Medicine (RMH) - Theses
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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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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”.