Episode 1.10 Rehabilitation Potential

MDTea Episode 10: Rehabilitation Potential

Presented by: Jo Preston (Consultant Geriatrician at St George’s Hospital) and Iain Wilkinson (Consultant Geriatrician at East Surrey Hospital).

Core Faculty: Sarah Jane Ryan – Physiotherapist, Tracy Szekely – Occupational Therapist and Pam Trangmar – Physician Associate.

This episode explores the evidence base for rehabilitation in older adults, in particular those with cognitive impairment. We also look at the question of what we mean by rehabilitation potential.

Click here for the show notes for this episode.

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Episode 10 Show Notes

Rehabilitation Potential

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Presented by: Dr Jo Preston & Dr Iain Wilkinson

Faculty:

Sarah- Jane Ryan – Physiotherapist, Tracey Szekely – Occupational therapist, Pamela Trangmar – Physician Associate

Broadcast Date: 24th May 2016

Learning Outcomes

Knowledge:

To understand the concept of rehabilitation potential and how multiple members of the MDT have an impact on this.

Skills:

To use the concept of rehabilitation potential with your patients and MDT.

Attitudes:

•         To understand person centered care and how this may impact upon rehabilitation potential

Definitions:

Formal / Scientific Definition:

Geriatric rehabilitation is a multidisciplinary set of evaluative, diagnostic, and therapeutic interventions whose purpose is to restore functional ability or enhance residual functional capability in elderly people with disabling impairments.

Boston Working Group on Improving Health Care Outcomes Through Geriatric Rehabilitation

Practical Definition:

Restoration of the individual to his or her fullest physical, mental and social capability

Rehabilitation of older people. Young et. al BMJ, 1998

Really started by Marjory Warren – who pioneered the idea of rehabilitation in older patients.

Marjorie Warren the mother of geriatric medicine

Not everyone will be suitable for rehabilitation, for example in the very end stages of a disease process, but we feel rehabilitation should be offered to all who may benefit.

• Assuming that most people have rehabilitation potential is a good place to start but may be unrealistic for some patients.
• Conversely, some people may appear to have little to gain from pure functional perspective but may be difference between some independence (can be physically or psychologically) or not – for example a patient following a stroke who is making little overall progress but being able to transfer would greatly improve their quality of life.

Important to first know that older adults do have things to gain from rehab.

Rehabilitation in patients with dementia

There is often a debate though about patients who have dementia – the evidence though is lacking at the moment but slowly increasing.

Efficacy of physical exercise intervention on mobility and physical functioning in older people with dementia: a systematic review. Pitkala et. al Experimental Gerontology 2013

Cochrane Review of Exercise Programs for People with Dementia. Forbes et. al 2015

The study below showed that a 12 week program of twice weekly small group exercise led to improvement in Berg Balance scale in nursing home residents all of whom had dementia, compared with those who did not participate..  

Effect of a High-Intensity Exercise Program on Physical Function and Mental Health in Nursing Home Residents with Dementia: An Assessor Blinded Randomized Controlled Trial. Telenius et. al PLoS one 2015

Specifically looking at hospitalised patients:

Following a hip fracture – patients with mild to moderate dementia showed similar gains to other patients.

Rehabilitation in Patients with Dementia following hip fracture: a systematic review. Allen et. al in ‘Physiotherapy Canada’ 2012

Rehabilitation specifically designed for geriatric inpatients has the potential to improve outcomes related to

• Function
• admission to nursing homes
• Mortality.

Inpatient rehabilitation specifically designed for geriatric patients: systematic review and meta-analysis of randomised controlled trials. Bachmann et. al BMJ 2010

Rehabilitation Potential

Concept of rehabilitation potential is important but there is not a very good shared understanding of what rehab potential means between MDT members.

A thematic analysis suggests judgement of rehab potential was based on three areas.

• Carry over
• Functional gain
• Recovery trajectory

Judgement on these three factors in this article seemed then to affect the interactions between MDT members and patients e.g. Balancing optimism and realism

What is rehabilitation potential? Development of a theoretical model through the accounts of healthcare professionals working in stroke rehabilitation services. Burton et. al 2015

A literature review looking at the assessment and selection of patients in acute hospitals for their need for inpatient rehabilitation before discharge concludes that the assessment of patients in acute hospital for rehabilitation is an important skill and it has the potential to improve patient outcomes. There is however a need for further research in this area.

The assessment and selection of potential rehabilitation patients in acute hospitals: A literature review and commentary. Peter New, The Open Rehabilitation Journal 2009.

Rehabilitation differs from the purely medical model in 2 ways:

1. Liaison between teams (the MDT) is absolutely imperative
2. Learning is taking place by the patient and relatives and this is the key process that is taking place.

Both of these have a focus on communication and our take home message is that communication is the key skill in rehabilitation and talking to the patient, being honest with them about their progress and wishes for the future and communication with the rest of the team is so so key. Just because the patient may not be making progress in your area does not mean that they are not making important progress with another member of the team (e.g they may not be making progress in terms of mobility following their stroke but might be making really important functional gains in terms of personal care which will affect not only their quality of life and ongoing care needs).

Rehabilitation – a new approach. Part two: the underlying theories. An Editorial by Wade in Clinical Rehabilitation 2015

Curriculum Mapping:

This episode covers the following areas (n.b not all areas are covered in detail in this single episode):

Curriculum	Area
NHS Knowledge Skills Framework	Suitable to support staff at the following levels: Communication level 1-3 Personal and People Development: Levels 1-3 Service Improvement: Level 1 – 2
Foundation Curriculum 2012	1.3 Continuity of care 1.4 Team working 2.1 Patient as centre of care 7.9 Interactions with different specialities and other professions 10.1 Manages patients with long-term conditions 10.4 Discharge planning
Foundation Curriculum 2016	2. Patient centred care 4. Self-directed learning 6. Interface with other healthcare professionals 10. The frail patient 10. Support for patients with long term conditions 11. Discharge planning
Core Medical Training	Core competences: Team working and patient safety Managing of long term conditions and promoting self-care Communication with colleagues and cooperation Symptom based competences: Immobility System specific competences: Geriatric Medicine
GPVTS program	Section 2.03 The GP in the Wider Professional Environment Core Competence: Managing medical complexity Section 3.05 – Managing older adults Core Competence: Managing medical complexity Core Competence: Working with colleagues and in teams Core Competence: Practising holistically and promoting health
ANP (Draws from KSF)	Section 6. Clinical examination Section 7.13 Iatrogenic problems including consequence of hospitalisation and bed rest. Section 7.21 Dementia Section 17. Rehabilitation Section 18. Discharge