Rehabilitation After Rehabilitation After Aneurysmal Aneurysmal Sub-Arachnoid Sub-Arachnoid Haemorrhage Haemorrhage Professor Anthony B Ward North Staffordshire Rehabilitation Centre Stoke on Trent, UK
Jan 18, 2018
Rehabilitation After Rehabilitation After AneurysmalAneurysmal
Sub-Arachnoid Sub-Arachnoid HaemorrhageHaemorrhage
Professor Anthony B WardNorth Staffordshire Rehabilitation
CentreStoke on Trent, UK
ACUTE CARE
ITU/ASUNeurosurger
yNeurology
Aneurysmal Subarachnoid haemorrhage
Hospital
Neurological Rehabilitation Inpatient Unit
incl. N/psychology
Tertiary Unit
(e.g. Neuro-behavioural
unit)
REHABILITATION MEDICINESPECIALIST
COMMUNITY SERVICES
Supported dischargeHospital at homeEarly community rehabilitation
Community reintegrationEnhanced participationDEA – supported return to work
Integrated care planningLong term supportSingle point of contactJoin health and social service planningMulti-agency care
Multi-disciplinary multi-agency Community Rehab Team
morecomplex
needs
lesscomplex
needs
highlycomplex
needs
2o care ward
A&E
Community
Collin C, Ward A B. ‘Rehabilitation Medicine 2011 & Beyond’. RCP London. 2010.
Neuropsychiatric service
incl. N/psych
NCEPOD Report
Lack of specialised rehabilitation in 2o care
Specialised rehabilitation in conjunction with neurosurgical services Problem with focused 3o rehabilitation services
Recognises impact of cognitive deficits over physical impairments
Lack of clinical neuropsychological services
Modelling for specialised rehabilitation
22 November 2013
NCEPOD ReportHow should specialised rehabilitation respond?
Rehabilitation Medicine & Neuropsychiatry the only medical specialties with competencies to manage the rehabilitation of aSAH patients
Rehabilitation MDT need range of professionals, including neuro-psychology input
Rehabilitation Medicine 187 consultants - small1
BSRM recommends a 50% increase in consultants2
Need to start rehabilitation as early as possible1
Major effort to promote specialised rehabilitation in the community
1. Collin C, Ward A B. ‘Rehabilitation Medicine 2011 & Beyond’. RCP London. 2010.2. BSRM. Rehabilitation Medicine - The National Position in 2007. London: British Society of Rehabilitation Medicine,
2007. http://www.bsrm.co.uk/Publications/RM2007-15-05-07-V6.pdf
Rehabilitation After aSAH
Global brain injury in association with vascular spasm
Patients behave more like those following acquired brain injury rather than stroke
So, rehabilitation based on acquired brain injury model
No Rehabilitation Medicine representation in expert working group
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Rehabilitation after SAH
Better acute care Saves lives Better outcomes for survivors
Examples Acute stroke units Thrombolysis Trauma system in England & Wales
Moves patients along paradigm
Warlow C, et al. 199922 November 2013
Death
Mild disability -no need for specialist
rehab
Mod. disabilit
yC, B ± P
Severe disabilityP, C & B
Mod. severe disabilityC, B ± P
Symptom free
Death
Mild disability -no need for specialist
rehab
Mod. disabilit
yC, B ± P
Severe disabilityP, C & B
Mod. severe disabilityC, B ± P
Symptom free
Coiling
Aneurysmal clipping
Impact on Inpatient RehabilitationMore people surviveMore have better outcomesFewer with physical disabilities?Fewer people referred for inpatient rehabilitation
BUTCore of patients with significant cognitive ± physical deficits
One-to-one supervision required Time to achieve goals
Greater expectations for return to full participationWork, leisure activities, family life
22 November 2013
Should We Be Concerned?Little/no point in gaining better survival from aSAH if this leaves people
with poor quality of life and a burden to society
Main message: Rehabilitation expensive, but disablement more expensive1
Need clear rehabilitation plan/prescription with timed measurable outcomes Need availability of package of rehabilitation interventions Longer initial hospital stays appear bad, but result in long term savings in cost
of care2
Driver to develop specialised community rehabilitation services1
1. Collin C, Ward A B. ‘Rehabilitation Medicine, 2011 & Beyond’. RCP London. 2010.2. Turner-Stokes L. Brain Injury 2007; 21 (10): 1015-1021.
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Functional Status of Patients Discharged from 3o care
n %
No symptoms 63 27
No significant disability despite symptoms 94 40.3
Slight disability 34 14.6Moderate disability 12 5.2Moderate-severe disability 26 11.2Severe disability 4 1.7Sub-total 233Patient died before discharge 39Insufficient data 31Total 303
Table 4.46 Functional Status of Patients at Discharge
I II VIVIII
Died
Severe disability
Mod/severe disability
Moderate disability
Mild disability
No disability despite symptoms
No symptoms
WFNS Grade
GCS
15 14-13 (-) 14-13 (+)
6-3 ( )12-7 ()
Outcomes
One-third return to pre-morbid employmentPhysical workAge of patient with aSAHChange of employment
Even those with good functional outcome left with significant neuro-cognitive impairment
Fatigue – big problem
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Rehabilitation Medicine Works Well recognised benefits for early rehabilitation1
Prompt response on ill effects of immobility & complications1, 2
Educating ‘acute staff’ of areas where rehabilitation is of major benefit3
Money spent on rehabilitation recovered with 5-9 fold savings4
Rehabilitation in all phases of health condition effective & cost-effective in some areas4
Direct costs for 12 month stroke survivors 4x higher5
Community based programmes effective, if properly funded4
1. Verplancke D, Snape S, Salisbury CF, Jones PW, Ward AB. Clin Rehabil 2005; 19 (2): 117-125. 2. Didier JP. Springer Verlag; 2004. p476. Paris: p 476.
3. Krauth C, et al. Rehabilitationswissenschaften Rehabilitation 2005; 44: pp e46-e56.4. Gutenbrunner C, Ward AB, Chamberlain MAJ Rehabil Med 2007; Suppl.1: S69.
5. Lundström E, et al. Stroke 2010; 41 (2): 319-324.
Cognitive Rehabilitation No evidence to support or refute effectiveness of memory training in rehabilitation
on functional outcomes after stroke1
Assessment vital – cannot do something about what is not known
Costs of specialist rehabilitation for neurobehavioural disability offset by medium & longer term savings in costs of support2
Costs of care during the first year after stroke associated with cognitive impairments, stroke severity & dependence in ADL3
Care in interpreting results
1. Nair R, Lincoln N. Cochrane Database of Systematic Reviews 2007, Issue 3.2. Worthington AD, et al. Brain Injury 2006; 20 (9): 947-957.
3. Claesson, L, Linden T, Skoog I, et al. Cerebrovascular Diseases 2005; 19 (2): 102-109.
Cost-Effectiveness Ratios (CERs)TBI survivors based on:
Life expectancies ranging between 5 & 30 years Estimated preference score of approximately 0.5
Incremental CER $19,000 - $109,000 / QALY gained
Adding rehabilitation costs increases CER to $57,000 - $244,000 / QALY
Sensitivity analysis indicates that estimates of life years gained are critical to estimated ratio If TBI survivors live >5 years, estimated CER seems favourable
Tilford JM, et al. J Trauma-Injury Infection & Critical Care 2007; 63 (Suppl. 6): S113-20.
Return To Work/Productivity
Everyone’s goal: ultimate success after rehabilitation Government, courts, individuals & families, rehab teams
Can rehabilitation achieve this? Poor achievement after TBI1 & aSAH
Complex issues leading to return /sustain work2
Components go beyond ability to perform work tasks2
Discipline of work Getting to workplace
Personal / people skills
1. Shigaki C, et al. Dis & Rehabil 2009; 31 (6): 484-489.2. Fadyl JK, et al. Dis & Rehabil 2010; 32 (14): 1173-1183.
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Strongest Recommendations for Cost Benefits (GRADE Classification)
Basis of research evidence available (from both RCT- & non-RCT-based literature) and potential for cost-benefits, recommend:
Early intensive rehabilitation, starting as soon as possible after onset1-4
Specialist programmes for all those with complex needs5, 6
Specialist vocational programmes for those with potential to return to work6, 7
1. Turner-Stokes L, et al. Cochrane Review: Multi-disciplinary rehabilitation for ABI in adults of working age. 2008; Issue 4.
2. Turner-Stokes L. J Rehabil Med 2008;40(9):691–701.3. Cope N, Hall K. Arch Phys Med Rehabil 1982; 63(9):433–7.
4. Engberg AW, Liebach A, Nordenbo A. Acta Neurol Scand 2006;113(3):178–84.5. 58th World Health Assembly, Doc A58/17. Geneva: WHO, 2005.
6. Black DC. London: TSO, 2008. 7. Waddell G, et al. Vocational Rehabilitation: What works, for whom, and when? 1st edn. London: TSO; 2008.
ConclusionOutcomes potentially better after aSAH & endovascular coiling
As long as survivors have good quality of life
Rehabilitation programmes pick up hidden disabilities Physical impairments obvious Psychological problems
Less obvious Likely to impair return to productivity Fatigue Some improve with treatment
Rehabilitation effective & cost-effective in some areasGreater investment may lead to better outcomes
Development of specialised community rehabilitation
22 November 2013