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

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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

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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