The 4th joint British Society of Rehabilitation Medicine (BSRM) and the Dutch equivalent the Nederland’s Vereniging Van Revalidatieartsen (VRA) Meeting was held in the pretty Spa Town of Harrogate in North Yorkshire, UK on 18th & 19th April, 2013 and attracted 252 delegates, with our Dutch colleagues making up just over half of the total. Thirteen posters were on exhibition.
The first day began with a pre conference BSRM/VRA amputee rehabilitation special interest group meeting in the morning. The meeting opened with a plenary session on pain, chaired by Professor Rob Smeets. Pain is prevalent in the neuro-rehabilitation patient population with reports ranging from 50% to 75% in those with Multiple Sclerosis, 32% following severe traumatic brain injury and up to 75% following mild traumatic brain injury. I certainly have found that that there are challenges in formulating a pain diagnosis in individuals with traumatic brain injury as well as in those with complex neurological conditions.
Pain in adolescence was considered in a presentation by Dr Jeanine Verbunt. She outlined that although a broad array of medical diagnoses are involved in adolescent pain conditions, a specific medical disease is identified in only 10-30%. Unexplained musculoskeletal pain is not always as self limiting as assumed: persistent rates of pain up to 30-64% after 4 years have been reported. In about 40% the pain would have a disabling impact on daily functioning. As rehabilitation practitioners we need to consider the current available evidence – which remains much less than that which addresses adult pain – on the underlying mechanisms for disability in adolescent pain.
Dr Frances Cole presented a range of approaches and tool options for individuals living with pain. These ranged from engaging patients in self assessment of their own health outcomes to changing unhelpful pain related behaviours. Such tools help in developing a participative partnership with health and social care practitioners and enhancing patient self efficacy.
There were three parallel sessions in the late afternoon, one which showcased free paper abstracts, another that looked at falls after stroke – underlying mechanisms and novel options for intervention, and a third session on hereditary spastic paraparesis.
Both the Dutch and UK rehabilitation trainees held a trainee meeting at the end of the first day. Much of the meeting was an exchange of experiences with our Dutch colleagues, with a trainee from each country giving an outline as to what training in rehabilitation involves. Dr Margaret Phillips gave a short talk on rehabilitation research in the UK. There appears to be regional variation in both opportunities and support for trainees to be involved in research, but it was encouraging to see the enthusiasm from trainees for getting involved in research. We were encouraged to do the European board examination by Prof Anthony Ward. The UK trainees historically have a very high success rate in passing this exam, so no pressure for current trainees then!
The last day of the meeting opened with a plenary session on Stroke with Professor Lynne Turner-Stokes chairing. Some exciting developments in understanding upper limb recovery at an early stage post stroke were presented by Professor Gert Kwakkel, from the department of rehabilitation medicine in the Netherlands, VU University Medical Centre in Amsterdam. There is growing evidence that the natural pattern of functional recovery can be modified and improved upon by intensive task oriented practice, preferably initiated within 6 months following a stroke. The impact of practice on the intrinsic and spontaneous learning mechanisms of neurological recovery remains poorly understood. A hypothetical phenomenological model for understanding skill reacquisition post stroke was presented.
It is well known that balance and gait capacities may considerably improve after supratentorial stroke and that this recovery may be facilitated by intensive task oriented practice. Studies that have sought to improve our understanding of the underlying mechanisms of functional recovery post stroke have focused mainly on kinematic, kinetic and electromyographic changes during the sub acute phase post stroke. Kinetics is studying the motion of objects (particles/rigid bodies etc.) and the forces that cause those motions. Kinematics is studying the motion of objects (particles/rigid bodies etc.) but not considering the forces, just examining the motion itself.
These studies have consistently highlighted the role of compensatory mechanisms and relatively little evidence for true restoration of original motor function. Rehabilitation efforts should therefore focus on optimal use of compensatory mechanisms to promote functional independence. Soft tissue surgery such as percutaneous Achilles tendon lengthening is one such intervention that aims to optimise compensatory motor function. As rehabilitation clinicians, we should fully assess our patients and consider all possible interventions which could help their rehabilitation process.
Professor Helen Rodgers outlined the structure of the UK National Institute for Health Research, and shared experiences from the Stroke Research Network in particular. The website on the NIHR was shown and it was encouraging how easy it was to navigate and locate information.
The BSRM National Training Programme was launched; there are 51 talks to be used at regional training events with the aim to have consistent teaching among trainees across different deaneries. This is currently being piloted in Newcastle, London and Wessex deaneries. The national training programme is to be reviewed every 2-3 years.
There were parallel symposia that ran concurrently in the late afternoon, making for difficult choices on which to attend.
The provision of early and specialist rehabilitation following major trauma is a relatively new concept in the UK. During the setup of trauma networks in England, the National Director for trauma recognised that earlier access to rehabilitation after trauma was necessary to improve the poor outcomes after major complex trauma, reported in the UK. To try and achieve better outcomes, the concept of a rehabilitation prescription was introduced in November 2011 by the Department of Health. Several forms of the prescription were created by various groups across the country, following on some work that was subsequently done, some more recent formats for rehabilitation prescriptions were described and the opportunities as well as challenges to their use were discussed. We had the opportunity to hear the Netherlands experience, from Dr Bea Hemmen, of Maastricht University Medical Centre, Maastricht. She discussed innovative rehabilitation for multi-trauma patients called the ‘supported fast track rehabilitation service’ – a scheme which ensured the timely delivery of rehabilitation measures with the demonstrated subsequent improvement of clinical measures.
In their transition to adulthood, young people with childhood onset disabilities such as cerebral palsy, spina bifida and neuromuscular diseases may experience problems in regulating their own life and taking responsibility for their health. At adult age they experience restrictions in participation. At present in both the UK and the Netherlands, networks of healthcare professionals and researchers are aiming to innovate transitional care for emerging adults with childhood onset disabilities (16-25 years of age). Professor Allan Colver, Donald Court Chair of community health gave an exciting presentation on the changes that occur in the adolescent brain. These include neurotransmitters (adolescence is an age where the brain shows peak sensitivity to dopamine) and differing rates of development of different areas of the brain. He concluded that pubertal hormones and brain development are still not fully understood. Many challenges to transition were discussed and ongoing current research at Newcastle University was outlined, which concentrated on the young person and what is important to them for successful transition. Dr Jetty van Meeteren and Dr Marij Roebroek gave a presentation on the approaches to transitional care from the Dutch transition network. They looked at the age-appropriate interventions focusing on autonomy in life areas.
The day concluded with a lively and exciting debate chaired by Dr Vera Neumann. It appropriately debated the issue: ‘This house proposes that, in people with long-term neurological conditions, we should promote independence and therefore avoid routine review by rehabilitation medicine services’. Dr Kate Sansam and Dr Imelda argued for the case, and were well balanced by Dr Ruth Kent and Dr Jetty van Meeteren against. I am reliably informed that a show of hands indicated a 50:50 split for the debate, which reflects my feelings on the topic.
This was a very successful and informative meeting with some very lively debate. It will result in several changes to my practice, and has enhanced my enthusiasm for what I consider to be an exciting and challenging speciality. I will be looking forward to the next meeting which is planned for December 2013, in London, the day after the Royal College of Physicians conference on vegetative and minimally conscious states.
ACNR 2013; 13:4:36-37