Team working in Rehabilitation
for neurological problems
…..a European perspective
Vera Neumann
Scope of talk
Evidence concerning value of teams in
rehabilitation:
From scientific literature
Personal experience
What makes a good team?
multidisciplinary team structure:
Who does what?
Who should lead?
Are teams really needed?
Potential disadvantages:
Patients may feel overwhelmed
Time-wasting
Increased use of (scarce) resources
Increased costs
Clinical teams - rationale
Clinical work needs a broad range of knowledge &
skills:
 selection of treatment options, often from a diverse
range. Management of, for example, back pain
may include medication, therapy and/or surgery.
Which approach?
 Co-ordination of varied interventions to achieve
agreed goals
 Critical evaluation & frequent revision of
plans/goals
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Rationale for MDTs
will any single team member
have all skills needed?
Evidence for teams in rehabilitation
From scientific literature – searched
Medline & other databases 1996-2008
Musculoskeletal rehabilitation
Cardio-respiratory ..
Neurological ..
Personal experience
Multidisciplinary teams in musculoskeletal
rehabilitation
Clinical field
Reviewer/1st author Studies (numbers
of participants)
MDT more
effective?
Generalised pain fibromyalgia
Karjalainen K,
2008
7 RCTs(1050)
“little evidence”
low back pain –
multidisciplinary
biopsychosocial
intervention
Guzman J, 2008
10 RCTs(1964)
Better function &
pain control
Following hip
fracture
Cameron ID, 2008
9 RCTs & quasirandomised CTs
(1887)
uncertain
Multidisciplinary teams in cardiorespiratory rehabilitation
Clinical field
Reviewer/1st
author
Coronary heart
disease
multidisciplinary
disease
management
McAlister FA, 2002 12 (9803)
Fewer admitted,
better control of
risk factors but MI
recurrence &
survival same
Chronic disabling
lung disease –
outpatient
multidisciplinary
rehabilitation
Griffiths TL, 2000
1 RCT (200)
lower hospital &
home visit rates
better walking &
health status
heart failure –
community MDT
treatment v usual
care
Stewart S, 2000
1 RCT (200)
Fewer admitted,
better diet & drug
compliance,
survival same
Studies (numbers
of participants)
MDT more
effective?
Multidisciplinary teams in neurological
rehabilitation
Clinical field
Reviewer/1st author Studies (numbers
of participants)
MDT more
effective?
Multiple sclerosis –
Inpatient MDT
Khan F, 2008
8 RCTs (747)
better activity
participation,
impairment
unchanged
brain injury –
community MDT v
information only
Powell J, 2002
1 RCT (110)
Probably better
than info alone
Severe TBI – MDT
v standard hospital
care
Semylen JK 1998
1 quasi-random CT Yes & carers less
(56)
distressed
MDTs in Spinal cord injury rehabilitation?
Very little published evidence…
MDTs in stroke – the evidence1
 3249 patients in Sweden, Finland, Australia, Canada &
UK randomised to stroke units with MDT working or
routine care where only 277/1346 exposed to
multidisciplinary rehabilitation.
Stroke units (with MDTs) showed:
 Better survival in 1st 4 weeks, especially in those with
severe stroke – Barthel <15/100 on admission
 fewer neurological, cardiovascular & immobility-related
deaths. Not due to medication.
 Less likely to need institutional care because less
dependant. (attributable to more carer involvement in
rehab?)
1. Stroke Unit Trialists' Collaboration. Stroke
1997
European position paper
JRM 42 ; 2010
Personal experience
Chapel Allerton Hospital, Leeds, UK
 post-acute rehabilitation following acquired neurological
(brain) injury.
 20 beds, ~140 patients/year.
MDT including:
 Nurses
 doctors
 Psychologists
 Physiotherapists
 Occupational therapists
 Speech & Language Therapists
 social workers
How our team works - 1
 Team decision on
acceptance based on
patient’s needs
potential for
improvement
resources
 Rehabilitation goals
set with patient
How our team works - 2
 Assessment –
recorded against
standardised
measures at weekly
meetings
 Multi-, inter- or transdisciplinary input to
address these
How our team works - 3
 MDT meets patient &
family to
review progress
plan further
rehabilitation
plan hospital discharge
 Referred on to community
services such as
Community Brain Injury,
Stroke or Multiple
sclerosis teams
Centre for the Rehabilitation of the Paralysed – CRP
What CRP does
physiotherapy
Making own equipment
Getting ready for home
Returning to work
Scope of talk
 Evidence concerning value of teams in
rehabilitation
 What makes a good team?
Outcome of ESPRM multidisciplinary workshop
From psychology & management literature
 multidisciplinary team structure:
Who does what?
Who should lead?
ESPRM congress workshop on teamwork
Vilnius, Lithuania. Sept 2011
Our task
To define each MDT member’s role
Core competencies
Contribution to team
in 3 situations:
Mobilisation in the acute setting following
trauma
training communication skills in the postacute setting
Community reintegration for those with
long-term needs
Results?
What makes a team successful?
physiotherapists’ views
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Communication
Cooperation
Common goals
members want to work in a team
listen to each other
respect and trust each other
speak a common language
That each team member take the responsibility for their
own professional competence and implement it
Occupational therapists’ views
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Leader ship
Size of the team
Organization support the team
Clear roles, responsibilities and functions
Time structure
Values shared
Communication
Competences needed
Skills to be able to solve conflicts
Time for team building
Effective documentation routines
Attitudes towards teamwork
Doctors’ views
 Agreed aims
 Agreement & understanding on how best to
achieve these [avoiding jargon unique to a
particular profession]
 Appropriate range of knowledge & skills for the
agreed task
 Mutual trust & respect
 Willingness to share knowledge & expertise &
speak openly
What makes a good team? Evidence
from elsewhere
What can go wrong? Interdisciplinary
working
Semi-structured interviews with experienced rehabilitation
nurses concerning their perceptions of physiotherapists
(PTs):
 PTs concerned with mobility only whereas nurses see
themselves as concerned with patients’ general wellbeing
 valued PT expertise in lifting & handling
 Frustrated that expertise not shared with them
 didn’t know why particular techniques had been selected
 had difficulty getting patients to do things they had seen patients
do with PTs
 Couldn’t respond to patients’ & Drs’ questions
 Therefore nurses didn’t continue mobility rehabilitation
eg at weekends
Dalley J. Clin Rehab 2001
Literature review
Literature review on teams & collaboration
in paediatric rehabilitation in health &
educational settings (Nijhuis. Clin Rehab 2007)
Working in Teams – report from British
Psychological Society (2001)
agreed aims and direction
good communication, avoiding jargon
Tower of Babel - Breugel
appropriate range of knowledge & skills for
the agreed task
 Strimmer for haircut?
mutual trust & willingness to share
information
Leadership???
a thorny question!
Misconceptions about doctors’ roles in
teams in UK
Doctors think they
 hold “ultimate responsibility” - can be sued if things
go wrong! GMC perpetuated this belief in UK
but
 rejected by law courts (Montgomery 92)
instead
 have a duty to provide adequate information,
training & support to others
 Each professional has individual responsibility to
uphold their profession’s standards
Role of doctor in teams?
Doctors tend to have:
 Knowledge & skills to
predict secondary
problems & prognosis
 broad training &
perspective
 training in critical analysis
Examples:
 Is it safe to transfer
patient to rehabilitation
unit or to discharge
home?
 Does patient need a
different treatment
modality?
 Is a new treatment
evidence-based, effective
& safe?
Team working in rehabilitation - summary
 Reasonable evidence that MDTs achieve better
results in low back pain, cardio-respiratory
disorders & certain fields of neurological
rehabilitation
 Theoretical basis for good team-working welldescribed in other settings
 limited evidence concerning key components of
successful teams in rehabilitation
 Leadership…open to debate!
Thank you
For further information please contact
vera.neumann@leedsth.nhs.uk