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Rehabilitation After Aneurysmal Sub-Arachnoid Haemorrhage

Rehabilitation After Aneurysmal Sub-Arachnoid Haemorrhage. Professor Anthony B Ward North Staffordshire Rehabilitation Centre Stoke on Trent, UK. more complex needs. Neuropsychiatric service incl. N/psych. ACUTE CARE  ITU/ASU Neurosurgery Neurology. Tertiary Unit (e.g. N euro-

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Rehabilitation After Aneurysmal Sub-Arachnoid Haemorrhage

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  1. Rehabilitation After Aneurysmal Sub-Arachnoid Haemorrhage Professor Anthony B Ward North Staffordshire Rehabilitation Centre Stoke on Trent, UK

  2. more complex needs Neuropsychiatric service incl. N/psych ACUTE CARE  ITU/ASU Neurosurgery Neurology Tertiary Unit (e.g. Neuro- behavioural unit) Neurological Rehabilitation Inpatient Unit incl. N/psychology highly complex needs less complex needs A&E 2o care ward Hospital Community Aneurysmal Subarachnoid haemorrhage Supported discharge Hospital at home Early community rehabilitation • REHABILITATION MEDICINE • SPECIALIST • COMMUNITY • SERVICES Community reintegration Enhanced participation DEA – supported return to work Multi-disciplinary multi-agency Community Rehab Team Integrated care planning Long term support Single point of contact Join health and social service planning Multi-agency care Collin C, Ward A B. ‘Rehabilitation Medicine 2011 & Beyond’. RCP London. 2010.

  3. 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

  4. NCEPOD Report • How 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 • Collin C, Ward A B. ‘Rehabilitation Medicine 2011 & Beyond’. RCP London. 2010. • 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

  5. 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

  6. 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. 1999

  7. Patients’ Outcome Paradigm Aneurysmal clipping Mod. severe disability C, B ± P Severe disability P, C & B Mod. disability C, B ± P Mild disability - no need for specialist rehab Symptom free Death Death Mod. severe disability C, B ± P Severe disability P, C & B Mod. disability C, B ± P Mild disability - no need for specialist rehab Symptom free Coiling 01/01/2020 7

  8. Impact on Inpatient Rehabilitation • More people survive • More have better outcomes • Fewer with physical disabilities • ?Fewer people referred for inpatient rehabilitation • BUT • Core of patients with significant cognitive ± physical deficits • One-to-one supervision required • Time to achieve goals • Greater expectations for return to full participation • Work, leisure activities, family life

  9. 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 • Collin C, Ward A B. ‘Rehabilitation Medicine, 2011 & Beyond’. RCP London. 2010. • 2. Turner-Stokes L. Brain Injury 2007; 21 (10): 1015-1021.

  10. Table 4.46 Functional Status of Patients at Discharge

  11. Functional Outcome at Discharge Died Severe disability Mod/severe disability Moderate disability Mild disability No disability despite symptoms No symptoms I II III IV V WFNS Grade GCS 15 14-13 (-) 14-13 (+) 12-7 () 6-3 ( )

  12. Outcomes • One-third return to pre-morbid employment • Physical work • Age of patient with aSAH • Change of employment • Even those with good functional outcome left with significant neuro-cognitive impairment • Fatigue – big problem

  13. 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 • Verplancke D, Snape S, Salisbury CF, Jones PW, Ward AB. Clin Rehabil 2005; 19 (2): 117-125. • Didier JP. Springer Verlag; 2004. p476. Paris: p 476. • Krauth C, et al. Rehabilitationswissenschaften Rehabilitation 2005; 44: pp e46-e56. • Gutenbrunner C, Ward AB, Chamberlain MAJ Rehabil Med 2007; Suppl.1: S69. • Lundström E, et al. Stroke 2010; 41 (2): 319-324.

  14. 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.

  15. 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.

  16. 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.

  17. 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 • 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. ActaNeurol 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? 1stedn. London: TSO; 2008.

  18. Conclusion • Outcomes 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 areas • Greater investment may lead to better outcomes • Development of specialised community rehabilitation

  19. Thank You

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