Rehabilitation Matters

Visit to Pace Rehab - An Excellent UK Prosthetic Rehab Centre

Too often I see that we do not give rehabilitation the attention it deserves in the UK.  Most of us have no idea of what such services could or should do for us until we have a personal need.  Even then, when we have the need we do not truly know what is possible.  We trust our clinicians to guide us but what are the beliefs that underly that guidance?  As we recover from amputation, stroke or other condition we are likely to have many years of life ahead of us; we would all prefer these years to deliver a decent quality of life but too often that's not the case. 

The fact is that NHS can't live up to our expectations for rehabilitation - the resources are not there - and increasingly clients who are able will find alternative ways of not only meeting their needs but exceeding their expectations.

Im just back from spending the day with PACE Rehabilitation in Cheadle near Manchester.  Their ethos in delivering prosthetic rehabilitation is about providing benefits to clients rather than just meeting their needs.  There is a vast difference between simply meeting peoples needs and equiping them for a full and happy life.  They work with clients to understand their hopes and dreams and work with them mentally, physically and technically to bring about great results.

PACE was started by an old friend and prosthetist Toby Carlsson along with Consultant in Rehabilitation Medicine, Earnest Van Ross.  They are very passionate about what they do and it shows.  Toby describes the work they do as "a priviledge".

At yesterday's referrers meeting we saw demonstrations and presentations to showcase the work done by PACE.  In addition to hearing from Toby and Earnest, we had presentations from Sue Turner on the counselling and the "buddy scheme" aspects of their work.  Howard Wolley demonstrated prosthetic cast taking and limb alignment whilst physiotherapist Carolyn Hirons involved us all in demonstrations of physiotherapy techniques for gait and improved function.

Colin Lynch, Paracycling World Champion, gave a very interesting presenation and demonstration that described how PACE had worked with him to imporve his cycling prosthesis. Taking him from top 10 to number one in the world.  Alan Roberts, a bilateral amputee following military trauma shared his rehab experiences with us to complete the day.

I have no vested interest in PACE - and I highly recommend them.

The ELLIOTT™ orthosis - Early Lower Limb Intervention Orthosis for Therapeutic Treatment

Early intervention with an orthosis to assist standing and then start early walking training is a good thing for many patients recovering from a stroke.  The primary goals of early orthotic intervention are to prevent or minimize impairments and maximize functional recovery.

For a number of years we have advocated the use of an "evaluation orthosis" with such neurologically involved patients.  This is valuable when it is too soon for a therapist to know whether a custom-fit orthosis is required.   However to be valuable as an evaluation tool, such an orthosis needs to have many of the merits of a custom fit device but with the ability to be adjusted easily even when coming "off the shelf".

It is important to avoid poor, ill fitting, solutions that give the therapist no control.

In contrast, proper timing and use of an orthosis can facilitate gait training, increase overall safety, offset contractures, improve sensory feedback.

Our USA based partners at Anatomical Concepts Inc have designed a new product that we will shortly bring to the UK market.  We will post details on anatomicalconcepts.com shortly

ELLIOTT™ (Early Lower Limb Intervention Orthosis for Therapeutic Treatment) is a prefabricated lower limb orthotic system that has been designed specifically for application in the acute, sub-acute and home health rehabilitation environments for management of the neurologically involved patient. 

This unique lower limb system consists of bilateral Knee Ankle Foot Orthoses (KAFO’s) referred to as ELLIOTT™ and ELLIOTT II™.

ELLIOTT™ consists of a KAFO (Knee Ankle Foot Orthosis) with three separate AFO (Ankle Foot Orthosis) variations that can be used either as part of a KAFO system or individually as AFO’s.

ELLIOTT II™ consists of a KAFO with three AFO’s that are part of the KAFO. The AFO segment can be quickly separated from the Knee Orthosis (KO) segment enabling the rehabilitation team member to use the KO independent of the AFO.

Utilizing either ELLIOTT™ product in the rehabilitation setting rectifies these concerns through the unique multipurpose design and multifunctional capabilities.

Having eight variations within the ELLIOTT™ system that are fully adjustable enables the rehabilitation team to intervene effectively and at the earliest point of the rehabilitation process.

ELLIOTT’s built in fully adjustable capabilities allows for accurate and effective joint positioning for gait and positioning augmentation to facilitate optimal outcomes. Single posterior upright minimizes bulk and impingement over bony prominences.   Secondary benefits consistent with early mobilization include; prevents DVT, skin breakdown, contracture formation, constipation and pneumonia.

Saving Money & Pressure Sores

Is it just me, but I'm seeing problems that I thought we had dealt with years ago resurfacing all over again.  Back in the 1980's and 1990's decubitus ulcers (pressure sores) were a big problem for the health service - both in economic and in human terms.  It seems the problem hasn't gone away. 

An analysis (Dr Foster Hospital Guide) of deaths in English hospitals has found 19 NHS trusts have higher rates than would be expected.  And pressure sores are still reported as a significant problem.

In the UK, NHS and related agencies are rightly striving to be more efficient and effective in providing care and so it wasn't a complete surprise when we received a call from an agency relating to our own product offerings in this area.  The implication being "Do we really need to use your product ?"

Since 1996 we have offered the PRAFO (Pressure Relief Ankle Foot Orthosis) Orthosis range to the UK and parts of Europe - we founded our business on it and worked hard to show it's merits as an effective pressure relieving technology for the heels and ankle area of the foot.  The heel area is one of the "at risk" areas of the body for patients who are relatively immobile and perhaps nutritionally compromised or diabetic.  Looking back at an article I wrote in 1996

"It has been estimated that 3% to 5% of all hospital inpatients will develop pressure sores either just before, during or after admission. Several sub-populations are at higher risk and its likely that costs will climb in line with demographic trends which by 2025 will see 25% of the population over 65 years of age"

I dont know the latest ulcer incidence figures for the UK as a whole but I'm pretty sure they won't be much better than they were twenty years ago.  Dr Fosters Guide reports some 6000 patients with pressure sores whilst in hospital. Unfortunately they can't say whether there were all hospital acquired. In the Trusts with the highest rates some 3.5% of patients were recorded as having pressure sores.

They point out that patients with pressure sores spend on average of 20 days in hospital compared with 10 days for those without sores. This adds up to an additional cost of more than £20m per year.

When there is a need to cut costs it is important to recognise the “true opportunity cost” of a particular intervention.  There is a cost of Acting and a cost of NOT Acting.  This is certainly true of not successfully dealing with pressure sores by preventing them.

We have always tried to argue with clinicians who wondered whether they could save £150 by not buying our product to prevent a heel ulcer.  Sometimes looking at it cynically, it might appear tempting to take a risk.  Not using the product looks like a saving - until say one person in ten gets a heel ulcer and all of the cost savings were blown out of the water.

Many patients treated for sores will have initially been admitted to hospital for some other condition.  As a pressure sore further limits a patient’s mobility and extends, for example, the use of a specialised bed then that resource, and all associated services, cannot turn to treat new patients.  For illustration, consider that for each sacral pressure sore which is prevented it becomes possible to undertake 16 total hip replacements.  This clearly emphasises the need for prevention when tackling this problem.

The important point is that competent clinicians can look at a patient and determine their individual level of risk.  The risk factors are well known and you would think this would lead to rational treatment decisions.

My complaint is that all too often someone takes a short sighted view of the need to save one on budget but completely misses the bigger strategic picture.  It looks like you saved a £100 but actually the saving was made at he the expense of thousands on someone elses budget.

A few years ago we won a clinical effectiveness prize for a poster entitled “Clinical Experience of the Pressure Relief Ankle-Foot Orthosis (PRAFO)” at the Scottish AHP Clinical Effectiveness and Practice Development Conference. 

This work looked at a small number of very severe cases of diabetic foot ulcers.  One case in particular comes to mind (See left) because the individual refused amputation (not an unusual situation) despite the severe calcaneal ulcer shown here.  The bone is clearly visible as we look at the lower part of the heel area.

I'm sorry if this is a distressing picture but if it is any consolation, severe neuropathy meant that pain was minimal.

The best solution for this individual would have been amputation. It would have accelerated recovery and the return to a reasonable quality of life would have been a case of a few months.  Having refused amputation the clinical challenge is very great.

For this type of ulceration the first rule is

"It's not what you put on the wound but what you take off"

In other words medicine and lotions and potions are not sufficent to deal with this problem.  One essential factor to encourage wound heeling was total pressure relief at the heel.

Using one PRAFO Orthosis and a great deal of antibiotic, podiatry and general medical care the wound eventually healed after 160 weeks. 

(See below)

Although this is quite a remarkable result, there is a sting in the tale - the patient died shortly after this wound healed having spent virtually 3 years with either lengthy hospital stays or daily visits.

An interesting point for us was that the perception we had previously been meeting from clinicians and adminstrators was that our orthosis was expensive - and yet as this case showed, despite the tens of thousands spent on other types of care, non of this would have achieved healing without using the PRAFO.

It is difficult to make decisions relating to health and health services.  Almost inevitably there will be "losers."  However, the least we can expect is rational treatment decisions that are looking at the true opportunity cost that applies.

The health service is full of well-meaning people but competence is also key and competence doesn't always seem to be in the right places.