries lack the health benefits of strong primary care and its function for health care coordination.

     

运用护理程序进行脑卒中偏瘫康复患者的健康教育

目的:探讨运用护理程序对脑卒中偏瘫康复患者进行健康教育的效果。方法:通过评估患者心理状态、对疾病相关知识、相关技能掌握的程度,观察运用护理程序有针对性地实践健康教育的效果。结果:136例患者自我护理和康复、保健意识在实施健康教育后有显著提高。结论:运用护理程序进行健康教育,有利于患者掌握偏瘫后相关的自我护理和康复保健知识,积极参与康复治疗,提高康复治疗效果。     

运用护理程序进行脑卒中偏瘫康复患者的健康教育

目的：探讨运用护理程序对脑卒中偏瘫康复患者进行健康教育的效果。方法：通过评估患者心理状态、对疾病相关知识、相关技能掌握的程度，观察运用护理程序有针对性地实践健康教育的效果。结果：136例患者自我护理和康复、保健意识在实施健康教育后有显著提高。结论：运用护理程序进行健康教育，有利于患者掌握偏瘫后相关的自我护理和康复保健知识，积极参与康复治疗，提高康复治疗效果。     

Serious games for upper limb rehabilitation: a systematic review

The aim of this research is to carry out a systematic review of the use of technological gaming platforms with serious games in the upper limb rehabilitation of patients with neuromotor disorders. Through a systematic review, the first two authors defined the inclusion criteria and extracted the data, resulting in 38 studies collected from B-On, PubMed and Medline. Ninety-two per cent of the selected articles were published since 2010. This review documents 35 different gaming platforms types. Twenty-one of the 38 articles included in this review conducted a clinical trial and of those only eight report improvements in the target population following the use of the games and platforms. This review concludes that a new paradigm is emerging in the rehabilitation field, characterized by the systematic use of technological gaming platforms with serious games in/for rehabilitation. The use of this approach seems to be beneficial. However, to facilitate the full integration of these platforms, it is necessary to conduct more research in this area, explore new approaches and carry out in-depth clinical studies into the benefits of these platforms.

• Implications for rehabilitation

• This review states that the use serious games and gaming platforms for upper limb rehabilitation are starting a new paradigm in the rehabilitation.

• For a full integration of this technologies in the rehabilitation field more studies are needed.

     

Individual, science, and society: ACRM's mission and the body politic

The core mission of the American Congress of Rehabilitation Medicine (ACRM)-using interdisciplinary research to "enhance the lives of persons living with disabilities"-has a role to play in the world. This mission draws on rehabilitation's origins in a strong belief system about the value of all individuals, regardless of the state of the body structure and function. This address draws on Scheper-Hughes and Lock's use of the body as a metaphor for a way in which society can think about its beliefs of the human body and disability; a body of science contributing to the evolution of rehabilitation; organizational bodies, both rehabilitation service organizations and ACRM as an organization; and the body politic, a concept used to talk about our engagement in society and its rules, policies, and priorities including research funding. In addition to highlighting excellent interdisciplinary clinical research, ACRM should continue development of a taxonomy of the rehabilitation process; it should endorse the World Health Organization's International Classification of Functioning, Disability and Health as a conceptual framework for research development; it should continue increasing attention on research on participation and the environment; and it should embrace the scientific community of people engaged in evidence-based policy and health services research.     

Provision of rehabilitation services for children with disabilities living in low- and middle-income countries: a scoping review

Background: Childhood disability is a growing global health priority. The purpose of this scoping review was to identify and summarize rehabilitation interventions used to support children with disabilities in low- and middle-income countries.

Methods: This scoping review involved a systematic search of electronic databases using a combination of subject headings and/or keywords related to child disability, rehabilitation, and low- and middle-income countries. Charting involved an iterative process whereby the full text of articles meeting the inclusion criteria were abstracted using a charting form. Data were charted according to pre-selected and emerging characteristics deemed relevant to the scoping review’s purpose.

Results: Eighty-one articles were included in the final analysis. Forty-three articles explored the use of screening and/or diagnostic tools in identifying children with disabilities in low and middle income countries, and 38 articles evaluated rehabilitation services for these children.

Conclusions: A number of rehabilitation strategies are available that have the potential to improve the identification of and outcomes for children with disabilities in low and middle income countries. Future research ought to advance the development, implementation, and evaluation of training programs for non-rehabilitation specialists (e.g., doctors, nurses, and teachers), non-specialist community members (e.g., community health workers), and caregivers in the area of rehabilitation, and evaluate the effectiveness of rehabilitation interventions in improving participatory outcomes and quality of life for children with disabilities.

• Implications for Rehabilitation

• Additional research is needed to understand the influence of rehabilitation on personal factors (e.g., self-efficacy and quality of life) and participation for children with disabilities.

• There is limited availability of experienced rehabilitation service providers, especially in rural areas, warranting additional research into the development and evaluation of non-specialist training programs, and the integration of rehabilitation concepts across health workforce education programs.

• Researchers from low and middle income countries appear to be underrepresented in published rehabilitation research, indicating a need to further promote the inclusion of this group through community-based participatory research.

     

Youth and young adults with cerebral palsy: their use of physician and hospital services

OBJECTIVES: To examine patterns of health care utilization among youth and young adults who have cerebral palsy (CP) and to provide information to guide the development of health services for adults who have CP. DESIGN: This study analyzed health insurance data for outpatient physician visits and hospital admissions for a 4-year period. SETTING: Six children's treatment centers in Ontario, Canada. PARTICIPANTS: The sample included 587 youth and 477 adults with CP identified from health records. Youths were 13 to 17 years of age, and adults were 23 to 32 years of age at the end of the data range. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We computed the annual rates of outpatient physician visits and hospitalizations per 1000 persons and compared these with rates for the general population. RESULTS: Annual rates of outpatient physician visits were 6052 for youth and 6404 for adults with CP, 2.2 times and 1.9 times higher, respectively, than rates for age-matched peers (P<.01). Specialists provided 28.4% of youth visits but only 18.8% of adult visits. Annual hospital admission rates were 180 for youth and 98 for adults with CP, 4.3 times and 10.6 times higher, respectively, than rates for age-matched peers (P<.01). CONCLUSIONS: It appears that youth and adults with CP continue to have complex care needs and rely heavily on the health care system. Comprehensive services are essential to support their health as they move into youth and adulthood. However, there appear to be gaps in the adult health care system, such as limited access to specialist physicians.     

Cardiac rehabilitation after heart transplantation in a patient with Becker's muscular dystrophy: a case report

Becker's muscular dystrophy (BMD) is associated with abnormal cardiac findings in 75% of cases; up to one third will develop ventricular dilatation leading to congestive heart failure, at times necessitating cardiac transplant. Candidates are selected from a base of heart failure patients who are usually New York Heart Association (NYHA) class III or IV. Treatment in a phase II cardiac rehabilitation program after transplantation is associated with functional improvement in patients without BMD, but there are no reports of patients with this disorder. We present the case of a 38-year-old man diagnosed with BMD with associated dilated cardiomyopathy. The patient was a NYHA class IIIa and underwent orthotopic cardiac transplantation for intractable heart failure followed by treatment in a phase II cardiac rehabilitation program. At the end of cardiac rehabilitation, his 12-minute walking distance had improved from 716.28 to 929.64 m (30% improvement), he had increased his conditioning metabolic equivalent level from 3.5 to 5.5 (55% improvement), he had a weight loss from 81.65 to 78.93 kg, and his body mass index changed from 23 to 22 kg/m2. The patient now has returned to work, is using a stationary bicycle once a day for 30 minutes, and is walking 1 hour a day. This suggests that treatment in a cardiac rehabilitation program is effective in patients with BMD after cardiac transplant.     

Time use of stroke patients in an intensive rehabilitation unit: a comparison between a Belgian and a Swiss setting

Purpose : Functional improvement after stroke has been related to the intensity of treatment. The present study was set up to observe how stroke patients spend their time in a rehabilitation unit. Method : Behavioural mapping was performed throughout a full working day in a Belgian and Swiss stroke unit. Results : Patients were most frequently involved in therapeutic activities, 28% of the day in Belgium and 45% in Switzerland. Physiotherapy accounted for the majority of the therapy time. The Belgian patients spent 27% of the day in their own room and Swiss patients 49% of the day. The most striking finding was that the Swiss patients spent nearly 1.5 hours per day more in therapy. Conclusions : Differences between the two settings could only partially be explained by more favourable patient-staff ratios in the Swiss setting. Autonomous practice, group therapy sessions and family involvement have to also be considered.     

偏瘫肩半脱位康复评定与放射学测量研究

目的：比较康复评定与放射学测量在偏瘫肩半脱位评定中的应用价值。方法：偏瘫肩半脱位３７例，平均年龄６０．１±１１．５岁，分为低张组和高张组。用Ｆｕｇｌ－Ｍｅｙｅｒ和Ｂｒｕｎｎｓｔｒｕｍ量表评定患侧上肢功能，测量双侧肩峰下间隙，肩峰肱骨外上髁距，摄双肩正位和后斜位片，用ｔ检验和Ｓｐｅａｒｍａｎ相关性检验。结果：两组患者疼痛发生率、Ｂｒｕｎｎｓｔｒｕｍ分期、双侧肩峰下间隙、肩峰外上髁距差异有非常显著性（Ｐ＜０．０１）；放射学测量双侧肱骨头的水平和垂直移位、肱骨绝对外展角差异有显著性（Ｐ＜０．０５）；肌张力与肩峰下间隙呈负相关，简易测量和放射学测量方法明显相关（ｒ＝０．３３６～０．３６４，Ｐ＜０．０５）。结论：触诊法、简易测量和放射学检查均可用于偏瘫肩半脱位的评定，其中肩峰肱骨外上髁距具有定性和定量双重作用，且方法简单，值得在康复评定中应用。     

A cross-sectional survey of critical care services in Sri Lanka: A lower middle-income country

Purpose

To describe the extent and variation of critical care services in Sri Lanka as a first step towards the development of a nationwide critical care unit (CCU) registry.

Materials and Methods

A cross-sectional survey was conducted in all state CCUs by telephone or by visits to determine administration, infrastructure, equipment, staffing, and overall patient outcomes.

Results

There were 99 CCUs with 2.5 CCU beds per 100 000 population and 13 CCU beds per 1 000 hospital beds. The median number of beds per CCU was 5. The overall admissions were 194 per 100 000 population per year. The overall bed turnover was 76.5 per unit per year, with CCU mortality being 17%.Most CCUs were headed by an anesthetist. There were a total of 790 doctors (1.6 per bed), 1 989 nurses (3.9 per bed), and 626 health care assistants (1.2 per bed). Majority (87.9%) had 1:1 nurse-to-patient ratio, although few (11.4%) nurses had received formal intensive care unit training. All CCUs had basic infrastructure (electricity, running water, piped oxygen) and basic equipment (such as electronic monitoring and infusion pumps).

Conclusion

Sri Lanka, a lower middle-income country has an extensive network of critical care facilities but with inequalities in its distribution and facilities.     

Compliance with standards of practice for health-related rehabilitation in low and middle-income settings: development and implementation of a novel scoring method

Purpose: To (A) develop a method for measuring compliance with standards, and (B) implementation of the method in 12 rehabilitation centers in six low and middle-income countries (LMICs).

Methods: In part A, existing standards were compiled and operationalized into scores, organized into 5 ‘scorecards’ and 15 ‘sub-scorecards’, then tested and refined in an iterative process. In part B, 12 rehabilitation centers in 6 countries implemented the standards using the new method, revealing relative performance between centers, and across different standards. Internal consistency of scores within domains was computed using Chronbach’s alpha.

Results: A standardized method for scoring compliance with standards for rehabilitation was developed. The method evaluated compliance with standards in five domains of practice: user focused approach, service outputs, finances, staff, and general management. Multiple standards within domains were strongly related, with Chronbach’s alpha >0.80 for all but the equipment and supplies domain. Overall, in the 12 rehabilitation centers examined, 36% of standards were met or exceeded. Compliance within each scoring domain was 56% (user-focused approach), 38% (service outputs), 27% (financial management), 30% (staff management), and 33% (general management). Two out of 12 (17%) of centers met more than two-thirds of the standards, 3 (25%) met more than one-third of standards, while the remaining 7 (58%) met less than one-third of standards.

Conclusions: A new, standardized method for measuring performance of rehabilitation services in LMICs was developed. The method examines standards in five rehabilitation practice domains, and can be used to understand barriers to quality performance, particularly in resource-constrained settings. Implementation of the method demonstrated that current compliance with standards is modest. Ongoing interest in new standards for rehabilitation practice should be accompanied by measures to ensure they are used to strengthen quality in an emerging rehabilitation sector.

• Implications for rehabilitation

• We developed a method for measuring compliance with standards for rehabilitation, and implemented the method in 12 rehabilitation centers in low and middle income countries.

• We demonstrate modest compliance with an adapted list of known standards of practice.

• New standards, scoring methods and evidence of current performance may assist service providers and policy makers to implement standards, and methods to strengthen rehabilitation services.

• Modest compliance with current standards suggest new emphasis on quality performance of health-related rehabilitation is needed

• New emphasis on standards for rehabilitation should be accompanied by consideration of how performance against those standards can be measured and improved.

     

Advancing rehabilitation research: An interactionist perspective to guide question and design

The purpose of this position statement is to propose an interactionist framework to bring together the existing literature and provide a unifying direction for rehabilitation research. The framework comprises three components: the conceptual model, the research question, and the research design. The interactionist conceptual model has been adapted from the World Health Organization International Classification of Functioning, Disability, and Health. The model forms the starting point that guides the specification of the research question, which, in turn, guides the selection of research design. This approach demands that the question takes precedence and that there be an extensive repertoire of research designs, each of which is valued for its ‘goodness-of-fit’ with the question, rather than an a priori, single hierarchical ordering of designs. Research designs must be appropriate for questions that examine the disability experience, development over the lifespan, multifaceted interventions, low incidence conditions, and development of new interventions. Analytical challenges include dealing with confounding, mediating, and moderating variables. Rehabilitation researchers – and those who fund their work – should consider and value the use of diverse research methods to best answer the questions posed from the interactionist perspective.