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Neurological AllianceNewbury, 21 April 20051 Restoring neurological function: putting the neurosciences to work in neurorehabilitation Action in Neurorehabilitation:

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Presentation on theme: "Neurological AllianceNewbury, 21 April 20051 Restoring neurological function: putting the neurosciences to work in neurorehabilitation Action in Neurorehabilitation:"— Presentation transcript:

1 Neurological AllianceNewbury, 21 April 20051 Restoring neurological function: putting the neurosciences to work in neurorehabilitation Action in Neurorehabilitation: Newbury Thursday 21 st April 2005 Raymond C Tallis F Med Sci

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3 Neurological AllianceNewbury, 21 April 20053 Background Prevalence of neurodisability State of the science (craft, art) Promise of neuroscience

4 Neurological AllianceNewbury, 21 April 20054 Current prevalence (estimated UK total) Long term effects of brain injury135,000 Cerebral palsy110,000 Multiple sclerosis85,000 Stroke300,000

5 Neurological AllianceNewbury, 21 April 20055 Future prevalence Many causes of neurodisability strongly age-related Population is ageing Prevalence may therefore rise Biggest challenge for health services in developed countries

6 Neurological AllianceNewbury, 21 April 20056 Background Prevalence of neurodisability State of the science (craft, art) Promise of neuroscience

7 Neurological AllianceNewbury, 21 April 20057 Neurorehabilitation Aim to maximise independence in people with neurological impairments Triple strategy: Prevent complications Adaptation to impairments (physical, psychological, environmental, social) Reversal of impairments

8 Neurological AllianceNewbury, 21 April 20058 ‘Higher level’ Interventions: Adaptation to impairment ‘ Lower level’, ‘hands-on’ interventions: Reducing impairment Benefits Retraining Support for carers Sensory stimulation Antispasticmanoeuvres Progressive resistive exercises Education Counselling Perceptual cueing Intensive repetitive activity Prevention of secondary complications Aids, Appliances, Adaptations Rehabilitation Strategies

9 Neurological AllianceNewbury, 21 April 20059 Neurorehabilitation: state of the art Much progress (for example, stroke) in: Preventing complications Adaptation to impairments Less progress in reversing impairments

10 Neurological AllianceNewbury, 21 April 200510 Crossing the Ecological Gap Abilities of client Aids, Appliances, Adaptations Demands of the world SupportServicesSupportServices

11 Neurological AllianceNewbury, 21 April 200511 Stroke Rehabilitation: The good news Organised stroke care saves lives and reduces disability –Langhorne et al 1993, Stroke Trialists 1997 These benefits are seen 5 and 10 years after the stroke –Indredavik, 1997, Indredavik, 2000, Lincoln, 2000 Some of these benefits are due to rehabilitation –Stroke Trialists 1997, Kwakkel et al, 1998

12 Neurological AllianceNewbury, 21 April 200512 Stroke Rehabilitation: The less good news We have little idea which components of the rehabilitation package are effective There is some evidence that higher-level interventions (e.g. occupational therapy visits) are effective –Walker et al, 1999 There is little evidence that specific ‘hands-on’ techniques have major or lasting effects on impairments –Lincoln et al, 1999, Pomeroy and Tallis, 2000

13 Neurological AllianceNewbury, 21 April 200513 Physical therapies to improve movement performance and functional ability post-stroke A few techniques work In many the evidence is equivocal No technique has major sustained effects on impairments This does not rule out major beneficial impact Pomeroy et al 2000

14 Neurological AllianceNewbury, 21 April 200514 Intensity: effect of augmented exercise therapy time after stroke: a meta-analysis Kwakkel et al Stroke 2004 31 papers, 2686 patients Small but favourable effect on ADL, IADL and walking speed but not for dexterity

15 Neurological AllianceNewbury, 21 April 200515 Intensity meta-analysis: caveats Methodological quality of papers ranged from 2-10 out of 14 In most papers intensity not the primary variable investigated

16 Neurological AllianceNewbury, 21 April 200516 Long term disability after first ever stroke and related prognostic factors in the Perth Community Stroke Study 1989-1990 Hankey et al. Stroke 2002; 33:1034-1040 Population of 138,700 sampled for first ever stroke over 18 months and followed up prospectively for 5 years 370 cases of first ever stroke and 277 patients survived for 30 days Of 30 day survivors of first ever stroke, approximately half survive 5 years One third remain disabled One in seven are in permanent institutional care

17 Neurological AllianceNewbury, 21 April 200517 Current imperatives Universalisation of best practice (less than half patients are admitted to stroke units at any time during hospital stay (Sentinel Audit, 2004) More effective approaches to reversing impairments

18 Neurological AllianceNewbury, 21 April 200518 Background Prevalence of neurodisability State of the science (craft, art) Promise of neuroscience

19 Neurological AllianceNewbury, 21 April 200519 The revolution in neuroscience Understanding brain damage and recovery New treatment modalities Advances in current therapeutic approaches New research methodologies

20 Neurological AllianceNewbury, 21 April 200520 Understanding brain damage and recovery Developmental neuroscience Advances in cognitive neuroscience Neuroimaging PET, MRI, MEG, TMS

21 Neurological AllianceNewbury, 21 April 200521 The revolution in neuroscience As it was As it is Stable structure Information (afferent input) Labile organisation Function

22 Neurological AllianceNewbury, 21 April 200522 Reorganisation Microscopic – synaptic Macroscopic - maps

23 Neurological AllianceNewbury, 21 April 200523 Somatosensory Cortex (black) before (A) and after (B) controlled tactile stimulation W.M.Jenkins et al J Neurophsiol. 1990;68:82-104 1 cm A B 1 mm

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25 Neurological AllianceNewbury, 21 April 200525 New technologies To promote understanding of recovery –e.g. functional neuroimaging To promote recovery –e.g. neural transplantation, drugs, electro- therapy

26 Neurological AllianceNewbury, 21 April 200526 New treatment modalities Electrical stimulation –Deep brain stimulation –Functional electrical stimulation Neural transplantation Drugs to promote neuroprotection and neuroplasticity

27 Neurological AllianceNewbury, 21 April 200527 Advances in current therapeutic approaches Maximising participation through rehabilitation Physical therapies to restore movement Rehabilitation engineering –Cybernetic technologies? –Robotics –Neuroimplantation devices

28 Neurological AllianceNewbury, 21 April 200528 New research methodologies Clinical trial designs: from single case studies to mega-trials Outcome measures Research synthesis

29 Neurological AllianceNewbury, 21 April 200529 Where we are now A better understanding of natural recovery of the damaged nervous system A better understanding of the scope of such recovery A better understanding of the ways in which such recovery may be promoted A better understanding of the way new treatments should be evaluated In short, promise of more effective ways of reversing impairments

30 Neurological AllianceNewbury, 21 April 200530 Towards a science of neurorehabilitation Characterising disorders –What are we trying to treat? Characterising treatments –What are we treating with? Measuring outcomes –Precisely what effect(s) do we expect? Devising treatments –Biologically plausible strategies that will not interfere with good acute brain care

31 Neurological AllianceNewbury, 21 April 200531 The challenge Turning this new knowledge into benefits for patients Crossing the gap between basic neuroscience and clinical care Ensuring continuing (two-way) dialogue and collaboration between basic neuroscientists, clinical scientists and practitioners

32 Neurological AllianceNewbury, 21 April 200532 Barriers Physical and cultural distances between basic scientists and clinicians Lack of knowledge and understanding of each other’s agenda and achievements Limited career opportunities for working on the interface and in wider collaborations Lack of infrastructure to support research strategies able to exploit the opportunities created by the neuroscience revolution

33 Neurological AllianceNewbury, 21 April 200533 The adolescent clinical science of neuro-rehabilitation Physical Therapy (e.g. “branded” therapies for stroke) –Rationale ill-defined, or intuitive and incorrect –Content & dose vague –Target Population poorly characterised –Inappropriate outcome measures Pharmacotherapy (e.g. ACEIs for cardiac failure –Clearly defined rationale (science- based) –Content & dose specified –Target population well characterised –Appropriate outcome measures

34 Neurological AllianceNewbury, 21 April 200534 Physiotherapy for patients with mobility problems more than 1 year after stroke: a randomised controlled trial Modest, transient benefits However, problems Theoretical framework of treatment unclear Content of treatment not specified Deficits characterised only according to side Outcome measures – Rivermead Index Green et al, Lancet, 2002

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36 Neurological AllianceNewbury, 21 April 200536 Mission of Academy The independent Academy of Medical Sciences promotes advances in medical science and campaigns to ensure these are translated as quickly as possible into benefits for patients.

37 Neurological AllianceNewbury, 21 April 200537 What is it and what does it do? Established in 1998 Equivalent of Royal Society Promote medical science across disciplinary boundaries Fellowship of 700 leading medical scientists in the UK

38 Neurological AllianceNewbury, 21 April 200538 Terms of reference of the report To identify, characterise and document opportunities arising out of advances in neuroscience to improve the care of patients with neurodisability

39 Neurological AllianceNewbury, 21 April 200539 Some possible misconceptions 1.Report implies there has been no progress in rehabilitation 2.Report has greater scope than it actually has 3.Report suggests that biological science can deliver alone –do it without psycho-social sciences –welfare of people with disability does not depend enormously on widest psycho-social context

40 Neurological AllianceNewbury, 21 April 200540 Report highlights multifaceted rehabilitation “A fundamental insight of rehabilitation is that limitations imposed on an individual by a disabling disease are not simply proportional to the quantity of biological impairment but also reflect material and social circumstances that individuals contend with” Acad Med Scis 2004;p11

41 Neurological AllianceNewbury, 21 April 200541 Will the emergent science displace… The art of rehabilitation? Traditional therapies?

42 Neurological AllianceNewbury, 21 April 200542 Environment matters Regeneration unorganised by appropriate information Regeneration organised by appropriate information Neural hairballs Neural circuitry

43 Neurological AllianceNewbury, 21 April 200543 Nothing works without it Behavioural benefits of foetal neocortical cell transplants in lesioned cortex seen only if animal housed in an enriched environment Mattson et al, 1997 Inhibitors of plasticity may be as important as stimulation for successful outcome in ischaemic lesions Karj et al 1999, Wenk et al, 1999 Brain derived growth factor reduced in an environment enriched post-ischaemic animal Johansson et al,1999

44 Neurological AllianceNewbury, 21 April 200544 Attention in rehabilitation We learn nothing we do not attend to Rehabilitation is about learning Patients need to attend to the treatment we give Robertson, 1999 The patient is a person in a world not just a nervous system in a skull and vertebral column

45 Neurological AllianceNewbury, 21 April 200545 Stimulation alters gene expression Huntington’s mice with enriched environment have delayed onset of symptoms Such stimulated mice have a larger peristraital cell volume by 13% Blakemore, Nature 2000

46 Neurological AllianceNewbury, 21 April 200546 Reversing Impairment [Dis]Organisation[Loss of] Function Information ‘External’ Input Assisted activity/Constraint induced therapy Prosthetic information (eg electrotherapy) Neural transplantation Drugs

47 Neurological AllianceNewbury, 21 April 200547 Report highlights complexity of rehabilitation “ A neuroscience-based approach to the reversal of impairment will not replace a multidisciplinary multi-agency approach. The complex mixture of cognitive, behavioural, psychosocial and environmental elements contribute to recovery of function. They form the clinical context within which the impact of neuroscience intervention must be evaluated” Summarised from: Acad Med Scis 2004;p11

48 Neurological AllianceNewbury, 21 April 200548 Recommendations 1.Regional Neurorehabilitation Research Centres 2.Highly skilled workforce 3.Research and infrastructure funding 4.Research culture development

49 Neurological AllianceNewbury, 21 April 200549 Recommendation 1 Regional Neurorehabilitation Research Centres “The NHS & academic community should collaborate to create a number of Regional Neurorehabilitation Research Centres (RNRCs) each closely associated with one or more universities” Doctors Therapists Nurses Clinical psychologists Neurobiologists Psychologists User groups, clinicians & researchers Sociologists Movement scientists Rehabilitation engineers Radiologists

50 Neurological AllianceNewbury, 21 April 200550 Recommendation 2 Highly skilled workforce “Recruitment, training and career structures should be improved as incentives for those undertaking or wishing to undertake research into neurorehabilitation” Current initiatives for undergraduate and postgraduate training in neurorehabilitation research should be strengthened New full-time academic posts needed Appropriate contractual arrangements to facilitate research activity by nurses, PAMs and others Staffing needs of service delivery nationally

51 Neurological AllianceNewbury, 21 April 200551 Recommendation 3 Research and infrastructure funding “The Higher Education Funding Councils and Department of Health should provide funding, in the first instance, for one to three RNRCs whilst the research councils and medical research charities should provide a portfolio of enabling funds” For HEFEC and DH to provide institutional funding for infrastructure for RNRCs For research councils and charities to provide competitive programme, grants, project grants & targeted career development awards

52 Neurological AllianceNewbury, 21 April 200552 Recommendation 4 Research culture development “A research culture should be fostered within the RNRCs to ensure knowledge is disseminated” A possible model – hub & spokes RNRCs initiate major programmes of research Smaller centres, e.g. DGHs, initiate smaller projects and participate in larger programmes Other centres, unable to initiate research projects, participate and help to shape protocols

53 Neurological AllianceNewbury, 21 April 200553 Example of a hub & spokes model National Translational Cancer Research Network Inclusive not exclusive Brings everybody in

54 Neurological AllianceNewbury, 21 April 200554 The future Build on opportunities presented by this report Continue to build scientific reputation and academic profile of all areas of rehabilitation

55 Neurological AllianceNewbury, 21 April 200555 Some questions Implementation of RNRCs –Real –Virtual Multi-disease or single disease Relationship within stroke between acute and rehabilitation research centres Early intervention –Good or bad ? Brain care

56 Neurological AllianceNewbury, 21 April 200556 Brain care and rehabilitation Brain care and rehabilitation are often seen as quite separate activities If rehabilitation is to take place early then they cannot be separated in time We must make sure that rehabilitation does not conflict with brain care especially of ischaemic penumbra More generally we should ensure that biochemical and physiological parameters are such as to maximise the likelihood of benefiting from active rehabilitation

57 Neurological AllianceNewbury, 21 April 200557 Brain care Oxygen Hydration Blood pressure Temperature Etc

58 Neurological AllianceNewbury, 21 April 200558 Summary 1.Academy of Medical Sciences report recognises the importance of neurorehabilitation research 2.Report emphasises the importance of holistic rehabilitation with a focus on neurorehabilitation 3.Recommendations about research opportunities and research organisation in the UK –Research Centres –Recruitment, training & career structures in research –Research and infrastructure funding –Research culture development in all clinical settings

59 Neurological AllianceNewbury, 21 April 200559 Bringing basic neuroscience and neurological rehabilitation closer Reducing the knowledge deficit –Two way dialogue between scientists and practitioners –Dialectic between clinical practice and scientific insights Crossing the cultural divide Meeting the organisational challenge Being prepared for a long haul

60 Neurological AllianceNewbury, 21 April 200560 Science-based neurological rehabilitation If ideas without experiments are empty, experiments without ideas are blind Kant

61 Neurological AllianceNewbury, 21 April 200561 Science-based neurological rehabilitation If science without therapeutic application is empty, therapy without a scientific base is blind

62 Neurological AllianceNewbury, 21 April 200562 Lessening the impact of disabling conditions: Building on the present Reducing Impairment AdaptationtoImpairment Now Future AdaptationtoImpairment ReducingImpairment Reducing dependence

63 Neurological AllianceNewbury, 21 April 200563 ‘Higher level’ Interventions: Adaptation to impairment ‘ Lower level’, ‘hands-on’ interventions: Reducing impairment Benefits Retraining Support for carers Neuroscience-based physiotherapy Drugs (growth factors, amphetamines) Education Counselling Functional neural transplantation Prevention of secondary complications Aids, Appliances, Adaptations Rehabilitation Strategies Retraining Electrotherapy

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70 Neurological AllianceNewbury, 21 April 200570 Report highlights multifaceted rehabilitation “A fundamental insight of rehabilitation is that limitations imposed on an individual by a disabling disease are not simply proportional to the quantity of biological impairment but also reflect material and social circumstances that individuals contend with” Acad Med Scis 2004;p11

71 Neurological AllianceNewbury, 21 April 200571 Report is about research opportunities & research organisation in the UK Does not address important issues of: delivery/organisation of neurorehabilitation services health economics of neurorehabilitation N.B. Does stress that if current best practice were available to all that the current outcome for patients would be improved greatly Acad Med Scis 2004;p11

72 Neurological AllianceNewbury, 21 April 200572 Neurodisability: state of the art Much progress (for example, stroke) in: Preventing complications Adaptation to impairments Less progress in reversing impairments

73 Neurological AllianceNewbury, 21 April 200573 What is neurological rehabilitation? A package of interventions designed to lessen the impact of disabling neurological conditions After Young 1996

74 Neurological AllianceNewbury, 21 April 200574 Future prevalence Many causes of neurodisability strongly age-related Population is ageing Prevalence may therefore rise Biggest challenge for health services in developed countries

75 Neurological AllianceNewbury, 21 April 200575 Neurorehabilitation Aim to maximise independence in people with neurological impairments Triple strategy: Prevent complications Adaptation to impairments (physical, psychological, environmental, social) Reversal of impairments

76 Neuroplasticity and the future of neurorehabilitation Raymond Tallis Professor of Geriatric Medicine Yorkshire ACPIN AGM

77 Neurological AllianceNewbury, 21 April 200577 What is neurological rehabilitation? A package of interventions designed to lessen the impact of disabling neurological conditions After Young 1996

78 Neurological AllianceNewbury, 21 April 200578 Rehabilitation Emphasis on function rather than pathology –Assessment –Training –Planning Pervasive ethos rather than sessional activities Minimising help Involvement of carers

79 Neurological AllianceNewbury, 21 April 200579 Principles of rehabilitation Prevention of dependency Emphasis on function/goal-orientation Multi-disciplinary/multi-agency Teamwork Progressive patient care

80 Neurological AllianceNewbury, 21 April 200580 Rehabilitation after stroke: effects of intensity Small but statistically significant improvement in terms of ADL Small but statistically significant improvements in functional outcome Generalisation on the basis of the analysis difficult because of poor methodological quality of the included studies Kwakkel et al Stroke, 1997

81 Neurological AllianceNewbury, 21 April 200581 The revolution in neuroscience Understanding brain damage and recovery New treatment modalities Advances in current therapeutic approaches New research methodologies

82 Neurological AllianceNewbury, 21 April 200582 New research methodologies Clinical trial designs: from single case studies to mega-trials Outcome measures Research synthesis

83 Neurological AllianceNewbury, 21 April 200583 Report highlights multifaceted rehabilitation “A fundamental insight of rehabilitation is that limitations imposed on an individual by a disabling disease are not simply proportional to the quantity of biological impairment but also reflect material and social circumstances that individuals contend with” Acad Med Scis 2004;p11

84 Neurological AllianceNewbury, 21 April 200584 Report is about research opportunities & research organisation in the UK Does not address important issues of: delivery/organisation of neurorehabilitation services health economics of neurorehabilitation N.B. Does stress that if current best practice were available to all that the current outcome for patients would be improved greatly Acad Med Scis 2004;p11

85 Neurological AllianceNewbury, 21 April 200585 Report is about a clinical research focus Advances neurorehabilitation Organisation of care e.g. stroke units Interventions to primarily enable people to adapt to disability e.g. OT trials New methodologies in research synthesis, outcome measurement and trials of complex interventions Advances neuroscience Understanding of driving neuroplasticity Neuroimaging to investigate brain pathophysiology & monitor treatment Brain-behaviour relationships e.g. attention, goal setting New treatments e.g. deep brain stimulation

86 Neurological AllianceNewbury, 21 April 200586 Will the emergent science displace… The art of rehabilitation? Traditional therapies?

87 Neurological AllianceNewbury, 21 April 200587 Environment matters Regeneration unorganised by appropriate information Regeneration organised by appropriate information Neural hairballs Neural circuitry

88 Neurological AllianceNewbury, 21 April 200588 Bill of Fare Background Academy of Medical Sciences Producing the Report Recommendations Where do we go from here ?


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