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Rehabilitation Teaching & Research Unit News
Collaboration | Innovation | Education | Evidence| Excellence

Rehabilitation and risk

When I teach medical students about giving advice to patients about returning to usual activities, I tell them to think about 2 related but distinct key concepts. The first key concept is whether the patient is actually able to perform the usual activity. This involves the assessment of function, and the ICF provides a really useful framework for what function is (but doesn’t tell us how to go about it). The second key concept is how risky it is for the patient to undertake the usual activity. Risk assessment is tricky. It demands a knowledge of the underlying pathology (rugby players might perform fine after a concussion but the risk of a second ‘hit’ is too much) as well as the ways the risk might be managed.

Management of risk is a common strategy in life as well as in rehabilitation clinical practice. This photo shows Kime Hut in the Tararua’s a couple of days ago. I was up there by myself, which is risky. But I (and my family) are reasonably happy with the management of that risk – well-equipped with warm gear, personal locator beacon, GPS, and an attitude to bail out when things turn dodgy (especially weather). Tragically, people die in this place, just 5 or 6 hours walk from civilisation. Kime Hut, itself is named after a tramper who died from hypothermia after being rescued and warmed too quickly.

Perception of risk is another interesting issue. The chances of death from driving in a car in the next year is 1 in 17,000 (2002) yet I encourage my teenage son to learn to drive. What are the risks of harm for a person living alone who needs assistance to get out of bed and into their motorised wheelchair? The overall risk of dying in a house fire in the next year are 1 in 90,000 (about 5 times less likely than dying in a car crash). There is a strong connection between autonomy and risk-taking so that the disability community can sometimes advocate for ‘the right to take risks’. If you are interested in reading more about this, take a look at this report from the Joseph Rowntree Foundation.

EULAR Congress Report

At the top of some mountain or other.

I was in Madrid in June for the European League against Rheumatism (EULAR) annual congress. This is the major European conference for rheumatology. Apart from the extreme heat, the major highlights were chairing a meeting of gout experts which helped arrive at some consensus decisions around gout terminology and listening to a presentation from Nottingham, UK that described a randomised controlled trial of nurse-led care for people with gout compared to usual care from their general practitioner. People who received nurse-led care did much better, in terms of gout control and medication use, reinforcing the benefits of structured education and frequent support and monitoring. In addition, I took advantage of the weather and the geographical proximity and went hiking in the Swiss alps between La Sage and Zermatt, covering about 75km in 5 days and about 7000m of climbing up over the passes and down into the valleys. Beautiful views of the Matterhorn and other mountains as well as mountain villages and their postcard perfect chalets.

Self-led management of rheumatoid arthritis

The management of rheumatoid arthritis (RA) has transformed in recent decades so the inflammatory arthritis is often well controlled with medications used in a treat-to-target strategy.  This “T2T” strategy requires measurement of RA disease activity using validated measures and increasing treatment until disease remission or at least a low disease activity state is achieved.  Currently the RA activity is determined during clinic visits however these are currently at arbitrary intervals so people are may be seen when they are well and appointments are not always available when people have increased arthritis activity and need medical help.  Some data suggest the assessment of RA activity by people with RA correlates fairly well with the assessment of disease activity by health professionals. RTRU academic, Dr Rebecca Grainger, has begun to explore the possibility of the assessment and monitoring of RA being led by the person with the disease rather than the health system.  In this new tech world, a phone app seem to be a good option to try.  Dr Grainger, in collaboration with her colleagues in RTRU, Hutt Hospital, and the Department of Information Science at University of Otago, first conducted a systematic review of all apps that could enable measurement of RA disease activity by people with RA and for those data to be transmitted to their rheumatology team for monitoring.  (This review can be downloaded for free here.)  They found the 19 potentially useable app for longitudinal assessment of disease activity,which fell into two categories: 1) simple calculators of disease activity or 2) data tracking tools for people with RA.  However, no apps used all the required validated instruments and allowed for data transmission. One high quality app “Arthritis Power” does a great job of longitudinal tracking of validated patient-reported outcomes (PRO’s) and is used for patient-led research but is not suitable for use in “telerheumatology” due to lack of measurement of tender and swollen joints, a key feature of RA activity measured by rheumatologists.

Next steps in this research has been to  involve people with RA and rheumatology health professionals to identify required features and functionality of an app for RA disease activity measurement, along with barriers to uptake and advantages of remote monitoring approach.  With this information, Dr Grainger’s team has built an app and currently planning how this may be integrated into clinical practice.  In parallel with this with, they have also co-designed with people with RA a training package of videos to teach joint count techniques.  This will be evaluated in clinics in Wellington, Christchurch and Dunedin in late 2017. Their goal is to enable people with RA to engage in their health care in ways that works for them while still providing appropriate assessment and oversight.  Not necessarily “self-management” but “self-led management:”.

How to write a discussion chapter

We created a new YouTube channel just for RTRU!  Here’s my first ever video for our new channel, which is on the topic of how to write a discussion chapter or section in a Masters or PhD thesis or for a publication in an academic journal.

 

Taking charge of chronic lung disease

Just this month, my colleagues and I were award a significant research grant from the Health Research Council of New Zealand to undertake a feasibility study to test a brief self-management intervention for people who have been admitted to hospital for problems with chronic obstructive lung disease.  I am undertaking this study with colleagues from the Department of Medicine (Bernadette Jones, Dr Tristram Ingham, and Prof. Mark Weatherall) in collaboration with Dr James Fingleton, a respiratory physician at the Capital & Coast DHB and researcher from the Medical Research Institute of New Zealand.  Also involved are Amanda McNaughton and Harry McNaughton who are currently living overseas.

The purpose of this study is to test a new intervention designed to help people more actively engage in the management of their own health and wellbeing after hopsitalisation for chronic obstructive lung disease (COPD), and to increase uptake of pulmonary rehabilitation – an existing programme of exercise and education that is known to reduce rehospitalisation rates for people with COPD. Every year in NZ there are over 12,000 hospital admissions for COPD, costing $60 million annually. Many of these are for repeat admission.  Our intervention,  if successful, could reduce costs of hospitalisation for COPD as well as improve people health and quality of life with the condition.  The intervention is cultural responsive and strength-based, focusing on empowering people to take charge of their own health rather than just providing them with inhalers, pills, instruction or information.  This research builds on our past work examining uptake of pulmonary rehabilitation in New Zealand, cultural factors influence uptake of pulmonary rehabilitation, and Dr Harry McNaughton past work with Dr Matire Harwood exploring a similar kind of self-management intervention for people with stroke.  We aim to begin work on this 2-year study this month.

A feasibility study, incidentally, is one that focuses on gathering information about the methods for a clinical trial to make sure that the clinical trial is a scientifically valid as possible before you begin.  Fully powered clinical trials are very expensive!  So you don’t want to begin one with question in your mind about whether participants will actually engage with your intervention or whether your assumption about your outcome measurements tool are correct.  In this feasibility study we will be testing our study methods, gathering information about clinical outcomes to inform a power calculation for a full clinical trial, and evaluate the acceptability of our intervention and study methods from the perspective of our study participants and their families.

Riding for wellbeing

RTRU PhD candidate, Rachelle Martin, attended the New Zealand Riding for the Disabled (NZRDA) national training days (27-28 May 2017) to provide preliminary feedback for her research evaluating the effectiveness of therapeutic horse riding to NZRDA board members, riding coaches and RDA group managers. The programme of study has included three phases of research: two qualitative studies exploring the context and potential mechanisms of effect by which therapeutic horse riding impacts on the health and wellbeing of children with disabilities, and a single-case experimental design study measuring to what extent, and in whom, these effects can be demonstrated. Rachelle is in the final stages of data collection and aims to submit her thesis in January 2018.

Testing the fidelity of occupational performance coaching

RTRU Senior Lecturer Dr Fi Graham is currently leading a project with colleagues Shruti Gadhari & Maryjane Mulcahey from Thomas Jefferson University in Philadelphia to examine how well paediatric rehabilitation therapists adhere to a coaching protocol in everyday practice. This project follows on from Dr Graham’s earlier research into Occupational Performance Coaching (OPC), a goal directed intervention for working with caregivers of people with disabilities. Research has shown that OPC can be effective in helping caregivers to achieve their goals but it’s not clear if trained therapists can or do actually apply the coaching in the way it was intended. Knowing how well and how much an intervention is being applied (generally referred to as intervention fidelity) is really important for us to make sense of research findings, and as a check in our own practice if we are to achieve the same level change reported in research. In this study, therapists are rating their use of coaching on a 20-item checklist after they think they’ve used coaching. They can also ask a peer who has observed their coaching to rate them. In this way, the checklist is intended to guide therapists to self-correct their use of coaching, as well as measure how much coaching was used. Findings from this study will be shared in 2018 through publications, conferences and coaching workshops, as well as featuring in a manual for OPC.