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Interviews

Vital rehab role under threat

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“Numbers are our biggest challenge as a profession,” says Diane Playford as she ponders the current state of the nation for rehab medicine physicians.

“Many medical specialties are small in the UK compared to our European colleagues, but rehab medicine is disproportionately small.”

November 2018 brought an end to Playford’s two- year tenure as president of the British Society of Rehabilitation Medicine (BSRM). She stepped down with the profession in which she has worked since 1995 at a crossroads.

In the UK there are currently around 180 consultants in rehab medicine, with a further 40 currently in trainee positions.

These professionals play a key role in shaping and improving rehab outcomes – yet their limited number means many patients and multidisciplinary rehab teams cannot benefit from their expertise or skills.

Various factors in the UK have resulted in the influence of the role shrinking in recent decades. Among them is the legacy of changes in the 70s and 80s that saw the two physical medicine fields, rheumatology and rehabilitation, veer off in separate directions. This shift left doctors in the latter camp focused largely on the most severe disabilities, and therefore a limited number of cases. This means patients with conditions that are managed with input from rehab medicine physicians in other countries do not receive such access to these professionals in the UK. This must change however, says Playford, or the standard of UK rehab compared to other nations could suffer over time.

“We need to articulate the role of the rehab physician more clearly. We also need to grow links with other specialties, many of whom use a rehabilitation approach but their core skills lie elsewhere.” She points to pain clinics as an example area where rehab physicians are being underutilised.

“The physicians or anaesthetists within a pain clinic will be technically very skilled at treating pain but may not be so good in the skills needed to help people function in everyday life. Rehab physicians have something to offer here, as do physiotherapists and psychologists. The more comprehensive the multidisciplinary team, the better the outcomes will be. It is relatively unusual to have a rehab physician in a pain clinic in this country but fairly common in other countries.”

Musculoskeletal rehab is another field in which Playford believes rehab physicians could and should play a greater role in patient care.

“We have very few rehab physicians working in musculoskeletal rehab. In other countries, musculoskeletal is a significant field for them; and this includes recovery from musculoskeletal trauma, management of lower back pain and vocational rehab for people with musculoskeletal conditions.

“I think there is a growing recognition that rehabilitation services for people with musculoskeletal conditions, particularly trauma, are very limited in the UK and need to be developed.

“Currently these services are largely delivered by physiotherapists, many of whom have practitioner or consultant practitioner roles and are very skilled. But when things get very complex, then the rehab physician has a contribution that at the moment is not being made.”

The historic move of rehab physicians towards only the most severe disabilities means many now work only with patients with combined physical and cognitive difficulties. As a result, members of the musculoskeletal population, whose difficulties are mostly physical, may miss out on their expertise.

This differs overseas, partly because of the impact of insurance-based systems in creating a stronger drive to get people back to work. “In other countries, rehab medicine has grown because of its very close links with vocational rehab. And that has also been very badly neglected here,” she says.

Another trend in the UK that is not widely replicated elsewhere is skilled therapists increasingly taking up the role of autonomous practitioner.

“This has many advantages, but there is also a disadvantage. The multidisciplinary team may face a complex problem that requires some of the skills of a physician, such as the prescription of medication, or consideration of medication in the context of other factors. Unless you have a prescriber on your therapy team – and there are some physiotherapy and nurse prescribers – you have to wait to get a referral to a rehab physician who has those skills.

“Alternatively, you can refer to a GP, but you can’t have that multidisciplinary conversation about the various factors contributing to spasticity and the best way that can be treated without a physician on the team.

“In not having physicians on the team, patients are missing out on prompt treatment. They are not getting the right treatment at the right time.

“I think teams that do have easy access to rehab medicine physicians really value their contribution. Many teams who’ve never had that experience would also value the opportunity of working with them.”

An example scenario could be a patient needing an expert physician to consider the impact of drugs which manage tone, but which also may have sedative, cognitive, mood and bladder function implications.

“It’s self-evident that having someone whose expertise lies in this area, amongst other things, will have a valuable contribution to make to the timely management of that patient.

“Multidisciplinary teams work well when they identify all the contributing factors to a patient’s presentation and to their function very accurately. That means they target their interventions in the right order and in the right way for that patient. That makes the team much more efficient.”

Against widespread inconsistencies, Playford believes the UK would benefit from a single, cohesive voice representing the multidisciplinary rehab team and its patients on a national level.

“It is right and proper that there are individual disciplines and professional concerns. If what patients need is access to a multidisciplinary rehab team, however, then there perhaps ought to be a voice that represents all the disciplines and all the patients.”

Stroke is an area where the collective voice of multiple professional groups has been able to influence change and improvements in care delivery, she says.

“Stroke has been strongly led by the stroke physicians, working with multidisciplinary teams. The big national meeting, the Stroke Forum, is a really successful clinical and academic gathering which is influential in the development of stroke services and
the dissemination of skills and knowledge around stroke.

“A really successful multidisciplinary environment has been created that drives the stroke agenda and this has been manifest in all sorts of things. You can see it in the nature of multidisciplinary data collection and the Royal College of Physicians’ multidisciplinary guidelines for example. We don’t have the same powerful voice for other conditions.”

Could such achievements in the stroke field be replicated more widely in rehabilitation? “You could, of course, find a voice for all traumatic brain injury, which is a very large and growing problem. You could have another for MS or Parkinson’s. But if you look at the skills required in multidisciplinary teams to treat those conditions, there is a lot of commonality.

“We perhaps need to separate generic skills that allow us to deliver treatment to large groups of patients from the very specialist skills that may need to be offered at a regional rather than district level. Some patients need a disease or symptom-specific team – but that’s a relatively small number of patients. “Ultimately, most patients want treatment close to home from a team that feels comfortable managing it. A louder and more collaborative representation of multidisciplinary rehabilitation teams
would perhaps help to ensure more patients receive this.”

Despite the many challenges facing UK rehab teams, there are plenty of reasons for optimism about future of rehab, says Playford. She is particularly enthused about advancements in neuroscience.

“This is a really exciting time for rehab generally. There is an enormous amount of interest within the neuroscience community in targeting treatments to individual patients. This will allow us to stratify patients in terms of their individual pathologies and genotypes and target the right treatment to the right patient. It also allows us to do the sort of clinical trials that need to be done that demonstrate positive results.

“At the moment, we tend to use treatments that we know will work in some patients, but we don’t know which those patients are. We therefore waste a lot of time and energy treating the wrong patients. The advances in neuroscience will allow us to match
the interventions to the patient and that’s really exciting.

“Soon we’ll be able to achieve really sophisticated imaging, enabling us to do real time analyses of, for example, EEG or polysomnography data. This will allow us to choose our drugs more carefully, based on the impact they are having on people’s cortical activity.

“They will also enable us to enhance neuro-plastic changes, allowing patients to make better recoveries.

“Then there is the technical stuff around robotics, exoskeletons and smart fabrics for lightweight orthotics. There is lots of really exciting stuff going on.”

In future Playford would welcome more research projects specifically focused on rehab. These are in short supply partly because there are so few rehab centres co- located with university hospitals, she says. Also, there are “very few” trained academic rehabilitation medicine physicians.

“There is some really good neuroscience looking at preventing disability, in the context of an acute neurological event. But there
is very little looking at how we improve treatments for people in the sub-acute and chronic phases.

“There is funding available for research into the early stages of rehab, in terms of preventing disability in the acute injury, but very little for later on. We need to meet this challenge and create more successful rehabilitation research platforms.”

Meanwhile, having stepped down from the BSRM helm in October, Playford believes the organisation remains in good health, but with a tough remit to deliver.

“The BSRM is a relatively small society which reflects the size of the rehab medicine community in the UK. I have to say I think it punches above its weight. It has produced a number of very useful guidelines and guidance and it is well represented within the clinical reference groups, the Department of Health, on national committees and at the Royal College of Physicians.

“The challenge for the society is to make sure that medical students and trainees are aware of rehab medicine as a specialty; and we are taking some steps to raise awareness of it as a fascinating career choice. Certainly it’s one I have never regretted.”

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Interviews

Making the shift from victim to survivor

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After having a stroke two years ago at the age of 39, former international swimmer Craig Pankhurst founded the charity Stroke of Luck to support stroke survivors through activity and exercise. Jessica Brown reports.

“Stroke survivors are in one of two places – they either see themselves as a victim, with a not very positive outlook,” Pankhurst says.

“Or they see their stroke as a bump in the road, but that no one will stop them from having a fulfilled life, just one that’s different to the one they were leading before.

“We put in a halfway line to move people from the victim to survivor mentality.”

Pankhurst wanted to build the charity’s website to enable interaction between stroke survivors and experts in neuropsychology and personal trainers trained to work with special population groups.

When the coronavirus pandemic hit the UK in March, Pankhurst decided to do live sessions on social media, where he brought in guests and spoke about his experience and the charity he’s set up – and says he got good interaction with viewers.

His efforts caught the attention of the World Stroke Organisation, which partnered with Pankhurst to create videos for stroke survivors for what they can do to aid their recovery safely at home, with the help of specialist physiotherapists.

The videos are uploaded by both Stroke of Luck and the World Stroke Organisation.

“I spoke to the World Stroke Organisation over a number of weeks and we agreed to collaborate to create story-specific exercise and activity videos for stroke survivors, to start releasing over 12 weeks, to see if they get good engagement.

“Then we’ll carry on, and do some more,” he says.

The videos are now organised into a library, colour-coordinated into red, amber and green, depending on the viewer’s ability. The library also includes specific videos for carers.

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Interviews

The man who couldn’t see numbers

The unusual case of a man who can’t see numbers has led researchers to argue that the brain can process things without a person being aware of what they’re looking at.

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Researchers from Johns Hopkins University studied a 60-year-old man known as RFS, who has a rare degenerative brain disease that prevents him from seeing numbers two to nine.

He would describe seeing one of these numbers as a tangle of black lines that changed every time he looked at it. He had otherwise normal vision, and had no problem identifying letters and other symbols.

The problem would happen before he knew which number he was looking at, which meant his brain had to at least know that numbers were in the same category before something could then go wrong; study author Mike McCloskey tells NR Times.

“It didn’t matter how we presented digits to him, they were always distorted,” says McCloskey, a researcher in the Cognitive Science Department at Johns Hopkins University.

The researchers didn’t know what they were looking for when they started working with RFS, as this specific pattern has never been recorded before. The closest recorded cases are of patients who see distorted faces.

The researchers, whose findings were published in the journal, ‘Proceedings of the National Academy of Sciences,’ also found that RFS couldn’t recognise anything placed near or on top of a number.

They recorded RFS’s brainwaves while he looked at a number with a face embedded on it, and found that his brain detected the face, even though he was unaware of it.

“In one experiment, we showed him a big digit with a face on top of it and recorded EEG signals to see how his brain responded to the face.

“Even though he couldn’t see the face at all, we could pick up a response in the brain 170 milliseconds after the face was presented.

“We saw a perfectly normal brain response to the face, which told us his brain unconsciously identified the face as a face, even though he wasn’t aware of it at all.”

In another experiment, they put words next to the numbers and told him a target word. When he saw the target word, his brain had a bigger response even though he said he couldn’t see the word. They also did tests where they placed a number in front of RFS and asked him to guess what a number was, to test implicit knowledge.

“Sometimes, blind people say they can’t see a light, but can often point to it accurately when forced to make a guess,” McCloskey says.

“We did that with him and saw absolutely no indication he had any implicit knowledge. He couldn’t tell us if numbers were the same or different, odd or even – yet the EEG showed his brain was responding.

The reason it could just be numbers that are affected, he says, is because evidence suggests the brain treats categories of things differently.

“Furniture, fruit and vegetables, for example, may be treated separately, so it’s possible for some areas to be affected and some not.”

The findings demonstrated that the complex processing needed to detect words, numbers and other visual stimuli isn’t enough to make a person aware of what they’re seeing.

“We can draw conclusions about what’s necessary for you to be aware of what you’re seeing. You’d think that, if the brain has done enough work on something to know it’s a face or a particular word, you’d be aware of it.

“These results tell us the brain can do an awful lot of processing on something you’re looking at without you being aware of it at all,” McCloskey says.

“Something else needs to happen after the brain has identified what it’s looking at before you become aware of it at all. ”

And the reason these findings apply to everyone else is because the researchers assumed RFS’s brain was the same as anyone else’s, except for this one thing that went wrong.

“In order to become aware of something, you have to do more than processing to allow you to identify what you see – we think this is true for everyone.”

As for RFS, who was a geological engineer, the story has a happy ending.

“Because RFS couldn’t see regular digits, this was a real problem for him. We created a new set of symbols for him for digits, to see if he could use those,” McCloskey says, as well as a calculator on his phone using the digits.

“He learned them very easily – we wondered if they’d get distorted for him but fortunately, they didn’t. He says he’s been using the symbols ever since – he uses them in his daily life and stayed in his job two years longer than he would’ve otherwise, because of them.”

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Interviews

“Assume brain injury” after domestic violence, researcher urges

Domestic violence survivors in hospital should automatically be tested for traumatic brain injury (TBI) because they, and doctors, may not be aware of the symptoms.

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That is according to researcher Jonathan Lifshitz, director of the Translational Neurotrauma Research Programme at the University of Arizona’s college of medicine.

When a patient goes to the doctor with a cough, they’re tested for numerous diseases to rule them out, but with intimate partner violence (IPV), Lifshitz says, we should “flip the script”.

He tells NR Times: “If the individual doesn’t have encyclopaedic knowledge of what TBI is, they may not offer all the symptoms up to their healthcare provider.”

Similarly, the brain injury itself may prevent the patient from being able to detect their symptoms.

Instead, practitioners should suspect that victims of IPV have a head injury, so they can be tested.

“If we tested all people experiencing intimate partner violence for TBI, and are able to screen them using objective tests, we’re going to have far fewer people who experienced intimate partner violence and go untreated,” he says.

In one study, Lifshitz found that 62 per cent of people subject to IPV and diagnosed with TBI were unaware of their TBI when they sought treatment.

While it’s a challenge to determine that someone has TBI, the risk of missing something, Lifshitz says, is much greater. And while increased testing would incur more cost, due to additional testing, Lifshitz says it would save money.

“An individual may be able to hold down a job better, be less dependent on services and won’t need healthcare services as much in the long run,” he says.

Lifshitz is involved in the Maricopa County Collaboration on Concussion from Domestic Violence (MC3DV), a county-wide collaboration in Arizona. It aims to increase the suspicion of head injury by analysing health data for patterns and problems that can be targeted with a county-wide approach.

It educates police officers to recognise symptoms, social workers to better identify abusive relationships, emergency services to profile forensic evidence and clinical partners to assess and treat symptoms of TBI and concussion.

Also, prosecutors through the Maricopa Country attorney’s office are supported in being able to build their case against the assailant; while scientists and process developers also help to bring everything together.

Meanwhile, social workers and nurses are educated on the signs and symptoms of TBI, proposing an objective measure where head injury is implied.

Hospitals are a key area of focus for MC3DV, where one challenge is rebuilding trust between medical practitioners and patients who have previously suffered discrimination, and as a result have a lack of trust.

“It would be easier to implement this change in one crisis shelter or emergency department, when we have the opportunity to regulate and control the organisation we’re working with and we can put in new policies and procedures,” Lifshitz says.

“When trying to coordinate multiple systems in multiple organisations, it’s much more challenging.

“While everyone is receptive to the topic, the problem is having enough resources to do it.”

MC3DV is also hoping to replicate state-wide efforts made in 2012 to better detect evidence of strangulation.

As a result, Maricopa County prosecutors attributed the rise in domestic violence prosecution and decrease in domestic violence deaths to this change.

“Arizona recently changed the way the legal system deals with strangulation, in terms of how it sees evidence,” Lifshitz says.

“Prosecution is much more rapid and severe; it’s unburdened the legal system because many more cases are starting as guilty.”

Lifshitz hopes better testing and evidence gathering will act as a deterrent for abusers, and provide additional motivation for victims to step forward, although, he concedes, psychological, emotional and financial controls an intimate partner has over their victim complicates this scenario.

“A patient wanting to seek treatment is very different from the ability to seek treatment,” he says.

Lifshitz hopes there will be some real changes to come out of the research programme.

“I’ve always needed a bigger social driving force to keep me motivated. It’s unconscionable to know about this and not do anything about it.

“This programme helps to bridge the gap between social work, police work and biomedical research, to attack this problem from multiple angles.

“The majority of the work we do is stepping back, looking at what healthcare data we might have, and asking very specific questions.

“We sit around the table not necessarily with the smartest people, but with the most passionate people. It’s not any one person doing the work, but relying on a community of providers to support the victims and warn abusers.”

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