Free Health Essays - The Multidisciplinary Roles Of The Healthcare Professional In The Rehabilitation Of The Stroke Patient
This essay looks at the changing nature of the role of the rehabilitation specialists working in the NHS over the years. It examines several aspects of the overall situation. It begins with a brief overview of the pathophysiology of the cerebro-vascular accident. It then considers the historical role of the rehabilitation specialists, and the evolution of that role, as the nature of the type of patient seen in both the hospitals and the community has changed. It explores some of the reasons for the change by means of a literature review.
This review continues as it both considers and critically reviews, a number of peer reviewed papers that shed light on the role and indeed value of multidisciplinary rehabilitation work, after a cerebro-vascular accident. Several of the papers reviewed consider the cost implications, some consider and evaluate new approaches to multidisciplinary care and others provide both commentary and insight into some of the core beliefs of the rehabilitation specialists.
It concludes with a consideration of the current NHS and Dept. of Health measures that are relevant to the issues particularly in the shape of the National Service Framework initiatives.
The essay is concluded with a discussion section in which the main themes of the piece are considered and discussed in the light of the other relevant findings in the review.
Introduction
In this essay we are going to consider the pathophysiology of a cerebro-vascular accident and the various means that are currently used for treating it.
There are still some clinicians working today who can remember the times when a stroke meant prescribing bed rest and awaiting whatever recovery was going to happen, with a positive expectation that the patient would eventually be left with some type of permanent neurological deficit. More often than not the patient, if they had suffered a severe stroke, would develop an orthostatic bronchopneumonia and succumb to that before and significant recovery could take place. (Pound et al 1998)
Mercifully, our knowledge, technology and abilities have improved to the point where the NHS currently provides major multidisciplinary stroke units where suspected stroke victims can be promptly admitted, investigated , diagnosed, treated and discharged. These units, almost without exception, are heavily reliant on the multidisciplinary approach of many different types of rehabilitation professional. (Nouri et al 1987). We shall examine the make up of these teams later on in this piece.
Cerebro-vascular accidents account for the use of one fifth of all the NHS medical beds in the UK (Wade et al 1994). The patients that they affect will generally stay in hospital for between 11 to 38 days (depending on the study) (Beech et al 1996). Many studies comment on the historical reason that patients spend a long time in hospital because of the often fragmented and haphazard nature of community care (Lindley et al 1995). It has to be pointed out however, that this assessment is currently about ten years old and made by hospital based consultant neurologists. One might hope that a similar assessment made today would paint a rather different picture. It is for this reason that we shall conduct a critical review of the current literature.
The term multidisciplinary team work and seamless service are often heard as phrases that are used to describe the modern service. (Walker et al 1999). Part of the purpose of the research of this essay is to try to determine how much of these concepts are real and practical in everyday clinical practice, and to what extent they are weasel-words trotted out by politicians and administrators to extol the virtues of their concept of the modern NHS.
Part of this apparent revolution in organisation and treatment, is due to the evolution of the National Service Frameworks that have been rolled out across the country over the recent years and the guidelines, targets and goals that they set have been a significant driving force in the restructuring of the pattern of delivery of healthcare in this particular (and other) fields.
In this essay we shall examine the impact of these changes and the impact that it has had specifically on the field of the Occupational Therapist within the confines of the multidisciplinary team. We aim to do this by the means of a selective and critical literature review of a number of peer reviewed papers, to help us to try to establish an evidence base (Sackett, 1996), for the topic.
Chapter Two
The pathophysiology of the cerebro-vascular accident.
The brain is comprised of approximately 10 billion interconnected neurones. It is an organ of bewildering complexity. Even the most knowledgeable neuroscientist would concede that we only understand a minute fraction of the capabilities and working abilities of the brain.
The brain starts to take on a recognisable form at about 5 days after conception. The organisation continues until it approaches its gross adult anatomy at about 18 weeks of gestation. The neuronal interconnections continue to develop until about 5 years old when new neurones are no longer formed. (Weinrich et al 2005)
The neuroscientist will tell us that ultimately all of the abilities and functions of the central nervous system, together with the facets of our personality that go to make a complete human being, are all the result of neuronal interconnections. These interconnections retain an ability to change (plasticity) well into adult life. The function of memory is thought to be a direct result of this phenomenon of plasticity. As life goes on, this plastic ability decreases, and as a result, various cognitive functions (including memory) become progressively impaired. (Caramia et al 1996)
The brain is divided into a huge number of discrete regional units, which are themselves all interconnected. It follows from this structure that damage to one part of the brain will generally produce a discrete, and sometimes predictable, pattern of deficit. (Chollet et al 1991)
The term cerebro-vascular accident actually covers a number of different pathologies. It refers, at an anatomical level, to the death of brain tissue, usually as the result of an interruption to the normal blood supply to that particular area.
(Cramer et al 2000)
The actual mechanism of the cerebro-vascular accident is generally either thrombotic or embolic. It is occasionally haemorrhagic. It is usually not possible to initially differentiate between these eventualities on clinical grounds, but there are various tests that can be done fairly quickly after the event, which can help to make a provisional diagnosis more certain. The diagnosis is generally important since the treatment options are, to a large extent, dependent of the actual diagnosis. (Demeurisse et al 1980)
The brain tissue is unique in the body insofar as it runs at a maximal metabolic rate at all times. The significance of this is that if there is an interruption in the blood supply for any reason, then the effects will be seen in the brain almost before any other organ. (Frackowiak et al.1997)
Mature brain tissue is virtually incapable of regeneration, and so it follows that brain tissue that is lost as a result of interruption of the blood supply, is irretrievably lost. Mercifully, the brain is adaptable to a degree, and when the function of one area is lost, there may be an apparent restoration of function because other areas can take over. It should be noted however, that this ability is generally very limited, and the higher functions, once lost, are seldom fully recovered. (Indredavik et al 1997)
There is the phenomenon of partial recovery which can occur after a stroke, and this may be due to a slow reduction in the local oedema that tends to arise after tissue damage. Tissue that has not been destroyed but only transiently impaired, can regain its function at a later stage. (Johansen-Berg et al 2002)
Chapter Three
Literature review
In this review we have considered a huge amount of literature and our first impression is that there are comparatively few good quality articles and papers that have been written on the subject. We have therefore been very selective in choosing those for review which have a good sound scientific evidence base and also help to amplify our understanding of the concepts of modern multidisciplinary practice.
The first paper that we shall review is an eye-catching paper with the unusual title Should elderly patients be made to sit in chairs? (Bliss 2003). The title belies the strengths of this particular article, as it is actually a very well written piece which considers many aspect of treatment which are relevant to the stroke patient.
It starts by drawing a picture of a typical stroke recovery ward with a number of elderly patients sitting slumped in high backed chairs and uses this image to pose a fundamental question What isthe evidence that elderly patients benefit from extended periods of sitting in chairs? How many patients need further investigationor palliative care rather than "mobilisation"?
As many experienced healthcare professional will testify, there appears to be a huge pressure (often justified as mobilisation or tradition) that patients should be made to get out of bed and mobilise during the day. (Parker et al 2001)
Bliss points to the time when most patients were expected to stay in bed when they were in hospital. In about the 1940s, there was a move to mobilise patients at the earliest opportunity, which was largely triggered by the surgeons, because they began to recognise that inherent dangers of the DVT. Coincident with this move, and possibly partly related to it, there was a massive increase in the recruitment of rehabilitation specialists. Occupational Therapists, Physiotherapists and many other disciplines began to appear on the wards in considerably greater numbers than had been seen previously, in an attempt to get people out of bed and back to a state where they could be safely discharged. (Steultjens et al 2002)
Bliss quotes a paper from the BMJ of nearly sixty years ago by Dr Asher (1947) in which he writes:
"The dangers ofgoing to bed", hewrote: "Look at the patient lying in bed. What a pathetic picturehe makes! The blood clotting in his veins, the lime drainingfrom his bones, the scybala stacking up his colon, the fleshrotting from his seat, the urine leaking from his distendedbladder and the spirit evaporating from his soul."
This paper is important to our considerations on two levels. Firstly there is a valid point regarding mobilisation which we shall discuss shortly, but also there is the important consideration that Bliss makes, that the nature of the patient has changed from the typical patient that Asher would have recognised in the 1940s, to the typical patient that we see today. Typically, the average age of the patient on a stroke rehabilitation ward sixty years ago, would have been 73 yrs. They would have been comparatively fit and fairly mobile. Their main problem was that they could not be discharged simply because they had nowhere suitable to go. As a consequence of this, they responded well to the ministrations of the rehabilitation professionals and would be comparatively easy to mobilise. The same typical patient today tends to be a full decade older, they tend to have multiple pathologies and be either newly injured or really very ill. They tend to have short admissions and these are confined to the time when they are acutely ill. (Indredavik et al 2000)
This, then clearly represents a different and more difficult challenge to the hospital based rehabilitation specialist.
With the general thrust being towards evidence-based medicine, we should consider just what are the actual advantages and disadvantages of mobilisation and bed rest. This is a point that we shall return to later, but Bliss lays out the physiological changes very concisely.
Bed rest (as opposed to simply sitting in a chair) confers a number of beneficial physiological changes to the body. It increases both the rate and volume of blood flow in the veins of the lower leg, lungs, major organs - including the brain - by the mechanism of reflex vasodilatation. Sitting causes reflex vasoconstriction, particularly in the feet. This is manifest by patients sitting in chairs complaining of cold feet.
The vasodilatation improves renal function by increasing renal blood flow. This helps by improving the electrolyte balance and eliminating excess fluid from the cardiovascular system. In the sitting position, electrolyte and fluid excretion is reduced, which can cause orthostatic oedema during the day and this can be accompanied by a problem with nocturia when the patient does go to bed.
The point about prolonged sitting and DVT is now well known. It has been demonstrated that the flow rate of blood in the femoral vein can increase 20 times when a patient is lying as opposed to sitting.
Patients who are allowed to sleep also derive a number of benefits. Adequate sleep improves the cognitive functions. Many aspects of performance and memory are impaired by poor sleep. The physiological changes induced by poor sleep include raising cortisol and catecholamine levels, lowering TSH levels, increasing lipid intolerance and thereby increasing the chances of Type II diabetes mellitus. The other major benefit that sleep delivers, is the increased output of anabolic hormones which are important in the healing role.
Bliss documents a number of other changes which we will not consider further, but the point is well made that an obsession with mobilisation and getting patients out of bed may not be the panacea that it is commonly thought to be. Bliss makes a valid point at the end of her paper. So that the reader does not take the wrong message from her conclusions she writes:
A 1996 review of trials that compared prescribed bed rest withambulation concluded that in all cases activity was better thanbed rest. (Stojcevic et al.1996) However, prescribed bed rest is not the same as restresulting from felt need. Exercising little and often and sittingout of bed for meals where practicable are obviously important,but so is the need for rest after exertion and after meals.
It is accepted that we have dwelt a little on this particular paper, but it is relevant to our considerations both because of the challenge to the generally perceived wisdom of the moment that mobilisation is a goal in itself, and also for the demonstration that the nature of the patient that we are dealing with has changed. (Clarke 1996)
Evidence based medicine that was applicable to Dr Asher's patient's may well not be applicable to those of today.
We shall now turn out attention to a number of trials which help to clarify the nature of the multidisciplinary roles of the rehabilitation specialists in he NHS of today. Gilbertson (et al 2000) produced a paper which gives a good evidence base for the assumption that rehabilitation specialists can actually produce a measurable improvement in the quality of life of the stroke patient. (Grimmer et al 2004)
The need for such a trial was outlined in the paper by Forster (et al 1992) who pointed to the fact that there was little in the way of evidence base to show that rehabilitation specialists actually achieved what everyone hoped that they were achieving when they were working with patients after a stroke.
Forster pointed to the fact that hospital discharge can be a critical point in the consideration of eventual quality of life of the patient, as many patients did not seem able to transfer the skills that they had been taught in hospital into the home environment. This was becoming all the more critical in consideration of the fact that there was a progressive move towards earlier hospital discharge into the community. (Corr et al 1995)
The design of the trial was a single blind trial that was both randomised and controlled. One drawback in its outcome was the fact that it only had a comparatively small entry cohort with only about 60 patients in each arm of the trial. Despite this, the results are certainly worthy of consideration. The objective of the trial was to establish whether targeted therapy from the rehabilitation specialists could produce a measurable benefit in the quality of life of the patient who had been recently discharged from hospital back into the community after a stroke.
The authors used the Barthel activities of daily living scale to quantify the outcome of the trial. (Wade 1992). They randomly allocated their patients to either a normal group or an intervention group. The latter group received a six week course of targeted intervention and was then assessed by an independent (and trial blinded ) assessor.
The authors reasoned that part of the difficulties in establishing a seamless interface between hospital and community services can be poor co-ordination of discharge planning. This could be compounded by lack of service access, psychological problems feelings of isolation and lack of confidence in the patient. (Gilbertson 1998)
They also point to the fact that previous studies in this area were not actually able to demonstrate any long term benefits of Community intervention (Drummond et al 1995) and (Logan et al 1997)
It should be noted that patients in the normal group had the usual provision of services that the NHS would normally provide, including the normal allocation of Occupational Therapist's activity and the provision of appropriate aids etc. The intervention group also had a series of 10 home visits over a six week period (each lasting about 30-45 mins) where specific patient orientated gaols and targets were set and a tailored achievement plan worked out for each, which was then implemented. The multidisciplinary aspects of this intervention were also stressed as the rehabilitation specialists also were encouraged to liaise with other agencies for the provision of appropriate services, aids and advice where necessary. (Walker et al 1999)
The outcomes of this particular trial were, in fact, quite surprising. As an overall finding, the intervention group had an average increase in Barthel index score (Wade 1992) of 5.7, with significantly fewer patients in the intervention group finishing the trial with a poor outcome. One other major difference that the authors comment on was that the intervention group had fewer readmissions to hospital in the follow up period after the trial.
Analysis of the costs involved showed that (by extrapolation) one full time equivalent rehabilitation specialist could manage a workload of about 90 patients per year with a cost of about 310 per patient. this would prevent about 10 poor outcomes. This translates to a financial cost of about 2,500 per poor outcome avoided.
One has to consider that these financial constraints are, of course, important in the NHS of today. We talk of a 10% poor outcome as a matter of course. The fact is that if you are the particular patient who has a poor outcome, then it is not a 10% problem, for you it is 100% (Dennis et al 1997)
The authors spend a significant part of their paper discussing the shortcomings of the trial. Critical consideration suggests that the trial design was good, and it appears to be well executed. It was indeed able to demonstrate a substantial benefit in terms of quality of life for the patient. Like the papers of Drummond and Logan, they were not able to demonstrate a sustained improvement in the quality of life as the effects appeared to wear off as the six week intervention period receded. (Gladman et al 1996)
The next paper that we shall consider is one that appears to have considerable practical importance to both the stroke victim and their carers. Falls are comparatively common in the elderly. They are even more common after a stroke when the patient is trying to re-establish full motor and co-ordination control of their body and there may also be a deficit in sensory mechanisms as well. (Wade et al 1992)
Between 13% and 37% (depending on study) are though to fall at some stage in the post-stroke recovery period. (Mion et al 1989) (Vlahoy et al 1990)
Patients who fall suffer a significant increase in both morbidity and indeed mortality, quite apart from other considerations such as general misery, pain, loss of confidence and other possible psychological sequelae. (Brandis 1999), with 70% of patients who fall being recorded as sustaining injury (Grenier-Sennelier et al.2002)
Haines (et al 2004) have just completed an excellent study which looks at the multidisciplinary input factors that can help to reduce the possibility of falls in the post stroke patient.
The authors point out that again, there has been little quality work in this area with only three published trials on the subject (Donald et al 1994) (Mayo et al 1994) (Tidejkssar et al 1993) and all of these were limited in their scope, and therefore their results.
The authors designed a controlled, randomised and blinded trial to see whether a programme of rational interventions would actually result in a reduction in the morbidity associated with falls after a cerebro-vascular accident. The trial was designed with an intervention group and a normal group. The interventions were surprisingly simple. The patients were given an explanatory booklet, a targeted and goal orientated exercise programme of strengthening, a co-ordination improvement exercises and an education programme and hip protectors.
The cohort size was very large with over 600 patients being studied
Again, it has to be conceded that the results were surprisingly good. The intervention group sustained 30% fewer falls over the whole study period, and those who did fall sustained 28% fewer injuries. The other significant factor was that of a small group of frequent fallers, there were progressively fewer falls in the intervention group. The authors provide a very detailed analysis of their figures, but the minutiae of these details are not specifically relevant to our considerations here. The important fact that we should take from this paper is the fact that multidisciplinary rehabilitation can be shown again to make a significant impact on the morbidity and mortality of recovering stroke victims if it is based on good evidence-based research. In this specific instance it must be realised that the impact is not only on the life of the victims themselves, but also on the lives of their carers and also on the finances of the health care services which is an equally valid consideration. (Hollingworth et al. 1993)
The authors also take the opportunity to point out that the morbidity related to falls is not limited to the bruising and obvious physical factors but there is the morbidity associated with the subsequent lack of confidence that can then pervade the lives of the patients.
The whole scope of the multidisciplinary role of the rehabilitation specialists is probably examined in its most valuable aspect, in the concept of the Hospital at Home initiatives that are becoming more commonplace across the country (Husain 1996)
The paper by Coast (et al 1998) is an impressive tour de force on the subject. In the paper the authors examine the roles of the various rehabilitation specialists. Not only what we might consider the mainstream specialists, but also the speech therapists, the dieticians, the psychologists and the general nurses. One of the specified outcomes is the analysis of the cost effectiveness of the projects. A great deal of the paper is taken up with a detailed breakdown of the financial implications of running the scheme when compared to the costs of maintaining a patient as an inpatient. The results are actually quite striking. In essence, they show that to maintain a post stroke patient in hospital for a three month period was about 3,200. To maintain the same patient in the Hospital from Home setting would cast about 2,500
Considering the cost implications from another perspective, this would imply that for every 10,000 spent by the NHS, routine hospital care could be provided for three and Hospital from Home could be provided for four.
Clearly this is only relevant if the cost saving can be shown to be made without a reduction in the level of care, or more accurately, the measured level of outcome. It is therefore doubly relevant that this particular study was run alongside another, (Richards 1998), which looked at the quality of life outcomes of the same group of patients.
As if to emphasise the multidisciplinary nature of the enterprise the authors detail the core staff who were involved in the day to day running of the project:
Two nurses (one G grade, one E grade)
One physiotherapist (senior 1, 0.8 whole time equivalent)
One Occupational therapist (senior 1, 0.5 whole time equivalent)
Three support workers (B grade auxiliary, flexible hours).
This core team was able to, (and frequently did), utilise the expertise and input from the rest of the primary healthcare team and the social services, if problems either arose or were anticipated. (Smith et al 1994)
One factor which proved difficult to quantify was the fact that patients who were treated under this scheme either did not go into hospital at all or were received back into the community earlier than might otherwise have been anticipated. This, of course, means that there were extra facilities to deal with patients who were still in the hospital, and this benefit simply cannot be quantified. This also exemplifies the point made by Bliss in the first paper that we reviewed and that is that it is the nature of the patient that is seen in hospitals that is changing as hospitals are progressively utilised to care for the acutely or seriously ill patient. (Netten et al.1996)
The other economic point to consider here is that not only were NHS costs per head reduced, but a patient being nursed or cared for in their own home has fewer costs themselves (both personal and their families) than if they were in a hospital.
Once again, as one would expect in a high quality paper, there is a large proportion of the paper which examines the shortcomings of the paper, together with potential sources of bias.(Donaldson et al. 1996). It has to be said, that although they are indeed covered, the trial design was very good so that the influence of bias and other confounding factors is thought to be really very small.
Earlier on in this paper we made comment on the importance of psychological factors in the rehabilitation programmes. A substantial proportion of post stroke patients loose their confidence in terms of mobility both in the house, and more especially outside the house. (Logan et al 2001). Logan (et al 2004) produced a well constructed study to see what impact could be made by targeting this particular problem in the community.
The authors constructed a randomised controlled trial with a cohort of nearly 170 patients who were randomised to one of two groups. They were either normal - where they received the normal post stroke care from the primary healthcare team , or intervention where they received visits from rehabilitation specialists (up to seven visits) together with details of transport practicalities such as bus timetables and transport mobility schemes.
The results were assessed by a trial blinded Occupational Therapist who assessed each patient after the trial was concluded. The results showed that the intervention group actually managed to get out of the hose much more often at every assessment stage than the control group.
It is also significant that those patients who were able to leave the house and become more mobile (from either group), reported increased feelings of self satisfaction and contentment than those who did not using the Nottingham assessment tool (Goldberg 1992)
Unlike many of the interventional programmes that we have reviewed and read in the preparation of this essay, the benefits of this particular study were not lost over time. It would appear that once a patient has gained both the confidence and the knowledge to become significantly mobile, then that confidence does not appear to be lost. One could also deduce from the results, although the authors do not specifically mention it, that once a certain period has been passed without becoming significantly mobile, it appears to be a progressively larger problem to confront, which some patients seen not to be able to do without significant help from either rehabilitation specialists or family and friends.
Once again we seem to be seeing the benefits of specific targeted therapy to this group of patients.
The next paper that we would like to review is a short commentary by Riddoch (et al 2000). In the same way that we commended the Bliss paper for challenging one of the basic core assumption about the nature of appropriate care, this paper looks at the assumption that rehabilitation has to consist of some form of sports related or perhaps specific exercise related programme, in order to be maximally effective. (Wolf et al 1993). This is particularly appropriate in post stroke patients, as they are clearly more likely to have some form of motor impairment, whether it is overt impairment of movement, or perhaps more subtle co-ordination or proprioceptive impairment. (Oliver et al 2000)
The author starts with the rather provocative statement that it is not possible to engage in "social and productive activities that involve little or no enhancementof fitness to lower the risk of mortality all cause as much as fitnessactivities do. It is on this premise that the article is based.
It is the author's contention that:
Neither high levels of cardiorespiratory fitness nor participation in vigorous activities that promote cardiorespiratory fitnessare necessary to decrease morbidity and mortality.
The point that he makes is that it is actually the volume and consistency of the activity that gives it therapeutic value rather than the exact nature of it. He poses the question,
How does the body know whether the exercise taken is on a treadmill or at the sink doing the washing up or the ironing? The body does not care whether the physical activity is undertakenas sport, exercise, hobbies, translocation, or householdchores.
He points out that studies have assessed the activity levels for health related benefits at 150 kcal/kg/day (Paffenbarger 1986), and that this level is currently the level that is recommended by a number of Government bodies (Dept of Health 1996) (I&II) as being the minimum requirement for the maintenance of health in the form of 30 mins brisk walking on a daily basis.
The authors points out that the same level of activity can be accomplished by moderate gardening or brisk housework. He is not aware of any particular studies that have equated housework with health, but he suggests that, on a first principles basis, that there is no reason why it should not be expected to be just as beneficial as the equivalent amount of exercise done in a different way.
In this essay so far we have tended to avoid the overt medicalisation of the issue because we felt that some of the major thrust of the enquiry might well be lost in the minutiae of medical research. We did come across one paper however, which does throw some light onto our investigation. One issue that is commonly faced by the rehabilitation specialists is how can one predict which type of patients, and indeed which type of pattern of disability, will respond to any particular type of treatment modality. A recent paper by Johansen-Berg (et al 2002) provided an eye catching resume of one piece of medical research which could help to answer this particular problem.
It would appear that her team have discovered a type of action potential in sensorimotor regions are associated withsuccessful motor rehabilitation. This can be detected by MRI scans. The hope is clearly that this can, in time, be translated into a practical predictor of therapy which can correlate with the clinical outcome for the patient.
One other significant paper that we should consider is the one by Rudd (et al 1997). This particular paper seems to encapsulate the entire thrust of this essay. It purports to examine the effectiveness of the community based multidisciplinary rehabilitation specialist team in the move to try to obtain early discharge of the stroke patient from the acute hospital bed.
In essence the study was simple. The authors took a cohort of over 300 patients and randomly distributed them into two groups. One group were discharged as soon as they were independently self caring, and the other group were kept in hospital to receive hospital based rehabilitation. The groups were compared after a twelve months period from discharge. The authors chose to use the Barthel score (Wade 1992) as the main measure of attainment. The paper is actually very long and detailed, and it has a number of subsidiary findings. The main findings are however, that the patients who were discharged early managed at least as well as those patients who were managed completely in hospital. A major difference was the degree of patient satisfaction which was considerably greater in the group who were rehabilitated in their own homes.
The corollary to this study is again that by discharging patients to a multidisciplinary rehabilitation specialist team in the community, the NHS can create a more efficient use of its hospital beds for the acutely sick patient.
Let us now consider the Government's response to the ideals of multidisciplinary rehabilitation specialists. Arguably the single most important initiative that the NHS has brought out in this regard is the series of National Service Frameworks that have been instituted and rolled out across the country over the last six years. They have announced a series of nationally agreed goals, standards and targets for the health service. They were presented to Parliament in a speech by Dr John Reid, the Sec. of State for Health in 2004 (Reid 2004).
The actual details of the National Service Framework need not concern us here other than we need to examine just how the government views the moves towards multidisciplinary rehabilitation.
Standard Five of the National Service Framework for the elderly is of particular use to us in this regard. It calls for:
Rapid access to TIA (transient ischaemic attack) and non-disabling stroke clinics to support primary care in diagnosis and prevention
Dedicated multidisciplinary acute inpatient stroke clinics caring for stroke patients in the first 7-10 days
Organised multidisciplinary inpatient local stroke rehabilitation units predominantly in community hospitals
An early supported discharge service of home based rehabilitation
Longer term rehabilitation and support through Day Hospitals and community rehabilitation teams
A nurse-led stroke review clinic and an information and support service for stroke patients and their carers
In specific example, the Epsom and St Helier University Hospitals NHS Trust (2004) have acted on this Standard and produced the following statement:
A team approach to the development and delivery of a therapeutic handling programme aimed at involving all team members, has improved care for stroke patients and also the confidence of staff in handling techniques.
Joint therapy sessions and group work make best use of resources and enhance working relationships.
This is good evidence that the multidisciplinary concept is currently being actively encouraged and implemented by the various healthcare-related administrative bodies in the country.
Chapter Four
Conclusions and discussions
We have read, assessed and assimilated a large number of papers in the preparation of this essay. There were a number of themes that were common to most of them. Firstly there is an undoubted trend and move towards the multidisciplinary approach of the rehabilitation specialists in the structure of the health care teams. This has long been the case in the primary care sector, but it is now becoming commonplace in the secondary sector as well. (Young 1999)
The second factor is that, until recently, there was a noticeable paucity of good quality papers on the subject. To some extent this has been remedied with a number of well constructed and well written papers that have been published in recent years and this may reflect the same realisation on the part of other professionals in the rehabilitation area.
The third important factor is that, although a great many papers rely on the provision of prescriptive measures in order to benefit the patient (which is fine), there is a noticeable move towards the concept of empowerment and education of the patient as a significant feature of the various therapeutic regimens. The emphasis on concordance rather than compliance (Marinker M.1997). It is the features such as the provision of bus timetables Logan (et al 2004) and information leaflets (Haines et al 2004) which bears testament to this movement.
Reflection on all of these factors (Gibbs 1988) has helped to produce an insight into a better understanding of the interdependence of the various professionals in the NHS. Not so very many years ago it was noticeable that, particularly in the secondary care provision, there was a distinctly insular attitude amongst the different disciplines. This is no longer nearly so apparent as healthcare professionals progressively seem to appreciate the need to pull in the same direction for the overall good of the patient. (Bryant P 2005).
It is also noticeable that a great many of the studies considered also have incorporated into them features of patient satisfaction and carer satisfaction when they make an overall assessment of the efficacy of the treatment (Marks-Moran 1996)
We must not lose sight of the fact that a cerebro-vascular accident is a life-changing event for the patient. It becomes almost a protective mechanism on the part of the healthcare professional, to consider the patient as a healthcare academic problem. The fact of the matter is that they are human beings and deserve the best care that they can be given. (Stroke Unit Trialists' Collaboration. 1997)
We have seen that modern investigations and treatments are consistently producing better results as time goes by. It is up to the healthcare professionals, and particularly the rehabilitation specialists, to act as the patient's Advocate in cases to ensure that they receive the best treatment that is currently available for them
It would appear that evidence-based therapies and treatments are the best way forward to achieve this goal.
In a seminal paper on the subject Sackett (1996) observes that:
Evidence-based health care is the conscientious use of current best evidence in making decisions about the care of individual patients or the delivery of health services. Current best evidence is up-to-date information from relevant, valid research about the effects of different forms of health care, the potential for harm from exposure to particular agents, the accuracy of diagnostic tests, and the predictive power of prognostic factors.
This definition was actually improved later by his student Merry (1998) who added to this definition the fact that he believed that good evidence based medicine
takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information.
It is only by a careful and critical weighing of the available evidence that we can come to a conclusion as to just what the best evidence base actually is for each particular subject. It is our hope that this particular essay has gone some way in this regard in the pursuit of our topic.
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