Medicine (RMH) - Theses
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ItemThe Role of Rehabilitation in Disaster Settings( 2020)Disaster may lead to significant economic losses, huge loss of lives, severe traumatic injuries, and psychological consequences which may result in long-term disability, requiring comprehensive multi- or interdisciplinary rehabilitation input for optimisation of physical and functional outcomes. The purpose of this thesis is to address the issues and gaps in knowledge for disaster rehabilitation. This thesis presents a body of work that incorporates five linked studies integrating different methodological models, such as The International Classification of Functioning, Disability and Health (ICF), Priority Sequence Model, The Integrated Care Models and Four-Phase Process by the World Health Organization (WHO), Model of Care for Traumatic Brain Injury (TBI), and Disaster Rehabilitation Continuum Cycle. Studies 1 and 2 are the first reviews to comprehensively evaluate the quality of TBI Clinical Practice Guidelines (CPGs) from a rehabilitative perspective using the Appraisal of Guidelines for Research and Evaluation II (AGREE-II) tool, and summarise recommendations from these relevant CPGs for applicability in disaster settings. The key rehabilitation recommendations for TBI survivors in disaster settings, include: patient/carer education, general physical therapy, practice in daily living activities and safe equipment use, direct cognitive/behavioural feedback, basic compensatory memory/visual and swallowing/communication strategies, and psychological input. Study 3 evaluated functional outcome, quality of life and community re-integration of community-based disaster survivors in Pakistan. The findings suggest that study participants (members of the Pakistani Armed Forces) seemed to have settled well in the community. The severity of impairments (such as walking, self-caring, fatigue, pain etc.) negatively impacted on participants’ community re-integration and in relation to their social roles and productivity. The longer the time since the injury was sustained, the fewer the impairments, and better community re-integration and perceived health status. Study 4 was a pilot study using a structured survey to gain insight from rehabilitation professionals, mainly rehabilitation physicians, regarding their preparedness and willingness for future deployment to disaster settings. Most participants (63%) expressed interest in future deployment to disaster settings, and only 24% had previously received some form of disaster management training. However, the survey provided valuable information on those who responded, including their experience in their respective profession, level of education, and types of preferred disaster management training etc. Study 5 is the first Disaster Rehabilitation Response Plan (DRRP) using a three-tier approach: Tier 1 - Immediate disaster response at a national or international level, Tier 2 - Deployment of rehabilitation medical personnel to the disaster settings, and Tier 3 - Rehabilitation management and community reintegration of disaster survivors. The DRRP can serve as a model for the International Society of Physical and Rehabilitation Medicine (ISPRM) to coordinate and deliver rehabilitation assistance with WHO in future disasters. Findings in this body of work confirm the complexity of disaster rehabilitation and the many challenges for integration of rehabilitation medicine in disaster management. It also supports the view that rehabilitation should be an ongoing process to maintain, restore and maximise function and health status in the long-term.
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ItemAdvance care planning in rehabilitation settings( 2019)Advance care planning (ACP) is the process whereby patients are able to communicate with family and healthcare providers regarding future health care choices in the event that they do not have the capacity to do so. In Australia, people are living longer with an increasing aging population and higher rates of chronic illnesses. Significant costs are involved in managing people with chronic illnesses including hospitalisation, rehabilitation and supportive care. ACP is known as an effective tool used in future care planning, and has many known benefits, including improving patient autonomy, enhanced shared decision-making processes with clinicians, better satisfaction with end-of-life (EOL) care, reduced rehospitalisation rates, and improved quality of life for patients and families. Despite known benefits of ACP, its evidence in rehabilitation settings and in specific populations such as cancer patients remains limited in the literature. There have been previous educational efforts with ACP in outpatient rehabilitation settings such as pulmonary and cardiac rehabilitation. However, beyond this, existing literature remains scarce on overall evidence of ACP in rehabilitation settings, in those nearing the EOL, and in those at risk of cognitive impairment. The main aim of this thesis is to investigate the evidence of ACP interventions in patients with cancer, including those with brain tumours (BT) and in rehabilitation settings. Four studies were developed in this thesis to address current gaps in evidence-based practice in ACP in these populations. A standardised framework was utilised to develop protocols for these studies. Firstly, a systematic review was developed to look into existing research regarding the efficacy of ACP interventions in patients with BT who are often managed in rehabilitation settings, at risk of cognitive impairment and nearing EOL. Two studies were then designed to investigate the experience of ACP in patients with BT. Of these two studies, one represented a pilot study to explore the experience of ACP in patients with BT in a tertiary hospital in Australia, and another was an extension of this study to further explore the experience of ACP in a larger cohort and included carer burden. Lastly, an ACP program was implemented in an inpatient rehabilitation setting in a tertiary hospital setting to address staff and systemic barriers to implementation and to improve ACP uptake. Gaps in evidence in relation to barriers and facilitators to ACP implementation in rehabilitation, and types of ACP interventions that can be implemented were identified and recommendations made to further develop and enhance ACP programs, and guide future research. Study 1 presented a systematic review of ACP in patients with primary malignant brain tumours (pmBT). There was only “low to moderate” evidence for ACP studies in this cohort. Only a single randomised controlled trial (RCT) evaluated a video decision support tool in facilitating ACP in patients with pmBT which showed a beneficial effect in promoting comfort care and confidence in decision-making. Positive effects of ACP included lower hospital readmission rates and intensive care unit utilization. None of the studies assessed mortality outcomes associated with ACP. The study highlighted that although there were some beneficial effects of ACP in pmBT population, the literature remains limited in this area with lack of intervention studies, and further studies with appropriate study design, outcome measures and defined interventions are required. Studies 2 and 3 investigated the awareness and experience of patients with BT in discussing ACP. Study 2, an initial pilot study, investigated the experience of patients with BT in discussing ACP, identified main symptoms experienced, physical and functional status, perceived quality of life (QoL) and level of coping. Qualitative analysis indicated good QoL and the use of problem focused coping strategies, however findings demonstrated limited awareness, understanding and documentation of ACP and variable views on appropriate timing of ACP discussions. Study 3 is an extension of this initial pilot study and further investigated a larger cohort of patients with BT, with the addition of assessing carer burden. The majority of patients had high grade gliomas, and there was a moderate level of carer burden. The ongoing limited ACP discussions between patients and healthcare professionals demonstrate the need for increased awareness of ACP in clinical practice, and also encourages the neuropalliative-rehabilitation model of care approach which integrates care amongst treating teams including neurology, neurosurgery, oncology, rehabilitation and palliative care to be able to provide timely ACP information to patients, This study also highlighted the need for multifaceted system-wide interventions in implementing ACP. Study 4 was designed to develop, implement and evaluate the effectiveness of an ACP program in an inpatient rehabilitation setting. The implementation of this program showed that a structured ACP program is feasible and effective in improving the prevalence of ACP discussions between rehabilitation patients with chronic illnesses and/or multiple comorbidities and rehabilitation staff, however short-term impacts on Medical Enduring Power of Attorney (MEPOA) nomination and Advance Directive (AD) completion rates remained inconclusive. This was the first study using process evaluation in assessing an ACP program and its feasibility. In conclusion, limited evidence still exist with ACP in patients with BT and in inpatient rehabilitation settings. The implementation of a structured ACP program is effective in increasing ACP discussions between rehabilitation patients and staff, and emphasises a multifaceted approach that is required for its feasibility. It is also easily replicated in other rehabilitation settings. Future larger and longer term follow up studies are still required to assess impact on other outcomes including QoL, quality of care and economic costs.
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ItemMedical rehabilitation in natural disasters( 2017)The number of severe natural disasters (such as earthquakes, storms, draught, floods etc.) has escalated in recent years. Natural disasters often occur unexpectedly, precipitously and with great magnitude of destruction, resulting in significant loss of life and long-term disability from severe injuries including spinal cord injury, traumatic brain injury, limb amputation, fracture, peripheral nerve injury, crush injury and psychological impairment. In the last two decades, advances in disaster response/rescue and field management, have improved the survival rates of disaster victims significantly worldwide. Current data shows a significant increase in the number of injuries sustained relative to mortality, indicating medical rehabilitation is integral to comprehensive disaster management. Empirical evidence on medical rehabilitation following natural disasters is increasing and various studies have reported effectiveness of rehabilitation in survivors. Evidence suggests early provision of rehabilitation programs reduce disability, leading to better clinical outcomes, and improves participation and quality of life of disaster victims. The World Health Organization (WHO) rehabilitation guidelines recommend implementation and access to rehabilitation during all phases of the disaster response. In line with this, there is strong consensus amongst global health authorities that medical rehabilitation should be initiated in the immediate emergency response phase, and should be continued in the community over a longer-term until treatment goals are achieved and survivors are successfully reintegrated into society. Many countries now recognize the importance of disaster planning, preparedness and management initiatives, and their disaster management capacity and collaboration has improved. Unfortunately, major disparities and gaps amongst countries exist, and those with a high disaster risk tend to have a low coping capacity, with inadequate disaster response/management plans. Many countries have limited or lack of access to appropriate services such as rehabilitation, where fragmented healthcare systems are compromised by lack of financial and political support. Rehabilitation-inclusive disaster management strategies/plans are yet to be developed in many countries, particularly in the Asia-Pacific region (where the majority of natural disasters occur). There is a concern in regards to the inadequacy of global organizational capacities and capabilities and matching of resources across the disaster cycle. In past large-scale disasters, it was beyond the capacity of many countries to have optimal disaster management and many were dependent on global humanitarian and medical assistance. This is reflected by the growing number of emergency medical teams (EMTs) responding to disasters worldwide. However, the influx of EMTs during past disasters presented immense challenges regarding response coordination and management. There was lack of standardized protocols/guidelines, coordination and evaluation mechanisms in place. This resulted in inadequate care delivery, particularly rehabilitation, with often devastating consequences for the affected individuals, families and communities. Although there have been improvements in the organization of emergency responses, care and services, this has often not extended to include rehabilitation services. Currently, there is increased scrutiny of the humanitarian response sector driven towards professionalism and accountability, to provide effective and appropriate interventions in different disaster settings. Further, there have been significant developments in international, regional and national collaboration and management capacities in disaster management, including implementation of disaster-risk reduction frameworks, quality and coordination mechanism of EMTs. One of the noteworthy developments is the establishment of the WHO-EMT Initiative and launch of EMT guidelines, including the ‘Minimum technical standards and ecommendations for rehabilitation in sudden onset disasters’. These guidelines not only classify medical response teams per their capability, but also set out the core standards for medical care of disaster victims. The WHO rehabilitation guideline provides standardized protocols for rehabilitation in future emergencies, acknowledging variations in type and patterns of injury, disease and subsequent long-term disability. It provides much needed direction for preparedness for rapid, professional, coordinated medical responses by both national and international response teams. It also provides guidance on building or strengthening the capacity of local and international EMTs within defined coordination mechanisms. A WHO registration system for all EMTs was initiated in July 2015, which enables establishment of a global registry of emergency medical response teams for deployment in future calamities. There are still immense challenges in putting these standards into practice in disaster settings. The successful implementation of these frameworks will require increased resilience of the rehabilitation community with multi-stakeholder partnerships. There is still much progress to be made on tackling the underlying drivers of disaster risk, such as poverty, climate change, rapid urbanization, and factors such as environmental degradation, poor local governance, population growth, economic development patterns, to establish a rehabilitation-inclusive disaster management model for future catastrophes. The aim is to strengthen national capacity, foster an environment of self-empowerment of EMTs and local health services, and work in rehabilitation within defined coordination mechanisms in disaster-affected area. This thesis explores the medical rehabilitation management of disaster survivors, following natural disasters. The aim was to provide evidence and systematic analyses of various rehabilitation interventions trialled in disaster survivors, in terms of their effectiveness, safety and cost-efficiency. Rehabilitation professionals’ role and gaps in evidence for medical rehabilitation in disaster management and Australian perspective were explored, specifically in the Asia-Pacific region. Further, a brief overview of current developments, challenges, and gaps in the rehabilitation-inclusive disaster management plan, including implementation of WHO guidelines, is discussed to improve care for victims of future calamities.
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ItemRehabilitation in traumatic brain Injury( 2016)Traumatic brain injury is the leading cause of death and disability for young adults in developed countries including Australia. Traumatic brain injury is a heterogeneous health condition and issues in traumatic brain injury change over time. The rehabilitation of persons with traumatic brain injury relies on the identification and management of these issues with the goal to minimise complications and to maximise functional outcomes. There is a need for clarity in the rehabilitation assessment and management of disability in traumatic brain injury. Patient perspectives are needed for a holistic approach to rehabilitation to address the biopsychosocial factors which affect functional outcomes in persons with traumatic brain injury. This thesis explores the rehabilitation assessment and management of disability following traumatic brain injury in adults. The aim of the thesis is to add clarity to the classification of traumatic brain injury and issues for the rehabilitation planning and management through International Classification of Functioning, Disability and Health. The International Classification of Functioning, Disability and Health Core Sets for Traumatic Brain Injury are applications of International Classification of Functioning, Disability and Health framework. This thesis examines the applicability of these in an Australian patient population. This thesis takes a mixed methods approach for qualitative and quantitative analyses of a trauma registry dataset; outcome measures; and patient perspectives. The methodology is based on non-parametric techniques for statistical analysis; ‘COnsensus-based Standards for the selection of health Measurements INstruments’ for examining outcome measures; and International Classification of Functioning Disability and Health framework. This thesis examines the hypothesis that current approaches to the assessment and management of disability in traumatic brain injury rehabilitation is evidence-based and is consistent with patient perspectives. The implementation of this research will shape how disability is assessed and managed in traumatic brain injury with direct relevance to the Australian context. The thesis consists of eleven chapters. Traumatic brain injury and its rehabilitation are presented in the Overview (Chapter 1) and the Literature Review (Chapter 2). The rationale for the methods in the thesis is presented in the Methods (Chapter 3). Section I (Chapters 4-6) examines the initial assessment of persons with traumatic brain injury for rehabilitation. Section II (Chapters 7-9) explores outcome measures in traumatic brain injury rehabilitation. Section III (Chapters 10) presents the Australian community patient perspective. The implications of these findings for implementation of research in traumatic brain injury rehabilitation are presented in the Discussions (Chapter 11). The seven chapters of Sections I to III incorporate: four systematic reviews of classification systems and outcome measures in traumatic brain injury rehabilitation; one qualitative analysis of patient perspectives (n=21); one registry dataset analysis (n=257); and one illustrative case study in traumatic brain injury rehabilitation (n=1). Section I consists of three chapters in the initial assessment of persons with traumatic brain injury for rehabilitation. Chapter 4 presents the classification of traumatic brain injury for rehabilitation through a systematic review. Current literature in the diagnostic criteria; severity grading; and traumatic brain injury nomenclatures are reviewed. There is a need for improved consensus in the classification system for traumatic brain injury. There is an agreement that post-traumatic amnesia is indicative of the diagnosis of traumatic brain injury if it is present following head trauma. The implications of the study for the rehabilitation assessment of persons with head trauma and the significance of post-traumatic amnesia as a case definition for traumatic brain injury is discussed. Chapter 5 presents the prognostic value of Glasgow Coma Score for traumatic brain injury rehabilitation through a trauma dataset analysis. This is an analysis of adult cases of blunt head trauma with post-traumatic amnesia. The likelihood of remaining in post-traumatic amnesia at two or three weeks is independently associated with Glasgow Coma Score at scene; Glasgow Coma Score at hospital admission; and the change in Glasgow Coma Scores in persons with post-traumatic amnesia. The importance of early Glasgow Coma Scores in traumatic brain injury rehabilitation planning is discussed. Chapter 6 presents challenges in the classification of traumatic brain injury through a case study. Disability following traumatic brain injury is determined by individual biopsychosocial factors in addition to the head trauma. Initial assessment for traumatic brain injury rehabilitation should incorporate personal factors in addition to the classification systems and the prognostic tools. Section II consists of three chapters in outcome measures in traumatic brain injury rehabilitation. Chapter 7 presents an overview of outcome measures in traumatic brain injury rehabilitation through a systematic review. The feasibility of ‘COnsensus-based Standards for the selection of health Measurements INstruments’ methodology to evaluate existing outcome measures in traumatic brain injury is discussed. Challenges in establishing the reliability and the validity of outcome measures in traumatic brain injury are addressed through a protocol based on the ‘COnsensus-based Standards for the selection of health Measurements INstruments’ for evaluating outcome measures in traumatic brain injury. Chapter 8 presents a detailed analysis of a participation outcome measure for traumatic brain injury using the four-point rating system of ‘COnsensus-based Standards for the selection of health Measurements INstruments’ through a systematic review. This study provides supportive data for the four-point rating system of ‘COnsensus-based Standards for the selection of health Measurements INstruments’. The use of this system to compare evaluative studies in outcome measures in traumatic brain injury is discussed. Chapter 9 presents a content analysis of participation outcome measures for traumatic brain injury using the International Classification of Functioning, Disability and Health Core Sets for Traumatic Brain Injury through a systematic review. Many participation concepts in the International Classification of Functioning, Disability and Health Core Sets for Traumatic Brain Injury are incorporated into existing participation outcome measures for traumatic brain injury. Implications of including non-participation concepts in the assessment of participation are discussed. Future directions for targeted and robust outcome measures in traumatic brain injury are presented. Section III consists of one study in the Australian community patient perspectives. Chapter 10 presents data for the validation of the International Classification of Functioning, Disability and Health Core Sets for Traumatic Brain Injury in the Australian community-dwelling persons with traumatic brain injury through focus groups and individual interviews. Most categories of the Comprehensive and Brief International Classification of Functioning, Disability and Health Core Sets for Traumatic Brain Injury were confirmed. Missed categories were accounted for by severity or time since injury. Additional categories were identified with implications for future applications of the International Classification of Functioning, Disability and Health Core Sets for Traumatic Brain Injury in comparable populations. This provides information regarding whether existing research and clinical perspective in traumatic brain injury are valid. This thesis examines the rehabilitation assessment and management of persons with traumatic brain injury. This thesis supports the hypothesis that current approaches to traumatic brain injury rehabilitation are supported by research evidence and patient perspectives. This has clinical implications for clinicians involved in the rehabilitation of persons with traumatic brain injury. Recommendations are made to conduct further research to improve clarity in the rehabilitation assessment of persons with traumatic brain injury and to develop targeted rehabilitation strategies for the biopsychosocial challenges which follow traumatic brain injury.
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ItemThe use of International Classification of Functioning, Disability and Health in motor neurone disease rehabilitation( 2011)Motor Neurone Disease (MND) is a relatively rare but fatal progressive neurodegenerative disorder of the motor system in adults. It causes diverse and challenging symptoms and disability. Given the broad spectrum of needs, current “gold-standard” management is ‘‘multidisciplinary care’‘ which includes neurological, rehabilitative and palliative care. This thesis focuses on the rehabilitation phases of multidisciplinary care through investigation of disability from the perspective of persons with MND and their caregivers using cross sectional and predominantly qualitative methodology. Six linked studies address current gaps in evidence-based practice and in services in MND rehabilitation. The studies review existing evidence for multidisciplinary care in MND, and explore the perspectives of MND patients and their caregivers on disability and service gaps. They further describe the disability impact of MND using a standardised framework endorsed by the World Health Organisation – the International Classification Functioning, Health and Disability (ICF) and finally, investigate the effectiveness of a peer support program, which complements rehabilitation in people with MND. Participants with a diagnosis of MND (n=44) were recruited from a tertiary MND clinic. This work was predominantly designed to test the hypothesis that issues relevant to multidisciplinary rehabilitation care from the perspective of the patient and caregiver can be addressed utilising the ICF framework. Gaps in evidence and service provision can then be identified to optimise clinical care in both clinical and research settings. Study 1 presented a systematic review of the effectiveness of multidisciplinary rehabilitation and care for MND. Despite some suggestion that multidisciplinary care improves quality of life and reduces hospitalisation and disability; findings were inconclusive as quality of evidence was poor. This study highlighted gaps in current research relating to methodological rigour and appropriate study designs and appropriate outcome measures. Studies 2 and 4 described the patient and caregiver’s perspective of MND-related disability and highlighted gaps in service and also the impact of MND on caregivers, thus allowing recommendations to be made for optimisation of clinical care and further development of service provision and health policies for people with MND and their caregivers. In particular, the need for coordinated care by neurology, rehabilitation and palliative care services (“neuropalliative rehabilitation” model) was highlighted. Studies 3, 4 and 5 moved a step towards addressing the current lack of a standardised language and consensus for the care for people with MND and their caregivers by mapping their disability experience and relevant environmental factors onto the ICF framework. Study 5 in particular explored relevant personal factors which have been identified as important but not yet been classified within the ICF. Study 6 was a small interventional study (n=7) that explored the value of a peer support program in persons with MND. Whilst the numbers were too small to make conclusive findings, it demonstrated the feasibility of such programs in persons with MND. In conclusion, the gaps in MND care identified should be prioritised for future service development using the “neuropalliative rehabilitation” model of care. For improved consensus of care and communication amongst treating clinicians, the framework of International Classification of Functioning, Disability and Health should be further explored in this population through development of a “core set”.