Evidence of effectiveness to assist commissioning of general rehabilitation, and specific services for rehabilitation following stroke and fractured neck of femur

Introduction
Rehabilitation is a core element in the practice of medicine for older people[1]. This document focuses upon evidence of effectiveness which may be utilised to assist with the development of rehabilitation services for older people.

Rehabilitation - what is it?
A working definition of rehabilitation is “the reduction of functional deficits without necessarily reversing the underlying biology of the disease” [2]. Its scope is wide and includes acute and chronic perspectives. For example, active treatment to reduce the severity of the underlying disease would be included (e.g. treatment of cardiac failure or pain relief in an arthritic knee), as would adapting the environment to the needs of a disabled person.

The definition embodies the concepts of:

• Impairment - the specific deficit
• Disability - the resultant limitation in functional capacity

Comprehensive rehabilitation needs to address a number of different levels which may be contributing to loss of function.

• The damaged system
• Other body systems
• Psychological attitudes
• Immediate material environment eg clothes
• The near environment eg housing / equipment
• Distant environment eg shops, social outlets
• Social support networks.

This interfaces neatly with broader concepts within Geriatric Medicine including the Comprehensive Geriatric Assessment (see below).

It is clear that a multiprofessional approach is required to intervene at all these levels. However rehabilitation can also be more focused, for example, at specific therapy to reduce the impairment associated with a painful shoulder.

Many of the skills of rehabilitation apply in a generic manner, and arise from attitudes of the team members towards their patients. The evidence is strongest for specific interventions in diseases such as stroke and post-fracture (see below). However, the principles can be extrapolated to a wider group of conditions and are similar in different age-groups, although the multiple needs of older patients, coupled with background frailty, may necessitate a lengthier and more complex process than in similarly impaired younger people.

 The stages of a rehabilitative process are:

• Assessment: identification, analysis and identification of problems
• Planning: analysing the problem(s) and setting goals
• Treatment: intervention to reduce disability and handicap
• Evaluation: check effectiveness of interventions and review (ie reassessment)
• Care: intervention to alleviate consequences of disability
• Advice: coping strategies for patients and carers

Evidence of effectiveness of comprehensive geriatric assessment (CGA)

Definition

The Comprehensive Geriatric Assessment addresses the diversity and complexity of older peoples needs. This encompasses their physical, social, psychological, economic, functional and environmental requirements.Consequently, problems in one or more areas can be tackled promptly and the appropriate management measures implemented.

Evidence of effectiveness of CGA

A 1993 meta-analysis of 28 controlled trials included 4,929 subjects allocated to one of five types of CGA and 4,912 controls. This concluded that CGA programmes linking geriatric evaluation with strong long-term management are effective in improving survival and function in elderly persons [3].

• The value of most effective ‘packages’ of CGA have been highlighted in a Consensus statement from the National Institute of Health in the USA [4]. This included Geriatric Assessment Units and combined Geriatric Assessment and Rehabilitation Units.

More recent data continues to support the evidence base for the efficacy of the CGA in Geriatric practice [5]. There is adequate data from several sources indicating benefits relating to functional status, quality of life, length of hospital stay and rates of readmission and institutionalisation. There remains, however, no apparent influence on survival as demonstrated by a meta-analysis of nine studies in 2004 [6].

 Evidence exists favouring the use of CGA in several different healthcare environments:

• General Practice [7]
• After a visit to the Emergency Department [8]
• Post-discharge from hospital [9]
• In the community [10]

There is additional data looking at combining the CGA with other intervention strategies.

One example of the effectiveness of both targeting and CGA coupled with multi-disciplinary intervention, was the demonstration that falls could be prevented in elderly people by targeting rehabilitation on those identified as being at high risk of falling [11].

Generic needs and specific conditions

Having identified impairments and disabilities through comprehensive assessment, there are alternative ways of delivering care. Typically, a generic approach, entailing assessment, rehabilitation, and reassessment is carried out in the in-patient geriatric wards. However more research on their efficacy is required. Alternatives to this include disease-specific approaches (such as in stroke and fractured neck of femur) and community-based schemes. These may be complementary, and their availability should depend on local factors such as geography, demographics and the healthcare infrastructure. . Whatever style of practice, rehabilitation should not cease on discharge from hospital and continue after discharge into the community, including all forms of residential and nursing care. Patients with mild to moderate cognitive impairment do benefit from rehabilitation programmes.

Evidence that rehabilitation after stroke improves outcome

There is a great wealth of evidence demonstrating the benefits of rehabilitation on the many different facets of stroke medicine.

In the United Kingdom , guidelines for the management of stroke patients have been produced by the Royal College of Physicians [12] and the Scottish Intercollegiate Guidelines Network [13]. They address aspects of both acute and rehabilitation stroke medicine. The English National Service Framework Standard 5: Stroke,[14]emphasises early and continuing rehabilitation, and the importance of the Stroke Unit as part of stroke patient care.

The Cochrane Database describes the well-established benefits of Stroke Units [15,16]. In their review of 23 trials, Stroke Units were demonstrated to benefit mortality, functional outcomes and independence at 1 year post-stroke. This was achieved without longer in-patient stays.

Other Cochrane reviews have examined the following areas:

• Early Supported Discharge for selected patients can reduce length of stay, but its effects on other outcomes need to be examined further [17].
• The evidence for the implementation of integrated care pathways for stroke remains inconclusive. However this may arise partially from the quality of the trials conducted to date [18].
• There is some evidence for the use of therapy-based rehabilitation for stroke patients in their home environment, with improvements in independence for activities of daily living [19]. More recent work in this area has demonstrated similar findings and also showed to reduce the risk of deterioration in ability [20].

Evidence that rehabilitation improves outcome after fractured neck femur

In the United Kingdom the most comprehensive guidelines for rehabilitation of patients with fractured neck of femur are from the Scottish Intercollegiate Guidelines Network [21].

A Report by the Royal College of Physicians of London as far back as 1989 [22] highlighted the need for early review by a geriatrician and for multiprofessional discharge planning. The years since have seen the development of orthogeriatric units although there remains much diversity in how individual units operate. The evidence to support this type of initiative is, rather less than exists for similar schemes especially stroke units.

A Cochrane review in 2001 examined 9 trials looking at the efficacy of multiprofessional rehabilitation of this patient group. Mortality and institutional care rates were less in those patients receiving co-ordinated inpatient rehabilitation, but the results did not reach statistical significance. On-going work looking at similar models of patient care, may provide better information in the future and are keenly awaited.

A report from the Audit Commission in 1995 [23] highlighted the wide diversity of patterns of care. The review of practice in nine hospitals showed marked differences existing in clinical practice with corresponding differences in outcome. The report emphasised the need to consider every aspect of care from the moment the patient arrives in the Accident & Emergency department. Particular points to emphasise include:

• Rapid resuscitation and attention to pain relief.
• Early ward transfer with full preoperative medical assessment including the need for pressure relief.
• Early surgery by an experienced surgeon and anaesthetist on a planned trauma list.
• Post operative review by a geriatrician to assess medical problems and plan rehabilitation.
• Multidisciplinary discharge planning with appropriate community follow up when needed.

Routine use of standard measures of patient outcomes

Good Practice Guidelines consistently recommend that all patients involved in rehabilitation programmes must be systematically evaluated at key stages using well-validated standardised measures [24] which embody aspects of impairment (often performed by physiotherapists), disability or dependency (eg Barthel and Mental Test Scores) Measures of user satisfaction and involvement are also important, as well as he views of carers.

Commissioning issues and the national service frameworks

Interfaces with other rehabilitative services (for children, school leavers, adults, learning disabilities, mental health and other patient groups) and in different locations (hospital, community, day hospital and wards, out-patient, and domiciliary) should be identified to ensure a comprehensive service is available to the community. Following the National Service Framework document of 2001 in England there has been significant development of Intermediate Care services, including residential rehabilitation. Although the evidence base for such services continues to evolve, they are becoming increasingly established as part of Community Geriatric Medicine.

The National Service Framework for Wales will be published soon.

Summary and conclusions

There is now evidence of the effectiveness of rehabilitation in several well-defined and important clinical areas relevent to older people. Health commissioners must be urged to provide resources for rehabilitation services. In the past lack of proof of benefit was probably due to inadequate provision of rehabilitation services as well as lack of effort in research and measurement of outcome. The onus is on rehabilitationalists to ensure that outcomes are measured. The next step will be consistent measurement of cost-effectiveness

 References

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