Transcript Oliver Zangwill Centre Presentation
Specialist services at OZC Andrew Bateman PhD MCSP
Ian ‘personal construct’ outcomes
Work hard and achieve things Happy and making others happy Head injury as the main thing in my life Feeling confident Pre-Injury self Ideal self 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 “GO OFF”, not achieve A problem for others One of the human race – just like every- one else Loss of confidence Change in ‘present self’ from start – end programme
History
Centre founded by Prof Barbara Wilson, opened November 1996 Modelled on Adult Day Hospital, Phoenix Arizona & Oklahoma programme Lifespan NHS Trust, Anglia & Oxford NHS Executive & MRC National Service Influenced by work of Prigatano, Ben-Yishay & Christensen
Who was Oliver Zangwill ?
Professor of Experimental Psychology, Cambridge University, 1952 - 1982.
1940’s Edinburgh working with war injuries.
Major influence on British rehabilitation.
First to apply neuropsychological knowledge to rehabilitation.
Mission Statement To provide high quality rehabilitation for the individual cognitive, social, emotional, vocational and physical needs of people with non-progressive brain injury
Oliver Zangwill Centre Team
Clinical Manager Director of Research Research OT Research Fellow Research Assistant Clinical Specialist OT HEAD III OT Senior I OT Therapy Assistant Specialist SALT Lead SALT Lead Psychologist Support Manager Specialist SALT (BIRT) Clinical Psychologist Clinical Psychologist Course Administrator Research Assistant Psychology Assistant Psychology Assistant Admin Assistant NeuroPage
Research student at Uni.Cambridge
Jackie Galway Andrew Bateman Neuro Rehabilitation Clinical Lead CCS, Stroke E.C. & F City & South, Huntingdon Jill Winegardner Clinical Psychologist, (B8) P/T (Clinical/Supervision 02 3/7) Research 2/7 AIMS CLAHRC Clare Keohane Head Specialist Speech & Language Therapist (8A) P/T 3/7. Mon, Tues, Thurs Cat Ford Clinical Psychologist (B8A) F/T Emma Rehab Psychology Assistant vol) Temp, F/T Barbara Wilson P/T (1/7) Leah Bousie Rehab Psychology Assistant (B4) F/T Fiona Ashworth Clinical Psychologist (B7) F/T Chantel Williams Rehab Psychology Assistant (B4) F/T Eve Greenfield Research Occupationa l Therapist MRC-CBU (P/T) Gemma Hardy Sue Brentnall Head Occupational Therapist (B8A) P/T (5½ days 28) Band 7 (vacant) F/T Carolyne Threadgold Rehabilitation Assistant (B4) P/T 4/7 Research Assistant MRC-CBU (F/T) April – 4/7 Clinical/SPM 1/7 CLAHRC Occupational Therapist (B5) F/T Anna Piasceka Donna Malley Occupational Therapist Clinical Specialist (B8A) Rachel Harrison Psychology Research Assistant Apr il (F/T) OZ 3/7 Clinical/SPM 2/7 CLAHRC (new student) Psychology Research Assistant OZ (F/T) (Voluntary) 1/7CBU Band 7 Maria Martin Saez FT Leyla Prince Specialist Speech & Language Therapist (B7) F/T Diana McCollum Specialist Speech & Language Therapist (B7) Seconded manager of paediatric team (2 Paed) 1/7 ozc clinicall (P/T 1/7) Mon Weds Michelle Young Support Manager (B5) P/T 30hrs 5½ days Supervise all admin Sharon McEwing Personal/ Administration Assistant (B3) F/T Rachel Everett Marketing & Courses Administrator (B3) P/T 20hrs 2x full days (Mon, Tues), 1x½ day (Weds) Helen Howe Bank admin P/T 12hrs Am – Tues, Thurs, Fri Donna Moore NeuroPage Administrator (B2) P/T 15hrs Full – Mon, Part Weds/Fri TEMP Band 3 (?F/T) (Amy Rideout)
The Team
3 Clinical Psychologists 2.6 (w.t.e.) Occupational Therapists 1.6 (w.t.e.) Speech & Language Therapists 3 Psychology/rehabilitation Assistants 1 Clinical Manager 4 Administrators Visiting Neuropsychiatrist (0.1 w.t.e) Access to Neurologist & Physiotherapy
Principles of rehabilitation approach
Holistic approach Addresses cognitive, emotional and social consequences of ABI Hierarchy of stages (engagement, awareness, mastery, control, acceptance, identity) Safe environment
5 activities of OZC
Assessment Rehabilitation Research Education NeuroPage service + neurorehab management for CCS
Assessment and Rehabilitation
Sources of Referrals
Private: Self-referral, relative, solicitor, insurance company.
NHS: G.P, NHS clinician, Consultant Weekly preliminary assessments Fortnightly detailed assessments 4 intakes per year for full programmes Referrals to Andrew Bateman, Clinical Service Manager.
Referral criteria
Adults with non-progressive acquired brain injury Medically stable - +/- 18 months post injury Not demonstrating severe disruptive behavioural disorders or marked physical disability Capable of managing in community B&B or self-catering accommodation.
Require IDT for cognitive, psychological and social issues restricting their participation in daily life
Client Demographics
Gender Female 27% 45+ 17% Age 16-24 19% Male 73% 35-44 22% 25-34 42% N=95
Client Demographics
Months Post Injury 5+ yrs 21% <=1 year 15% Anoxia 6% CVA 8% OHI 3% Aetiology Other 6% 4-5 yrs 14% 1-2 yrs 23% N=95 3-4 yrs 12% 2-3 yrs 15% CHI 77%
Living arrangements
Local B&B or Hotel accommodation Self-catering or rental Travel reimbursement for people receiving benefits Care support Own evening meal
Stages of Assessment
Preliminary Assessment: • 1 day • 1 clinician and assistant psychologist • Neuropsychological screening assessments & discussion with client & significant other • Future actions agreed Detailed Assessment: • 8 days • Formal neuropsychological assessments • Functional discussion & observation • Experience aspects of the programme • Future actions agreed
Assessment
Holistic neuropsychological assessment by experienced clinical team cognitive functioning, incl. attention, memory & executive skills perceptual skills speech & language skills, incl. social communication assessment of mood & behaviour independent living skills, incl. vocational aspects social context, incl. family & environmental considerations
The role of ‘formulation’
The process of deriving hypotheses concerning the nature, causes and factors influencing current problems or a client’s current situation. Considers the multitude of possible influences on an individual’s level of functioning and psychological state Helps clinician, clinical team and the client to understand the problems.
The role of ‘formulation’
Range of assessments and treatment interventions carried out by different professionals. Opportunity to bring together results of these assessments into a single coherent formulation Promotes a shared understanding of problems - visual element useful Aids team working
Family/social support Brain pathology Stroke, head injury, etc Pre-morbid factors e.g. coping style
Cognitive Impairment
e.g. Memory Perception Language Attention Executive Insight
Affect
e.g. Depression Anxiety Anger Confidence Motivation Loss
Physical
e.g. Hemiplegia Sensory loss Dysarthria Pain
Functional consequences
e.g. Work ADL Leisure Driving Evans, Wilson et al 2009
Family factors Brain pathology Aneurysm
Personal beliefs Cognition & communication
Memory Problem solving Dual tasking
Identity:
who am I now?
Affect
Depression Worry & rumination
Physical
Headache Fatigue Body image
Loss of role Functional consequences
e.g. Avoidance of children avoidance of anything that highlights difficulties A biopsychosocial model (Evans, 2002)
Holistic Neuropsychological rehabilitation aims to:
enable the client to gain awareness and understanding of the consequences of his/her brain injury, facilitate acceptance and adjustment to the consequences of brain injury enable the client to adopt compensatory strategies Therapeutic encounters are structured around the clients’ goals that will relate to functional daily activities, participation and vocational domains.
Aims of rehabilitation
Our rehabilitation aims are to: • Improve social participation • Enable engagement in meaningful activity in the home and community • Improve acceptance and understanding of the consequences of brain injury • Promote wellbeing of client and family
Environment Occupation Affective Spirituality Cognitive Physical Leisure Person From
Enabling Occupation: An Occupational Therapy Perspective, © CAOT 1997
Neuropsychological assessment Psychometric Localisation Cognitive theoretical models Exclusion models Ecologically valid models Following evaluation may need to revise approach Pre-morbid personality and life style Personality assessments Interviews European Injury Questionnaire Brain Injury Community Rehabilitation Outcomes
Patient and family
Nature of brain injury?
Severity?
Extent?
Location?
Neurological investigations Imaging Monitoring over time Reassessment Current problems Cognitive Emotional Psychosocial Behavioural How much recovery to expect?
Theories of recovery Cause of brain damage?
Studies of changes over time Assess to identify these in detail Models of cognitive functioning Language Reading Memory Executive Functioning Attention Emotional and Psychosocial Models e.g. models from Cognitive Behaviour Therapy Effect of affect on memory, attention, etc Behavioural Models e.g. SORKC Behavioural assessments Observations Natural settings Simulated settings Self report measures interviews Questionnaires Checklist Rating scales Decide on treatment (negotiate goals with patient, family and staff members) Will you focus on Impairments Disabilities or Handicap?
How will you teach/achieve this?
(Refer to theories of learning) How will you evaluate success or otherwise?
Will you try to Restore lost function?
Encourage anatomical reorganisation?
Use residual skills more efficiently?
Find an alternative means to the final goal?
Modify the environment?
Use a combination of the above?
From Wilson 2009 What evidence is there for the success of these approaches
Core Components (our reply to Prigatano core components)
Therapeutic milieu Compensatory strategies Involvement of family Psychological therapy Functional & vocational meaningful activities Shared team understanding
Stages of the Rehabilitation programme
Full Rehabilitation programme • 24 weeks total • Intensive & integration phases • 1:1 & group sessions – Cognitive group – Understanding Brain Injury group – Mood Management group – Communication group – Psychological Support group – Other groups • Client-centred goal planning Reviews 3, 6 & 12 months post-programme
IPC
Allocated at DA & for Programme/Reviews Main liaison with family and other professionals/services Oversees programme for participants Weekly contact Co-ordinates reports & referrals
Goals
Starting point at assessment with question ‘What are your goals for rehabilitation?’ Other tools used are the COPM, Rivermead Life Goals questionnaire and individual interviews.
A team meeting is used to establish ‘SMART’ wording.
Goal Categories
Understanding Brain Injury E.g. Show an accurate understanding of her difficulties and be able to explain these to 2 relatives and 2 members of the Centre staff Managing Daily Activities Independently E.g. To be able to prepare a simple evening meal for the family on a weekly basis with supervision using identified strategies
Goal Categories
Recreational Activities E.g. Will be engaged in 2 chosen leisure activities on at least a weekly basis (playing pool and wood-work).
Work or Study Plans E.g. Will be engaged in a work trial and have an identified plan for return to paid employment within 6 months.
Outcomes
Goal Achievement Standardised Questionnaires EBIQ DEX CSI EuroQuol COPM
Research
Research
Professor Barbara Wilson OBE Clinical team Development, application & evaluation of developments in rehabilitation research.
Current research programme Recent presentations & publications Links with MRC
Feeling hopeless about the future Feeling sad Feeling lonely Feelings of worthlessness Feeling inferior Feeling lonely, even when with others Feeling life is not worth living Preferring to be alone Crying easily Threshold map for depression subscale of EBIQ n=226 patients (baseline)
EBIQ Depression subscale
Four items with significant mis-fit therefore removed leaving robust 5 item scale before and after data person location data entered into t test n=44 start mean score 9.95; discharge 8.64; t = 3.4; p<0.01
Differential item functioning - before and after rehab.
Impact of rehabilitation on self rated responses to EBIQ item 9, (feeling hopeless about the future) uniform differential item function, n=44; F=4.12, p<0.05
F=4.08; p=0.04
Markers of recognition
& success at OZC
Client outcomes and feedback Visiting scholars 2008-9 from Thailand, Granada and Madrid, Toronto, Sao Paulo Published RCP guidelines for stroke Published peer-reviewed articles Published book Invited papers/conference speeches (?how many) New scholarship/learning to meet objectives eg anatomy (ongoing) vision (workshop, collaborations ongoing) New PhD students Lectureship in University Cambridge CLAHRC practitioner researchers
Courses
Courses
A series of courses & workshops are run each year Can offer courses specific to needs in topics related to neuropsychological rehabilitation Further info. on current courses go to www.ozc.nhs.uk
NeuroPage
NeuroPage
Currently 40 people using service regularly Useful for people with memory difficulties, and dysexecutive difficulties Evidence based service recent text to voice development - ideal for those who can’t read Text messaging developments, new “generations” of phones (eg video/image messages)