Specialist
services at
OZC
Andrew
Bateman
PhD MCSP
Ian ‘personal construct’ outcomes
Work hard and achieve
things
1
2
3
4
5
6
7
“GO OFF”, not
achieve
Happy and making
others happy
1
2
3
4
5
6
7
A problem for others
Head injury as the main
thing in my life
1
2
3
4
5
6
7
One of the human
race – just like everyone else
Feeling confident
1
2
3
4
5
6
7
Loss of confidence
Pre-Injury self
Ideal self
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
Lead SALT
Specialist
SALT
Specialist SALT
(BIRT)
Lead Psychologist
Support Manager
Clinical Psychologist
Clinical Psychologist
Course Administrator
Research Assistant
Psychology Assistant
Psychology Assistant
Admin Assistant
NeuroPage
Jackie Galway
CCS, Stroke
Research student at
Uni.Cambridge
Jill Winegardner
Andrew Bateman
E.C. & F
Neuro Rehabilitation Clinical Lead
City & South,
Huntingdon
Clare Keohane
(Clinical/Supervision 02 3/7)
Clinical Psychologist,
(B8) P/T
Head Specialist Speech &
Language Therapist
AIMS
Research 2/7
CLAHRC
(8A) P/T 3/7. Mon, Tues, Thurs
Cat Ford
Clinical
Psychologist
Barbara
Wilson
(B8A) F/T
P/T (1/7)
Emma
Leah Bousie
Rehab
Psychology
Assistant
Rehab
Psychology
Assistant
vol) Temp, F/T
(B4) F/T
Eve
Greenfield
Research
Occupationa
l Therapist
Gemma Hardy
Research
Assistant
MRC-CBU
(P/T)
Head Occupational
Therapist
(B8A) P/T (5½ days 28)
Leyla Prince
Clinical
Psychologist
1/7 CLAHRC
Psychology
Research
Assistant OZ
(F/T)
3/7
Clinical/SPM
OZ (F/T)
Rachel Everett
(Voluntary)
1/7CBU
Marketing &
Courses
Administrator
Rachel Harrison
Occupational
Therapist (B5) F/T
Band 7
Maria Martin Saez
FT
Michelle Young
Support Manager
(B5) P/T 30hrs 5½
days
Supervise all admin
Psychology
Research
Assistant
2/7 CLAHRC
Donna Malley
Occupational
Therapist Clinical
Specialist
(B8A)
clinicall
(new student)
Anna Piasceka
Seconded manager
of paediatric team
(P/T 1/7) Mon (2 Paed) 1/7 ozc Weds
(B4) F/T
Apr
il
(B7)
(B7) F/T
Rehab
Psychology
Assistant
April – 4/7
Clinical/SPM
Diana McCollum
Specialist Speech
& Language
Therapist
Specialist Speech
& Language
Therapist
(B7) F/T
Chantel Williams
MRC-CBU
(F/T)
Sue Brentnall
Band 7 (vacant)
F/T
Carolyne Threadgold
Rehabilitation
Assistant (B4) P/T 4/7
Fiona Ashworth
Sharon
McEwing
(B3) P/T 20hrs
Personal/
Administration
Assistant
(B3) F/T
2x full days
(Mon, Tues),
1x½ day
(Weds)
Helen Howe
Bank admin
P/T 12hrs
Am – Tues, Thurs,
Donna Moore
NeuroPage Administrator
(B2) P/T 15hrs
Full – Mon, Part Weds/Fri
Band 3 (?F/T)
(Amy Rideout)
TEMP
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
Age
45+
17%
Female
27%
16-24
19%
35-44
22%
Male
73%
N=95
25-34
42%
Client Demographics
Aetiology
Months Post Injury
5+ yrs
21%
OHI Other
6%
3%
<=1 year
15%
Anoxia
6%
CVA
8%
1-2 yrs
23%
4-5 yrs
14%
3-4 yrs
12%
N=95
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
Cognitive
Impairment
e.g. Memory
Perception
Language
Attention
Executive
Affect
Insight
e.g. Depression
Anxiety
Anger
Confidence
Motivation
Pre-morbid
factors
e.g. coping style
Physical
e.g. Hemiplegia
Sensory loss
Dysarthria
Pain
Loss
Functional consequences
e.g. Work
ADL
Leisure
Driving
Evans, Wilson et al 2009
Family factors
Brain
pathology
Personal beliefs
Aneurysm
Affect
Depression
Cognition &
communication
Memory
Problem solving
Dual tasking
Physical
Headache
Fatigue
Body image
Worry &
rumination
Identity:
who am I now?
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
Affective
Social
Physical
Occupation
Spirituality
Cognitive
Physical
Leisure
Person
From Enabling Occupation: An Occupational Therapy Perspective, © CAOT 1997
Pre-morbid personality
and life style
Patient
and
family
Current problems

Cognitive

Emotional

Psychosocial

Behavioural
Neuropsychological
assessment
 Psychometric
 Localisation
 Cognitive
 theoretical
models
 Exclusion
models
 Ecologically
valid
 models
Personality assessments
Interviews
European Injury Questionnaire
Brain Injury Community Rehabilitation Outcomes
Nature of brain injury?

Severity?

Extent?

Location?
Neurological investigations
Imaging
Monitoring over time
How much recovery
to expect?
Theories of recovery
Cause of brain damage?
Studies of changes over time
Reassessment
Behavioural assessments

Observations
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

Natural settings
Simulated settings
Questionnaires Checklist
Self report measures
Rating scales
interviews
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)
Following evaluation may
need to revise approach
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)

Thank you for your attention!
[email protected]
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Oliver Zangwill Centre Presentation