Service provision for adults with long-term disability: A review of services for adults with chronic neuromuscular conditions in the United Kingdom

Digital Health Rehabilitation Can Improve Access to Care in Spinal Cord Injury in the UK: A Proposed Solution

Lack of specialist beds, inadequate finance and shortage of skilled staff make it difficult for Spinal Cord Injury Centres (SCICs) in the United Kingdom (UK) to admit all newly injured individuals. Length of stay of those admitted can be too brief. At discharge, follow-up care is sparse and inadequate. We therefore propose that specialist spinal units redefine their roles and act as catalysts to build capacity by enhancing expertise in the wider community. SCICs can devolve certain tasks locally to less specialised units with their support, training, and guidance. This Commentary further proposes that use of Digital Health Technologies, (i.e., to deploy telemedicine, telehealth, and telerehabilitation), can enhance rehabilitation opportunities. The authors set-forth their vision for a comprehensive web portal that will serve as a primary resource for evidence-based practice, information on guidelines, care pathways, and protocols of SCI management. At any stage during the acute management of SCI and following discharge, rehabilitation specialists could conduct remote consultation with persons with SCI and acute care specialists via the web portal, allowing timely access to specialist input and better clinical outcomes. The proposed portal would also provide information, advice and support to persons with SCI and their family members. The strategic use of digital health technologies has been shown to result in cost and time savings and increase positive outcomes.

Transition of patients with neuromuscular disease and chronic ventilator-dependent respiratory failure from pediatric to adult pulmonary care

Improvements in medical care have allowed many children with neuromuscular disease and chronic respiratory failure to survive into adulthood. There are currently no published guidelines to facilitate transition from pediatric to adult respiratory care in this population. The transition process in neuromuscular disease and chronic respiratory failure is uniquely challenging in that the patients are often declining in health and losing independence as they approach adulthood. Barriers to transition include lack of access to adult providers, incompatible health insurance, loss of resources within patients' medical structures, absence of transition preparation, and patient and family insecurity with a new healthcare system. The six core elements and optimal time frame of transition should be applied, with special consideration of the psychosocial aspects associated with neuromuscular disease. Successful transition revolves around information, open communication between young adults and their medical care team, and individualized planning to ensure optimal health and quality of life.

Orthotic management of instability of the knee related to neuromuscular and central nervous system disorders: qualitative interview study of patient perspectives

OBJECTIVES

Adults with knee instability related to neuromuscular disorders or central nervous conditions often experience mobility problems and rely on orthoses to improve function and mobility. Patient views of device effectiveness and acceptability are underexplored. Our study aimed to elicit device users' perspectives regarding fitting, acceptability, effectiveness and use of orthoses, and identify important treatment outcomes.

DESIGN

Qualitative descriptive study using in-depth semistructured interviews. Interview transcriptions were coded and thematically analysed, using 'Framework'.

SETTING AND PARTICIPANTS

A purposive sample of 24 adult users of orthotic devices. Nineteen patients were recruited across three National Health Service sites, and five people through charities/patient support groups in England. Half of the participants had been diagnosed with poliomyelitis, and the remainder with multiple sclerosis, Charcot-Marie-Tooth disease, spinal injury or spina bifida, and stroke. The median age of participants was 64.5 years (range 36-80 years).

RESULTS

Patients' medical condition impacted significantly on daily life. Participants relied on orthotic devices to enable engagement in daily activities. Patient goals for mobility were linked to individual circumstances. Desired treatment outcomes included reduction in pain, trips and falls, with improved balance and stability. Effectiveness, reliability, comfort and durability were the most valued features of orthoses and associated with reported use. Obtaining suitable footwear alongside orthotic devices was a significant concern. Time pressures during device fitting were viewed negatively.

CONCLUSIONS

Orthotic devices for knee instability play a crucial role in promoting, maintaining and enhancing physical and psychological health and well-being, enabling patients to work, engage in family life and enjoy social activities. Future research should consider how best to measure the impact of orthotic devices on patient quality of life and daily functioning outside the clinic setting, as well as device use and any adverse effects.

TRIAL REGISTRATION NUMBER

This qualitative study was retrospectively registered as Current Controlled Trials ISRCTN65240228.

Orthotic management of instability of the knee related to neuromuscular and central nervous system disorders: systematic review, qualitative study, survey and costing analysis

BACKGROUND

Patients who have knee instability that is associated with neuromuscular disease (NMD) and central nervous system (CNS) conditions can be treated using orthoses, such as knee-ankle-foot orthoses (KAFOs).

OBJECTIVES

To assess existing evidence on the effectiveness of orthoses; patient perspectives; types of orthotic devices prescribed in the UK NHS; and associated costs.

METHODS

Qualitative study of views of orthoses users - a qualitative in-depth interview study was undertaken. Data were analysed for thematic content. A coding scheme was developed and an inductive approach was used to identify themes. Systematic review - 18 databases were searched up to November 2014: MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, Cumulative Index to Nursing and Allied Health, EMBASE, PASCAL, Scopus, Science Citation Index, BIOSIS Previews, Physiotherapy Evidence Database, Recal Legacy, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessment database, Cochrane Central Register of Controlled Trials, Conference Proceedings Citation Index: Science, Health Management Consortium, ClinicalTrials.gov, International Clinical Trials Registry Platform and National Technical Information Service. Studies of adults using an orthosis for instability of the knee related to NMD or a CNS disorder were included. Data were extracted and quality was assessed by two researchers. Narrative synthesis was undertaken. Survey and costing analysis - a web survey of orthotists, physiotherapists and rehabilitation medicine physicians was undertaken. Telephone interviews with orthotists informed a costing analysis.

RESULTS

Qualitative study - a total of 24 people participated. Potential for engagement in daily activities was of vital importance to patients; the extent to which their device enabled this was the yardstick by which it was measured. Patients' prime desired outcome was a reduction in pain, falls or trips, with improved balance and stability. Effectiveness, reliability, comfort and durability were the most valued features of orthoses. Many expressed frustration with perceived deficiencies in service provision relating to appointment and administrative systems and referral pathways. Systematic review - a total of 21 studies (478 participants) were included of people who had post-polio syndrome, inclusion body myositis, were post stroke or had spinal cord injury. The studies evaluated KAFOs (mainly carbon fibre), stance control KAFO and hip KAFOs. All of the studies were at risk of bias and, in general, were poorly reported. Survey and costing analysis - in total, 238 health-care professionals responded. A range of orthoses is prescribed for knee instability that is related to NMD or CNS conditions, approximately half being custom-made. At least 50% of respondents thought that comfort and confidence in mobility were extremely important treatment outcomes. The cost of individual KAFOs was highly variable, ranging from £73 to £3553.

CONCLUSIONS

Various types of orthoses are used in the NHS to manage patients with NMD/CNS conditions and knee instability, both custom-made and prefabricated, of variable cost. Evidence on the effectiveness of the orthoses is limited, especially in relation to the outcomes that are important to orthoses users.

LIMITATIONS

The population included was broad, limiting any in-depth consideration of specific conditions. The response rate to the survey was low, and the costing analysis was based on some assumptions that may not reflect the true costs of providing KAFOs.

FUTURE WORK

Future work should include high-quality research on the effectiveness and cost-effectiveness of orthoses; development of a core set of outcome measures; further exploration of the views and experiences of patients; and the best models of service delivery.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42014010180. The qualitative study is registered as Current Controlled Trials ISRCTN65240228.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Inclusion of persons with disabilities in systems of social protection: a population-based survey and case-control study in Peru

OBJECTIVE

This study aims to assess the needs of people with disabilities and their level of inclusion in social protection programmes.

DESIGN

Population based-survey with a nested case-control study.

SETTING

Morropon, a semiurban district located in Piura, northern Peru.

PARTICIPANTS

For the population survey, a two-stage sampling method was undertaken using data from the most updated census available and information of each household member aged ≥5 years was collected. In the nested case-control study, only one participant, case or control, per household was included in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Disability was screened using the Washington Group short questionnaire. A case, defined as an individual aged ≥5 years with disabilities, was matched with one control without disabilities by sex and age (±5 years). Information was collected on socioeconomic status, education, health and rehabilitation and social protection participation.

RESULTS

The survey included 3684 participants, 1848 (50.1%) females, mean age: 36.4 (SD: 21.7). A total of 290 participants (7.9%; 95% CI 7.0% to 8.7%) were classified as having disability. Adults with disabilities were more likely to be single (OR=3.40; 95% CI 1.54 to 7.51) and not to be working (OR=4.36; 95% CI 2.26 to 8.40), while those who did work were less likely to receive the national minimum wage (ie, 750 PEN or about US$265; p=0.007). People with disabilities were more likely to experience health problems. There was no difference between those enrolled in any social protection programme among participants with and without disabilities.

CONCLUSIONS

People with disabilities were found to have higher needs for social protection, but were not more likely to be enrolled in social protection programmes. The Peruvian social protection system should consider adding disability status to selection criteria in their cash transfer programmes as well as implementing disability-specific interventions.

Innovative care model for patients with complex muscle diseases

PURPOSE OF REVIEW

Many neuromuscular disorders require complex multisystem management. This is especially true for the rapidly growing numbers of young adults surviving congenital and childhood onset conditions following improved multidisciplinary care and the routine use of home ventilation. Surveys from the United Kingdom and Netherlands indicate that neuromuscular disorder patients report their services to be at best 'average' and more often 'poor' in quality. Centralization of care to a small number of specialist centres to increase critical mass and thus improve the expertise of clinical teams has been recommended.

RECENT FINDINGS

A recent audit of unplanned hospital admissions for neuromuscular disorder patients has substantiated data from patient surveys. Patients often had no access to a neuromuscular specialist or had fragmented care; 37.5% of 359 unplanned neuromuscular disorder emergency admissions were identified as potentially avoidable.

SUMMARY

A Neuromuscular Complex Care Centre has recently opened in the United Kingdom to provide holistic patient-centred care in a purpose built adapted environment with high staff to patient ratio. Elective multisystem assessments will be co-ordinated into a 'one stop' admission, bringing the specialists to the patient. The centre will provide first point of contact with 24-h telephone access 7 days a week and will advise and support local hospitals on the management of acutely unwell patients. Regular multidisciplinary meetings of specialized consultants and therapists will improve communication and maximize outcomes. In the long term, we anticipate this high-quality development to be cost-effective in reducing the frequency of outpatient appointments and emergency/critical care admissions.

Long term non-invasive ventilation in children: impact on survival and transition to adult care

Background

The number of children receiving domiciliary ventilatory support has grown over the last few decades driven largely by the introduction and widening applications of non-invasive ventilation. Ventilatory support may be used with the intention of increasing survival, or to facilitate discharge home and/or to palliate symptoms. However, the outcome of this intervention and the number of children transitioning to adult care as a consequence of longer survival is not yet clear.

Methods

In this retrospective cohort study, we analysed the outcome in children (<17 years) started on home NIV at Royal Brompton Hospital over an 18 year period 1993-2011. The aim was to establish for different diagnostic groups: survival rate, likelihood of early death depending on diagnosis or discontinuation of ventilation, and the proportion transitioning to adult care.

Results

496 children were commenced on home non invasive ventilation; follow-up data were available in 449 (91%). Fifty six per cent (n=254) had neuromuscular disease. Ventilation was started at a median age (IQR) 10 (3-15) years. Thirteen percent (n=59) were less than 1 year old. Forty percent (n=181) have transitioned to adult care. Twenty four percent (n=109) of patients have died, and nine percent (n=42) were able to discontinue ventilatory support.

Conclusion

Long term ventilation is associated with an increase in survival in a range of conditions leading to ventilatory failure in children, resulting in increasing numbers surviving to adulthood. This has significant implications for planning transition and adult care facilities.

Adult care for Duchenne muscular dystrophy in the UK

Survival in Duchenne muscular dystrophy (DMD) has increased in recent years due to iterative improvements in care. We describe the results of the CARE-NMD survey of care practices for adults with DMD in the UK in light of international consensus care guidelines. We also compare the UK experience of adult care with the care available to pediatric patients and adults in other European countries (Germany, Denmark, Bulgaria, Czech Republic, Hungary, and Poland). UK adults experience less comprehensive care compared to children in their access to specialized clinics, frequency of cardiac and respiratory assessments, and access to professional physiotherapy. Access to the latter is especially poor when compared to other European adult cohorts. Although the total number of nights in hospital (planned and unplanned admissions) is lower among UK adults than elsewhere in Western Europe, social inclusion lags behind other Western European countries. We observe that attendance at specialized clinic is associated with more frequent cardiac and respiratory assessments among adults, in line with international best practice. Attendance at such clinics in the UK, though comparable to other countries, is still far from universal. With an increasing adult population living with DMD, and cardiac and respiratory failure the leading causes of death in this population, we suggest the need for an urgent improvement in adult access to specialized clinics and to consistent, comprehensive best practice care.

Implementation of multidisciplinary advice to allied health care professionals regarding the management of their patients with neuromuscular diseases

PURPOSE

Patients with neuromuscular diseases (NMDs) do not always receive appropriate allied health care. This is partially because of the large heterogeneity among these conditions, some of which are quite rare. Individual allied health care professionals, therefore, have relatively little opportunity to develop relevant experience with these patients. To overcome this problem, we developed specialist multidisciplinary advice regarding management of patients with NMD for occupational therapy (OT), physical therapy (PT) and speech therapy (ST) in a primary care or rehabilitation setting. The aims of the study were to explore to what extent this allied health care advice was implemented with a focus on the amount of therapy received and to explore possible barriers to implementation.

METHODS

One-hundred two patients visited the Neuromuscular Centre Nijmegen for OT, PT and ST consultations. Integrated allied health care advice was written on the basis of these consultations and a multidisciplinary meeting. All patients, their therapists and rehabilitation physicians received this advice. Following the advice, questionnaires were sent out at baseline and at 6 months follow up, collecting data on implementation of the amount of therapy suggested and on possible barriers for adherence.

RESULTS

Advice for ST and OT was fully implemented in primary care, but only partially (58%) in a rehabilitation setting. Advice to reduce the amount of PT was implemented in only 15% of the cases. Possible barriers were related to the advice itself (feasibility of treatment duration, correctness and completeness), the patient (motivation) and the professional (experience in treatment of NMDs). Therapists expressed a desire to have the opportunity to discuss the treatment advice with the multidisciplinary team.

CONCLUSIONS

The extent to which multidisciplinary advice was implemented differed for OT and ST compared to PT and for the setting (primary care or rehabilitation). Possible barriers were identified at different levels. We recommend follow-up telephone calls to provide therapists opportunity for discussion.

Electric powered wheelchairs for those with muscular dystrophy: problems of posture, pain and deformity

PURPOSE

To identify areas of difficulty encountered by a regional wheelchair service in providing Electric Powered Indoor/outdoor wheelchairs (EPIOCs) to those with muscular dystrophy (MD) in the early years of their provision--particularly posture, pain and deformity.

METHOD

Wheelchair service records of all users between April 1997 and March 2000 were reviewed retrospectively and issues relating to weakness, pain/discomfort, deformities, other medical issues, weight change, function, posture and driving were documented on a purpose-designed proforma. Adjustments and modifications were documented over the 2-year period following chair delivery.

RESULTS

Of 325 EPIOC users on the departmental database, 29 had MD (15 Duchenne's), whose users charts were reviewed. Almost 80% of users needed clinical review within 2 years, mostly due to a scoliosis. Other problems were postural (66%), medical (48%), pain (31%), functional (24%) and weight change (14%). The commonest prescriptions were for specialised seating (24%), lateral supports, headrests and footrests (21% each).

CONCLUSIONS

The rate of disease progression was not planned for by the service. Most clients were seen in response to deterioration, rather than anticipating it. Planned reviews within 1 year appear essential for teenagers with MD with the dual issues of rapid maturation and progressive disease.

Predictors of disrupted social participation in myotonic dystrophy type 1

OBJECTIVE

To identify personal and environmental predictors of the most disrupted participation domains in people with myotonic dystrophy type 1 (DM1).

DESIGN

Cross-sectional study.

SETTING

Outpatient neuromuscular clinic.

PARTICIPANTS

Adults (n=200; 121 women), age 18 years or older (mean age, 47 y), with a confirmed diagnosis of DM1 were selected from the registry of a neuromuscular clinic (N=416). Fifty-two participants had the mild phenotype and 148 the adult phenotype.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Social participation in mobility, housing, employment, and recreation was assessed with the Life Habits Measure. Disrupted participation was based on whether help was needed in performing most life habits because of incapacities or environmental barriers. Environmental factors were assessed by using the Measure of the Quality of the Environment. Personal factors were assessed with standardized instruments including the Berg Balance Scale, the Krupp Fatigue Severity Scale, and manual muscle testing.

RESULTS

A large proportion of participants (45%-61%) reported disrupted participation in all 4 domains. Lower-extremity strength (odd ratios [OR], 15.0-5.5; P<.050) and higher fatigue (OR, 6.0-2.6; P<.05) were present in participants with disrupted participation. With regard to environmental factors, family support (OR, 3.6-2.5; P<.05) and public services (OR, 2.8-2.2; P<.05) were perceived as barriers for participants with disrupted participation in most domains.

CONCLUSIONS

This study identified personal and environmental factors that may influence the trajectory toward disrupted participation in individuals with DM1. Fatigue, strength, family support, and public services were found to be independent predictors of disrupted participation.