Functional Restoration Programmes

Transcription

1 Functional Restoration Programmes Voca%onal Rehabilita%on Associa%on Annual Conference 21st June 2011 Paul Mills DipRGRT MCSP

2 Introduc)on q Rehabilitation outline q Functional Restoration Programmes (FRPs) q Critical FRP components q Benefits derived from FRPs q Invite discussion about vocational rehabilitation measures allied to FRPs

3 Rehabilitation Vocational Emphasis Work and productivity are vital to health and well being (National Institute for Clinical Excellence (NICE) Guidelines, 2009) Rehabilitation should restore a person who has been injured or suffered an illness to as productive and as independent a lifestyle as possible through the use of medical, functional and vocational interventions. (ABI/TUC Working Group 2002) Vocational rehabilitation is a commonly used term that has different meanings for different people. Most often, it refers to the process of helping people who have disabilities or ill-health to remain in, return to or move into meaningful activity, work or paid employment. (College of Occupational Therapists Vocational Rehabilitation Strategy 2008)

4 Rehabilitation Descriptors q Active Rehabilitation Programmes q Back In Action Programmes q Back School Programmes q Pain Management Programmes q Pain Clinics q Vocational Rehabilitation Programmes q Functional Restoration Programmes q Work Conditioning Programmes q Work Hardening Programmes q Work Simulation Programmes q Graduated Return to Work Programmes q Condition Management Programmes NHS - Private - Part time - Full time - Full time residential - and other combinations

5 UK Rehabilitation Services Evolution: q 1 st World War Military q 2 nd World War Headley Court and others (Continuing and expanding process) q 1950s 1970s Regional and Industrial Rehab Centres (1980s Closures) q Tunbridge and Mair Reports (Recommendations for the future of Rehabilitation Services) q Dame Carole Black Working for a Healthier Tomorrow q Lord David Freud Government Work Programme Rationale q UK Rehabilitation Council Call for Review of Rehabilitation

6 Rehabilitation: An answer to the UK s Economic Woes? The cost of sickness to UK business and society is substantial: q It has been estimated that absence from work due to sickness costs around 12 billion each year q In February 2007, 7% of the working population in England and Wales were claiming Incapacity Benefit and over 87% of those had been claiming for more than a year, at an estimated cost of 13 billion q The HSE estimates that 1.01 million people are currently affected by MSDs each year, resulting in 11.6 million lost working days (7% of the total days lost due to illness)

7 Rehabilitation: When & how to intervene? q Most people with acute spinal (and other MSK) disorders recover without intensive treatment. q Those who remain disabled and absent from work beyond the first 2-3 months of primary interventions face a longer term prognosis q Persons in this latter category are likely to encounter significant biopsychosocial and economic barriers to recovery. Ø There is strong evidence that structured multidisciplinary rehabilitation programmes, including cognitive behavioural principles to tackle psychosocial issues, are effective for helping people with persistent musculoskeletal disorders return to work. (COST B13 Working Group 2004; Hoffman et al. 2007; MacEachen et al. 2006; Mahalik et al. 2006; Schonstein et al. 2003; Seferiadis et al. 2004)

8 Rehabilitation Delivery a continuum; a process; not determined by a single act or intervention Waddell, Burton, Kendall (2008). Psychosocial Flags Framework q... implies that rehabilitation can no longer be a separate, second stage intervention after treatment is complete. The evidence shows that the best time for effective rehabilitation is between about 1 and 6+ months off work (the exact limits are unclear). q... demands that health care should both relieve symptoms and restore function and that these go hand in hand. Work is not only the goal: work is generally therapeutic and an essential part of rehabilitation. q... obstacles to recovery are often predominantly psychosocial in nature, rather than the severity of pathology or impairment. In this situation, rehabilitation must focus instead on identifying and overcoming the health/psychological, and social/occupational obstacles to recovery and (return to) work. Extracts from Executive Summary: Concepts of Rehabilitation for the Management of Common Health Problems: Evidence Base. (Waddell, Burton, Bartys Commissioned by The Corporate Medical Group, Dept Work and Pensions, UK)

9 ABI/TUC Proposed Procedure Flowchart 3/6 Months? MEDICAL PLATEAU FUNCTIONAL & VOCATIONAL REHABILITATION Getting Back to Work ABI/TUC Rehabilitation Discussion Paper (2002) RETURN TO WORK

10 NICE Clinical Guideline 88, May 2009 Low back pain; Early Management of Persistent non-specific low back pain Consider: q A structured exercise programme tailored to the individuals needs q A supervised exercise programme in a group of up to 10 people q Up to 100 hours of a combined physical and psychological treatment which includes a cognitive behavioural therapy approach Vocational intervention: q The concept of early intervention is central to vocational rehabilitation, because the longer anyone is off work, the greater the obstacles to return to work and the more difficult vocational rehabilitation becomes. (Vocational Rehabilitation: What works, for whom, and when (Waddell, Burton, Kendall). See also: European Guidelines for the Management of Chronic Non-specific LBP. Clinical Guidelines for the Management of Persistent LBP (CSP 2009). Department of Health Musculoskeletal Services Framework

11 Problems Arising from Lack of Timely Rehabilitation q Repeated clinical failures; increased perception of disability q Benefit dependency and acquired-illness behaviour q Alienation from the workplace; social isolation and depression q Disabled mindset; symptom exaggeration q Psychosocial pressures at home q Litigation may become a dominant factor

12 Func)onal Restora)on Programmes The term functional restoration was coined by Tom Mayer and Vert Mooney to specify interdisciplinary programmed care geared toward minimising disability. Functional restoration emphasizes physical and behavioural improvements over pain eradication and relies heavily on guidance from repeated measurement of function (R. G. Hazard. Spine Vol 20 Number 21, pp (1995)).

13 The Aim of Functional Restoration Programmes Employer WIN Employee Jointly Agreed Goals at outset: Maximum level of Functional Activity WIN WIN Referrer/State

14 FRP Flowchart Referrer iden)fies poten)al Clients Unsuitable Unsuitable Programme Admission Ini)al screen for suitability Formal Referral Authority to proceed Pre- Admission Assessment Assessment Update Therapist Daily Progress Report Week 1&2 Consultant Review Clinic Week 3 Consultant Discharge Clinic Discharge Reports + Recommenda)ons e.g. limita)ons/restric)ons on work ac)vi)es Voca)onal rehab plan Lifestyle Leisure Pursuits Consolida)on Phase

15 Functional Restoration Programmes Purpose... Outcome driven: o Restore function to occupational readiness o o o Management of pain Achieve safe, durable, vocational outcomes Return to usual home and life activities Focus Interdisciplinary team: o Medical o Functional o Psycho-social o Vocational Delivery Primary measures of success: o o o Return to work Renewed self-confidence Client satisfaction

16 Functional Restoration Programmes - Critical Components (1) MDT staff Organisation: Consultant direction Medication management Robust planning & communication structure to coordinate treatment plan and intervention thro Case Managers and Vocational Rehab Specialists Measurement : Measurement of physical / functional capacities before, throughout and after treatment to guide training and inform resumption of work and other activities Consistent client centred MDT/inter agency co-operation Staff-client ratio: maximum 10

17 Functional Restoration Programmes - Critical Components (2) Exercise & training: Emphasis on active exercise and development of personal coping strategies Minimal individual therapy treatment modalities Whole body and spinal training for flexibility, strength and endurance Integrated simulation of work and other functional activities CBT Initial psychosocial and socioeconomic evaluation to inform goal setting and training plans CBT; group focus, indentify individual counselling needs if appropriate Case management: work and lifestyle planning with consideration of socio-economic issues Exercise, self-management and lifestyle education

18 Individual FRP Modalities q q q q q q q q q q q Group Exercise and Individual Programmes Warm-up and Stretching Mobilising Strength and Cardiovascular training Cognitive Behavioural Therapy (CBT) Lifestyle Education Individual Physiotherapy Hydrotherapy Functional Activity Recreational therapy Relaxation

19 PERIOD - TIMES Warm Up TYPICAL DAILY PROGRAMME Period Mobilisation Mat Exercises Period Strength Mat Exercises Period Functional Activity Break Period Period CVR Suite Lunch Functional Restoration Programme Summary of Content Conditioning and Lifestyle Education Period CBT Group Session Recreational Therapy 7% Functional Activity & Vocational Guidance 13% Hydro 6% Briefing & Education Admin 5% 1% Warm Up & Mobilisation 17% Consultant Assessment 2% Strength (floor exercise) 13% Period Recreational Therapy Period Hydrotherapy Break Period Strength Suite Period Relaxation Break Free time and Dinner Evening Activity Individual Treatments 2% Cardiovascular 13% CBT 5% Strength (strength suite) 13% Relaxation 3%

20 Measurement of Performance (1) Measures will be applied, as appropriate, during neuromusculoskeletal assessment for admission, then on programme and at discharge and may include: Joint ranges of movement Sitting tolerance (duration) Standing tolerance (duration) Walking tolerance (10 metre walk test /or 10 metre shuttle walking test) Strength progression acquired through resistance training records CVR progression acquired through cardiovascular training records monitoring also, where applicable, BP and heart rate Assessment Tools (Questionnaires) including those introduced by supervising Consultants or Cognitive Behavioural Therapists

21 Measurement of Performance (2) When appropriate, and with the informed consent of individual clients, tools/ protocols are introduced within rehabilitation programme routines to provide objective analysis and measurement of performance. These may include measurement and correlation of : q Physical effort: fitness, cardiovascular tolerances and strength q Client s physical abilities: mobility, agility, dexterity and handling q Reliability of client s pain and disability reports q Reported job demands: various simulations

22 Objective Measurement Tools

23 Summary of hours accumulated over 3 week active programme WEEK 1 WEEK 2 WEEK 3 TOTAL Programme contact = 25 hours Programme contact = 25 hours Programme contact = 25 hours 75 hours Social interac%on/ reinforcement priori%es contact = 12 hours (Mon Thurs) Social interac%on/ reinforcement priori%es contact = 12 hours (Mon Thurs) Social interac%on/ reinforcement priori%es contact = 12 hours (Mon Thurs) 36 hours Day 5 Review clinic with Therapy Team and Consultant Day 10 Review clinic with Therapy Team and Consultant Day 15 Discharge clinic with Therapy Team and Consultant 111 hours 3 week programme 111 hour produc)ve engagement ; a simulated work and social pasern

24 FRPs Summary of Benefits q Consultant-led process; orchestration of MDT maximising client s potential to benefit q Joint agreement of goals promoting partnership between Client, MDT and Referrer q Motivation through group dynamics; shared experience reducing impact of isolation q Close support facilitating individual planning, progression and self-management q Strong encouragement for individual to take responsibility for recovery q Fosters positive attitude to RTW - functional activity oriented q Residential non-hospital setting provides helpful influence towards successful achievement of physical and psychosocial coping strategies q Co-ordination with CM/VRM to identify interdisciplinary and vocational needs q Follow up to evaluate and support implementation of rehabilitation plan during consolidation phase

25 Standards/Codes of Practice & Accreditation (List not exhaustive) Quality Assurance Audit: Care Quality Commission (CQC) UKRC Rehabilitation Standards The 2007 Rehabilitation Code UKRC PAS 150: 2010 Providing Rehabilitation Services (BSI) Health Professions Council National Governing Bodies

26 Origin Some Pilot Programme Successes Occupation Outcome o PHI claim (1yr) o EL claim (1yr) o EL claim (3mths) o PHI claim (1yr) o EL claim (1yr) o PHI claim (2yr) o PHI claim (2yr) o PHI claim (1yr) o Motor policy/rta (9mths) o PHI claim (4yr) o PHI claim (2yr) o Stonemason o Scaffolder o PE Teacher o Stage Technician o Carpenter o Plasterer o Regional Sales Manager o Carpenter o Accountant o Print Engineer o Facilities Manager o RTW o RTW (Driver) o RTW o RTW o RTW o RTW o RTW o RTW o RTW o Retraining for RTW o RTW

27 Client Feedback I feel that I gained a tremendous amount from participating in the programme, not only physically, but also I gained a positive mental attitude. I had achieved such an improvement that I felt confident of being able to return to normal life and my job. Three weeks on from finishing the programme, I was able to pass a thorough medical examination and return to my work. This involves 3 weeks of 12 hour shifts in the rigorous environment of an offshore platform. For the first time in four years, I am totally pain free. I continue with the exercise programme given to me by Spring, and see daily improvements in my movements, strength, and confidence. John Kirwan - Client

28 Postscript A niche of usefulness and self respect exists for every man, however handicapped, but that niche must be found for him. To carry the process of restoration to a point short of this is to leave the cathedral without a spire. John Galsworthy, 1918

29 Summary Avoiding the unhelpful alternatives? q Slide into chronic disability q Long term dependency Maximum gains through: q Positive early intervention q Return to Work focused approach Discussion