Rehabilitation Q3 2019 by Mediaplanet UK&IE

Q3 / 2019 A PROMOTIONAL SUPPLEMENT DISTRIBUTED ON BEHALF OF MEDIAPLANET, WHICH TAKES SOLE RESPONSIBILITY FOR ITS CONTENTS

MR WINSTON KIM FRCS (ORTH) The robotic revolution in knee replacement surgery. » p4

CHRIS BRYANT MP More than 1.3 million people are living with the eﬀects of brain injury. » p6

STEVEN ASPINALL Exercise is cheap, has huge beneﬁts and minimal side-eﬀects. » p10

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“Rehabilitation services are not simply a ‘nice to have’. They are absolutely vital because of the contribution they make to the quality of the lives of patients and their families.” Dr Krystyna Walton P2

We’re here to get you access to the best rehabilitation, medical care and support to help you regain the independence you’ve lost as a result of an injury or illness.

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Why rehabilitation is good for patients — and the NHS Rehabilitation services make a real difference to the lives of patients and generate NHS costsavings, says Dr Krystyna Walton, President, British Society of Rehabilitation Medicine.

or any society, rehabilitation services are not simply a 'nice to have'. They are absolutely vital because of the contribution they make to the quality of the lives of patients and their families. Rehabilitation following an acute event, or deterioration in an existing condition, is an essential component of the journey for that person from being a ‘patient’ to being a ‘person’. Imag ine if no rehabi litat ion was available after major surgery or injury, or a traumatic health event such as a brain haemorrhage. Without the support of expert rehabilitation teams, patients may not be able to return to the lives they led before, go back to work, fulfil their parenting or other relationship responsibilities, or generally optimise their health outcomes. And while it's true that people who have suffered severe brain injuries may never be able to achieve any level of autonomy or independence, specialised rehabilitation can

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ensure their quality of life is the best it can be. It means they can be cared for in a non-hospital environment, that all their medical needs are met and that their families are well-supported, too.

Without the support of expert rehabilitation teams, patients may not be able to return to the lives they led before, go back to work.”

Recognising and overcoming the barriers to rehabilitation Effective rehabilitation does not come from a single source. Instead, it is powered by teamwork from, for example, occupational therapists, physiotherapists, psychologists and other practitioners who have an understanding of the medications and treatments that will enhance an individual's rehabilitation — and those that won't. But t h i s t y pe of spe c ia l i sm requires funding and, while some local areas have good rehabilitation service provision, others do not. For instance, The National Clinical Audit for Specialist Rehabilitation following Major Injury (NCASRI) found that only 40% of individuals

in Major Trauma Centres (MTCs) receive specialist in-patient neurorehabilitation. It also highlighted a shortfall of 330 beds, and a lack of health professionals, including consultants in rehabilitation medicine. It 's a v a r i able pic t u re . I 'm fortunate to work in a very pro-rehabilitation environment; although I'm aware of colleagues who do not. They have to deal with low staffi ng levels, a reduced skills mix and a nagging feeling that their contribution to patient care is being undervalued. Funding issues within the National Health Service can also make it difficult to access rehabilitation-enhancing technology.

Positive developments and cause for optimism Dealing with these challenges is a complex task in the NHS, where there is no unified commissioning across the whole of the patient pathway and where different Clinical Commissioning Groups have different priorities for community provision. That said, positive developments give cause for optimism in the area of trauma rehabilitation. For example, the Getting it Right First Time (GIRFT) Project, led by NHS England, recently ran a workshop on aspects of rehabilitation. The British Society of Rehabilitation Medicine is still continuing to drive the major trauma rehabilitation agenda and, thanks to a programme of Major Trauma Centre peer review panels, there are standards that MTCs have to meet. As NCASRI revealed, there is robust evidence to suggest that rehabilitation doesn't just make a difference to

INTERVIEW WITH:

DR KRYSTYNA WALTON President, British Society of Rehabilitation Medicine individuals. Used well, it can make a difference to the economy in terms of cost savings to the NHS, too. It's another reason why we should cherish and champion our rehabilitation services. WRITTEN BY: TONY GREENWAY

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Why case management is valuable for clients with catastrophic injury A good case manager is central to a person’s rehabilitation journey, particularly if following a life-changing injury. But what is their role — and why is it so important?

ineteen-year-old Ellis lives a full life. He never lets the fact that he has cerebral palsy hold him back. Ellis loves going to the pub, socialising with friends and family, going on holiday and watching football and rugby. Key to Ellis’ life is his case manager, Janine, who has worked with him since he was six. Janine’s job is to support Ellis to live his life the way he wants to live it. Over the years that she has supported him, she has seen him develop into a remarkable young man. “Ellis’ sociability has been a constant but, in the past two years, he has really developed his organisational skills,” reveals Janine. “He’s taken an interest in actually managing some of his own affairs, has his own bank account and manages some of his own funds. He has a role in shift planning and can make the long-term changes that he wants. He’s planning a much wider range of activities.”

Supporting people to lead fulﬁling lives after injury Janine works for Independent Living Solutions Ltd, a company that is instructed by solicitors to provide case management for people in need of specialist rehabilitation care while their litigation cases are ongoing. “Many of our clients have sustained a catastrophic injury, either through accident or clinical negligence,” says Alison Barker, Managing Director. “The aim is to return them to a fulfiling life and to empower them to do as much as they can for themselves as they recover and adjust to the effects of their injuries.” Case management — as defined by the Case Management Society UK — is “a collaborative process, wh ich a ssesses, pla n s, i mple ments, co-ordinates, monitors and evaluates the options and services required to meet an individual’s health, social care, educational and employment needs.” Alison believes that this is the best way to rehabilitate anyone after

a catastrophic injury. “It’s the case manager’s role to liaise with different stakeholders,” she says. “Without them pulling the different strands together, things would be fragmented.” A client-focused service to meet rehabilitation goals A case manager’s day is varied, but may include agreeing goals w it h c l ient s, rev iew i n g c a re teams, liaising with rehab therapists, organising carer training and making sure that adaptive equipment is functioning properly. I n t he b e s t s c en a r io s, c a s e managers will work with a fairly small group of clients: approximately four to six. “That way, they know their clients and their families inside out, so that when things aren’t going so well, case managers can take the lead in finding a solution,” says Alison. There are two key elements to creating a good case management service, says Alison. The first is making sure it is always client-fo-

cused (“Clients need to be at the centre of everything”). The second is expertise: “Case managers must be experienced hea lt hca re professiona ls,” she insists. “They must have the right skillset to cope with the challenges of working with people whose lives have been irrevocably changed by catastrophic injury.” Yet, to Ellis, Janine is more than just a case manager. “We can talk about anything,” he says. On their working relationship Janine reports: “I am never surprised by anything Ellis does but I am, on occasions, absolutely thrilled with what he’s achieved and some of the things he wants to do.” Thanks to his growing sense of independence and confidence, Ellis is currently organising a city break. “I’m in the process of planning a weekend away in London to watch England and New Zealand then be there for Remembrance Sunday,” he says. “I’d like to thank Janine and my carers for getting me to this stage.”

INTERVIEW WITH:

ALISON BARKER Managing Director, Independent Living Solutions Ltd WRITTEN BY: TONY GREENWAY

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Would you have your knee replacement surgery carried out by a robot?

THIS ARTICLE REPRESENTS SOLELY THE EXPERT VIEWS OF THE CONTRIBUTORS

KAREN PRINS Chief Executive Officer, BMI Healthcare

Would you have your knee replacement surgery carried out by a robot? Thousands of people have done so over the last few years, and now patients at BMI The Clementine Churchill Hospital in West London, BMI The Alexandra Hospital near Manchester and BMI Werndale Hospital in Carmarthen can too.

he t h re e hospit a l s have robotic-assisted systems, which are designed to make the surgery more precise, resulting in less impact on soft surrounding tissues of the knee and a straight-forward recovery. “The use of robots in surgery is not new, so patients can feel reassured that the use of them in surgery has been tested thoroughly,” says BMI’s Chief Executive Dr Karen Prins. “The availability of robotic-assisted surgery gives patients the option for a bespoke operation.” 3D modelling to ensure a precise fit The robot uses 3D modelling to assess the extent of diseased bone and surface mapping to capture the patient’s individual joint profile. A tracking mechanism turns off the system if the surgeon attempts to remove healthy bone during the operation, ensuring that only diseased bone is removed prior to being replaced with the desired implant.

Consultant Orthopaedic Surgeon, M r Wi n ston K i m, of BM I The A lexandra Hospital, said: “ The robotic assisted procedure allows for a more precise and accurate knee replacement implant, tailored to the patient’s anatomy and alignment. In comparison to traditional methods, the system has the potential to increase the likelihood of a more natural-feeling knee after surgery.” Research shows reduced pain after robotic-assisted surgery Research studies indicate that total joint arthroplasties performed under robotic-assisted surgery are associated with reduced pain, improved recovery and reduced length of hospital stay compared with conventional job-based operations.

Read more at healthawareness.co.uk

The robotic revolution in knee replacement surgery A Q&A with leading surgeon: Robotic-assisted knee replacement operations could be a game-changer for patients, improving accuracy and shortening recovery times. INTERVIEW WITH:

MR WINSTON KIM, FRCS (ORTH)

Consultant Orthopaedic Surgeon, Specialist in Knee and Hip Surgery, BMI The Alexandra Hospital

r Winston Kim, Consultant Orthopaedic Surgeon, performed the first robotic-assisted knee replacement and partial knee replacement in the north of England, and has

Experience the freedom

the largest series in the NorthWest. His patients include former professional footballer and CEO of the Professional Footballers’ Association, Gordon Taylor. What are the benefits of robotic-assisted knee surgery? “Quite rightly, knee replacement patients want and expect their new knees to feel as natural as possible. Unfortunately, knee replacement surgery – unlike hip replacement surgery – has a patient dissatisfaction rate associated with it, and it’s usually because the new knee has not been implanted in exactly the right position. “The knee is a sophisticated joint and there isn’t a ‘one replacement fits all’ solution. Everyone has a

different shaped knee with different soft tissue tension – and so, in a conventional operation, a surgeon must use a certain amount of judgement when positioning an implant. Get it slightly out of alignment and the results can feel a bit stiff. “This is why some people say robotic-assisted knee surgery is a game-changer. The benefit is that it implants the knee replacement in exactly the right alignment and position, every time. In essence, it offers a bespoke implantation technique to individual patients.” Is robotic-assisted surgery also available to patients who only need a partial knee replacement? “Yes. One of the other benefits of robotic-assisted surgery is that

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Robotic knee surgery: better, faster results for patients Patients who have robotic-assisted knee surgery can expect better experiences before, during and after their operation. The technology may even allow them to be treated as day cases in the future. INTERVIEW WITH:

surgeons who would always opt to perform a full knee replacement – simply because they do them more frequently – are given the confidence to perform a partial knee replacement instead. Obviously, the advantage of a partial replacement for the patient is that only the affected part of the knee is replaced, preserving most of the knee joint. That means a smaller incision, less cut muscle, less blood loss, and consequently less pain, quicker recovery, quicker return to day-today function and return to work.” Are there any pre-op requirements for patients undergoing robotic-assisted knee surgery? “Standard X-rays are the starting point, but no further imaging is necessary because the system maps the patient’s anatomy at the start of surgery. No CT scans means no radiation. “During surgery, pins will be put into the patient’s shin bone and thigh bone – and these pins have sensors on them which communicate with the robot. This is partly why robotic-assisted surgery takes

about 20-30 minutes longer than conventional surgery.”

refined over time with constant innovation and improvement.”

What can patients expect with regards to recovery times? “A f ter a ny k ne e re pl ac ement surgery, there will be a recovery period, which can vary from three to six months to two years. With robotic-assisted knee surgery, we’ve seen remarkable, pain-free outcomes with very quick recovery times. Gordon Taylor, the professional footballer, had his knee replaced using this technology. His wife had it done, too, and both were very happy with it.”

What do you hope robotic-assisted knee surgery will ultimately achieve? “If you’ve had a robotic-assisted knee replacement, you can be confident t h at yo u r s u r g e r y w a s f u l l y optimised – and you have real-time evidence that your replacement knee was implanted accurately. “People are reassured by this technology and it allows patients to focus on the necessary rehabilitation after surgery. That’s key because, as surgeons, we need to perform knee replacements that meet the expectations and requirements of today’s patients who want the best possible function, in as short a time as possible.”

How long has this type of technology been available? “For around five years. From the surgeon’s point of view, the technology does cost more but, because the knee is implanted more precisely and the patient is happier with the final result, the risks of revision surgery (repeat surgery) will potentially be lower and the long-term savings will be greater. And, of course, robotic-assisted surgery technology will become further

WRITTEN BY: TONY GREENWAY

Read more at healthawareness.co.uk

MR MATTHEW BARTLETT Consultant Orthopaedic Surgeon, London North West University Healthcare NHS Trust and Clementine Churchill Hospital “I rarely perform knee replacement surgery without robotic assistance these days,” says Mr Matthew Bartlett, Consultant Orthopaedic Surgeon at London North West University Healthcare NHS Trust and BMI The Clementine Churchill Hospital. “I tell patients that I prefer robotic-assisted surgery because of the increased accuracy it affords,” he says. He explains that with conventional surgery, a rod is inserted t h r o u g h t h e fe mu r t o g u id e alignment. This is not necessary in robotic-assisted operations, which makes them less invasive and gives better control of bleeding. Mr Bartlett and his team have been using robotics for over a year.

He believes knee surgery patients are recuperating faster and mobilising more quickly as a result. “We’re working towards decreasing the length of post-operative in-patient stay,” he says. “In America, knee patients can be treated as day cases with use of robotics. That’s our ambition, too, eventually.” Quicker mobility for patients Most patients are positive and relaxed about use of robotics in surgery, explains Mr Bartlett, “particularly when they are reassured that it’s just a tool I use to perform the operation.” After all, if technology can improve the patient experience then it makes complete sense to use it. “As surgeons we can’t rest on our laurels,” says Mr Bartlett. “My view is that unless I’m constantly advancing then I’m failing in my responsibility to my patients. Once we get to the point where there are no complications and 100% of patients are completely satisfied with their knee surgery, then maybe we can take a step back. I don’t think we’ll ever get to that point — but we have to keep trying.” WRITTEN BY: TONY GREENWAY Read more at healthawareness.co.uk

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Access to rehabilitation services for all WRITTEN BY: CHRIS BRYANT MP & Chair, All-Party Parliamentary Group on Acquired Brain Injury

All-Party Parliamentary Group on Acquired Brain Injury launch report on acquired brain injury and neurorehabilitation. “Acquired brain injury is a hidden epidemic. We are saving more lives but we need to ensure that everyone gets the neurorehabilitation support they need to live as full a life as possible,” says Chris Bryant MP and Chair of the All-Party Parliamentary Group on Acquired Brain Injury (APPG on ABI) speaking at the launch of a report ‘Time for Change: Acquired Brain Injury and Neurorehabilitation’. There are more than 1.3 million people living with the effects of brain injury at a cost to the UK economy of £15 billion per annum or 10% of the National Health Service (NHS) budget. The excellent advances in emergency and acute medicine mean that many more children, young people and adults now survive with an ABI, however, many of these individuals require early and continued neurorehabilitation to optimise all aspects of their physical, cognitive, behavioural and psychosocial recovery, and to maximise their long-term potential. All too often, they don’t get it. Neurorehabilitation is one of the most cost-effective interventions available on the NHS, but there are large variations in the provision and access to neurorehabilitation services across the UK. The report outlines the critical role of neurorehabilitation in the ABI care pathway, and the need for rehabilitation prescriptions for all brain injury survivors following discharge from acute care so they know what neurorehabilitation they need. The report reviews the implications for children and young people with ABI when most of their neurorehabilitation takes place in the education system. The high incidence of ABI among offenders is discussed, as is the impact of neurorehabilitation on behavioural change and reoffending. The current issues in sport-related concussion are outlined as well as the need for an improved welfare system that is easily accessible. The report summarises the key issues and makes several recommendations. Chris Bryant concludes: “ABI affects nearly every government department so a coordinating task force is required to address the issues and recommendations as a matter of urgency. The APPG on ABI intends to unite all the departments involved in order to drive change for brain injury survivors”. Read more at healthawareness.co.uk

Rehabilitation ﬁnding a voice WRITTEN BY: DR ANDREW BATEMAN Chair, United Kingdom Acquired Brain Injury Forum

After a brain injury, rehabilitation requires collaboration between a team of specialists who can implement a bespoke prescription for that person.

ehabilitation has an image problem. Among the general public it is not well understood and when asked “what does rehabilitation mean to you?”, I wonder what idea springs to mind. For most of the general public, ‘rehab’ is a thing for people overcoming a drug or alcohol addiction, but the term rehabilitation covers a far broader spectrum. Yet the teams implementing the multiple strands within rehabilitation are often invisible despite their very patient and skilled work. Making rehabilitation visible A life-changing event such as a traumatic head injury can result in many interacting problems. Often we meet brain injury survivors who appear to ‘look fine’ but the difficulties they are experiencing are not visible: altered emotions, communication skills and thinking skills, strained relationships, loss of employment and many more challenges. The almost invisible work in the background of these scenarios involves identifying and working with these – almost invisible – problems. The team of rehabilitation doctors, psychiatrists, psychologists, speech and language therapists, occupational therapists and physiotherapists must devise plans that grasp the interactions between the problems. And this work requires more than a quick check-up. Rehabilitating after a brain injury Brain injury doesn’t dramatically

alter the life expectancy of an individual, so survivors may be left with residual impairments for a long time. One of t he most overlooke d aspects of rehabilitation is that w h ic h s u p p o r t s p e o p l e w it h long-term conditions and disabilities to manage their health and wellbeing in the longer-term. Professionals providing rehabilitation are found in a wide number of health and social care settings. This workforce is multi-disciplinary and across sectors. They may be working to provide ‘prehab’ (prepare for treatment), offering rehab at an early stage after a brain injury to prevent conditions escalating, or later, providing rehabilitation that helps people re-gain function and independence. Sometimes, rehabilitation is described as ‘slow-stream’ because the progress made takes months or years. Who has the right to rehabilitation? Wh ic hever s c en a r io, t here i s strong evidence that rehabilitation is cost-effective and beneficial for people after brain injury. Survivors, however, are not always clear that they have a right to rehabilitation and across the UK there is inconsistency in the rehabilitation services available. This is compounded by a lack of information about the services, with no one place or directory for such information. One of the many ways that this problem can be solved is through

spreading the idea of rehabilitation prescription. If doctors use the language of rehab presc r ipt ion w it h t hei r patients, as they come home to the community holding a rehabilitation plan, then they can hold their local MPs and community health service providers to account if the prescribed treatments are not available. We may yet need a pile of unfulfilled prescriptions to identify the inequalities and missing services. Rehabilitation is gaining traction in government Rehabilitation professionals and brain injury survivors requiring their help in the UK at least have cause for optimism. In the last year or so, the All Party Parliamentary Group has been chaired by MP Chris Bryant (Rhondda). He has taken these issues into debates, engaged with ministers from all departments of government, and explained the economic benefits of paying attention to the need for rehabilitation. Char it ies, such as Un ited Kingdom Acquired Brain Injury Forum, the Society for Research in Rehabilitation and the British Society of Rehabilitation Meeting, will be holding conferences this aut u m n where cl i n ic ia n s a nd academics will be engaging with this image problem.

Read more at healthawareness.co.uk

Expert neuro rehabilitation and specialist care Supporting people with acquired and complex disabilities to maximise their independence. Our state-of-the-art centre opens in Spring 2020 with accessible technology in a homely environment.

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Different health service providers are working together to transform the lives of patients with acquired brain injuries and progressive neurological conditions.

ichelle Montrose knows the power of collaborative working in rehabilitative care settings. When different clinicians and therapists pull together, she says, it can transform patients’ lives. Mont ro s e i s t he Reg i s tere d Manager at Priory Oak Vale Gardens, a Liverpool-based centre providing extended inpatient rehabilitation care for people with an acquired brain injury or complex and progressive neurological conditions. “We work collaboratively in two different ways,” she explains. “First of all, we’re part of the Cheshire and Merseyside Rehabilitation Network, work ing w ith N HS tr usts and hospitals to provide a pathway of care for people who require active and specialist rehabilitation at various stages of acuity. Secondly, there’s the internal collaboration that goes on within our own unit, so that everyone who works here is involved in some element of a person’s rehabilitation journey.”

Taking a person-centred approach That mea n s ever y memb er of staff has their part to play. “It includes everyone from our experienced nurses to the person who does the laundry, to our chef who works closely with our speech and language therapists to provide the right type of meals for individual patients,” says Montrose. “A s a c ent re, we a l s o work closely with a number of specialist community clinicians, such as a diabetic specialist nurse and podiatrists.” Rehabilitation isn’t a onesize-fits-all process (“What might work for one patient might not work for another,” says Montrose), so this person-centred care approach isn’t just preferable. It’s vital. Collaboration also ensures continuity of care, which benefits the patient’s family. “It means family members can receive advice and support about the next stage of their

loved one’s rehabilitation journey, and have confidence that healthcare professionals are making the best decisions for the patient,” explains Montrose. And, of course, this seamless way of working is also helpful to staff. “When a patient is referred to us from another service, good communication and information sharing ensures the handover goes smoothly,” says Montrose. “Plus, it allows staff in both locations to have back and forth conversations to share information and learnings.” Making a real difference to patient recovery Montrose has seen the positive results of collaborative working with her own eyes. She mentions one patient who, after a severe brain injury, was admitted to Oak Vale Gardens in a state of low awareness. On the occasions when they were more alert, they weren’t able to understand where they were or why they were being provided

with personal care. They weren’t eating either, and the team struggled to make any kind of breakthrough. H o we ve r, p e r s i s t e n c e a n d , crucially, teamwork, paid off, says Montrose. “The consultant liaised closely with our nursing team and local GP practice, our therapists from different disciplines worked together, and com m issioners gave t heir support by funding specialist neuromusic therapy. As a result of these actions, the patient’s life was turned around. In fact, we’re now working with community services and planning for this person to go home. Yes, they will always need 24-hour care — but they are eating, drinking and responding to people in a way that was unimaginable before. That’s incredibly gratifying.” WRITTEN BY: TONY GREENWAY

INTERVIEW WITH:

MICHELLE MONTROSE Registered Manager, Oak Vale Gardens

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Exercises can reduce your risk of falls and injury in later life

WRITTEN BY: CHRISTOPHER TUCKETT Chartered Physiotherapist

Chartered physiotherapists say these six simple daily exercises will strengthen your muscles and improve your coordination and balance.

hile most people understand that they need to do exercise to remain fit and healthy, this exercise normally takes the form of aerobic exercise (such as walking or swimming), many people are seemingly unaware that they should also be doing regular ‘resistance’ exercise to strengthen their muscles, and balance challenges to improve their balance. In fact, the UK Chief Medical Officers’ physical-activity guidelines recommend that older adults should undertake activities to improve their muscle strength and balance on at least two days a week. But what does resistance exercise entail? What is a balance challenge? And why are they important? It’s critically important because many activities of daily living (such as getting dressed or rising from a chair) require both balance and strength to be completed easily and safely. Thankfully, many types of daily activities can have a positive impact on muscle and balance outcomes. While it’s impossible to list them all, a simple rule of thumb is – if the activity or exercise requires you to exert effort against a resistance then it is likely to be helping to strengthen your muscles (e.g. carrying heavy shopping). The key is making this a regular, sustained and gradually progressive process, which is where exercise can be more beneficial.

Six exercises for older adults to try

These six simple daily exercises from the Chartered Society of Physiotherapy will help to strengthen your muscles and improve your coordination and balance – and all you need is a chair.

1. Heel raises: stand tall, holding the back of a sturdy kitchen-type chair or kitchen sink, then lift your heels off the floor, taking your weight onto your big toes. Hold for three seconds, then lower with control. Repeat 10 times.

2. Toe raises: stand tall holding the same support, then raise your toes – taking your weight on your heels. Don’t stick your bottom out. Hold for three seconds, then lower with control. Repeat 10 times. 3. Sit to stand: sit tall near the front of a chair with your feet slightly

back. Lean forwards slightly and stand up (with hands on the chair if needed). Step back until your legs touch the chair then slowly lower yourself back into the chair. Repeat 10 times.

4. Heel-toe stand: stand tall, with one hand on your support. Put

one foot directly in front of the other to make a straight line. Look ahead, take your hand off the support and balance for 10 seconds. Take the front foot back to hip width apart. Then place the other foot in front and balance for 10 seconds.

5. Heel-toe walking: stand tall, with one hand on a support like a

kitchen cabinet. Look ahead and walk 10 steps forwards, placing one foot directly in front of the other so that the feet form a straight line. Aim for a steady walking action. Take the feet back to hip width apart, turn around and repeat the steps in the other direction.

6. One-leg stand: stand close to your support and hold it with one hand. Balance on one leg, keeping the support knee soft and your posture upright. Hold the position for 10 seconds. Repeat on the other leg.

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Taking the lead WRITTEN BY: RUTH TEN HOVE Assistant Director, Chartered Society of Physiotherapy

The provision of effective, community-based rehabilitation services must be a huge priority for UK healthcare providers, and physiotherapy is key to their success.

e’re living and working in a changing world, where people are living longer, but are not necessarily fitter and healthier. In our ageing population, the prevalence of long-term conditions and – in particular – of people living with more than one long-term condition, is contributing to the demand for a change in the way healthcare services are delivered. Self-management and at-home rehabilitation More ser v ices w il l need to be delivered closer to people’s homes. This is because there is an increasingly important role for prevention and self-management to empower people to take personal responsibility for their health; furthermore, there is a wider role for digital technology and innovation in shaping the future delivery of healthcare. The N H S Engla nd long-ter m plan makes a real commitment to improving rehabilitation services. Over the next 10 years, a far greater proportion of NHS resource will be directed to support people with recovery and rehabilitation, and into services that meet people’s needs outside of hospital and in their own homes. In England, £4.5 billion is promised for primary and community health services and there

are similar policy commitments in the rest of the UK. What action is the Chartered Society of Physiotherapy taking? Within this context, the Chartered Society of Physiotherapy has started working with members of the profession and key stakeholder organisations to ensure that money is spent on better rehab. We have, and will continue to have, an increasing demand on our rehab services. This is not just about the older population living longer, but also enabling people of working age with long-term conditions to live fulfilling lives. There is an opportunity for us to take stock of what is working well (lots is!) and to influence how rehab services could be delivered for the future. What is the ideal rehab situation? We know what excellent rehab looks like: a full assessment that looks at all your health and care needs. It will support you to establish personalised ambitious goals, which are backed up with an appropriate and funded plan that makes a difference to an individual’s quality of life. And empowering people to take responsibility for their own health

and continue their rehab using local amenities (social prescribing). We also know, from our national work on hip fracture, the importance of being able to provide continuity of rehab across the pathway, being of the appropriate intensity and frequency to achieve individualised goals. It is time to think differently about how we approach rehab. In particular, how we meet the needs of the population who are living with a number of conditions. These will include: • building effective and sustainable hip fracture networks, charged with raising quality across the whole hip fracture pathway; • working with others to improve access to pulmonary rehab services; • gaining consensus across the profession in the development of community rehab standards; • working with NHS England primary care networks to ensure inclusion of community rehab. Read more at healthawareness.co.uk

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Prescribing exercise - the crucial WRITTEN BY: STEVEN ASPINALL healthcare Chief Executive, British Association of Sport tool Rehabilitators and Trainers (BASRaT) The cost of physical activity to the UK is £7.4 billion and, in the time it takes Usain Bolt to run 100m, the NHS has spent £10k on treating preventable chronic diseases. These hard hitting stats can be counteracted by exercise; so, how we can encourage people to move more?

xercise has many benefits: it can reduce the risk of major illnesses and chronic diseases and can help lead to a healthier and even happier life. Physical activity can boost self-esteem, mood, sleep quality and energy, as well as reducing the risk of stress, depression, dementia, heart disease, stroke, diabetes and some cancers. Sport rehabilitators are specialists in exercise prescription and treat musculoskeletal disorders and conditions such as cardiovascular disease, respiratory illnesses, diabetes and obesity. By helping patients become more active, sports rehabilitators can play a key role in reducing the impact of musculoskeletal conditions and physical inactivity. The wonder drug Exercise is cheap, has huge benefits and minimal side-effects. It really is a ‘wonder drug’ and has even been called a ‘miracle cure’. Age is irrelevant; benefits from physical activity can be gained at any age. Getting people moving through simple messaging Terms like ‘exercise’ or ‘sport’ can have a negative effect on uptake. We need to focus on getting people moving, encouraging people to start small and gradually increase what they do. Guidance recommends 150 minutes of moderate exercise per week. In real terms, this is merely 20 minutes of brisk walking a day. Swapping 20 minutes of TV for a quick walk is achievable. The easiest way to get moving is to make activity part of everyday life, like walking or cycling instead of using the car. Muscle strengthening activities Guidance also recommends: “8–12 repetitions of muscle strengthening activities involving all major muscle groups, twice a week”. Without context, most people may be bewildered by this, but this can be achieved through heavy gardening, climbing stairs, hill walking, cycling, dancing, yoga and push-ups, sit-ups and squats. Moderate and vigorous activity Simply put, it is important to raise your heart rate, breathe faster and feel warmer. At moderate intensity you can talk but you can’t sing. Vigorousintensity activity requires working even harder and can bring further health benefits. You should be breathing hard and fast, and your heart rate will have gone up quite a bit. How to ﬁt exercise into busy lives • During a commute, walk part of the journey, avoid lifts and take the stairs. • At lunch, power walk during lunch – you’ll be more alert afterwards. • At weekends, gardening and cleaning can give an effective work out. Walk to the shop and carry groceries, clean the car and walk the dog. • Get into the habit of parking at the far end of the car park and walking to the entrance. What does the future hold if we want to reduce NHS costs and encourage exercise? This progress will require physical activity expertise in every GP surgery. Why not prescribe exercise at every meeting? Of course, there are circumstances when exercise might not be best advised. Further reading at ReachMyGoal.org has advice and ideas for exercising, including a flowchart to check whether it is OK to exercise.

Who makes up the team for musculoskeletal rehabilitation? WRITTEN BY: DR ROBIN CHATTERJEE, Secretary, British Association of Sport and Exercise Medicine (BASEM)

Rehabilitating a musculoskeletal (MSK) problem is a complex issue; an individualised programme involving several stages, and several healthcare professionals is needed.

istorically the term ‘rehabilitation’ originates from the Latin ‘Re’, which means ‘again’ and ‘habitare’, which means ‘make fit’. What does musculoskeletal rehabilitation have an effect on? Musculoskeletal rehabilitation is the process by which clinicians are able to help individuals who have muscle, bone, joint, tendon or ligament problems return to their previous levels of physical fitness, improve symptoms, increase self-worth, reduce pain and optimise functional ability and independence. This may also involve improving the quality of their psychological, emotional or social life as these factors often have a symbiotic relationship with the state of one’s physical health. MSK disorders that may benefit from rehabilitation can be broadly categorised into rheumatological problems (such as arthritis), non-surgical MSK issues (such as back, knee or hip problems that cannot be operated on), MSK pain of unknown cause, post-operative orthopaedic patients, sporting injuries and amputees. What must be considered for MSK rehabilitation? Rehabilitating an MSK problem is a complex issue; an individualised programme involving several healthcare professionals is needed. Patients are initially assessed for their baseline levels of physical activity, mental health, and wellbeing and also their degree of motivation to

make lifestyle changes. Modifiable personal lifestyle factors, which can affect the ability to be active, are also addressed in addition to prescription of exercise. These are sleep, nutrition (including hydration levels), posture, and emotional and mental well being. The multi-disciplinary rehabilitation team A co-ordinated, integrated multi-disciplinary approach is required to give the patient the best chance to return to their previous physical state. Me m b e r s of t h i s te a m c a n comprise of some or all of the fol low i ng: spor t a nd exerc i se medicine doctor, rehabilitation doctor, orthopaedic surgeon, physiotherapist, occupational therapist, exercise physiologist, nutritionist, dietician, podiatrist, psychologist, psychiatrist, prosthetist. What physical therapy is involved? This part of the rehabilitation process is mainly led by physiotherapists. It follows many of the same principles of training. Training deals with strengthening normal tissues. Rehabilitation involves strengthening injured tissue. Physical rehabilitation can be divided into early, intermediate and late stage where the aims of rehab are to protect the injured area and manage pain in the early stage, address strength and proprioception in the intermediate phase and improve agility, coordination and endurance in the late stage. Physical therapy can sometimes include the fitting of casts, braces,

orthotics (splints) or prosthetics (artificial limbs). Exercise prescription Exercise prescription is designed to act as an adjunct to the standard pharmacological management that the patient is already receiving. The overarching aim is to reduce some medications, if possible, and use a holistic approach to improve overall morbidity. The objective is to integrate purposeful movement into the daily schedule of the individual. The importance of nutrition, sleep, mental and emotional well being Many people have MSK pain of unknown cause where all tests, investigations and scans are normal. These are often the trickiest patients to rehabilitate. In these cases, the individual has to be assessed holistically. A patient-centred approach is taken where the whole patient, and not just a single body part, is assessed. Changes to diet, the ergonomics of their workplace, footwear, stress, or other such factors may instigate a significant change in a person’s physical self, consequently alleviating their MSK pain. To summarise, MSK rehabilitation is more than just addressing the affected body part. It is treating the whole individual and is a complex process that involves many specialist clinicians working together in a structured and integrated manner. Read more at healthawareness.co.uk

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Rheumatoid arthritis treating the effects and not just the disease WRITTEN BY: WENDY HOLDEN Medical Advisor and Consultant Rheumatologist, Arthritis Action

Self-managing arthritis involves learning methods to help manage both the physical and mental symptoms of the condition. As arthritis affects everyone in a different way, self-management means that individuals can choose the strategies that best suit their needs.

anaging weight, sensible use of pain-killing medicines, gentle exercise, and therapies to help with the mind, sleep or pain-related worries are some techniques that can help with arthritis-related symptoms. Weight management For every extra pound over a healthy weight, it is thought that an extra five pounds goes straight through the weight-bearing joints, especially the knees, hips and ankles. This means joints are carrying an extra five stones in weight if someone is one stone overweight (or the weight of a very heavy rucksack!) and this can clearly make joint pain worse. The good news is – just losing 10% can make a huge difference, in improving pain and mobility. Staying active Staying active is essential, as lack of exercise leads to weaker muscles, which are then less able to support the joints, leading to pain and instability. Simple exercises to improve muscle strength can be as effective for pain as prescription painkillers. These exercises can also help improve balance and function, keeping people independent and sometimes delaying the need for surgery for much longer. If someone is new to exercise, it is important to slowly increase the level to avoid initial pain, so setting realistic and achievable goals is vital. An ideal plan should include aerobic exercise to improve cardiovascular fitness, resistance exercise to improve muscle strength, and flexibility exercises to maintain suppleness. Medication, including painkillers and anti-inﬂammatory drugs Medicines unfortunately can’t cure arthritis but using painkillers and sometimes antiinflammatory medicines sensibly can often make symptoms more bearable. Joint injections can also sometimes help. Try using painkillers before rather than after any form of physical activity, for the best effects. Anti-inflammatory medicines should ideally be used at the lowest possible dose, for the shortest time to avoid harmful side-effects. Stay positive; sometimes the pain disappears entirely The pain of arthritis can make people feel low or depressed, especially if it is difficult to perform usual activities or keep up with family or friends. The good news is that arthritis pain often comes and goes, sometimes even going

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completely. Staying positive on a bad day by knowing that the pain will settle, and simple pain-management techniques including relaxation, distraction and counting blessings can really help. Living with arthritis does not have to mean progressive pain and disability. Selfmanagement can help with both the physical and mental impact of arthritis and can help people continue to live an independent, active and fulfilling life. A patient perspective: “I concentrate on staying active” Jen n ifer Devonshire, 32 , is a Member of A r t h r it is Act ion w it h Seronegat ive Rheumatoid Arthritis. “I have found my local rheumatology department only really have time and capacity to treat the disease and not its effects on my body, so self-management is vital for me. “I concentrate on staying active, doing focused exercises recommended by my physiotherapist and podiatrist to target the muscles supporting my joints without putting pressure on them, as well as swimming, which moves my whole body while supporting the joints. “It can be difficult to find what works best when my joints are swollen but I have a collection of very gentle things I can do even on the worst days. “I also take supplements such a vitamin D, calcium, and omega 3 oils to help bones and joints as well as overall health. I try to stay tuned in to how my diet affects my pain levels and eat anti-inflammatory foods like fresh fruit and vegetables, rather than too much processed food.”

Arthritis Action’s online self management resource Arthritis Action recently launched the UK’s first online self-management resource, consisting of 20 videos by health experts, covering the main aspects of living w ith arthritis, including exercise, diet, complementary therapy and other suggestions. The resource can be found here: arthritisaction.org.uk/onlinesme Read more at healthawareness.co.uk

Fitting the goal to the person, not the person to the goal WRITTEN BY: JANET SCHMITT, Director of Care and Therapy, Queen Elizabeth’s Foundation for Disabled People (QEF)

If a person’s strongest desire is to be able to play with their children on the floor, then demonstrating how therapy can work towards achieving this will tap into their motivation to develop their abilities.”

anet Schmitt has over twenty years’ experience of neuro rehabilitation and is passionate about helping each person to be themselves again after a stroke, brain injury or neurological illness. Every person is different and it’s this individuality that needs to be at the heart of neuro rehabilitation. Good neuro rehabilitation isn’t done to someone, it’s achieved by the person themselves. It is important to frame therapy in the context of how it will help to achieve someone’s goals, not clinical targets. If a person’s strongest desire is to be able to play with their children on the floor, then demonstrating how therapy can work towards achieving this will tap into their motivation to develop their abilities. Building on personal motivations and being as inventive as possible enables people to increasingly be themselves. Being unrealistic is OK It can be easy for clinicians or families to fall into the trap of thinking someone is being unrealistic with their dreams. But, our hopes and dreams are what get us going and motivate us to achieve something different. Naturally this varies for each person and we have a limited time frame and funding restrictions to work within, so we need to hone therapy into what will have the most impact for that person in their life. Person centred care involves everyone Every decision, internal process and expectations of every employee needs to revolve around what helps an individual get back to being themselves. We all find different people we click with, so chefs, care assistants, porters, housekeepers (as well as therapists) are all equally important to finding out what someone’s interests are and what makes them laugh. Look beyond our walls A poor environment can limit a person’s aspirations. If something can only be achieved in one place, what happens when that person is ready to move on? We must look beyond our walls and create an environment where people can safely push the boundaries of their abilities, in a way that’s also relevant to each person’s real world.

Good neuro rehabilitation isn’t done to someone, it’s achieved by the person themselves.” Assistive technology offers greater dignity Readily available and emerging technology can offer greater control over personal space. If a person decides they are ready for bed, for example, using a pre-programmed voice command to close their blinds, turn off the TV and switch off the lights, stops them having to wait for help. These might appear to be small actions but being able to control them yourself creates dignity and builds a sense of self determination.

About QEF (Queen Elizabeth Foundation for Disabled People) The team at QEF have worked hard to develop a bespoke, state-of-the-art centre that puts person centred care at the heart of our neuro rehabilitation and specialist care service. This has led to the creation of adaptable therapy areas that can be tailored to each person’s needs and an emphasis on social and personal space, both inside and outside. There will also be readily available, voice or switch activated technology in every bedroom, so each person has a greater sense of personal control, which they can continue to use beyond our service. Often, families feel that QEF has given back their dad/mum/husband/daughter there can be no real greater feedback for a rehabilitation service than that! Find out more at: qef.org.uk/CRCappeal

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