Australasian Faculty of Rehabilitation Medicine

The Australasian Faculty of Rehabilitation Medicine (AFRM), a Faculty of the Royal Australasian College of Physicians (RACP), provides training and continuing education for Rehabilitation Medicine Fellows and trainees throughout all stages of their career.

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About AFRM

Our mission

AFRM Fellows and trainees are committed to providing high quality rehabilitation care to individuals and communities in Australia and Aotearoa New Zealand.

Our mission is to train, accredit and support medical practitioners in the management of functional loss, activity limitation or participation restriction arising out of illness and injury. We represent, connect and advocate for the diverse community of Rehabilitation Medicine Fellows and trainees in Australia and Aotearoa New Zealand.

 
dr-adair-profile-photo
AFRM member Dr Dawn-Louise Adair FAFRM (RACP) Ngāti Whatua, Ngā Ruahine

Rehabilitation Medicine is the diagnosis, assessment and management of an individual with a disability due to illness or injury. Rehabilitation physicians work with people with a disability to help them achieve an optimal level of performance and improve their quality of life.

AFRM Stakeholder Engagement Project

Fellows and trainees can help spread the word about the unique value of Rehabilitation Medicine for patients, other health professionals and the community by participating in the AFRM Stakeholder Engagement Project.

Scope of practice

These scopes of practice are developed to define appropriate practice for physicians who specialise in rehabilitation medicine in Australia and Aotearoa New Zealand and are adapted from the American Academy of Physical Medicine and Rehabilitation document (Physiatric Scope of Practice) with permission.

General Rehabilitation Medicine

The purpose of outlining scope of general rehabilitation medicine practice is to established parameters for rehabilitation medicine physicians who hold Fellowship of the AFRM.

The AFRM's focus on interdisciplinary training and teamwork makes the rehabilitation medicine physician the best qualified specialist to lead teams of allied health staff, nurses and other medical practitioners (specialists or general practitioners) in providing coordinated, patient-focused, individualised programs of goal-directed rehabilitative care.

General Rehabilitation Medicine is a:

  • Principal Medical Specialty in Australia and a Vocational Scope of Practice in New Zealand
  • diverse specialty whose members are trained to facilitate the best possible recovery of function over the full range of common and uncommon medical and surgical conditions seen in contemporary practice
  • practice that's collaborative and involves input from a diverse range of health care professionals focused on optimizing the health and well-being of those with short-term or long-term disability

General Rehabilitation Medicine physicians:

  • use knowledge and skills – developed through the AFRM training program, equivalent overseas or post-fellowship training – to manage all patient types with medical, musculoskeletal, neurological and neuromuscular disorders with an emphasis on maximising functional ability and quality of life
  • practice, diagnose and treat patients from adolescence and young adulthood through to the very elderly
  • can manage children in certain circumstances but generally don't provide a full range of rehabilitation services to children – see Paediatric Rehabilitation Rehabilitation Scope of Practice
  • treat patients affected by function limiting and/or painful conditions involving the central, peripheral and autonomic nervous systems, the cardiopulmonary system and the musculoskeletal system as well as those who experience disability due to illness or injury affecting other body systems
  • hold a unique blend of education, training and experience which makes the rehabilitation medicine physician an ideal treating or consulting physician for patients who have impaired function due to debility and deconditioning, including older patients and those with reduced function as a result of chronic diseases or other complex health conditions
  • are experts in the assessment, treatment and management of people with permanent disability as a result of injury or illness
  • are well placed to manage patients with occupational or sports-related musculoskeletal or neuromuscular injuries
  • use appropriate laboratory and imaging studies, but they are also trained in the clinical interpretation of other diagnostic studies that evaluate musculoskeletal and neuromuscular systems such as CT, bone scan, MRI, and musculoskeletal ultrasound
  • are specially trained in the use of therapeutic exercise, orthotics, prosthetics and other rehabilitation equipment and modalities and can prescribe these precisely to meet the patient’s specific needs
  • may engage in the delivery of health services through new models of care and modalities like in-reach rehabilitation, early supported discharge, rehabilitation in the home and other community rehabilitation and integrated care models, reablement and restorative models of care, ambulatory care services as well as virtually via telerehabilitation
  • possess a holistic approach, experience in integrated care with primary care physicians and training in leading interdisciplinary teams
  • are skilled in secondary and tertiary prevention for ambulatory patients in the community e.g. in ambulatory care services and interdisciplinary falls prevention services, as well as for patients who have stroke, neurological or musculoskeletal conditions, osteoporotic fractures or fragility, to prevent relapse or recurrence of injury or to improve function or quality of life

Rehabilitation Medicine physicians who have completed Rehabilitation Medicine specialty training have adequate training in the following areas:

  1. Inpatient and outpatient musculoskeletal and neurological assessment, diagnosis and rehabilitation.
  2. Acute and persistent pain management.
  3. Injury prevention, conditioning, fitness and wellness.
  4. Non-surgical spine medicine and rehabilitation.
  5. Rehabilitation management of sports and sports injuries.
  6. Rehabilitation management of occupational injuries and vocational rehabilitation.
  7. Therapeutic and diagnostic injection techniques, such as trigger point, soft tissue and joint injections.
  8. Assessments of function, disability and impairment.
  9. Prosthetic and orthotic prescription.
  10. Mobility aid, wheelchair and seating prescription.
  11. Rehabilitation management of patients with (upper and lower) limb amputations or limb deficiency.
  12. Rehabilitation management of patients with acquired brain injury.
  13. Rehabilitation management of patients with spinal cord impairment through injury or disease.
  14. Management of spasticity, dystonia and hypertonia.
  15. Rehabilitation management of rheumatological and other joint diseases and arthroplasty (pre- and post-surgery) and post-fracture rehabilitative care.
  16. Tissue disorders such as burns, ulcers, lymphoedema and wound care.
  17. Rehabilitation management of older people, including the management of frailty and geriatric syndromes.
  18. Rehabilitation management of pulmonary and cardiac conditions.
  19. Rehabilitation management of oncological conditions (pre- and post-treatment, and recovery).
  20. Rehabilitation of patients who are debilitated or deconditioned as a result of multi-system disease, prolonged immobilisation or prolonged hospitalisation.
  21. Rehabilitation and coordination of care and management of individuals with developmental and intellectual disorders such as cerebral palsy, spina bifida and other congenital disorders.
  22. Long term management of the person with disability, in liaison with the individual, their family and their general practitioner and other healthcare providers.
  23. Chronic diseases management, particularly in secondary and tertiary prevention, to prevent relapse or recurrence of conditions, and improve function and quality of patients, e.g. falls prevention, osteoporotic re-fracture prevention.
  24. Leadership and clinical and administrative management of rehabilitation medicine services and other related clinical services.

In addition, some rehabilitation physicians can demonstrate qualifications and expertise that qualifies them to practice in other areas:

  1. Interventional diagnostic and therapeutic spinal and peripheral pain management procedures utilising x-ray and ultrasound guidance
  2. Interventional techniques for spasticity management
  3. Electrodiagnostic medicine
  4. Manual medicine techniques
  5. Assessment of capacity and of permanent impairment, preparation of medical and medico-legal reports and provision of expert medical opinion in rehabilitation medicine

Scope of Practice — General Rehabilitation Medicine (PDF)

Paediatric Rehabilitation Medicine

The purpose of outlining scope of Paediatric Rehabilitation Medicine practice is to established parameters for Rehabilitation Medicine physicians who hold Fellowship of the AFRM and provide rehabilitation services to children and young people aged 0 to 18 years.

Paediatric Rehabilitation Medicine:

  • involves the interdisciplinary care of children with acquired and congenital disabilities with an emphasis on maximising functional independence
  • includes the provision of comprehensive rehabilitation services to children and young people with disability due to injury or disease
  • aims to enable the highest possible level of physical, mental and social functioning
  • treats inpatients, non-inpatients and in the community with congenital or acquired neurological, musculoskeletal and genetic conditions resulting in functional impairments for which rehabilitation is assessed to be beneficial in reducing the effects of disability
  • requires the coordinated efforts of an interdisciplinary team

The core competencies in Rehabilitation Medicine include but are not limited to:

  • patient medical and rehabilitation evaluation
  • patient medical and rehabilitation management
  • patient and family education and support
  • administration and leadership
  • prevention
  • continuing medical education
  • clinical research
  • quality management

Paediatric Rehabilitation Medicine physicians:

  • on occasion provide rehabilitation services to adults who have experienced congenital or paediatric onset conditions. Reference to the Scope of Practice for Adult Rehabilitation Medicine.
  • interests and expertises are not exclusive to holders of Fellowship of the AFRM
  • completion of training enables them to provide leadership to interdisciplinary teams in the provision of coordinated, patient and family-centred and goal-directed rehabilitation programs
  • recognise their own abilities and limits in the context of the rehabilitation team, provide advocacy for their patients and their families and defend their rights in society
  • are expected to continue to develop their competencies to ensure a high level of patient care throughout their practice
  • attitudes and behaviours for professional practice include:
    • patient focus
    • professional role
    • maintenance of professional standards
    • interdisciplinary management
    • patient advocacy

The AFRM affirms that all physicians who have completed Paediatric Rehabilitation Medicine specialty training have adequate training in the following areas:

  1. Inpatient and outpatient medical and rehabilitation management of children and young people with musculoskeletal or neurological conditions requiring rehabilitation.
  2. Assessment of body structure and function impairments, activity limitations and participation restrictions, and evaluation of the potential for rehabilitation.
  3. Communication with other health practitioners including other health disciplines in the formulation and execution of rehabilitation plans.
  4. Promotion of prevention and/or early identification and management of conditions that may result in worsening/progressive disability.
  5. Rehabilitation assessment and management of children and young people with cerebral palsy.
  6. Management of hypertonia and hyperkinesia, including provision of interventions such as botulinum toxin A injections, phenol nerve blocks, management of intrathecal baclofen pumps and the selection of children and young people for selective dorsal rhizotomy or deep brain stimulation.
  7. Rehabilitation assessment and management of children and young people with acquired brain injury.
  8. Rehabilitation assessment and management of children and young people with congenital and acquired limb deficiencies.
  9. Assessment for and prescription of assistive equipment including orthotics, prosthetics, mobility aids and communication devices.
  10. Rehabilitation assessment and management of children and young people with neural tube defects.
  11. Provision of information and support at antenatal counseling sessions in regard to likely outcomes for children born with neural tube defects or congenital limb deficiencies.
  12. Rehabilitation assessment and management of children and young people with spinal cord injury or disease.
  13. Assessment of skin care and management of wounds.
  14. Rehabilitation assessment and management of children and young people with neuromuscular conditions.
  15. Rehabilitation assessment and management of children and young people with musculoskeletal conditions.
  16. Rehabilitation assessment and management of children and young people with developmental/genetic/chromosomal syndromes resulting in physical disabilities.
  17. Provision of appropriate services to enable effective and timely transition to adult services for young adults with complex and chronic disabilities.

The scope of practice has been written with reference to:

  1. Australasian Faculty of Rehabilitation Medicine (AFRM) Rehabilitation Physician Scope of Practice Adult Rehabilitation Medicine (November 2017).
  2. The Royal Australasian College of Physicians (RACP). Physician Readiness for Expert Practice Training Program (PREP). Paediatric Rehabilitation Medicine Advanced Training Curriculum (December 2013).
  3. RACP Advanced Training in Rehabilitation Medicine. 2015 Program Requirements Handbook. AFRM (2016).
  4. RACP Advanced Training in Paediatric Rehabilitation Medicine. 2016 Program Requirements Handbook. AFRM, Paediatrics and Child Health Division (2016).

Scope of Practice — Paediatric Rehabilitation Medicine (PDF)

Key resources

Rehabilitation medicine resources includes information on:

Governance

AFRM governance comprises of the AFRM Council and 13 committees across education, regions, training and, policy and advocacy. Learn more about the AFRM Council and committees


Training in Rehabilitation Medicine

The AFRM oversees three RACP specialty programs in Rehabilitation Medicine: PREP General Rehabilitation MedicinePREP Paediatric Rehabilitation Medicine and the new redesigned Rehabilitation Medicine program.

On AFRM resources, you'll find key information for trainees.

We support our trainees to become competent, self-directed, lifelong learners with the professional skills and expertise to work with people with a wide variety of disabilities and improve their future outcomes.

Bi-National Training Program (BNTP)

The AFRM conducts the BNTP on the last Wednesday of every month from February to November. These training lectures are broadcast across Australia and Aotearoa New Zealand. 

Note: These sessions are not intended to prepare trainees for the AFRM Fellowship Examinations.

Register for the AFRM Bi-National Training Program 2024

Join the BNTP

Lectures are currently online attendance only and pre-registration is required. After registering, a webinar link will be emailed to you. To register, view the lecture you wish to register for on the RACP events list.

Recordings and presentation slides

Recordings and presentation slides that AFRM have permission to publish, are uploaded to the AFRM training resources page following each lecture. Trainees will require their MIN and password to access this material.

NSW Lecture Series – Wednesday sessions

The 2024 sessions of the AFRM NSW Lecture Series have been suspended from February until further notice.

We apologise for any inconvenience and hope to have the sessions up and running again soon. We will provide updates on this page when they become available.

Past recordings and presentation slides

Recordings and presentation slides that AFRM has permission to publish are available on the AFRM Training resources page. Trainees will require their MIN and password to access this material.

AFRM Trainees' Webinar series

On AFRM resources, you will find out more about the AFRM Trainees' Webinar series, formerly known as the AFRM Annual Training Meeting, including a video archive.

This is an annual event where trainees can learn exam preparation tips, the transition from trainee to Consultant and brush up their knowledge on other key rehabilitation medicine topics included in the curriculum.

Examinations

AFRM offers a number of examinations, which are designed to test your knowledge and clinical problem-solving skills. 

Find out more about our examinations.


News

Read the latest editions of the AFRM eBulletin.


Rhaïa

Rhaia banner_2020

The Rhaïa eBulletin is published for the Australasian Faculty of Rehabilitation Medicine (AFRM). The newsletter is primarily a communication for AFRM Fellows and trainees to provide up-to-date information for readers in the areas of education, practice, advocacy, research and AFRM affairs.

Read the latest editions of the Rhaïa eBulletin.

March 2024

Editor Introduction

The theme for this issue is ‘Experiences in Rehabilitation Medicine across differing cultures and communities’ and I wish to express my gratitude to my colleagues for taking the time to write about their personal experiences and for contributing to this edition. 

Most of us have travelled overseas and some have worked overseas. My own experience of Singapore was when I travelled there in 1972 as a medical student during the Christmas break. I was not impressed when immigration took me off the bus and cut my hair and gave me one day to leave. Vowing never to return I was tempted back over 30 years later when I transited on Singapore Airlines and Dr Sherry Young invited me to apply for a position at Changi Hospital. It was obviously the right move when the first advertisement I saw was one for hair restoration for my now thinning scalp. All was forgiven!

I was impressed by the cleanliness of the hospital. My own Adelaide hospital had felt the effects of the collapse of the state bank resulting in the cut back of services including the cleaning of hospitals. Many years of grime had accumulated on the windows.

As would be expected, technology was important. I was interested in the automated ground vehicles (AGV) travelling through the hospital delivering food to each of the wards. When someone stood in front of one they announced in polite female robotic English “get out of the way please, AGV coming through”. Occasionally two would come across each other and become stuck, imploring each other with the same phrase over and over, neither moving out of the way. One time, I was at a patient feedback session and after the complaints or compliments of hospital food and waiting times, an elderly lady explained that she had come to take her cognitively impaired husband home. She and the transport driver collected him in a trolley and wheeled him into the lift but instead of getting out at the ground floor, they ended up lost in the basement. In the matrix of the basement were where the AGVs resided.

Of course, the husband’s trolley collided with one, and the AGVs instantly thinking it was a food trolley, started to lift the trolley and deliver it. At that point the husband woke up, completely disoriented and confused, screaming that he was being attacked by a giant cockroach. The wife started to beat the AGV with her walking stick. Eventually they extracted themselves and made their escape. It was the best (and most unique) feedback session that I have ever had.

AGVs in the basement
AGVs in the basement

Ever since then I have treated the AGVs and the cleaning robots with great respect. You never know when Arnold Schwarzenegger may appear.

When maid robots eventually appear, I can forsee the problems that rehabilitation has with maids in Singapore being repeated. It has always been interesting to me for the team to be spending days/weeks assisting elderly patients with disability to re-learn to be independent in ADLs, but as soon as the maid appears, many are happy to lie back to be fed or pushed around on a wheelchair.

Maid in Singapore
Maid in Singapore

Terminator aside, I am very thankful for having experienced the different atmosphere of differing culture and interactions with my patients and the support and comradeship of colleagues in Singapore.

Dr Tze Chao
One of my colleagues, Dr Tze Chao Wee experienced the reverse journey, from Singapore to Australia

Roy Lee

Editor

Training Down Under in the Top End

Time flies. It has been ten years since I started my training in Australia. I am writing to share my experience as a rehabilitation medicine Advanced Trainee in Australia from the perspective of a Singaporean. Singapore has a well-established training program in rehabilitation medicine. It is a three-year program that one enters after exiting from a three-year internal medicine training program. Being a local graduate, it was an unusual decision to pursue training in rehabilitation medicine via the AFRM training route. As unusual as it may seem, I decided to do it anyway with many uncertainties in my mind.

I started training at Changi General Hospital in the eastern part of Singapore. The unit is an accredited training unit with the AFRM. My supervisor was Dr Roy Lee, who happens to be the current editor of Rhaïa. All was going well, and I could have spent four years in Singapore to complete my training. However, I thought it might be a good idea to get overseas experience, and my supervisor concurred. Thus, my journey down under began, and excitement and uncertainties were to follow.

I started looking for a suitable training position, and I recall that it was already the latter part of the year, and most jobs were already filled. I chanced upon an advertisement in the fortnightly AFRM Bulletin for a registrar position at Royal Darwin Hospital (RDH). I had been to Australia many times but never to Darwin; hence I thought it might be an excellent opportunity to spend some time in Darwin should I be accepted. I wrote in and was granted an interview. I do not have much recollection of the interview, but I guess it went well enough for me to get the job. This was followed by submitting mountains of paperwork for employment, visa, and medical registration. The whole process was very well taken care of by the medical recruitment officers at RDH.

It was early morning at the end of January 2013 when the plane touched down at Darwin International Airport. I was fortunate to secure on-site accommodation at the hospital, so I hopped into a taxi and headed straight for RDH. It was pitch dark, and I could not see much on the taxi ride. I arrived at the main door of RDH in less than 15 minutes. I went up to the security who was already expecting my arrival. He promptly took me to the temporary hospital accommodation, located across a car park, a few hundred metres away. As my family would join me soon, I was allocated a three-bedroom house. The house was rather dusty but essentially self-contained. I spent the next few days sorting out paperwork, orientation and so on before work started officially.

The first few months were a struggle. I was unfamiliar with the workflow, the computer system and did not know a single soul. Fortunately, I had a great team to work with, who were patient and tolerant of my ignorance. This included the many interns, RMOs, therapists, nurses, social workers, the all-knowing CNC, fellow rehabilitation registrars and rehabilitation physicians.

There were many interesting experiences, and I would like to highlight a few examples.

RDH has a general rehabilitation unit. It was great as the case mix was diverse and you got exposure to various rehabilitation patients, from mundane strokes and the usual brain injuries and spinal cord injuries to exotic infections, some with devastating consequences. A few notable cases included a patient who was referred for functional decline or deconditioning but turned out to be a case of Gullian Barre syndrome. Another case was that of a morbidly obese amputee who lived in a remote part of Australia for which discharge planning was a nightmare. However, it was a case where you probably learnt all the things that can possibly go wrong with discharge planning. I shall refrain from any further specifics to avoid breaching patient confidentiality.

I was very excited to be told that I would attend outreach clinics, but I did not imagine the distance involved. Coming from the island state of Singapore, where travelling 20km to work is considered far, the sheer distance of the outreach clinics was beyond my imagination. The most extreme was a trip to Gove District Hospital, just over a thousand kilometres from Darwin. We caught an early morning one-hour flight to Gove Airport in Nhulunbuy before returning the same evening. Other outreach clinics included trips to Katherine District Hospital, three hundred-odd kilometres from Darwin. In this case, the Director of Rehabilitation Medicine drove the prosthetist and I to Katherine. We set off early in the morning in darkness, and seeing the sunrise along the way to Katherine was terrific. I remember sitting in the passenger seat, trying my best to stay awake as I thought it would be rude to doze off while the boss was driving. This trip was slower paced as we stayed overnight for a second clinic the following day. However, on another occasion, it was a day trip. I cannot imagine how tiring it was for my boss to have to drive us back after a full day of clinic, but we made it back safely.

The long-case presentation was never something I enjoyed as a trainee, but I am fully cognisant of its educational value. I recall my first long case in Darwin. Before this, I had already done several long cases, so the process was not foreign to me. It was a Saturday morning, and I clerked the patient assigned to me for the long case and then presented to my consultant. I did badly, and my consultant certainly did not mince his words during the feedback. As a result, I probably suffered from ‘borderline’ post-traumatic stress disorder and dreaded long cases for some time. Looking back, I learnt a lot from that single long case, and it profoundly impacted how I approached my long cases and the rehabilitation management of patients after that. Needless to say, I passed all my other long cases after that. Being actively involved in the local rehabilitation medicine training program, I now use the long case format as the basis for case discussions with the trainees. I hope I have not caused any distress in the process.

One of my consultants arranged for us to drive around in a modified vehicle. If I recall correctly, it came with a spinner knob, and hand-operated accelerator and brake. It was not entirely intuitive, but it was an exciting experience, and I was glad I did not crash the car in the process.

Aboriginal and Torres Strait Islander peoples. I initially thought one interpreter would do all the interpreting for Aboriginal and Torres Islander languages, but I was wrong. There are some 250 Indigenous languages, including around 800 dialects, as I came to understand. While many Aboriginal and Torres Strait Islanders have conversational English skills, an interpreter is still highly valuable in the consultation to draw out specific nuances. Ineffective healthcare communication can lead to poor outcomes and distrust of medical professionals. The kinship system can be highly complex to an outsider and could have a bearing on some of the choices that Aboriginal and Torres Strait Islander people make, including healthcare decisions. I found that gaining trust through effective communication is paramount, as once I earned their trust and they understood that I was trying to help as much as possible, they were very grateful for what I did.

Apart from training and work, let me move on to something non-academic: the weather. I arrived in January, usually the wettest month of the year with monsoonal storms. I was caught in a storm on my first day after returning from the shops with some groceries and was thoroughly drenched. No umbrella is built to handle the storm. The cool season from May to July was probably the most pleasant for me. The humidity during the build-up from October to December was stifling. Darwin is in tropical cyclone territory, and I was fortunate not to experience any cyclones during my one-year stay in Darwin. The horrors of Cyclone Tracy in 1974, which devastated Darwin, are well documented by the Museum and Art Gallery of the Northern Territory, with an entire section dedicated to it. I did ask my landlord (I had moved to a private rental after staying a few weeks in the temporary hospital accommodation) what to do should there be an impending cyclone. She told me to ensure I had sufficient food and water and to hide in the bathroom. The bathroom is located right in the middle of the house with no windows and is “cyclone-proof”.

Friends. I became good friends with my fellow rehabilitation registrars in Darwin, and we remain in contact. Dr Krystal Song is a rehabilitation physician at Royal Melbourne Hospital while Dr Lucy Madebwe is a rehabilitation physician at Royal Hobart Hospital. I remember the times we spent in tutorials with the consultants, hunting down various allied health professionals for more teaching, messing around in the P&O workshop, practising for OSCEs and so on. We enjoyed coffee at the café and meals over the weekends. They were hard-working people and remained steadfast in their work. I learnt the art of perseverance from them. We shared something in common; we were born outside Australia, which is perhaps why we gravitated towards each other. We have caught up several times since I left Australia and one complaint that I have is that they have yet to visit Singapore!

I found frogs in the toilet bowl. It happened not once but several times. I did have a shock as it was totally unexpected. My first instinct was to flush it down the toilet bowl, but it did not work. All it did was give the frog a nice shower. Eventually, I had to coax it to leave the house and back to the yard where it belonged. Google says it is not uncommon, but again having lived in an apartment all my life in Singapore, frog in the toilet bowl has never been a problem.

Lastly, I must mention the good fortune that descended upon me the first week into my rotation. I was offered a car for my use during my stay in Darwin. This offer came from one of the rehabilitation physicians. The kind gesture touched me. It was a first-generation white Toyota Prius. The car was probably more than ten years old and came with a perpetual engine fault warning. We tinkered with it for a while but could not pinpoint the problem. In any case, the car functioned flawlessly for the entire year I was using it. I felt so special driving this ‘classic’ petrol-hybrid car around. It was unique and perhaps one of the few in the Territory or even Australia at the time. I took great care of the car, washing and polishing it from time to time. I am happy that I returned the car to her owner a year later, looking as ‘new’ as she was a year earlier, and accident-free.

I can go on and on. I hope I have given a snippet of my life as an international medical graduate working as a rehabilitation registrar in Darwin. It was a great experience, and I encourage trainees in other Australian states to consider a training stint in Darwin. Things may have changed since my trainee days, but I am sure time spent in Darwin will bring on a different valuable dimension of rehabilitation medicine training. I want to end by extending my appreciation to Dr Gavin Chin and Dr Howard Flavell for turning an ignorant Singaporean registrar into a rehabilitation physician, during my stint in Darwin.

Dr Tze Chao Wee FAFRM (RACP), FFPMANZCA

Changi General Hospital, Singapore

Dr Jonathan Strayer also had a mild culture shock coming to Australia from the USA:

Americans and Australians: 'Two nations separated by a common language.'

For those looking for a pithy analysis of the American medical system contrasted with that of Australia, this is not that article. For a lighter take on the Australia-USA contrasts – ­­­read on! 

On 18 March 1997, my wife Lori and I found ourselves at an altitude of 35000 feet, somewhere over the South Pacific Ocean. We were grimly chuckling at the Qantas overhead video as a duo sang a humorous ditty detailing the many blue ringed, funnel-webbed, taipan snakey and white-sharky ways one could die in our soon-to-be new home, Australia. What had we gotten ourselves into?

At that time, I had been in physiatry (PM&R) practice for four years at a top facility, The Institute for Rehab & Research (TIRR) in Houston, Texas. I was working as junior faculty in a busy academic/neurotrauma-focused facility at the biggest medical center in the USA. Certainly challenging, busy, productive and lucrative but not meeting the itch for exploration, novelty and (dare we say) adventure. 

My entry into medicine was not without obstacles. At age 18, I survived a C6,7 fracture leading to incomplete tetraplegia. As such, I was challenged throughout my training to ensure I was physically up to the task. Upon completion of my MD, I realised that working in rehabilitation medicine (US Physical Medicine & Rehab; aka physiatry) allowed me to capitalise best on my strengths and experiences. The safe course would have been to stay focused on my American academic medical career. But what fun is there in the safe course?

I had met Ruth Marshall at an ASIA (American Spinal Injury Association) meeting in 1995 and 1996. She mentioned she was recruiting for a Staff Specialist to join her in Adelaide, in exotic South Australia. We were mesmerised by tales of Oz: the climate, culture, wildlife, and of course, the Barossa Valley viticulture. We had other Australian links: I worked with Dr Stephen Wilson at the Paralympics; a colleague Bill Donovan had spent time in Perth, working with Sir George Bedbrook. Lori and I were at an opportune moment in our lives: no debt, no kids, and healthy parents – an ideal time to live abroad. One of Lori’s colleagues questioned our sanity saying, “Why are y’all going to Australia? It’s just like Texas!”

It is hard to migrate to Australia – especially as a physician. It takes persistence, endless faxes, notarising, interviewing, record requesting, and a vast amount of paper. My disability necessitated additional medical statements since Australia does not readily admit those with permanent disabilities. Our insistence on moving with our auto-baby – a 1967 Oldmobile Cutlass (dark blue with white convertible top), certainly complexified things. But in the flush of youth (and ignorance), we Strayers were absolutely up for a challenge. We landed in Sydney, met by our friend Stephen Wilson, shown around the Rehab and SCI royalty, before renting a car so we could drive to Adelaide. We were mostly successful coaching each other to keep to the LEFT, and it went well. We were struck by the beauty, lush vegetation, winding roads. Canberra was a hidden gem. Melbourne was an exciting metropolis. The Great Ocean Road inspired awe and not a little anxiety! All along friends and future colleagues introduced us to Australian art, song, and culture. We even had a short course in ‘Strine’ (thank you Stephen Wilson).

Our arrival in Adelaide was similarly warm and sunny. We loved Adelaide, with its wide streets and parklands, cafes, museums, concerts, and people. It was, as they say, ‘a large country town’. We had a temporary rental flat in North Adelaide, and I started work while Lori established our resources in the community: banking, stores, and the lot. Of these jobs, I had it easy. Certainly, there are differences in medical practice, jargon, and procedure, but humans are humans. Figuring out how to get a pint of milk in Adelaide after 7pm is (was) hard! 

My initial weeks of work were struck by several facts: first Americans and Australians are as Shaw said, “two nations separated by a common language”. Second, that medical decision making was driven largely from medical need, not corporate greed. And third, that there was virtually NO gun violence. When I’d left Houston, nearly half my SCI service was gun-related, as the USA was in the grips of a terrible wave of drug fuelled firearms injury. We were gobsmacked when we heard an Adelaide news report that ‘a convenience store was held up with a man armed with a big stick’. Yes Dorothy, we were not in Kansas anymore!

The rehabilitation community was incredibly friendly and drew me into the AFRM fold. I was quite touched, and found my new colleagues supportive, warm, and quite accepting of my disability – as Rehab Specialists should. There were caveats though. My American specialty training went far enough to start work. But to continue I’d need to complete the AFRM examinations. At that time the oral exams were modelled on the RACP – quite different to American Oral Boards. Having never failed a test since kindergarten, it is humbling to admit it took me two tries to crack that ‘short case nut’.

With time I grew acquainted with challenges in the Australian medical system. It is a system directly accountable to the patient. Elective surgery wait times were a matter for the news headlines. It was inconvenient that my patients could (rarely) appeal to the government for perceived problems with their care in the form of a ministerial. However, it was empowering to know that I could do the same. The system was accountable to each patient, not faceless insurance corporations. 

Contrast two similar patients: In the US, BR, a 28 year-old mother of two with a C6 complete tetraplegia due to car crash. She underwent surgeries acutely then diligently completed her six weeks of rehab at our centre. At the end of her rehabilitation, she was functional in her wheelchair, requiring moderate assistance for aspects of self-care and mobility. Since her private insurance didn’t provide for this, family were called upon, requiring her husband to provide care, arrange for housing adaptations, spend all their assets, and quit employment to qualify for state-provided care. A similar patient, mid-twenties woman in rural SA survived a C7 injury due to road traffic accident. She survived her acute surgery and rehab courtesy of Medicare, went home to a situation where she received support for accessible housing and limited care hours, allowing her to live independently, seek education and employment. (Specific details obscured to maintain patient confidentiality). It is (or should be) a source of national shame that in the USA more than a half a million people file for bankruptcy due to their medical expenses, contrasted with virtually none in other similar countries.

The vast thinly populated interior of Australia posed distinct challenges in delivering care. This is solved in part by bringing patients vast distances to the medical centre at Hampstead, frequently for longer hospitalisations – stay lengths inconceivable in the USA. We ran clinics in remote locations – Port Lincoln and in the Northern Territory. I participated in the initial deployment of telemedicine systems – a feature we are now all too familiar with in this post-COVID world. I was pleasantly surprised at the cultural diversity I saw in Adelaide: heavy with Asian, European, and Aboriginal influences. I had expected plum pudding and got an international smorgasbord. 

As for the administrative aspects of medical care, I found these to be similar to those in the USA, varying in structure and name, but similar in function and practice. These concerned quality measures, functional measures, hospital safety, patient confidentiality. I did chafe at the smaller menu of medications available to me, but largely did not miss these. I found the expertise at every level to be high; from doctors and nurses; to psychologists and social workers; to physios and OTs. I saw professionals proud of their work, eager to learn, collaborate, and innovate. It was not all smooth sailing, but the Ozzie collaborative spirit really came through. We did great things with modest resources.

Our path also allowed us to experience Australian medicine from the patient side as well. In 1998 our son Daniel arrived with only minor complications, and we were extremely gratified by the support services available to new families. Two years later, our daughter Brianna came along, though surprised us by making her appearance 11 weeks early. She spent many weeks progressing through Neonatal ICU to an eventual discharge home. Her care was top-notch – our neonatologist had trained in Cincinnati – my alma mater. I would note that the financial impact of this stay had it occurred in the USA would have been brutal. 

In 2001, we started asking some critical questions as to when we should head back stateside. I started casually asking my contacts and was a bit shocked at a slightly cool response. I was a bit of an exotic; not on the reliable American path anymore. It took a while to find a situation that worked, and in June 2003 we sadly bade our friends and colleagues goodbye and headed back to the USA. I entered a practice at the University of Cincinnati Medical Center, and the Cincinnati Veterans Administration Hospital. Interestingly, I found that VA medical care to be strikingly similar to that in Australia – a single payer system of care largely driven by patient medical needs, without profit mania. Though the USA has made gains in providing a fair health system to all, it still falls quite short of this mark. I am certain that many people have grown tired of me pointing to Australia as an example of what a fair, cost-effective and flexible medical system could be for us Yanks. Alas, I do not see this happening any time soon. 

At this time, I continue to work directing the Dayton VA SCI clinic. Both kids are in the middle of long, costly university careers, so I must stay in the trenches. We look back fondly at our time in Australia, and proudly regard our achievements in the Land Down Under. I am so grateful for the help and friendship we received from the medical community and specifically those in the AFRM: Ruth Marshall, Stephen Wilson, James Middleton, Miranda Jelbart, Adrian Winsor, Peter Anastassiadis, Roy Lee, Maria Crotty, Doug Brown, Sue Rutowski, Howard Flavell, Gavin Chin, and many more. It may be confusing to some of my American colleagues, but I am proud to sign my name including the letters FAFRM (RACP). 

Dr Jonathan Strayer

Dr Jon Strayer FAFRM (RACP)

University of Cincinnati Medical Center

Although this article from Spinal Cord was published in 2013, readers may find this item comparing SCI rehabilitation units between a number of countries including India, Netherlands, USA, Australia etc interesting.

Distances are not insurmountable in rehabilitation medicine as I found out from Dr Jennifer O’Riordan who was once working in both Singapore and Australia at the same time.

My whole journey into telehealth

In 2011 and 2012 I worked at Dubbo Private Hospital doing a fly in/fly out service twice a week. I established an inpatient rehabilitation unit for them and an outpatient service. The outpatient service rapidly became one catering for pain and cognitive impairment as these were the areas GPs were looking for help in.

I had planned to stay on in Dubbo for quite some time, but family circumstances took me to Singapore. The ward work was taken over by another doctor and my departure to Singapore was delayed by red tape. My outpatients were left in limbo.

It was the manager of the hospital in Dubbo at the time saying to me “you should do this new telehealth so that you can keep looking after your patients” that started my whole journey into telehealth.

So, I contacted all my referring GPs and asked them if it would work, and after ironing out a few technical issues, the overwhelming response was YES!

For rural NSW, in areas where the closest big centre is at least an hour’s drive away, telehealth has been life-changing. Imagine being the sole GP in a small town where you look after the hospital and the nursing home, and everyone else in between. Your population of patients is ageing and pragmatic and they don’t want to or can’t drive for over an hour on high-speed country roads to see a specialist. They are likely to say to you, “It’s okay doc, we trust you to do your best” but you know that your best is not what they could get if they could see a specialist.

Then these patients who trust you come to you to get their medical forms filled out for their driver’s licence, but you’re really not sure if they are safe to drive and you wonder how you are meant to work that out. You know that the patient will be devastated by the loss of their licence as it may leave them stranded on a rural property. Situations like this arise all the time for rural GPs and telehealth has given them a way to get help.

The consultations are often heartwarming, with elderly patients trying to understand this new technology, struggling to work out where the camera is, and usually talking to the accompanying practice nurse rather than myself. I have had patients jump with fright when I start talking to them, and others who kept trying to hold my hand through the screen.

I have come to know many of the GPs and nurses in these towns very well over the years and I have so much respect for what they do. The nursing homes in small rural towns are the best in the country, with staff who know the patients on a personal level, home cooked meals, and a genuine desire to keep their patients close to their homes and their families for as long as they possibly can. The remuneration in terms of financial return is poor – I bulk bill all of the patients, and many of them are very complex; but the remuneration in other ways is significant. In these consults you know how much your advice is appreciated; how much you are genuinely helping the GPs in these remote places; and most of all you know that you are providing a service to these patients that they could never access otherwise.

I have been doing this telehealth for over 10 years now and I have no plans to stop.

Jennifer O’Riordan

Rehabilitation Physician

Readers may be interested in some further information regarding telemedicine in rehabilitation. Useful links include:

Kanaga’s story

In September 2022, I experienced a life changing moment that made me realise that rehabilitation medicine has the potential to change people’s lives immensely. I shared my story with a few of my mentors and it was recommended that I write it up as an article.

In January 2017, I visited a rural sub-acute rehabilitation centre in South India called Amar Seva Sangum (ASS) – this was during my family holiday. This centre is an NGO but very unique as it is run by the disabled for the disabled. I was fascinated by the work that is done at ASS and I have been returning and doing clinics annually in person, plus fortnightly telehealth rehabilitation clinics from Australia since 2017.

ASS was founded in Ayikudy, Tirunelveli District, Tamil Nadu, India, in 1981 by Shri S. Ramakrishnan, with a handful of disabled students. At the age of 21, Shri S. Ramakrishnan was keen to become a naval officer. After completing his engineering course, during the last round of his physical fitness testing he fell and sustained a cervical spinal cord injury and became tetraplegic. In 1992, a young, chartered accountant, a wheelchair user affected by muscular dystrophy, Shri S. Sankara Raman, left his lucrative practice at Chennai and joined Shri S. Ramakrishnan. Their dream was to build a ‘Valley for Disabled’ by empowering and rehabilitating disabled people. I feel they have achieved their dream.

I wanted to contribute my expertise to this centre as it includes a sub-acute spinal rehabilitation unit, outpatient stroke, cerebral palsy, and other neurological conditions clinic. They also have a school for cerebral palsy children (from newborn on) and a normal school for low socio-economic income family’s children and children with disabilities attend this school. A few of the kids with disabilities are from very remote towns and from extremely low socio-economic backgrounds so they board at ASS for their schooling.

During my first ever visit to ASS in January 2017, I was asked to do spinal clinics. I was seeing many male spinal patients and suddenly I realised there were no female spinal patients, and in fact, there was no female spinal unit. When I asked about female spinal patients, they said we don’t have any and females don’t get spinal cord injury (SCI). I was upset and said that there are no female SCI patients because you are not catering for them, and anyone can get SCI. I rebelled and said I would not see any more patients until they let me see a female spinal patient or any female patient.

One of the female physios said there is a female polio patient, and she is in a wheelchair, if I want, I can see her. I told them to take me to her and I went to another outpatient setting and I met this girl. She was a tiny little shy girl in a small wheelchair. I was shocked to hear she was 18 years old, and she looked like a spinal bifida patient rather than a polio one. She was three feet tall and 24kg. She did not give any eye contact as she was extremely shy, so I asked her how long she had been in a wheelchair. She said she didn’t know but she hadn’t walked since childhood and her parents always carried her everywhere. She had been in a wheelchair since entering ASS.

The next question I asked was how she was managing her bladder and bowel. She said she usually didn’t get out of the wheelchair once she got into it, but if she has to, she puts plastic sheets between her wheelchair and bed, as she leaks urine continuously. She sleeps on plastic sheets, otherwise she will mess her bed. Her bowels are always a problem. She had diarrhoea one week and constipation another week, and she alternated between enema and diarrhoea stopping tablets. Clearly this girl had never been educated on bladder and bowel continence.

With her permission I asked if I could examine her genitals and do PR examination to find out about the type of bladder and bowel she had. She reluctantly agreed after all the female staff convinced her. On examination, I discovered that she had completely excoriated genitals and she had no anal tone and sensation. I suggested intermittent self-catheters to enable her to empty her bladder completely. Everyone was surprised to hear that as they had never heard of female intermittent self-catheters, but they were well aware of male self-catheters. I educated all the female staff and the patient with diagrams, and after my return to Australia, I sent them information on self-catheters.

Although I had been doing telehelath rehab clinics at ASS since 2017, I was mainly asked to see spinal patients in the subacute spinal unit. Once I asked a staff member about that girl and they said she was doing her self-catheters and got discharged from ASS as she completed her year 12 schooling.

I regularly receive pictures of the kids with special needs achievements, and at one such incident in February 2022, I was sent a picture of a girl with a trophy for playing in the national basketball championship. I felt it might have been the same girl whom I met in 2017. When I asked about the girl’s details, they said, “oh no she is the polio patient” and they called her by some other name so I didn’t give it any further thought. In September 2022, I received another picture of the same girl representing India in international wheelchair basketball winning a silver medal. This time I sent a message to the ASS secretary’s wife asking her to check with the girl to see if she remembered seeing a doctor in 2017 at the clinic. Within 15 minutes, I received a very sweet voice message from this girl saying that her name was Kanaga and she has been looking for me for the last six years to thank me, as I had changed her life completely.

I contacted the girl and asked her what she meant by it. Kanaga said that she was always told she had polio and never heard of the word spina bifida until I mentioned it to her. She was born in Elangi, a very remote town near Tenkasi and both her parents are daily wage labourers. She has two younger brothers. Since the time she was born she has had problems with her bladder and bowel and her parents took her to many hospitals for bladder issues and everyone told them that she had to live with her bladder incontinence. She and her family were used to her bladder problems and never felt it was an issue. Her parents and her brother always carried her to school. She joined the ASS boarding school as she moved to high school.

In January 2017, someone came to the hostel and said that there is a doctor from Australia who is happy to see patients, and if anyone had any problems, they should go to the clinic rooms. She thought she was fine and never considered her bladder and bowel issues real problems, so thought she needed to put up with them – and therefore she did not attend the clinic. Then at midday, she was called in and told that the Australian doctor is refusing to see patients unless she visits her – and that’s how Kanaga came to see me.

Kanaga told me that she couldn’t believe how, within five minutes, I had changed her life. She told me that no other doctor had ever asked her about her bladder or bowel.  She learnt how to do intermittent catheters and has been managing her bowel and bladder independently. She said that prior to seeing me every week, she would have urinary infections with severe tummy pain and foul smelling urine, and didn’t like to leave her home or hostel and socialise. She said she frequently had heat boil in and around her genitals and was in lot of pain.

Since the time she became continent she never looked back. She started progressing and excelling in her studies and sports and is now representing India in women’s wheelchair basketball. She completed her Bachelor of Commerce degree and is doing her MBA degree. She has developed so much confidence and is speaking up for women in wheelchairs. She has also been selected for national-level para powerlifting and won a silver medal. She said she has not had any UTIs or heat boils and she is continent of her bowels as well. She never knew she could have a normal life and achieve things.

Kanga 1 Kanga 2

When I heard her story, I was completely dumbfounded as I never realised that simple advice, which we take for granted in Australia, could change someone’s life so much. I still can’t believe how a tiny person like her – just three feet tall with such tiny arms – can be a wheelchair basketball player. This girl is mentally so strong and was just waiting for an opportunity to prove herself to the world. She had the fire in her belly to achieve so many things but was restricted due to her incontinence.

I am so proud to be a rehabilitation physician and it is true that we rehabilitation physicians definitely “make the saved life worth living”.

Dr Sumitha Gounden

Head, Rehabilitation Medicine
Orange Base Hospital

Professor Mark Slatyer was working with the ADF in Afghanistan. This record of one of those days is reprinted from Rhaïa in 2014.

A Day in Afghanistan

The morning started early at 0430 hours. I went for an 8km run around the airfield, and then popped off to the mess for breakfast, and had a trauma call at 0630 hours to check that all of the equipment, and all bays, were ready to receive whatever trauma comes in today. 
 
We started our clinic in the morning at approximately 0800 hours. I saw a range of injuries, including a cervical spine injury with radicular pain, meniscal tear, and a hyperthermia. The ambient temperature is 40° today. It is a dry, dusty heat that moves across the valley, which is part of the Silk Road that dates back thousands of years. The Base is surrounded by high mountains and in the summer, there is a sweltering heat complicated by dust and sandstorms. In the winter, in the immediate Base area, the temperature goes down to -10°, whilst outside the gate and up in the mountains the temperature can go down to -30°. Today, that is not our problem.
 
The beeper goes off and we run over to the other bombproof building across the road and prepare for three Afghani nationals who have been injured today in an Improvised Explosive Device (IED) blast. There were two young boys who were goat herding with their uncle in the mountains. Before we were allowed to see the patients, the patients must be cleared of any possible weapons or anything else that may injure us. Those are taken off them so we can commence our treatment. As this in an American facility, treatment is according to the American Facility standard, the Early Management of Severe Trauma (EMST) or Advanced Trainee Life Support (ATLS). We were running one of the trauma bays and the Americans were running the other two bays.
 
The use of ultrasound is very important. The only diagnostic imaging we have access to is plain x-ray and ultrasound. We have a small Sonosite machine, and it is used for rapidly assessing abdominal trauma or other thoracic trauma. If need be, we can do a very crude echocardiogram.
 
One of the boys comes in and we are able to diagnose that he has some fragments in his liver as we can see active bleeding. We commence resuscitation. His airway is okay. His brother is not so lucky, and he requires urgent aggressive resuscitation with blood, and he goes straight to theatre, whilst the first brother waits. He has multiple fragment wounds, and even though I am a rehabilitation physician, I end up assisting in the resuscitation before I scrub to assist two other Australian Medical Officers in the abdominal surgery.
 
What strikes you is the severity of the injuries. Blast injuries give you much more complex injuries which can involve the airway, the abdomen, and limbs, and the change that has occurred in the surgical management of these patients is incredible, very dramatic, and very different.
 
Many of the changes that have occurred in surgical care will not enter civilian practice for many years. There is even implementation now of freeze-dried blood, and some of the evacuation techniques, e.g., the use of unpiloted drones as aerial ambulances, is currently undergoing trials by various Defence Departments.
 
We finish the surgery: it went for about two and a half hours, and then we go back for a cup of coffee and a little bit of sit down for a while. I see a couple of patients, one with heatstroke, another with gastroenteritis requires IV infusion, and then we get organised, put on our body armour, get out weapons and go up to the Afghani National Army (ANA) camp, to mentor the medical officers in their compound at Tarin Kowt.
 
It is easy to be critical about the ANA:  we come from a different culture, and we are very different. 

ANA have very different backgrounds: their training is not the same as it is in Australia to be medical officers, and they require a lot of assistance. Some of the medical officers are incredibly bright and very motivated, and require little supervision, while others require a lot more supervision and training.
It is good work, I enjoy it. You cannot be impatient with them. You have some chai, as long as it is not Ramadan, and continue on and try and do what you can to make things better for the local population, as well as the army personnel.

The Afghan people are very hospitable and very generous people and, despite the religious and cultural differences, I find them easy to work with. Not everyone does but I enjoy the work although it is very demanding. There are other jobs that I cannot really talk about, but overall, it is a long day that can go on from early morning up to twenty hours/day. We are on-call for emergencies in the hospital as well as primary care activities, which can occur at any time. Some of it is primary care, some of it is rehabilitation, a lot of it is trauma emergency medicine, but I enjoy it.
 
I have done eight trips to the Middle East in the last six years, and it has taken its toll in terms of my absence from practice. Mostly my colleagues are understanding, but sometimes they are not.
 
How long will it go on? Our political leaders are telling us that it is phasing down, however there is a lot of medical work, and I am not sure what role, if any, I may play in the future.
 
I commend being in the ADF as a specialist. It offers unique and very satisfying experiences under extreme circumstances.

Professor Mark Slater

It is not just overseas, but also in Australia, that rehabilitation medicine can be a challenge when faced with someone with a diverse background as Dr Wan Mei Ang explains:

An ordinary day in my orthotics clinic

I was working in with my experienced orthotist, Sarah when a new patient walked in with an altered gait, not unexpectedly. It was Mrs M. She was a Middle Eastern lady in her fifties, accompanied by a caucasian lady of similar age. My first thought was ‘this must be the interpreter’. The note in the ‘remark’ column of my clinic list, however, said “Interpreter offered but patient declined”. I was slightly puzzled. We went on introducing ourselves to each other. Mrs M was from Afghanistan. The lady with her was Annie who said she was a family friend who knew Mrs M well and could help in the communication process, although she did not speak Mrs M’s language, Farsi. I became a little more puzzled. I started by explaining that we would usually prefer to have an interpreter. Both Mrs M and Annie declined.

As the history taking began, I got to know that Mrs M had late effects of poliomyelitis. She had her first knee-ankle-foot orthosis (KAFO) made after arriving in Australia, about 15 years ago. The KAFO was very aged, way beyond repair, but she had insisted on continuing to use it and had refused to try using her spare KAFO made (overseas) two years ago.

“Do you have falls?” I asked Mrs M. “Yes”. “What causes the falls?” She smiled politely at me. “How do you fall?” “I go on the floor. Then pain here,” she said, pointing to her lower back. Annie tried. “What makes you fall?” “What are you usually doing when you fall?” No response apart from nodding.

Our orthotist picked up the KAFO. The knee joints were flimsy. Mrs M probably fell when the knee failed to lock. I suggested getting an interpreter at this point. “I think we’ll be okay. We’ll see how we go.” Annie insisted. Annie went on to explain that Mrs M struggled with many domestic tasks. With the bilateral Trendelenburg gait, she showed on her short walk in and her failing KAFO, it was not difficult to understand why. She lived with her brother and her elderly mother who had Alzheimer’s dementia. She was the carer for her mother and, in fact, received Carer Payment. I asked whether Mrs M had any formal support services. She told me she had applied for the National Disability Insurance Scheme (NDIS) recently but had been rejected. I tried to explore the reasons for rejection. This time I was met with head shaking, and a faint smile with a sense of bewilderment.

After completing a physical examination, the orthotist Sarah and I decided that it was safest for Mrs M to start using her spare KAFO while we kept her preferred, aged KAFO in the department as reference for fabricating a new one. We knew that getting accustomed to a new KAFO would not be easy, as she would be like many other patients who preferred their old shoes, old prostheses, and old braces.

Pointing to the spare KAFO Mrs M brought in, which was made two years ago and appeared to be appropriate and functioning, Sarah said, “We’d like you to start wearing this new brace. The old brace is too old, it’s not safe to be used any more. We have to keep it here. We will make you a new one similar to it.”

Orthotics clinic

“When can you repair (this)? This is falling down,” Mrs M asked, pointing to the thigh band of the old KAFO with torn leatherwork. “Can you do this today? I can’t walk without it.” Annie intervened. “No, you cannot take it home with you. It’s not safe to use anymore.” At this point I decided that it was impossible to continue without an interpreter. After a long wait, we finally gained access to a phone interpreter. It took another 5 to 10 minutes to get the message about the new KAFO across.

We then talked about NDIS. I explained that I was happy to provide a medical support letter for her reapplication. I explained that I was concerned about her current carer role for her mother. After another 15 minutes of talking via the interpreter, it turned out that Mrs M had responded in her first NDIS application that she was ‘completely independent’ in all her functional tasks, for fear of losing her entitlement to the Carer Payment. It took yet another 15 minutes to explain to Mrs M that continuing to provide hands-on care to her mother when she herself suffered deteriorating mobility could prove detrimental to both her and her mother, and that she should accept help whenever required, whilst exploring alternative income sources that might suit, such as the Disability Support Pension.

In the end, Mrs M walked out after 1 hour and 30 minutes of consultation time, while my next two patients waited with growing impatience. Before walking out (in her spare KAFO which seemed to fit perfectly - well, at least for now), she said in her limited English, smiling and pointing to the orthotist Sarah and myself, “Thank you to the two doctors. Other doctors don’t tell me what happens.” I smiled back, and for a moment, we connected – without needing a word in common. My ordinary day in clinic was perhaps not so ordinary after all.

This scenario will not be new to many of us. It is just yet another example to highlight that challenges in providing healthcare to people of culturally and linguistically diverse (CALD) backgrounds lie not just in the language itself but cover the realms of health literacy, as well as cultural expectations and understanding.

NB: Names have been changed for identity protection.

Dr Wan Mei Ang

Upcoming editions ...

The theme for the next editions of Rhaïa are:

  • Physician health and lifestyle
  • Ethics and rehabilitation medicine
  • Administration, research, education and AI

I welcome any charities from our AFRM family on any of these or other topics.

January 2022

Editor introduction

This Rhaïa edition provides insight into cancer, spinal cord injury (SCI), and geriatric rehabilitation. Firstly, it is pleasing to see a lot more activity and growing interest amongst our colleagues, especially our younger Fellows, in the cancer rehabilitation space. Cancer patients are increasingly needing access to rehabilitation care and interventions. A recent exploratory pilot survey of rehabilitation colleagues working in cancer rehabilitation in Australia and Aotearoa New Zealand (AoNZ) identified inadequate funding, lack of staff with expertise, and lack of collaboration between acute cancer care services and rehabilitation as major barriers towards successful implementation of cancer rehabilitation programs.1

The hope is to gradually dismantle these barriers, support a strategic approach to ensuring that cancer rehabilitation programs are available in our region, and develop sustainable, holistic cancer care models. Our cancer Special Interest Group (SIG), relevant working groups, and interested rehabilitation Fellows will play a vital role in promoting the awareness of cancer rehabilitation amongst acute specialty teams and community care providers. They will contribute to capacity building, establishing clinical guidelines, policies and pathways, encouraging research activities, and increasing advocacy of this area for the future.

With SCI rehabilitation, the latest SCI data from the Australian Spinal Cord Injury Register (ASCIR) showed 187 new cases of adult traumatic SCI in 2017-2018.2 Similar to previous findings, the majority were of younger age (25-34 years old), male gender, had neurological level of injury at C4 and incomplete tetraplegia (43 per cent) at discharge. Land transport crashes (46 per cent) represented the leading cause, followed by falls (36 per cent). For non-traumatic SCI (vascular disorders, degenerative conditions, cancer), out of 131 cases, males accounted for 60 per cent and the mean age was 58 years (range 19-89 years).

As we are aware, the short- and long-term disabilities faced by SCI patients are multiple. Useful resources can be found on SCI organisational websites (AQA Victoria, ParaQuad Tas, ParaQuad NSW, Spine & Limb Foundation WA, SCIA, SpinalCure, Spinal Life) and through societies such as ANZSCoS and ISCoS. Interesting research trials being undertaken include the eWalk (transcutaneous neurostimulation for SCI, Sydney) and robotic assisted game-based therapy.

We are also facing a population with increasing life expectancy. The need for ‘geriatric rehabilitation’ is growing in our region and so is the need for rehabilitation physicians with the essential skills to manage issues in older people. These can include sensory impairments (vision, hearing), falls, osteoporosis, malnutrition, depression, and cognitive impairment, including delirium and dementia. Professor Ian Cameron flags this area as a critical topic and Professor Mary Galea discusses osteosarcopenia.

I would like to express my utmost appreciation to all of our writers for their contribution to this edition of Rhaïa especially during a very busy and challenging year. If you have any interesting rehabilitation news that you would like to share with your colleagues, please let us know and we can include it in future publications. I wish you all the very best and I am sure that we are all looking forward to new and exciting things ahead in 2022.

Dr Krystal Song
Editor

References:

  1. Song K, Amatya B, Khan F. Cancer rehabilitation in Australia and New Zealand: a pilot cross-sectional survey. The Journal of The International Society of Physical and Rehabilitation Medicine 2021; 4(3): 146-155.
  2. Australian Institute of Health and Welfare: Harrison J, O’Brien D, Pointer S. Spinal cord injury, Australia, 2017–18. Injury research and statistics series no. 136. Cat. no. INJCAT 219. 2021. Canberra: AIHW.

Readers, please note that the below articles were written several months ago. Given the fast changing circumstances of the COVID-19 pandemic, some information may have changed since the articles were originally written, particularly in relation to the COVID-19 situation in Victoria.

President’s Report

I congratulate Editor Krystal Song for drawing together three very important areas of rehabilitation practice: cancer rehabilitation, spinal cord injury, and geriatric rehabilitation in this edition of Rhaïa.

I hope all three areas are now seen as core business by rehab medicine departments, but it was not always thus. They remind us how things change. Spinal Injury units were first established many decades ago in response to the number of young patients who were catastrophically injured in accidents, and whose prognoses were dire without specialist knowledge and treatment. The demographics have changed greatly during my career from a predominantly young person’s injury to one which is now seen almost as frequently in a much older population, related to falls.

In the early part of my career, cancer treatment was not something that involved rehabilitation services much at all. Fortunately, this has changed in the past 20 years and much of the credit is due to passionate advocates such as Professor Andrew Cole, who has contributed to this edition. Geriatric rehabilitation remains a very important part of practice for many of us and an important interface between us and our geriatric medicine colleagues in many of our hospitals and community practices.

Our colleague, Dr David Bowers, passed away recently and unexpectedly in the full flight of his professional career. Many of you would have known him, a spinal injury rehabilitation physician at the Royal North Shore Hospital in Sydney. Fitting tributes to his care and compassion were expressed on behalf of his colleagues and patients at his funeral service which was, of course, greatly limited in scope due to COVID-19 restrictions. On behalf of the Faculty, we would like to convey our sincere condolences to his wife and children.

Work at the Faculty continues on many fronts in a COVID restricted way, just as you are experiencing in your own hospitals and practices. We continue to meet regularly at executive and council level but these are all virtual meetings now. The unpredictable nature of the pandemic continues to frustrate attempts to normalise events. My recent plan to attend the New Zealand Rehabilitation Association meeting during the travel bubble and when things were more settled evaporated very rapidly and now appears hopelessly optimistic in retrospect. You probably have started attending virtual international meetings as I have. Whilst I find the convenience of not having to travel very helpful, I have had to confront the reality that these sessions are generally live in the middle of the night here, which tends to be rather disorienting if not overpoweringly soporific.

All the Faculty Examinations for 2021 have concluded, including the delayed Victorian Module 2 Examination in Melbourne, which was held on October 10th. Clearly, the COVID situation in Sydney and Melbourne were of concern and there was a contingency plan to delay until November if needed. We have started preparations for our 2022 examinations. The landscape for next year is not clear yet, although with vaccination rates at the level that they are, we are hopeful that there may be more normality by that time. Meetings of the Examination Working Group, comprised of the Faculty Executive, Chair of Assessment Committee and College education staff have been a regular feature of the last 12 months.

We are progressing our plans for a greater academic presence by virtue of a permanent academic post on the Faculty Council, which is underway and will link to a permanent research committee of Council. We continue to meet regularly with the Australian Rehabilitation Outcomes Centre (AROC), represented by the Director of UOW Health Services Research Institute Kathy Eagar, newly appointed Medical Director of AROC Maria Crotty, and recently appointed Director of AROC Ross Clifton. AROC is currently undergoing a strategic review, seeking to use its reputation as the best health benchmarking system in Australasia to seek ways where that data can be used to influence health policy at a state and national level. We are currently still seeking a Chair of the Management Advisory Group to replace Dr John Estell whose term finishes soon.

The place of rehabilitation in COVID-19 continues to be a very important topic. Dr Susan Graham represents the Faculty on the College’s COVID-19 Expert Reference Group and was recently involved in organising webinars on Long COVID. We remain concerned at reports of reduction in rehabilitation services and resources throughout the country in response to the need to expand acute services, particularly in Sydney recently and in Melbourne last year. Our concern is that these resources are often not restored or alternative proposals seem to appear almost under the guise of COVID. The literature suggests that there will be significant need for rehabilitation services for so called Long COVID and we need to be mindful that this may be the opportunity to ensure that rehabilitation services are not allowed to be permanently reduced and marginalised.

The College launched the ROC (RACP online communities) with the official launch of the Faculty community in October. I urge all members to join the online community. We hope that it will provide an easy method of communication between members, which will avoid the previous intractable problems when lists of email addresses were not available. We hope to be able to set up much easier direct communication for Branch Committees and Special Interest Groups.

There are always vacancies occurring in Faculty Committees, all the way up to executive and we are constantly looking to identify the next generation of Fellows to take over the important roles at the head of many of our committees. We need long-term successors for the Chairs of the Faculty Assessment and Faculty Training Committees and the President-elect becomes available in May 2022. I ask that all New Fellows consider where you could help and where your interest may lie. Those who have been working hard on committees already are requested to seriously consider moving to the Chair of the committee if you can. Committee members are often in the best position to take over the chair as they have a good understanding of how the committee works. It is often more difficult for someone to step in as the Chair of a committee when they have not been involved within before.

Rural colleagues have recently raised the issue of lack of continuity of trainees working in rural services and the difficulties this raises for their services from time to time. The rural workforce is a very big issue at both government and College level. The maldistribution of our health workforce is well documented and is indeed part of the problem with Indigenous health. Dr Jeremy Christley is the Faculty representative on the College’s Regional and Rural Physician Working Group. Rural training is a complex issue and one which the Faculty considered formally about 10 years ago, although the focus was about attracting Fellows to work in the country.

Trainees who have worked in the country are more likely to consider a rural career as a realistic option. I have had recent talks with the Australian College of Rural and Remote Medicine and the Rural Health Alliance both of whom understand the issue of convincing health professionals to see a rural career as a realistic medium- or long-term option. This is a complex issue and needs consideration of both the projected long-term rural workforce, the quality of the training experience, and the burden, both socially and financially, on trainees particularly now that many of our trainees are older than a generation ago and their life can be correspondingly more complicated. I am hopeful that if we can delineate and try to address the economic and social disincentives where they exist and simultaneously promote the value of rural training, this will allow us a non-controversial path to increase the number of trainees taking up country positions.

Please continue to make yourself aware of our College and Faculty prizes available every year. Please take the time to look at the College website and consider your colleagues who might be appropriate to nominate for these medals. There are several scholarships for those wishing to undertake research, with some specifically reserved for AFRM trainees and Fellows and others available to the wider College membership. Please promote these to your trainees and New Fellows who may be interested in a career in research.

A considerable amount of time was spent during the last two to three years developing materials to support an increase in the profile of rehabilitation medicine. These include PowerPoint presentations, brochures, and letters of introduction that can be used by Fellows to inform employers, area health service executives, and other health stakeholders of the value of rehabilitation medicine and its contribution to the health landscape. Unfortunately, much of this effort has been swamped by the pandemic that essentially sweeps all before it, but we have continued to meet with stakeholders to help them understand more about who we are and what we do. I have found these meetings to be beneficial, making personal links to partner organisations when the time is appropriate.

I continue to be very grateful for the support and assistance of my fellow Executive Members Jenny Mann (President-elect), Tim Geraghty (immediate past President), Caitlin Anderson (Chair, Faculty Education Committee), and Richard Seeman (Chair, Aotearoa New Zealand Branch), as well as our College staff, Jane Henderson (Executive Officer), Jo Goldrick (Faculties Manager) and Phil Munro (Peak Bodies Manager). I wish you all the very best in these trying times and we look forward to when the coming and expected COVID surges in New South Wales and Victorian hospitals have passed their peaks.

Dr Greg Bowring
AFRM President

Cancer rehabilitation

Until recently, cancer survivors have comprised only a small part of most rehabilitation physicians’ case load. Although some cancers have long been cured with early treatment, recent advances in chemotherapy, radiation therapy and immunotherapy now mean that treatment of quite advanced metastatic disease can lead to prolonged patient survival, for example with melanoma, breast, and prostate cancer. This, however, may be associated with significant impairment and functional disability. In this century, cancer has become another chronic disease, and survivors will respond to rehabilitation programs, just as others living with more ‘benign’ diseases do.

Rehabilitation helps cancer patients maximise their functional abilities and quality of life at each stage in their journey, as first recognised by Dietz in 1969. Programs start with preventive measures from the time of first diagnosis, later using restorative measures to regain premorbid functions lost with cancer treatment or combined with the effects of frailty in older cancer survivors. If significant physical problems are present (e.g., neurological or musculoskeletal impairments after treatment of cancer), intensive goal-orientated multidisciplinary programs are of great help. Finally, even in the later stages of the journey, relatively simple rehabilitation interventions provided jointly with palliative care clinicians can maximise residual mobility, activities of daily living or continence function, and greatly improve quality of life for both patients and their carers.1

Oncology care clinicians may not be aware of good outcomes from rehabilitation, may be focused on disease management rather than functional decline, or may wrongly think that if cancer-modifying treatment is of no further use, then rehabilitation also has little to offer. Likewise, cancer survivors and carers may assume and simply accept that progressive functional loss is inevitable with disease progression. All these are barriers to cancer survivors receiving appropriate access to rehabilitation.

Apart from major physical impairments, uncontrolled pain with depression, decreased activity and deconditioning are major causes of lost functional ability. It is important that baseline rest pain is properly controlled, with extra analgesics prescribed prior to general activities likely to provoke episodic pain (e.g., physiotherapy). Other activities that cause pain can be carefully deconstructed, to identify the specific motion or position that triggers pain, which can then be dealt with.

Both frailty and cancer are not uncommon in older people, and presence of frailty may well predate a cancer diagnosis. With early recognition, the older cancer survivor can be moved towards a non-frail state if given a combined program of nutritional support and physical exercise. This is especially important if there is complicating nausea or anorexia associated with chemotherapy or radiation therapy programs. At any age, if deconditioning is present in a cancer survivor, they should be offered an appropriate rehabilitation program for this, especially if their goals in life recovery include a return to work.

For cancer survivors with neurological deficits due to primary or metastatic brain or spinal cord lesions, and where the underlying malignant disease process has been treated and stabilised, there is good evidence that they respond to rehabilitation therapy with similar functional recovery, as do patients recovering from strokes or spinal cord ‘benign’ lesions, matched for anatomical location. This applies to therapy programs in individuals with speech and/or cognitive involvement, as well as with peripheral neurological involvement, whether from chemotherapy or individual peripheral nerve impingement by tumours.

It is particularly important that cancer survivors with brain stem disease are offered detailed speech therapy, occupational therapy, nutritional and swallowing programs, with appropriate dietary modifications or alternative feeding approaches, to avoid chest infections and frustrations with dysarthric speech and visual/coordination problems.

As with all rehabilitation, training and support of carers is most important, to maximise quality of life at home for the cancer survivor and their family/carers.

There is no place for therapeutic nihilism in the rehabilitation of a cancer survivor!

Associate Professor Andrew M Cole FAFRM
HammondCare Health, Greenwich Hospital
UNSW, School of Population Health NSW

References:

Cole AM. Medical rehabilitation and the palliative care patient. In: Cherny NI, Fallon MT, Kaasa S, Portenoy RK, Currow DC, editors. Oxford Textbook of Palliative Medicine. 6th ed. Oxford, England: Oxford University Press; 2021. P.255-264.

An update on cancer pain

Cancer rehabilitation is increasingly recognised as a crucial component of care for cancer survivors, with rehabilitation clinicians playing an integral role in supporting cancer patients during most phases of their cancer trajectory.1,2 Cancer pain is one of the most common symptoms experienced by cancer patients, with potential occurrence in any cancer type and at any stage from diagnosis to end-of-life care.3 Cancer pain can be classified as acute or chronic pain, and is defined as ‘pain that arises from cancer itself and/or treatment-related complication(s)’.4 If not managed well, cancer pain can have a significant impact on patients’ physical and psychological functions, resulting in difficulties carrying out their day-to-day activities and community roles.

Cancer pain is a complex condition that involves various pathophysiological mechanisms. Common cancer pain syndromes include chemotherapy-induced peripheral neuropathy (CIPN), pathophysiological fractures, widespread pain syndromes and persistent post-surgical pain.5 Contributing factors include nociceptive pain from surgery, radiation therapy, and cancer itself, from invasion of cancer into tissue or bone.

Peripheral and central sensitisation from persistent inflammation and repeated nociceptive input from cancer treatment and investigations may also contribute to persistent cancer pain.6 Many factors influence the experience of cancer pain including the patient’s background, experiences, cognitive status, and perpetuating biopsychosocial factors such as dealing with the notion of death, fear of cancer recurrence, and traumatic experiences from cancer treatments.7 Therefore, a thorough assessment of cancer pain is essential in understanding the mechanism of pain, patient factors, prognostic factors, and expectations of pain management to help guide appropriate treatment.

To date, there is limited evidence for the most effective treatment for cancer pain. Overall, a multidisciplinary approach to pain management is recommended due to the multi-faceted nature of cancer pain and associated symptoms that co-occur such as fatigue, anxiety and/or depression. Pharmacologically, opioids remain the mainstay of treatment for cancer pain but there is increasing awareness of the detrimental long-term effects of opioid use, especially in those with chronic pain syndromes. Side effects include constipation, cognitive impairment, endocrine disorders, and dependence.

Anti-neuropathic agents commonly used in cancer pain include anticonvulsants and antidepressants, but their efficacy is mixed and limited in evidence. Other adjuncts include steroids, alpha-agonists, and anti-inflammatories. Medicinal cannabis is emerging as an option but there is lack of evidence for its use in cancer pain, with implications of cost and tolerability in Australia.8 Non-pharmacological strategies and interventional techniques may be effective in opioid-unresponsive pain and should be considered to reduce polypharmacy and its effects. Nerve blocks, such as epidural injections, can be considered if there is an anatomical target or nociceptive driver. For those with opioid-unresponsive pain or side effects, an intrathecal opioid pump could be considered.

In conclusion, due to the complexity of cancer pain and its management, current evidence supports a more holistic approach to the management of cancer pain, with beneficial effects shown for rehabilitation programs incorporating multimodal interventions such as exercise and psychological strategies.

Dr Jamie Young MBBS, FAFRM, FFPMANZCA, Clin Dip Pall Care, AFRACMA, PhD
Pain & Rehabilitation Specialist
Peter MacCallum Cancer Centre VIC

References:

  1. Lisy K, Denehy L, Chan R, Khan F, Piper A, Jefford M. The state of cancer rehabilitation in Australia. Journal of Cancer Rehabilitation 2018; 1:9-13.
  2. Chowdhury RA, Brennan FP, Gardiner MD. Cancer rehabilitation and palliative care - Exploring the synergies. Journal of Pain and Symptom Management 2020; 60(6): 1239-1252.
  3. Van Den Beuken-Van MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. Journal of Pain and Symptom Management 2016; 51(6):1070-90.
  4. Yoong J, Poon P. Principles of cancer pain management: An overview and focus on pharmacological and interventional strategies. Australian Journal of General Practice 2018; 47(11):758-62.
  5. Caraceni A, Weinstein SM. Classification of cancer pain syndromes. Oncology 2001; 15(12):1627-40.
  6. Falk S, Bannister K, Dickenson AH. Cancer pain physiology. British Journal of Pain 2014; 8(4):154-62.
  7. Zaza C, Baine N. Cancer pain and psychosocial factors: a critical review of the literature. Journal of Pain and Symptom Management 2002. 24(5):526-42.
  8. Lintzeris N, Driels J, Elias N, Arnold JC, McGregor IS, Allsop DJ. Medicinal cannabis in Australia, 2016: the cannabis as medicine survey (CAMS‐16). Medical Journal of Australia 2018; 209(5):211-6.

Breast cancer rehabilitation: Current challenges

It is estimated that over 19,000 Australian women were diagnosed with breast cancer in 2020. This is a startling statistic, but encouragingly, over 90 per cent will survive at least five years.1 During my time seeing women for rehabilitation who have had a recent diagnosis of breast cancer, I have been in awe of their overwhelming positivity, future-thinking approach, and their remarkable ability to continue being mother, daughter, wife, friend and work colleague during what will be one of the most challenging and demanding times of their lives. For this very reason, breast cancer rehabilitation needs to be multi-faceted. It needs to assist women physically, emotionally, and practically to return to these roles which give their lives meaning and purpose. 

The list of potential complications following breast cancer treatment is long. Physical effects, which are not necessarily any more or less burdensome than many of the emotional and psychological challenges, include lymphoedema, nerve palsies, chemotherapy-induced peripheral neuropathy, joint pains, fatigue, hot flushes, cording, adhesive capsulitis, osteoporosis, treatment related cardiac toxicity, and cancer-related fatigue. As rehabilitation physicians, we are uniquely placed to assist in the treatment of every single one of these issues. Yet, unless patients are referred to us, our skills go unused and patients miss out on prevention of and early intervention for cancer and treatment related complications.

As an example, a study by Younus et.al (2010) reported that 83 per cent of patients on aromatase inhibitors (AI) described joint-related pain, but only six per cent were referred to rehabilitation.2 Yet, the first line treatment for AI related joint pain is exercise. A breast cancer diagnosis should go hand-in-hand with a referral to rehabilitation, since increasing evidence is available for the benefits of exercise pre-surgery and whilst undergoing chemo- and radiation therapy treatment. At present, it is common for acute cancer care services to make a referral to rehabilitation once treatment is close to completion. However, a proactive approach to rehabilitation involving referral at time of diagnosis can help identify current issues and anticipate future impairments that may occur as a consequence of treatment or disease progression. Increasing awareness of the benefits of early rehabilitation amongst the community is also key; patients are powerful in initiating their own referrals. If patients knew that exercise improves survival and reduces all cause and breast cancer mortality, wouldn’t more patients ask their oncologists or breast surgeons for a rehabilitation referral? Surely the answer is, yes!

It is imperative that cancer rehabilitation programs are tailored to disease stage. A one-size-fits-all model for breast cancer fails to consider the wide-ranging differences in physical and psychosocial needs between those women with early-stage versus metastatic disease. Caution is required with exercise in those with metastatic bone disease due to risks of pathological fracture and spinal cord compression. MacMillan Cancer Support guidelines recommend that Mirel’s classification is used to determine relative fracture risk and therefore the potential need for prophylactic surgical treatment before exercise is undertaken.3

Mirel’s classification (Table 1) quantifies fracture risk based on site, pain, extent of cortical involvement and whether the lesion is lytic, blastic or mixed, and can be calculated from plain x-ray. Objective assessment of fracture risk allows exercise programs to be tailored to the individual patient to reduce potential complications and target safe exercises which still maximise physical outcomes. Activity for those with metastatic bone disease should avoid excessive torsion and reduce shear and compressive forces on affected skeletal sites. Metastases causing functional bone pain, especially in the lower limbs, may be suitable for prophylactic fixation prior to commencement of an exercise program (Table 2). Surgery for these patients has been shown to increase mobility and improve pain, thereby optimising function and improved quality of life.

Table 1: Mirel’s classification3

 

Score

 

1 point

2 points

3 points

Site

Upper limb

Lower limb

Peritrochanteric area of femur

Pain

Mild

Moderate

Functional impairment

Lesion

Blastic

Mixed

Lytic

Lesion size

<1/3 bone cortex

1/3 - 2/3 bone cortex

>2/3 bone cortex

 

Table 2: Mirel’s Clinical Recommendations3

Mirel’s Score

Clinical Recommendation

≤7

Radiotherapy and observation

8

Use clinical judgement

≥9

Prophylactic fixation

 

Further, there is a need to break down the socio-economic divide in provision of breast cancer rehabilitation. It is well documented that those with lower levels of education and income are less often referred to rehabilitation, have more advanced cancer at time of diagnosis, and have greater levels of comorbidity; all of which contribute to poorer outcomes.4 There needs to be improved accessibility to timely rehabilitation interventions for cancer patients across various cancer streams within the public health system in Australia and more funding dedicated to ‘prehab’ cancer services. Prehab for cancer patients can lessen the potential cardiotoxic effects of chemotherapy, improve tolerance to chemotherapy through systemic conditioning, prevent sarcopenia, and target specific body regions susceptible to disease or treatment-related dysfunction.

There is a long way to go before we can confidently say that there are adequate rehabilitation services for the over 70,000 women living with breast cancer in this country. However, the grass roots of current breast cancer rehabilitation programs demonstrate encouraging results and hopeful prospects for further growth. Let’s all raise awareness of our skill set in this area and continue to talk more about cancer rehabilitation, both within our specialty and outside of the rehabilitation sphere.

Dr Faye Jansen
Rehabilitation Physician, FAFRM
Cabrini Health Elsternwick, VIC

References:

  1. Australian Institute of Health and Welfare. Cancer data in Australia 2021 report. [Accessed 4/8/2021]. Website: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/contents/summary
  2. Younus J, Kligman L. Management of aromatase inhibitor–induced arthralgia. Curr Oncol 2010; 17(1):87–90.
  3. Physical activity for people with metastatic bone disease: Guidance for healthcare professionals. Macmillan Cancer Support 2020. [Accessed 4/8/2021]. Website: https://www.macmillan.org.uk/healthcare-professionals/news-and-resources/guides/physical-activity-for-people-with-metastatic-bone-disease
  4. Bradshaw PT, Ibrahim JG, Khankari N, et al. Post-diagnosis physical activity and survival after breast cancer diagnosis: the Long Island Breast Cancer Study. Breast Cancer Res Treat 2014; 145:735–42.

Epworth Health cancer rehabilitation initiatives

Depending on cancer type, cancer effects and cancer-related treatments received, cancer patients may present with various rehabilitation issues including fatigue, pain, lymphoedema, chemotherapy induced peripheral neuropathy, steroid myopathy, deconditioning, and malnutrition. They often experience associated psychological distress and reduced overall quality of life. Cancer rehabilitation is increasingly recognised as a strategy to optimise the functional outcomes of cancer survivors from the time of diagnosis and throughout the trajectory of cancer continuum including treatment, survivorship, and advanced stages.

Current evidence supports cancer rehabilitation interventions in helping reduce symptom burden and improve quality of life amongst cancer patients. Evidence has also shown that exercise itself is beneficial in improving aerobic fitness, physical functioning, muscle strength, health-related quality of life, and reducing fatigue levels amongst patients with various cancer diagnoses.

Rehabilitation physicians play an important role in acute, subacute-inpatient, and subacute-outpatient care settings in being able to offer expertise in functional assessment and helping address impairments and activity limitations of cancer patients. At Epworth Healthcare in Victoria, a number of recent initiatives had been implemented to meet the rehabilitation needs of cancer patients across the care continuum. Of note, an ‘in-reach’ rehabilitation physician consult service was established this year within the acute haematology ward at Epworth Freemasons.

The rehabilitation physician assesses referred patients for physical and functional issues impacting on acute recovery and progress, working closely with acute therapists in setting achievable short-term goals. For patients who are not ready to participate in three hours of uninterrupted therapy per day (usual criteria for transfer to an inpatient rehabilitation unit) or are impacted by fatigue, this approach allows rehabilitation to commence in an acute setting for cancer patients. The rehabilitation physician also supports the nurse assessors in assessing suitability and readiness of patients for inpatient rehabilitation at Epworth standalone rehabilitation facilities, versus patients more suitable for co-located acute haematology services and rehabilitation unit at Epworth Richmond.       

Epworth Richmond offers an integrated inpatient haematology-rehabilitation service to those who are unable to participate in outpatient-based rehabilitation programs due to factors such as ongoing medical and nursing support needs, being significantly deconditioned, living in rural or remote locations, and ongoing cancer-related treatment plans. This particular inpatient program delivers both medical care and rehabilitation interventions including exercise, functional retraining, nutritional supplementation, and supportive counselling following acute cancer treatment or treatment of cancer related complications. A joint effort between acute haematology and rehabilitation teams aims to provide more efficient collaborative care and coordination of chemotherapy and radiation therapy treatment plans, monitoring of treatment-related response and management of any side-effects.

With outpatient-based rehabilitation programs, breast and general oncology outpatient rehabilitation programs are available at Epworth Hawthorn and general oncology outpatient rehabilitation programs at Epworth Camberwell, Epworth Brighton, and Epworth Geelong. The “Enhance” program, which is specifically designed for breast cancer patients, is an eight-week oncology program with exercise and education components. A multi-disciplinary team is involved including a physiotherapist, exercise physiologist, psychologist, occupational therapist, dietician, social worker, breast care nurse, and rehabilitation physician. This team provide comprehensive assessment of breast cancer patients and management of their functional impairments. Whilst this is a group-based service and patients vary in age, diagnosis, treatment and experiences, additional individual therapy is available where required to maximise functional outcomes for those patients.

With an ageing population and increasing cancer incidence, the need for rehabilitation services for cancer patients continues to increase. At Epworth Healthcare, the aim is to expand the ‘in-reach’ service across more acute cancer streams and to further develop inpatient and outpatient rehabilitation services and programs to meet the heterogenous needs of cancer patients.

Dr Sarah Kofoed & Dr Woo-Jin (Jeena) Kim
Rehabilitation Physicians, FAFRM
Epworth Healthcare, VIC

A review of rehabilitation in lymphoma

This article is a summary of a recently published review1:

“Amatya B, Khan F, Lew TE, Dickinson M. Rehabilitation in patients with lymphoma: An overview of Systematic Reviews. J Rehabil Med. 2021; 53(3): jrm00163”

Lymphomas are malignant neoplasms of the haematopoietic system, with aberrant proliferation of mature lymphoid cells or their precursors.2 They are broadly classified into non-Hodgkin’s lymphoma (NHL, 90 per cent) or Hodgkin’s lymphoma (HL). The new World Health Organization classification stratifies lymphomas based on the cell of origin (B-cell, T-cell/natural killer-cell and HL) or clinical behaviour (aggressive or indolent). An estimated 590,000 new cases of lymphoma (3.2 per cent of all cancers) were diagnosed in 2018 worldwide and its incidence is escalating, with a projected increase to approximately 919,000 by 2040.3,4 Amongst haematological malignancies globally, NHL is a leading cause of death and estimated to cause over 248,000 deaths (2.6 per cent of all cancers) in 2018.3 The total global economic burden of lymphoma is unknown. Treatment and supportive care requirements are resource intensive, with significant financial implications for patients, families, and healthcare systems. Loss of productivity also occurs as a result of the disease, treatment-associated morbidity, and premature mortality.

Current advancements in treatments and cancer detection/diagnosis have improved survival rates for patients with lymphoma (PwL), with age-standardised five-year net survival in adults ranging from 40 to 70 per cent globally in 2010-2014.5 The incidence of NHL is associated with increasing age, improved supportive care and availability of reduced-intensity chemotherapy regimens (such as PEP-C, R-miniCHOP, R-CVP), which are critical for older patients. Lymphomas and their treatment can be associated with short and medium-term residual deficits (physical, cognitive, psychosocial, and behavioural impairments), activities of daily living (ADL) limitations and participation restrictions. Treatment procedures (such as radiation therapy, chemotherapy, and/or surgery) can cause side effects and complications such as neuropathy, cardiotoxicity, cachexia, fatigue, deconditioning and myopathy. Further, various adjustment issues, increased care needs, inability to drive and return to work, financial constraints, and marital stress are reported during the transitional period.

Rehabilitation plays an integral part of any cancer management and there is evidence suggesting the beneficial effects of comprehensive rehabilitation. There is, however, an unmet need in the cancer population whereby only a limited number of survivors receive appropriate rehabilitation. Many general cancer guidelines do not incorporate recommendations for specific rehabilitation interventions. Therefore, this recent review evaluated existing evidence from published systematic reviews for the effectiveness of rehabilitation strategies for improved function, impairments, and participation in PwL.

A multipronged approach was undertaken for the comprehensive literature search, which included a search of health science databases: Cochrane Library, PubMed, EMBASE, and CINAHL (from inception to 1 October 2020), bibliographies of pertinent articles, journals, and grey literature. The study selection process was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All relevant data was extracted using standard proforma based on Cochrane methodology. The Measurement Tool to Assess Systematic Reviews (AMSTAR-2) was used to critically appraise the selected reviews. The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) tool assessed the quality of evidence for each outcome in terms of risk of bias, inconsistency, indirectness, imprecision (random error) and publication bias. The quality of evidence was classified as: ‘high-quality’, ‘moderate-quality’, ‘low-quality’ or ‘very low-quality’ based on the difference between the effect estimate and true effect. 

Overall, 12 systematic reviews (n = 101 studies, 87132 PwL) fulfilled review inclusion criteria, evaluating three broad categories of rehabilitation interventions (physical modalities, nutrition, and complementary medicine). Most reviews were of moderate to low methodological quality. The findings suggested moderate-quality evidence for exercise programs for improved fatigue and sleep disturbance; low-quality evidence for exercise therapy alone and Qigong/Tai chi for improved symptoms and overall quality of life, and an inverse association between sunlight/ultraviolet radiation exposure on NHL incidence, low-quality evidence for beneficial effects of yoga for sleep disturbances, and inconclusive evidence for the association of physical activity and lymphoma risk.

Despite established guidelines, standardised protocols for acute management of PwL and specific guidelines on structured rehabilitation programs are yet to be published. There was significant heterogeneity amongst the included systematic reviews in terms of primary studies involved, lymphoma patients, intervention protocols, rehabilitation settings, and the outcomes measured. Many of the evaluated interventions were too broadly described; specifically exercise interventions, without sufficient details (optimal settings, type, intensity and duration of therapy, cost-effectiveness) to enable replication of these interventions. Participant characteristics were heterogeneous amongst the studies regarding characteristics of lymphoma (type, lesion location and area, time since lymphoma, other comorbidities, age) that resulted in variability of findings. Further, the primary trials within the included reviews varied in their description of control arms, assessment time points, length of follow-up and outcome measures used. Therefore, pooling data for quantitative analyses was not possible, and a best-evidence synthesis was described using qualitative analyses.

This is the first review to systematically evaluate evidence from published systematic reviews to determine the effectiveness of rehabilitation interventions in PwL that aim to assist and guide treating clinicians in choosing an appropriate treatment approach. Despite a range of rehabilitation modalities used in this patient population, high-quality evidence for many is sparse. Some beneficial effects of exercise programs were noted for fatigue, psychological symptoms, and quality of life. The existing gaps in research and practise identified a need to be addressed in future robust studies.

Dr Bhasker Amatya, MD MPH DMedSci & Professor Fary Khan, FAFRM
Royal Melbourne Hospital & Peter MacCallum Cancer Centre, VIC

References:

  1. Amatya B, Khan F, Lew TE, Dickinson M. Rehabilitation in patients with lymphoma: An overview of Systematic Reviews. J Rehabil Med 2021; 53: jrm00163.
  2. Mugnaini EN, Ghosh N. Lymphoma. Prim Care 2016; 43: 661-675.
  3. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68: 394-424.
  4. International Agency for Research on Cancer. Global Cancer Observatory (GCO) 2020  [cited 2020 16 Sep]; Website: https://gco.iarc.fr/
  5. Allemani C, Matsuda T, Di Carlo, et al. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet 2018; 391: 1023-1075.

Walking after spinal cord injury: Fact or fantasy?

To walk again - this is the ultimate goal that every person with spinal cord injury (SCI) yearns for.  As clinicians working in spinal rehabilitation medicine, we are always asking the question: How far are we from finding a “cure” for SCI?

Most recently, I had the privilege of chatting with a special guest, Professor Simon Gandevia, who is pioneering the world’s first randomised controlled study on transcutaneous spinal cord stimulation and walking in SCI.  

Professor Gandevia (MD PhD DSc FAA FRACP) is an internationally renowned clinical neurophysiologist and researcher in the area of human movement and motor impairments.  He is also the Deputy Director and co-founder of Neuroscience Research Australia (NeuRA), a leading institute on brain and nervous system research.

Professor Simon Gandevia

Professor Simon Gandevia

Professor Gandevia, thank you so much for your time today. Can you tell us about your current research? 
The primary new work going on at NeuRA is eWALK, a special trial involving transcutaneous (surface) spinal cord stimulation to see if this can help people with thoracic paraplegia to walk better. It is a chronic intervention lasting 12 weeks with stimulation sessions, three times a week. It’s a big commitment from the research team and even more so, from the participants.

e-WALK Trial

e-WALK Trial

What makes your trial unique? 
The critical thing is that our trial has a sham stimulus. So, it is a proper randomised controlled trial. And this is a world first. The researchers, the assessors, almost everyone has no idea whether the intervention is being delivered, or not delivered. And that is crucial to us.

Congratulations, that sounds like a real breakthrough!  For those of us not involved in research, can you explain why randomised trials are so important? 
You need proper trials; you don’t want to just hear dramatic case reports of something that may have caused the patient to move better. You’ll find that there are whole groups of people who are clearly desperate in favour of things working. So, you need proper research to find the rehab therapy that actually works. That is the focus for research spending.

Are you able to provide us a sneak preview, and tell us what your preliminary results are so far? 
I can share with you that the trial is going surprisingly smoothly. There have been no unforeseen issues. This is good because it’s not trivial to move someone in and out of the gym, lifting them up in harnesses and using body weight support and treadmills.

Has COVID affected your trial? 
It certainly changed how we did things. During this year, we needed appropriate protective gear for the therapists and participants. As in most medical research facilities, we insist on a high degree of vaccination coverage, so the risk for both the participants and staff is reduced.  Surprisingly, in the midst of COVID, we got the trial up and running. We’re hoping to accelerate dramatically in January. 

Well done! What other spinal cord injury research are you involved in?
We’re looking at different forms of training to help people with spinal cord injury cough better, because the likelihood of dying from pneumonia is about 150 times greater than that of the general population. There are other trials to see whether surface abdominal stimulation can enhance breathing, coughing, and bowel function in SCI.  And some colleagues are doing work on virtual reality to see if that can enhance the sensory experience of people with functionally complete SCI.

Do you think there will ever be a “cure” for spinal cord injury? 
Over my career, unfortunately, I’ve only seen ‘smallish’ improvements. I’m not an expert in cellular and various gene-based therapies. But it has been somewhat disappointing. There are many clues about therapies that may work in small animals, such as mice and rats. But it’s different translating that change into the much larger human spinal cord, where the circuitry may be more complex.

The therapy that appears to show most promise at the moment is some form of electrical stimulation.  That is, activating the circuits that have survived and sending inputs to them, either from below or top down. The aim is to promote some degree of neuroplasticity and reprogramming to achieve some functional improvement.

Is it difficult to do SCI research in Australia? 
It is extremely difficult to get rehabilitation type trials funded on the national stage for spinal cord injury. It is considered a niche area, not necessarily affecting a lot of people, but even a small improvement in a single patient’s function can make a huge difference to their life.  A small gain can be amplified into a bigger effect. Spinal Cure Australia have been funding our current research.

Simon, what made you study medicine? 
I got into medicine because I wanted to do something in science, and I came from a medical family.  I also wanted to do something in law, but that wasn’t possible back then, which shows you how old I am! Halfway through medicine, I stopped and I did a PhD in physiology and went back into medicine. It exposed me to physiology, neurophysiology, and clinical medicine and I was able to blend these things together.

How did you get into the area of spinal cord injury research? 
In my early days, when I was a PhD student and even as a medical student, I did research in Ward One at Prince Henry Hospital on people with spinal cord injury. So, my interest goes back a long way.  And it’s been seriously reactivated in the last few years when we set up the Spinal Cord Injury Research Centre at NeuRA.

I just wanted to find out what you do in your spare time, if you have any extra time with everything you do! 
Yes, it is important to have spare time. I do a lot of things actually, but the easiest one to describe is I sculpt stone and wood. I started shortly after I graduated from medicine and I’ve kept it going.  I’ve even had a sculpture exhibition and sold pieces.  It is a creative outlet, and sometimes I have something pleasant at the end.  

Creative outlets give you some time when you can lose yourself and think about other things. It can be helpful to thinking about a particular patient or a particular problem. All of that processing can be quietly going on while you are chiselling away at a bit of wood.

May we see one of your masterpieces? 
Hardly masterpieces - this one I like is called “Torso”.  It’s a little bit spinal-ish as well!

Simon Gandevia sculpture: “Torso”

Simon Gandevia sculpture: “Torso”

Wow, this is amazing! It’s very beautiful and medically themed, I think I see a belly-button.

Simon, if people have questions about your work or trial, how can they best contact you? 
Email for those interested in more information about the eWALK trial: ewalk@neura.edu.au

To view links to key studies that are currently underway, visit the Spinal Injury Research Centre at NeuRA

Thank you so much for your time, Simon. You’ve given us such fascinating insight into your work and life. And thank you for all the research you do for our spinal patients. Both clinicians and patients appreciate it. We wish you the best of luck with your eWALK trial and look forward to the results.

Monica Ling FAFRM
Spinal Rehabilitation Medicine Specialist
Prince of Wales Hospital, NSW

New Zealand Spinal Cord Injury Registry: The journey thus far

Spinal Cord Injury (SCI) is rare, but complex. SCI can occur at any age and due to medical advancements, most people who have sustained SCI have near normal life expectancy. This brings progressive complexity. SCI management requires specialised multidisciplinary and coordinated approach of care from initial presentation through to life in the community. In Aotearoa New Zealand (AoNZ), adult acute care, rehabilitation, and follow up services for people with SCI are provided by the two supra-regional services. These are located in Christchurch under the Canterbury District Health Board (CDHB), and in Auckland under the Counties Manukau Health (CM Health).

Registries have been identified as key instruments in improving patient care and helping achieve optimal social, economic, and quality of life outcomes. Registries also assist health care planning, establish clinical research priorities, and allow international comparison of data. The need for a New Zealand SCI Registry (NZSCIR) was first identified in 1968. It was felt that a registry would be ideal to collect high-quality prospective data, with the potential to inform clinicians of the contributions of acute care, rehabilitation, and community interventions towards longer term patient outcomes. Various attempts to establish a registry in AoNZ have been unsuccessful in the past. Various researchers have published several challenges arising from the absence of a structured SCI registry.1

The NZ Spinal Cord Impairment Action Plan (2014-2019) was developed with the aim of achieving the best possible health and well-being outcomes for people who sustain SCI.2 Establishing an AoNZ SCI registry was a core objective of this action plan. A 12-month feasibility pilot study was undertaken in 2014 by CDHB, Accident Compensation Corporation (ACC), and Burwood Academy of Independent Living (BAIL) to investigate the implementation processes required to set up a SCI registry and provide the foundation for a business case. As part of the study, two registries were analysed and compared. These registries compared were The Rick Hansen SCI Registry (RHSCIR) and Victorian Spinal Injury Database. The RHSCIR was identified as an established, well-resourced national registry, with a high level of acute and surgical data, longitudinal follow up and having internationally standardised data sets and links with other international registries. This registry also provided the ability to partner with Rick Hansen Institute (RHI), with minimal cost for utilisation of a developed registry platform.3

NZSCIR was established in 2016 in partnership with the RHI, ACC, CM Health and CDHB, following the pilot study.1 It took eight months to develop and has been ongoing since 1 August 2016. An implementation plan was set up with RHI and protocols were developed including entry of non-traumatic SCI data (which was not part of the RHI data set) and adjusted to meet ethics requirements.3 A governance group was formed with representation from consumers, researchers, clinicians, funders, and managers. A registry coordinator at each site was established. Since inception, the NZSCIR publishes an annual report that is publicly available. 4

The most recent annual report is for the 2019 calendar year.4 Prior to establishment of NZSCIR, incidence of SCI in AoNZ was estimated at 30 per million, with approximately half being traumatic SCI. Based on NZSCIR 2019 annual data, the 2019 incidence was 45 per million (traumatic and non-traumatic SCI, inclusive of cauda equina) with 30 per million for traumatic SCI alone (Figure 1).

Traumatic and non-traumatic SCI

Figure 1: Percentage of traumatic and non-traumatic SCI

The leading cause of traumatic SCI in people aged 46 and above in 2019 is falls (Figure 2). The proportion of SCI from a fall increased from 17 per cent in the 0-30 age group to 82 per cent in the >76 years category. Transport followed falls as the next common cause of traumatic SCI, representing the leading cause of SCI in those under the age of 45 years. Most sport injuries included water sports (diving into pools or rivers).

Causes of traumatic SCI

Figure 2: Causes of traumatic SCI

Vertebral column degenerative disorders were the most common cause of non-traumatic SCI (29 per cent) (Figure 3). Further non-traumatic SCI causes included malignant neoplasms (19 per cent), vascular disorders (17 per cent), infection (14 per cent), and other (21 per cent).

Causes of non-traumatic SCI

Figure 3: Causes of non-traumatic SCI

Using the Ministry of Health prioritised ethnicity reporting, across all participants, most were of European descent (59 per cent), followed by Māori (19 per cent) and Pacific people (17 per cent). Pacific people includes Samoan, Tongan, Niuean, and Cook Island Māori. People may choose more than one ethnicity and categories are not exclusive (Figure 4).

Ethnicity by SCI type

Figure 4: Ethnicity by SCI type

NZSCIR also captures length of stay (LOS) in acute and rehabilitation settings (Figures 5-8). The median LOS in 2019 was 16 days in acute care (down from 17 in 2018) and 55 days in rehabilitation (down from 63 in 2018). Those with tetraplegia spent more time in acute and rehabilitation settings (median 72 days) than those with paraplegia (59 days). Combined median LOS (not shown on graph) in rehabilitation for those with tetraplegia is down trending (2019 - 52 days; 2018 - 57 days; 2017 - 76 days).

Auckland Acute - 2019 LOS (days) distributions

Figure 5: Auckland Acute - 2019 LOS (days) distributions

Christchurch Acute - 2019 LOS (days) distributions

Figure 6: Christchurch Acute - 2019 LOS (days) distributions

Auckland Rehabilitation - 2019 LOS (days) distributions

Figure 7: Auckland Rehabilitation - 2019 LOS (days) distributions

Christchurch Rehabilitation - 2019 LOS (days) distributions

Figure 8: Christchurch Rehabilitation - 2019 LOS (days) distributions

The average age of NZSCIR participants was 51 years (Figure 9). Of those with traumatic SCI, the international trend of bimodal age distribution included the first peak occurring in young adults between 15 – 29 years, and the second peak occurring amongst older adults. AoNZ’s second age peak occurs between 45 – 60 years, which is younger than international trend. The number of those with non-traumatic SCI tend to steadily increase with age, peaking at age 60 – 75 years.

Age group by SCI type

Figure 9: Age group by SCI type

The rates of surgery are higher in traumatic SCI compared to non-traumatic SCI (72 per cent vs. 66 per cent). On discharge, 36 per cent were independently walking in the community (able to walk 100 metres unsupervised with or without aids). Those with non-traumatic SCI were more likely to be walkers in the community (42 per cent vs. traumatic SCI 34 Per cent). Seventy per cent of discharges are to private residences in the community.

Secondary complications include pain, infections, and pressure injuries. On discharge, 72 per cent were receiving treatment for pain. Thirteen per cent of participants had urinary tract infections (UTIs) during their acute stay and 34 per cent during their rehabilitation phase. Respiratory complications occurred in 26 per cent of participants during the acute phase and 19 per cent during rehabilitation. Those with traumatic SCI were much more likely to have respiratory complications compared to those with non-traumatic SCI. Pressure injuries occurred in acute care in 12 per cent of cases and during rehabilitation phase in 22 per cent of cases.

NZSCIR has full Health and Disabilities Ethics Committee approval and report regularly to the Committee. The data access process is robust and requires researchers to undergo a rigorous request and review process before they gain access to de-identified data. Dashboard aggregate data can be collected for conference presentations, quality improvement activities within supra-regional spinal services, and service analyses. Clinicians have access to their own patients’ data for audits. Protocols can be assessed using NZSCIR data, such as the timing of traumatic SCI participants admitted to specialist centres and surgery.

Setting up and maintaining NZSCIR has not been without its challenges. Recruiting and consenting patients has been one of the challenges. Potential participants are approached for consent and if declined, a minimal data set is obtained as per the ethics approval. Consent rates have partially improved with increased allocation of workforce resources. Work is underway to assess the reasons why patients are declining the full data set for the registry. Issues with incomplete data entry were addressed by providing education and dedicated non-clinical time to clinicians for data entry. Securing long term funding for maintenance of registry is an ongoing challenge. Limited resources have delayed commencing and continuing with community data collection and entry. Follow-up of some participants has also been difficult. Despite these challenges, there are definite benefits of the NZSCIR in improving the understanding and management of SCI in AoNZ, whilst facilitating the translation of research into clinical practice. One of the key limitations of the NZSCIR is the absence of collection of any data for patients with SCI that have not been seen by either CM Health or CDHB supra-regional Spinal Services. 

Dr Bensy Mathew, Dr Suresh Subramanian, Dr Dawn-Louise Adair
Auckland Spinal Rehabilitation Unit, New Zealand

We would like to acknowledge Tracey Croot (nzscir@cdhb.health.nz), BSU site NZSCIR coordinator and Jessica Ozumba (nzscir@middlemore.co.nz) ASRU NZSCIR site coordinator for their contributions to this article.

References:

  1. BSU SCI Registry Development Project (2015). Website: https://www.burwood.org.nz/bsu-sci-registry-development-project/
  2. New Zealand Spinal Cord Impairment Action Plan 2014-2019. Website: https://www.health.govt.nz/publication/new-zealand-spinal-cord-impairment-action-plan-2014-2019
  3. Howard-Brown C et.al. Establishment of the NZSCIR and its challenges. 2018 - Poster Presentation.
  4. New Zealand Spinal Trust. NZSCIR Annual Report 2019. Website: https://www.nzspinaltrust.org.nz/i-need-information/new-zealand-spinal-cord-injury-registry-nzscir/nzscir-statistics-and-information/

Ben's long and winding road to medicinal cannabis - Story by Ian Baker (Australian Quadriplegic Association)

(Reproduced with permission)

After years of awakening early and in pain, Ben Gruter swallowed some cannabis and slept for 10 hours. The former policy advisor to government now takes cannabis daily - and legally.

It has been 85 years since an American anti-marijuana propaganda film warned parents about the “Reefer Madness” that lay in wait for their children.

It has been nearly 30 years since former US President Bill Clinton denied he inhaled the marijuana that he had admitted to trying.

And it is a little more than five years since the Access to Medical Cannabis Act 2016 passed in Victoria, making it the first Australian state to legalise therapeutic use of the controversial drug. Other states have followed.

In Victoria, any doctor may apply to prescribe cannabis for any condition. However, it is not likely that your local GP will do so, and for three main reasons.

Firstly, almost no cannabis preparations have been registered as prescription drugs. Secondly, little is established about what ailments cannabis might help with, and how.

Thirdly, a common ingredient of medicinal cannabis, THC, is classed as a Schedule 8 poison and a drug of addiction like morphine, methadone, and amphetamine. A doctor must therefore seek authorisation before prescribing it for you and may perceive the approval process to be very onerous.

Nevertheless, a Senate inquiry was told early last year that more than 19,000 Australians had been prescribed medicinal cannabis, and there is evidence that the number has risen rapidly since.

Persistent pain

One such Australian is former academic and state government policy adviser Ben Gruter, 65, who has been living with paraplegia from an incomplete T5 spinal cord injury since 2012.

When he resolved to try medical cannabis, Ben had spent seven years experimenting with other treatments for his persistent neuropathic pain, which arrived with his injury. He experiences the pain as located in his right leg, extending from his hip to his foot.

“It’s pain caused by damage to the nerves,” explains Ben, who is a peer mentor with Australian Quadriplegic Association (AQA)/Spire.

“It feels like the most intense pins and needles you’ve ever felt. Some people describe it as burning.

“It’s constant from the moment I wake up until the time I go to bed. Stress will make it worse; being relaxed makes it better.”

Surveys indicate that more than half of people living with spinal cord injury live with neuropathic pain.

Prior treatments

Ben spent 16 months in treatment and rehabilitation after his injury, which arose from a bleed in his spinal column. Initially, he was given Panadol for his pain and when he sought more relief, he was prescribed an opioid, Oxynorm, and a pregabalin based anti-anxiety drug, Lyrica.

“By 12 months, it was pretty clear that not only weren’t these drugs working, but I was having terrible side effects,” Ben reported.

Under the care of a pain team at the Austin Hospital, he tried alternative opioids, three anti-depressants and ketamine, an anaesthetic. He said that his pain remained very troubling, except when ketamine put him to sleep.

Subsequently, Ben was treated by a multidisciplinary team at the hospital’s outpatient Pain Clinic, finding some relief in hydrotherapy and in the cognitive behavioural therapy offered by the team’s psychologist.

“Unfortunately, they could only have me as a patient for six months”, he explained, “because it’s a high demand service.”

Marital conflict

When he was injured, Ben had been married for just four and a half years, to Christine.

“The partner or other family members of someone with a spinal cord injury are also severely affected by it,” Christine observed.

“I think for me, the worst of it has been Ben’s pain. Seeing him in pain has just been horrific.

“And the effects of a lot of the medication he was given have been awful.”

Memory loss is a recognised side-effect of pregabalin. Christine says conflicts arose at home from Ben’s memory lapses.

“We would have a specific conversation about something and the next day, Ben would deny that we even discussed it,” she revealed. “I actually just thought he was being difficult.”

I know a friend

Ben said that he sought to reduce side-effects and cut his risk of addiction by decreasing his consumption of painkillers, in consultation with his GP.

For a few months, he took no drugs at all. Today, he takes no pregabalin and no Oxynorm, instead using an alternative opiate, Tapentadol, in a slow-release formulation.

“When Ben did go off all the drugs, it wasn’t living,” Christine said.

“The pain was so consuming; he just couldn’t do anything. He didn’t want to go out. He didn’t want to communicate with anyone. He couldn’t stand the grandkids coming in because they were noisy.”

It was Christine who suggested to Ben that he might try cannabis. The topic had come up in conversation with a friend whose husband also had a spinal cord injury.

“My friend said it had been helpful,” Christine recalled. “And her husband said it was helpful.

“So we met up and had a discussion, the four of us.”

Absolutely fantastic

“I’d seen the press reports,” says Ben, who like Christine had been exposed to the recreational use of cannabis when he was younger.

“Some medical practitioners said it’s very helpful. Other practitioners said it’s not helpful, and all the evidence isn’t in.

“I went into it with an open mind.”

At bedtime one evening, Ben used a dropper to administer himself a small dose of black-market cannabis oil, orally.

“For years, I’d been sleeping about three hours each night before I woke up in pain,” he said of the result.

“That first night when I took cannabis, I slept for 10 hours.

“It was absolutely fantastic.

“I got a little high and I got a dry throat. I didn’t get munchies.”

Christine added: “And he woke up like a human, instead of a pain unit.”

Obtaining medicinal cannabis

At the beginning of 2019, Ben sought a prescription from his GP for medicinal cannabis. He says his doctor told him he would help, but then concluded that the application for approval would be too burdensome. Instead, the GP wrote a referral to the specialist clinic that had treated Ben’s acquaintance.

Medicinal cannabis typically comes in two forms, only one of which contains THC - the component credited with producing euphoria. The active ingredient of the other form is CBD, which does not produce a high but is believed to have therapeutic value.

After interviewing Ben and reviewing his history, the clinic prescribed him CBD, advising him to increase the dose each week until it was effective.

“When I wasn’t getting a good enough effect, they added THC,” Ben reports.

The cannabis comes from a Melbourne compounding pharmacy in tablet-sized resin lozenges, by registered mail. The lozenges are packed in small plastic containers that carry Ben’s prescription details (the medication is available in other forms).

He takes half a CBD lozenge orally twice a day and then a THC lozenge at bedtime.

“My understanding is that a typical joint is about 10 milligrams of THC,” Ben said, referring to the recreational user’s cannabis-infused cigarette. “I take 6.25 milligrams of THC. So this is probably a little bit more than half a joint.

“On the dose that I take, I don’t get high. If I was taking a lot more, I would.

“It does make me drowsy - both the CBD and the THC make you drowsy. It tastes terrible. And I have a dry throat.

“I don’t know what would happen if I tried to really suppress the pain and take a lot more of it. I don’t want to try that, because I think I’d just fall asleep. So what’s the point of that?”

Hello Singapore!

From Christine’s perspective, the therapy has been transformative.

“I would say within two or three weeks, Ben was engaging,” she says. “He was engaging with me whereas he had been quite withdrawn before. He was engaging with the grandchildren. He was engaging with friends. We were going out. We were socialising.

“Within six weeks of him starting it, we had our first overseas holiday. Our first in seven years!”

The couple spent a week in Singapore, testing Ben’s capacity to make a flight twice as long to The Netherlands, where he was born.

“We had such a wonderful time. We were out every day. We couldn’t take the cannabis with us, but it took four days to wear off and then Ben still had his opioids.”

Prior to starting his cannabis therapy, Ben said: “I wouldn’t have dreamt of doing that trip.”

And he said the benefits have continued.

“The way I would describe it, is that it’s like the pain has been moved a bit away from you. So you are not focused on the pain anymore.

“The pain’s still there, perhaps level four rather than level six on a scale of 10, but it’s better. It’s not in your face.”

“And it’s not on his face,” Christine said. “He’s a lot more relaxed.”

A drug is a drug

Medicinal cannabis is not subsidised under the Pharmaceutical Benefits Scheme and Ben’s prescription costs the couple about $500 a month. That’s significant for them, and they’re aware it would be out of reach for some people.

They would like to see medicinal cannabis become available more cheaply and more readily. Ben would also welcome changes to traffic law.

Driving under the influence of THC is illegal and unlike alcohol, no threshold is specified.

“I’ve heard stories of people who won’t take THC because they’re afraid for their licence,” Ben said.

He added: “I take a very, very small dose, and that’s also worth saying. It is possible that I will need a higher dose in the future. But I don’t need it now.

“And I’ve got to say that although I’m a fan of cannabis - it’s probably the most benign of the drugs that I take for pain. It would be nice to get to a stage where I didn’t have any drugs and could just rely on physiotherapy and psychological pain management systems.”

Commentary by Dr Andrew Nunn – Medical Director of the Victorian Spinal Cord Service

Thank you Ben for your measured personal insight on your careful use of cannabis for pain following spinal cord impairment. Your personal account raises some issues for us all, and maybe very necessarily opens up this can of worms.

It is important that we do this, but it is also tricky. We need to develop a balanced view so that people with spinal cord injury, and those prescribing and funding the use of medicinal cannabis are well informed. The legislation on medicinal cannabis seems to be ahead of the science and a spectrum of issues and views.

Here is some commentary on the topic from the Australian Pain Society, a multidisciplinary not-for-profit organisation that seeks optimal access to pain prevention and management for all people (date reviewed: 19 March 2021).

“Cannabis-derived products are now available for use with therapeutic intentions in Australia and New Zealand. By far the most common reason for their use is chronic pain, however there is a critical lack of evidence that it provides a consistent benefit for any type of chronic non-cancer pain. More than 90 per cent of Special Access Scheme – Category B (SAS-B) approvals have been for chronic pain of various types.

The evidence available is either unsupportive of using cannabinoid products in chronic non-cancer pain (CNCP) or is of such low quality that no valid scientific conclusion can be drawn. Cannabidiol-only [CBD] formulations have not been the subject of a published randomised controlled trial (RCT) for pain indications, yet they are the most prescribed type of product.

In addition, evidence of harms does exist, particularly in relation to sedative effects, interactions with other medications, and neuropsychiatric effects (for products which contain tetrahydrocannabinol [THC]).

Given the above, the clinical use of cannabinoid products cannot be ethically recommended outside a properly established and registered clinical trial environment until high-quality evidence for specific indications is published.”

I see in this cautious approach legitimate concern about the possibility we will create a new problem relevantly similar to the over-prescription of OxyContin and other opioids for pain management in the United States, if with less florid complications. So we must think broadly.

Our Spinal Cord Service explored evidence and trial protocols with the industry pre-COVID, and we hope to understand this better through starting a trial on therapeutic use for spasticity.

Here are 12 points that deserve our attention:

  • There are well over 1000 cannabis strains available, plus now many plant hybrids.
  • Production methods for therapeutic use are variable, with many derivatives for each plant depending on fractionation method and even synthetic THC available.
  • Cannabis formulations usually combine CBD and THC, and these can be supplied in many different proportions.
  • Physiology is complex. There are many receptors in every body system, hence multiple applications (pain, spasticity, sleep and so on).
  • Cannabis can have many positive and negative effects, so a balance is needed.
  • Smoking is clearly not the best way to administer and other options such as oral, nasal or skin absorption contribute variability in both absorption of the medication and duration of action. 
  • There are many types of spinal cord injury, so the optimal dose will be very individual and time of action variable, plus placebo effects must be considered.
  • Cannabis would often be used in combination with other agents. As Ben has recognised, it is important that we look at eclectic approaches and resist the assumption that we can procure a “quick fix”.
  • Commercial drug costs and marketing are becoming a major influence.
  • Prescribing cannabis is tricky and is subject to laborious follow-up requirements.
  • Use of medicinal cannabis has functional considerations for driving and work.
  • Research trials show varied results and for limited number of participants.

I believe we need to bring fresh eyes and an open mind as we consider the many views that are out there as well.

Dr Andrew Nunn
Director Victorian Spinal Cord Service, Austin Health VIC

Rehabilitation and older people – Geriatric rehabilitation

AFRM has been an international leader through its syllabus in rehabilitation and older people for many years. The syllabus was developed about 20 years ago and has been refined on several occasions. It should be revised again because of the explosion of literature about frailty, and post COVID-19 rehabilitation for older people.

In Australasia, we generally use the inclusive term rehabilitation and older people. However, in many countries, the other label “geriatric rehabilitation” is used.

There is much interest in Europe in this topic. An interdisciplinary group including rehabilitation physicians, geriatricians, nursing home physicians and other health professions is working to define geriatric rehabilitation specifically. The definition that has been formulated is – geriatric rehabilitation is a multidimensional approach of diagnostic, therapeutic and rehabilitative interventions, with the purpose of optimising functional capacity and independence, promoting physical activity, and preserving social participation in people with frailty and disabilities.

In Australia, we have COVID-19, an ageing population, the Royal Commission into Aged Care Quality and Safety and the recent Australian Institute of Health and Welfare Report on the prevalence of dementia as current issues. All suggest that rehabilitation and older people is a critical topic.

Professor Ian Cameron, FAFRM
Hornsby Hospital, NSW
John Walsh Centre for Rehabilitation Research
Chair in Rehabilitation Medicine, The University of Sydney

Osteosarcopenia and ageing

Osteosarcopenia is a musculoskeletal syndrome characterised by concurrent low muscle mass and function (sarcopenia), and low bone mineral density (osteoporosis). This “hazardous duet” has shared common risk factors and biological pathways.1 Osteosarcopenia has a strong association with impaired physical performance and balance, increased risk of falls and fractures.

Osteoporosis

Osteoporosis is a microarchitectural loss of bone tissue leading to decreased density and bone fragility. The preferred method of testing is a dual-energy x-ray absorptiometry (DEXA) scan of the central skeleton to measure bone mineral density (BMD) of the lumbar spine and hip (T scores). The World Health Organization (WHO) criteria for diagnosis of osteopenia and osteoporosis are T-scores of below -1 and below -2.5, respectively.

Risk factors for osteoporosis include older age, female gender, high alcohol intake, current smoking, obesity, menopause (females), low body weight, living in residential aged-care facilities, and low mobility and function. Peak bone mass is reached by the end of the third decade, and declines thereafter, more so in females. Between 24 and 49 million individuals over 50 years in North America, Europe, Japan, and Australia have osteoporosis.

The common consequences of osteoporosis are vertebral fractures and fragility fractures of the hip, wrist and humerus. Vertebral fractures are often clinically silent, with a higher risk of severe fracture in women than men over 70 years, but a higher risk of mild vertebral fracture in males. Fifty per cent of all low trauma fractures are non-hip and non-vertebral. All result in an increased risk of subsequent fracture, and all are associated with an increased risk of premature mortality.

With ageing, there is an imbalance between bone resorption and deposition, leading to accelerated loss of bone mass, and significant marrow fat infiltration.2 Women lose almost 50 per cent of trabecular bone and 30 per cent of cortical bone mass with oestrogen depletion following menopause, whilst men lose 30 per cent of bone mass during their lifetime.

Sarcopenia

The term sarcopenia is derived from the Greek: sarx = flesh and penia = loss, and refers to loss of muscle mass associated with ageing. However, sarcopenia is not only a disease of ageing, but shares common mechanisms with sarcopenia in chronic diseases (e.g., COPD, cancer) and endocrine diseases (e.g., diabetes, thyroid disease).3 This condition was recognised with separate ICD-10-CM code. Sarcopenia should not be defined solely on loss of muscle mass. Although muscle weakness is an inevitable consequence of sarcopenia, skeletal muscle becomes intrinsically weaker in old age, and the relationship between age-related reduction of muscle mass and strength is often independent of body mass (e.g., sarcopenic obesity).

The prevalence of sarcopenia increases with age; it is present in 10 per cent of people aged 60-70 years, and 30 per cent of those aged 80+ years. Sarcopenia has negative health consequences with a fourfold higher risk of mortality in people aged 79+ years, a threefold higher risk of functional disability, a significant association with risk of falling, a higher risk of hospitalisation, and prolonged hospitalisation.

Contributing factors to sarcopenia are changes in the nervous system and in muscle. With ageing, a loss of spinal motor neurons due to apoptosis results in a drastic reduction in muscle fibre numbers and size. In addition, there is a decline in neural organisation, an impaired capacity for reinnervation of denervated muscle fibres, and structural alterations in the neuromuscular junction. At the muscle level, there is a glycolytic-to-oxidative shift (i.e., a fast to slow twitch muscle transformation). This differs from the muscle changes associated with disuse atrophy, where there is a slow to fast twitch muscle transformation. Other features of sarcopenia are impaired muscle protein synthesis, impaired metabolic pathways, and fatty infiltration affecting mainly type II fibres.

Sarcopenia in spinal muscles is an independent predictor of vertebral compression fracture. Severe sarcopenia is associated with substantial increases in vertebral compression in the thoracic spine and shear loading along the whole spine.

Screening and assessment

Osteoporosis/osteopenia is diagnosed by DEXA. Fracture risk algorithms include the FRAX and QFracture (UK), the Garvan algorithm (Australia), and the CAROC (Canada).4 Whilst fragility fractures of the hip, wrist, and humerus have a clear clinical presentation, vertebral fractures are often silent. These may be identified through monitoring of height over time (a prospective height loss of >2cm), rib-pelvis distance (distance between costal margin and pelvic rim) for lumbar fractures, and occiput to wall distance for thoracic fractures.

The SARC-F tool5 is a screening tool for sarcopenia and clinical assessment should include measurement of handgrip strength, and the Short Physical Performance Battery (strength, function, balance). Muscle mass may be estimated using DEXA (reference standard), bioelectrical impedance (a surrogate measure), and CT or MRI.

Diagnostic criteria for sarcopenia vary among reference groups. The Consensus of the European Working Group on Sarcopenia in Older People6 recommends diagnosis based on documentation of criterion 1 plus criterion 2 or 3:

  1. Low muscle strength – probable sarcopenia
  2. Low muscle mass (appendicular skeletal muscle mass (kg)/height2 less than two SD below mean of reference group) – confirms diagnosis
  3. Low physical performance – severe sarcopenia if all criteria met

Management of osteoporosis and sarcopenia

Antiresorptive drugs such as bisphosphonates, denusomab or selective oestrogen receptor modulators are the first line approach for osteoporosis. However, fracture risk reduction with drugs is modest because the microstructural deterioration is not reversed. Anabolic agents (e.g., Teriparatide) and Romosozumab (humanised monoclonal antibody) enhance osteoblast activity.

There are no pharmacological treatments for sarcopenia. Non-pharmacological treatments include ensuring adequate calcium, vitamin D and protein intake, and limiting coffee and alcohol consumption and tobacco use. However, resistance exercise is a key evidence-based recommendation for management of osteosarcopenia and a number of trials have shown it to be beneficial in improving balance, bone health, and muscle.7,8

Professor Mary Galea AM PhD FAHMS
University of Melbourne, VIC

References:

  1. Crepaldi G, Maggi S. Sarcopenia and osteoporosis: A hazardous duet. J Endocrinol Invest 2005; 28(10 Suppl):66-68.
  2. Hirschfeld HP, Kinsella R, Duque G. Osteosarcopenia: where bone, muscle, and fat collide. Osteoporos Int 2017; 28:2781-2790.
  3. Borba VZC, Costa TL, Moreira CA, et al. Sarcopenia in endocrine and non-endocrine disorders. Eur J Endocrinol 2019; 180:R185-R199.
  4. Leslie WD, Lix LM. Comparison between various fracture risk assessment tools. Osteoporos Int 2014; 25:1-21.
  5. Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. JAMDA 2013; 14:531-532.
  6. Cruz-Jentoft AJ, Bahat G, Bauer J et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019; 48:16-31.
  7. Watson SL, Weeks BK, Weis L et al. High intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Mineral Res 2018; 33:211-220.
  8. Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev 2009; (3):CD002759.

January 2022

Editor introduction

This Rhaïa edition provides insight into cancer, spinal cord injury (SCI), and geriatric rehabilitation. Firstly, it is pleasing to see a lot more activity and growing interest amongst our colleagues, especially our younger Fellows, in the cancer rehabilitation space. Cancer patients are increasingly needing access to rehabilitation care and interventions. A recent exploratory pilot survey of rehabilitation colleagues working in cancer rehabilitation in Australia and Aotearoa New Zealand (AoNZ) identified inadequate funding, lack of staff with expertise, and lack of collaboration between acute cancer care services and rehabilitation as major barriers towards successful implementation of cancer rehabilitation programs.1

The hope is to gradually dismantle these barriers, support a strategic approach to ensuring that cancer rehabilitation programs are available in our region, and develop sustainable, holistic cancer care models. Our cancer Special Interest Group (SIG), relevant working groups, and interested rehabilitation Fellows will play a vital role in promoting the awareness of cancer rehabilitation amongst acute specialty teams and community care providers. They will contribute to capacity building, establishing clinical guidelines, policies and pathways, encouraging research activities, and increasing advocacy of this area for the future.

With SCI rehabilitation, the latest SCI data from the Australian Spinal Cord Injury Register (ASCIR) showed 187 new cases of adult traumatic SCI in 2017-2018.2 Similar to previous findings, the majority were of younger age (25-34 years old), male gender, had neurological level of injury at C4 and incomplete tetraplegia (43 per cent) at discharge. Land transport crashes (46 per cent) represented the leading cause, followed by falls (36 per cent). For non-traumatic SCI (vascular disorders, degenerative conditions, cancer), out of 131 cases, males accounted for 60 per cent and the mean age was 58 years (range 19-89 years).

As we are aware, the short- and long-term disabilities faced by SCI patients are multiple. Useful resources can be found on SCI organisational websites (AQA Victoria, ParaQuad Tas, ParaQuad NSW, Spine & Limb Foundation WA, SCIA, SpinalCure, Spinal Life) and through societies such as ANZSCoS and ISCoS. Interesting research trials being undertaken include the eWalk (transcutaneous neurostimulation for SCI, Sydney) and robotic assisted game-based therapy.

We are also facing a population with increasing life expectancy. The need for ‘geriatric rehabilitation’ is growing in our region and so is the need for rehabilitation physicians with the essential skills to manage issues in older people. These can include sensory impairments (vision, hearing), falls, osteoporosis, malnutrition, depression, and cognitive impairment, including delirium and dementia. Professor Ian Cameron flags this area as a critical topic and Professor Mary Galea discusses osteosarcopenia.

I would like to express my utmost appreciation to all of our writers for their contribution to this edition of Rhaïa especially during a very busy and challenging year. If you have any interesting rehabilitation news that you would like to share with your colleagues, please let us know and we can include it in future publications. I wish you all the very best and I am sure that we are all looking forward to new and exciting things ahead in 2022.

Dr Krystal Song
Editor

References:

  1. Song K, Amatya B, Khan F. Cancer rehabilitation in Australia and New Zealand: a pilot cross-sectional survey. The Journal of The International Society of Physical and Rehabilitation Medicine 2021; 4(3): 146-155.
  2. Australian Institute of Health and Welfare: Harrison J, O’Brien D, Pointer S. Spinal cord injury, Australia, 2017–18. Injury research and statistics series no. 136. Cat. no. INJCAT 219. 2021. Canberra: AIHW.

Readers, please note that the below articles were written several months ago. Given the fast changing circumstances of the COVID-19 pandemic, some information may have changed since the articles were originally written, particularly in relation to the COVID-19 situation in Victoria.

President’s Report

I congratulate Editor Krystal Song for drawing together three very important areas of rehabilitation practice: cancer rehabilitation, spinal cord injury, and geriatric rehabilitation in this edition of Rhaïa.

I hope all three areas are now seen as core business by rehab medicine departments, but it was not always thus. They remind us how things change. Spinal Injury units were first established many decades ago in response to the number of young patients who were catastrophically injured in accidents, and whose prognoses were dire without specialist knowledge and treatment. The demographics have changed greatly during my career from a predominantly young person’s injury to one which is now seen almost as frequently in a much older population, related to falls.

In the early part of my career, cancer treatment was not something that involved rehabilitation services much at all. Fortunately, this has changed in the past 20 years and much of the credit is due to passionate advocates such as Professor Andrew Cole, who has contributed to this edition. Geriatric rehabilitation remains a very important part of practice for many of us and an important interface between us and our geriatric medicine colleagues in many of our hospitals and community practices.

Our colleague, Dr David Bowers, passed away recently and unexpectedly in the full flight of his professional career. Many of you would have known him, a spinal injury rehabilitation physician at the Royal North Shore Hospital in Sydney. Fitting tributes to his care and compassion were expressed on behalf of his colleagues and patients at his funeral service which was, of course, greatly limited in scope due to COVID-19 restrictions. On behalf of the Faculty, we would like to convey our sincere condolences to his wife and children.

Work at the Faculty continues on many fronts in a COVID restricted way, just as you are experiencing in your own hospitals and practices. We continue to meet regularly at executive and council level but these are all virtual meetings now. The unpredictable nature of the pandemic continues to frustrate attempts to normalise events. My recent plan to attend the New Zealand Rehabilitation Association meeting during the travel bubble and when things were more settled evaporated very rapidly and now appears hopelessly optimistic in retrospect. You probably have started attending virtual international meetings as I have. Whilst I find the convenience of not having to travel very helpful, I have had to confront the reality that these sessions are generally live in the middle of the night here, which tends to be rather disorienting if not overpoweringly soporific.

All the Faculty Examinations for 2021 have concluded, including the delayed Victorian Module 2 Examination in Melbourne, which was held on October 10th. Clearly, the COVID situation in Sydney and Melbourne were of concern and there was a contingency plan to delay until November if needed. We have started preparations for our 2022 examinations. The landscape for next year is not clear yet, although with vaccination rates at the level that they are, we are hopeful that there may be more normality by that time. Meetings of the Examination Working Group, comprised of the Faculty Executive, Chair of Assessment Committee and College education staff have been a regular feature of the last 12 months.

We are progressing our plans for a greater academic presence by virtue of a permanent academic post on the Faculty Council, which is underway and will link to a permanent research committee of Council. We continue to meet regularly with the Australian Rehabilitation Outcomes Centre (AROC), represented by the Director of UOW Health Services Research Institute Kathy Eagar, newly appointed Medical Director of AROC Maria Crotty, and recently appointed Director of AROC Ross Clifton. AROC is currently undergoing a strategic review, seeking to use its reputation as the best health benchmarking system in Australasia to seek ways where that data can be used to influence health policy at a state and national level. We are currently still seeking a Chair of the Management Advisory Group to replace Dr John Estell whose term finishes soon.

The place of rehabilitation in COVID-19 continues to be a very important topic. Dr Susan Graham represents the Faculty on the College’s COVID-19 Expert Reference Group and was recently involved in organising webinars on Long COVID. We remain concerned at reports of reduction in rehabilitation services and resources throughout the country in response to the need to expand acute services, particularly in Sydney recently and in Melbourne last year. Our concern is that these resources are often not restored or alternative proposals seem to appear almost under the guise of COVID. The literature suggests that there will be significant need for rehabilitation services for so called Long COVID and we need to be mindful that this may be the opportunity to ensure that rehabilitation services are not allowed to be permanently reduced and marginalised.

The College launched the ROC (RACP online communities) with the official launch of the Faculty community in October. I urge all members to join the online community. We hope that it will provide an easy method of communication between members, which will avoid the previous intractable problems when lists of email addresses were not available. We hope to be able to set up much easier direct communication for Branch Committees and Special Interest Groups.

There are always vacancies occurring in Faculty Committees, all the way up to executive and we are constantly looking to identify the next generation of Fellows to take over the important roles at the head of many of our committees. We need long-term successors for the Chairs of the Faculty Assessment and Faculty Training Committees and the President-elect becomes available in May 2022. I ask that all New Fellows consider where you could help and where your interest may lie. Those who have been working hard on committees already are requested to seriously consider moving to the Chair of the committee if you can. Committee members are often in the best position to take over the chair as they have a good understanding of how the committee works. It is often more difficult for someone to step in as the Chair of a committee when they have not been involved within before.

Rural colleagues have recently raised the issue of lack of continuity of trainees working in rural services and the difficulties this raises for their services from time to time. The rural workforce is a very big issue at both government and College level. The maldistribution of our health workforce is well documented and is indeed part of the problem with Indigenous health. Dr Jeremy Christley is the Faculty representative on the College’s Regional and Rural Physician Working Group. Rural training is a complex issue and one which the Faculty considered formally about 10 years ago, although the focus was about attracting Fellows to work in the country.

Trainees who have worked in the country are more likely to consider a rural career as a realistic option. I have had recent talks with the Australian College of Rural and Remote Medicine and the Rural Health Alliance both of whom understand the issue of convincing health professionals to see a rural career as a realistic medium- or long-term option. This is a complex issue and needs consideration of both the projected long-term rural workforce, the quality of the training experience, and the burden, both socially and financially, on trainees particularly now that many of our trainees are older than a generation ago and their life can be correspondingly more complicated. I am hopeful that if we can delineate and try to address the economic and social disincentives where they exist and simultaneously promote the value of rural training, this will allow us a non-controversial path to increase the number of trainees taking up country positions.

Please continue to make yourself aware of our College and Faculty prizes available every year. Please take the time to look at the College website and consider your colleagues who might be appropriate to nominate for these medals. There are several scholarships for those wishing to undertake research, with some specifically reserved for AFRM trainees and Fellows and others available to the wider College membership. Please promote these to your trainees and New Fellows who may be interested in a career in research.

A considerable amount of time was spent during the last two to three years developing materials to support an increase in the profile of rehabilitation medicine. These include PowerPoint presentations, brochures, and letters of introduction that can be used by Fellows to inform employers, area health service executives, and other health stakeholders of the value of rehabilitation medicine and its contribution to the health landscape. Unfortunately, much of this effort has been swamped by the pandemic that essentially sweeps all before it, but we have continued to meet with stakeholders to help them understand more about who we are and what we do. I have found these meetings to be beneficial, making personal links to partner organisations when the time is appropriate.

I continue to be very grateful for the support and assistance of my fellow Executive Members Jenny Mann (President-elect), Tim Geraghty (immediate past President), Caitlin Anderson (Chair, Faculty Education Committee), and Richard Seeman (Chair, Aotearoa New Zealand Branch), as well as our College staff, Jane Henderson (Executive Officer), Jo Goldrick (Faculties Manager) and Phil Munro (Peak Bodies Manager). I wish you all the very best in these trying times and we look forward to when the coming and expected COVID surges in New South Wales and Victorian hospitals have passed their peaks.

Dr Greg Bowring
AFRM President

Cancer rehabilitation

Until recently, cancer survivors have comprised only a small part of most rehabilitation physicians’ case load. Although some cancers have long been cured with early treatment, recent advances in chemotherapy, radiation therapy and immunotherapy now mean that treatment of quite advanced metastatic disease can lead to prolonged patient survival, for example with melanoma, breast, and prostate cancer. This, however, may be associated with significant impairment and functional disability. In this century, cancer has become another chronic disease, and survivors will respond to rehabilitation programs, just as others living with more ‘benign’ diseases do.

Rehabilitation helps cancer patients maximise their functional abilities and quality of life at each stage in their journey, as first recognised by Dietz in 1969. Programs start with preventive measures from the time of first diagnosis, later using restorative measures to regain premorbid functions lost with cancer treatment or combined with the effects of frailty in older cancer survivors. If significant physical problems are present (e.g., neurological or musculoskeletal impairments after treatment of cancer), intensive goal-orientated multidisciplinary programs are of great help. Finally, even in the later stages of the journey, relatively simple rehabilitation interventions provided jointly with palliative care clinicians can maximise residual mobility, activities of daily living or continence function, and greatly improve quality of life for both patients and their carers.1

Oncology care clinicians may not be aware of good outcomes from rehabilitation, may be focused on disease management rather than functional decline, or may wrongly think that if cancer-modifying treatment is of no further use, then rehabilitation also has little to offer. Likewise, cancer survivors and carers may assume and simply accept that progressive functional loss is inevitable with disease progression. All these are barriers to cancer survivors receiving appropriate access to rehabilitation.

Apart from major physical impairments, uncontrolled pain with depression, decreased activity and deconditioning are major causes of lost functional ability. It is important that baseline rest pain is properly controlled, with extra analgesics prescribed prior to general activities likely to provoke episodic pain (e.g., physiotherapy). Other activities that cause pain can be carefully deconstructed, to identify the specific motion or position that triggers pain, which can then be dealt with.

Both frailty and cancer are not uncommon in older people, and presence of frailty may well predate a cancer diagnosis. With early recognition, the older cancer survivor can be moved towards a non-frail state if given a combined program of nutritional support and physical exercise. This is especially important if there is complicating nausea or anorexia associated with chemotherapy or radiation therapy programs. At any age, if deconditioning is present in a cancer survivor, they should be offered an appropriate rehabilitation program for this, especially if their goals in life recovery include a return to work.

For cancer survivors with neurological deficits due to primary or metastatic brain or spinal cord lesions, and where the underlying malignant disease process has been treated and stabilised, there is good evidence that they respond to rehabilitation therapy with similar functional recovery, as do patients recovering from strokes or spinal cord ‘benign’ lesions, matched for anatomical location. This applies to therapy programs in individuals with speech and/or cognitive involvement, as well as with peripheral neurological involvement, whether from chemotherapy or individual peripheral nerve impingement by tumours.

It is particularly important that cancer survivors with brain stem disease are offered detailed speech therapy, occupational therapy, nutritional and swallowing programs, with appropriate dietary modifications or alternative feeding approaches, to avoid chest infections and frustrations with dysarthric speech and visual/coordination problems.

As with all rehabilitation, training and support of carers is most important, to maximise quality of life at home for the cancer survivor and their family/carers.

There is no place for therapeutic nihilism in the rehabilitation of a cancer survivor!

Associate Professor Andrew M Cole FAFRM
HammondCare Health, Greenwich Hospital
UNSW, School of Population Health NSW

References:

Cole AM. Medical rehabilitation and the palliative care patient. In: Cherny NI, Fallon MT, Kaasa S, Portenoy RK, Currow DC, editors. Oxford Textbook of Palliative Medicine. 6th ed. Oxford, England: Oxford University Press; 2021. P.255-264.

An update on cancer pain

Cancer rehabilitation is increasingly recognised as a crucial component of care for cancer survivors, with rehabilitation clinicians playing an integral role in supporting cancer patients during most phases of their cancer trajectory.1,2 Cancer pain is one of the most common symptoms experienced by cancer patients, with potential occurrence in any cancer type and at any stage from diagnosis to end-of-life care.3 Cancer pain can be classified as acute or chronic pain, and is defined as ‘pain that arises from cancer itself and/or treatment-related complication(s)’.4 If not managed well, cancer pain can have a significant impact on patients’ physical and psychological functions, resulting in difficulties carrying out their day-to-day activities and community roles.

Cancer pain is a complex condition that involves various pathophysiological mechanisms. Common cancer pain syndromes include chemotherapy-induced peripheral neuropathy (CIPN), pathophysiological fractures, widespread pain syndromes and persistent post-surgical pain.5 Contributing factors include nociceptive pain from surgery, radiation therapy, and cancer itself, from invasion of cancer into tissue or bone.

Peripheral and central sensitisation from persistent inflammation and repeated nociceptive input from cancer treatment and investigations may also contribute to persistent cancer pain.6 Many factors influence the experience of cancer pain including the patient’s background, experiences, cognitive status, and perpetuating biopsychosocial factors such as dealing with the notion of death, fear of cancer recurrence, and traumatic experiences from cancer treatments.7 Therefore, a thorough assessment of cancer pain is essential in understanding the mechanism of pain, patient factors, prognostic factors, and expectations of pain management to help guide appropriate treatment.

To date, there is limited evidence for the most effective treatment for cancer pain. Overall, a multidisciplinary approach to pain management is recommended due to the multi-faceted nature of cancer pain and associated symptoms that co-occur such as fatigue, anxiety and/or depression. Pharmacologically, opioids remain the mainstay of treatment for cancer pain but there is increasing awareness of the detrimental long-term effects of opioid use, especially in those with chronic pain syndromes. Side effects include constipation, cognitive impairment, endocrine disorders, and dependence.

Anti-neuropathic agents commonly used in cancer pain include anticonvulsants and antidepressants, but their efficacy is mixed and limited in evidence. Other adjuncts include steroids, alpha-agonists, and anti-inflammatories. Medicinal cannabis is emerging as an option but there is lack of evidence for its use in cancer pain, with implications of cost and tolerability in Australia.8 Non-pharmacological strategies and interventional techniques may be effective in opioid-unresponsive pain and should be considered to reduce polypharmacy and its effects. Nerve blocks, such as epidural injections, can be considered if there is an anatomical target or nociceptive driver. For those with opioid-unresponsive pain or side effects, an intrathecal opioid pump could be considered.

In conclusion, due to the complexity of cancer pain and its management, current evidence supports a more holistic approach to the management of cancer pain, with beneficial effects shown for rehabilitation programs incorporating multimodal interventions such as exercise and psychological strategies.

Dr Jamie Young MBBS, FAFRM, FFPMANZCA, Clin Dip Pall Care, AFRACMA, PhD
Pain & Rehabilitation Specialist
Peter MacCallum Cancer Centre VIC

References:

  1. Lisy K, Denehy L, Chan R, Khan F, Piper A, Jefford M. The state of cancer rehabilitation in Australia. Journal of Cancer Rehabilitation 2018; 1:9-13.
  2. Chowdhury RA, Brennan FP, Gardiner MD. Cancer rehabilitation and palliative care - Exploring the synergies. Journal of Pain and Symptom Management 2020; 60(6): 1239-1252.
  3. Van Den Beuken-Van MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ. Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. Journal of Pain and Symptom Management 2016; 51(6):1070-90.
  4. Yoong J, Poon P. Principles of cancer pain management: An overview and focus on pharmacological and interventional strategies. Australian Journal of General Practice 2018; 47(11):758-62.
  5. Caraceni A, Weinstein SM. Classification of cancer pain syndromes. Oncology 2001; 15(12):1627-40.
  6. Falk S, Bannister K, Dickenson AH. Cancer pain physiology. British Journal of Pain 2014; 8(4):154-62.
  7. Zaza C, Baine N. Cancer pain and psychosocial factors: a critical review of the literature. Journal of Pain and Symptom Management 2002. 24(5):526-42.
  8. Lintzeris N, Driels J, Elias N, Arnold JC, McGregor IS, Allsop DJ. Medicinal cannabis in Australia, 2016: the cannabis as medicine survey (CAMS‐16). Medical Journal of Australia 2018; 209(5):211-6.

Breast cancer rehabilitation: Current challenges

It is estimated that over 19,000 Australian women were diagnosed with breast cancer in 2020. This is a startling statistic, but encouragingly, over 90 per cent will survive at least five years.1 During my time seeing women for rehabilitation who have had a recent diagnosis of breast cancer, I have been in awe of their overwhelming positivity, future-thinking approach, and their remarkable ability to continue being mother, daughter, wife, friend and work colleague during what will be one of the most challenging and demanding times of their lives. For this very reason, breast cancer rehabilitation needs to be multi-faceted. It needs to assist women physically, emotionally, and practically to return to these roles which give their lives meaning and purpose. 

The list of potential complications following breast cancer treatment is long. Physical effects, which are not necessarily any more or less burdensome than many of the emotional and psychological challenges, include lymphoedema, nerve palsies, chemotherapy-induced peripheral neuropathy, joint pains, fatigue, hot flushes, cording, adhesive capsulitis, osteoporosis, treatment related cardiac toxicity, and cancer-related fatigue. As rehabilitation physicians, we are uniquely placed to assist in the treatment of every single one of these issues. Yet, unless patients are referred to us, our skills go unused and patients miss out on prevention of and early intervention for cancer and treatment related complications.

As an example, a study by Younus et.al (2010) reported that 83 per cent of patients on aromatase inhibitors (AI) described joint-related pain, but only six per cent were referred to rehabilitation.2 Yet, the first line treatment for AI related joint pain is exercise. A breast cancer diagnosis should go hand-in-hand with a referral to rehabilitation, since increasing evidence is available for the benefits of exercise pre-surgery and whilst undergoing chemo- and radiation therapy treatment. At present, it is common for acute cancer care services to make a referral to rehabilitation once treatment is close to completion. However, a proactive approach to rehabilitation involving referral at time of diagnosis can help identify current issues and anticipate future impairments that may occur as a consequence of treatment or disease progression. Increasing awareness of the benefits of early rehabilitation amongst the community is also key; patients are powerful in initiating their own referrals. If patients knew that exercise improves survival and reduces all cause and breast cancer mortality, wouldn’t more patients ask their oncologists or breast surgeons for a rehabilitation referral? Surely the answer is, yes!

It is imperative that cancer rehabilitation programs are tailored to disease stage. A one-size-fits-all model for breast cancer fails to consider the wide-ranging differences in physical and psychosocial needs between those women with early-stage versus metastatic disease. Caution is required with exercise in those with metastatic bone disease due to risks of pathological fracture and spinal cord compression. MacMillan Cancer Support guidelines recommend that Mirel’s classification is used to determine relative fracture risk and therefore the potential need for prophylactic surgical treatment before exercise is undertaken.3

Mirel’s classification (Table 1) quantifies fracture risk based on site, pain, extent of cortical involvement and whether the lesion is lytic, blastic or mixed, and can be calculated from plain x-ray. Objective assessment of fracture risk allows exercise programs to be tailored to the individual patient to reduce potential complications and target safe exercises which still maximise physical outcomes. Activity for those with metastatic bone disease should avoid excessive torsion and reduce shear and compressive forces on affected skeletal sites. Metastases causing functional bone pain, especially in the lower limbs, may be suitable for prophylactic fixation prior to commencement of an exercise program (Table 2). Surgery for these patients has been shown to increase mobility and improve pain, thereby optimising function and improved quality of life.

Table 1: Mirel’s classification3

 

Score

 

1 point

2 points

3 points

Site

Upper limb

Lower limb

Peritrochanteric area of femur

Pain

Mild

Moderate

Functional impairment

Lesion

Blastic

Mixed

Lytic

Lesion size

<1/3 bone cortex

1/3 - 2/3 bone cortex

>2/3 bone cortex

 

Table 2: Mirel’s Clinical Recommendations3

Mirel’s Score

Clinical Recommendation

≤7

Radiotherapy and observation

8

Use clinical judgement

≥9

Prophylactic fixation

 

Further, there is a need to break down the socio-economic divide in provision of breast cancer rehabilitation. It is well documented that those with lower levels of education and income are less often referred to rehabilitation, have more advanced cancer at time of diagnosis, and have greater levels of comorbidity; all of which contribute to poorer outcomes.4 There needs to be improved accessibility to timely rehabilitation interventions for cancer patients across various cancer streams within the public health system in Australia and more funding dedicated to ‘prehab’ cancer services. Prehab for cancer patients can lessen the potential cardiotoxic effects of chemotherapy, improve tolerance to chemotherapy through systemic conditioning, prevent sarcopenia, and target specific body regions susceptible to disease or treatment-related dysfunction.

There is a long way to go before we can confidently say that there are adequate rehabilitation services for the over 70,000 women living with breast cancer in this country. However, the grass roots of current breast cancer rehabilitation programs demonstrate encouraging results and hopeful prospects for further growth. Let’s all raise awareness of our skill set in this area and continue to talk more about cancer rehabilitation, both within our specialty and outside of the rehabilitation sphere.

Dr Faye Jansen
Rehabilitation Physician, FAFRM
Cabrini Health Elsternwick, VIC

References:

  1. Australian Institute of Health and Welfare. Cancer data in Australia 2021 report. [Accessed 4/8/2021]. Website: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/contents/summary
  2. Younus J, Kligman L. Management of aromatase inhibitor–induced arthralgia. Curr Oncol 2010; 17(1):87–90.
  3. Physical activity for people with metastatic bone disease: Guidance for healthcare professionals. Macmillan Cancer Support 2020. [Accessed 4/8/2021]. Website: https://www.macmillan.org.uk/healthcare-professionals/news-and-resources/guides/physical-activity-for-people-with-metastatic-bone-disease
  4. Bradshaw PT, Ibrahim JG, Khankari N, et al. Post-diagnosis physical activity and survival after breast cancer diagnosis: the Long Island Breast Cancer Study. Breast Cancer Res Treat 2014; 145:735–42.

Epworth Health cancer rehabilitation initiatives

Depending on cancer type, cancer effects and cancer-related treatments received, cancer patients may present with various rehabilitation issues including fatigue, pain, lymphoedema, chemotherapy induced peripheral neuropathy, steroid myopathy, deconditioning, and malnutrition. They often experience associated psychological distress and reduced overall quality of life. Cancer rehabilitation is increasingly recognised as a strategy to optimise the functional outcomes of cancer survivors from the time of diagnosis and throughout the trajectory of cancer continuum including treatment, survivorship, and advanced stages.

Current evidence supports cancer rehabilitation interventions in helping reduce symptom burden and improve quality of life amongst cancer patients. Evidence has also shown that exercise itself is beneficial in improving aerobic fitness, physical functioning, muscle strength, health-related quality of life, and reducing fatigue levels amongst patients with various cancer diagnoses.

Rehabilitation physicians play an important role in acute, subacute-inpatient, and subacute-outpatient care settings in being able to offer expertise in functional assessment and helping address impairments and activity limitations of cancer patients. At Epworth Healthcare in Victoria, a number of recent initiatives had been implemented to meet the rehabilitation needs of cancer patients across the care continuum. Of note, an ‘in-reach’ rehabilitation physician consult service was established this year within the acute haematology ward at Epworth Freemasons.

The rehabilitation physician assesses referred patients for physical and functional issues impacting on acute recovery and progress, working closely with acute therapists in setting achievable short-term goals. For patients who are not ready to participate in three hours of uninterrupted therapy per day (usual criteria for transfer to an inpatient rehabilitation unit) or are impacted by fatigue, this approach allows rehabilitation to commence in an acute setting for cancer patients. The rehabilitation physician also supports the nurse assessors in assessing suitability and readiness of patients for inpatient rehabilitation at Epworth standalone rehabilitation facilities, versus patients more suitable for co-located acute haematology services and rehabilitation unit at Epworth Richmond.       

Epworth Richmond offers an integrated inpatient haematology-rehabilitation service to those who are unable to participate in outpatient-based rehabilitation programs due to factors such as ongoing medical and nursing support needs, being significantly deconditioned, living in rural or remote locations, and ongoing cancer-related treatment plans. This particular inpatient program delivers both medical care and rehabilitation interventions including exercise, functional retraining, nutritional supplementation, and supportive counselling following acute cancer treatment or treatment of cancer related complications. A joint effort between acute haematology and rehabilitation teams aims to provide more efficient collaborative care and coordination of chemotherapy and radiation therapy treatment plans, monitoring of treatment-related response and management of any side-effects.

With outpatient-based rehabilitation programs, breast and general oncology outpatient rehabilitation programs are available at Epworth Hawthorn and general oncology outpatient rehabilitation programs at Epworth Camberwell, Epworth Brighton, and Epworth Geelong. The “Enhance” program, which is specifically designed for breast cancer patients, is an eight-week oncology program with exercise and education components. A multi-disciplinary team is involved including a physiotherapist, exercise physiologist, psychologist, occupational therapist, dietician, social worker, breast care nurse, and rehabilitation physician. This team provide comprehensive assessment of breast cancer patients and management of their functional impairments. Whilst this is a group-based service and patients vary in age, diagnosis, treatment and experiences, additional individual therapy is available where required to maximise functional outcomes for those patients.

With an ageing population and increasing cancer incidence, the need for rehabilitation services for cancer patients continues to increase. At Epworth Healthcare, the aim is to expand the ‘in-reach’ service across more acute cancer streams and to further develop inpatient and outpatient rehabilitation services and programs to meet the heterogenous needs of cancer patients.

Dr Sarah Kofoed & Dr Woo-Jin (Jeena) Kim
Rehabilitation Physicians, FAFRM
Epworth Healthcare, VIC

A review of rehabilitation in lymphoma

This article is a summary of a recently published review1:

“Amatya B, Khan F, Lew TE, Dickinson M. Rehabilitation in patients with lymphoma: An overview of Systematic Reviews. J Rehabil Med. 2021; 53(3): jrm00163”

Lymphomas are malignant neoplasms of the haematopoietic system, with aberrant proliferation of mature lymphoid cells or their precursors.2 They are broadly classified into non-Hodgkin’s lymphoma (NHL, 90 per cent) or Hodgkin’s lymphoma (HL). The new World Health Organization classification stratifies lymphomas based on the cell of origin (B-cell, T-cell/natural killer-cell and HL) or clinical behaviour (aggressive or indolent). An estimated 590,000 new cases of lymphoma (3.2 per cent of all cancers) were diagnosed in 2018 worldwide and its incidence is escalating, with a projected increase to approximately 919,000 by 2040.3,4 Amongst haematological malignancies globally, NHL is a leading cause of death and estimated to cause over 248,000 deaths (2.6 per cent of all cancers) in 2018.3 The total global economic burden of lymphoma is unknown. Treatment and supportive care requirements are resource intensive, with significant financial implications for patients, families, and healthcare systems. Loss of productivity also occurs as a result of the disease, treatment-associated morbidity, and premature mortality.

Current advancements in treatments and cancer detection/diagnosis have improved survival rates for patients with lymphoma (PwL), with age-standardised five-year net survival in adults ranging from 40 to 70 per cent globally in 2010-2014.5 The incidence of NHL is associated with increasing age, improved supportive care and availability of reduced-intensity chemotherapy regimens (such as PEP-C, R-miniCHOP, R-CVP), which are critical for older patients. Lymphomas and their treatment can be associated with short and medium-term residual deficits (physical, cognitive, psychosocial, and behavioural impairments), activities of daily living (ADL) limitations and participation restrictions. Treatment procedures (such as radiation therapy, chemotherapy, and/or surgery) can cause side effects and complications such as neuropathy, cardiotoxicity, cachexia, fatigue, deconditioning and myopathy. Further, various adjustment issues, increased care needs, inability to drive and return to work, financial constraints, and marital stress are reported during the transitional period.

Rehabilitation plays an integral part of any cancer management and there is evidence suggesting the beneficial effects of comprehensive rehabilitation. There is, however, an unmet need in the cancer population whereby only a limited number of survivors receive appropriate rehabilitation. Many general cancer guidelines do not incorporate recommendations for specific rehabilitation interventions. Therefore, this recent review evaluated existing evidence from published systematic reviews for the effectiveness of rehabilitation strategies for improved function, impairments, and participation in PwL.

A multipronged approach was undertaken for the comprehensive literature search, which included a search of health science databases: Cochrane Library, PubMed, EMBASE, and CINAHL (from inception to 1 October 2020), bibliographies of pertinent articles, journals, and grey literature. The study selection process was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All relevant data was extracted using standard proforma based on Cochrane methodology. The Measurement Tool to Assess Systematic Reviews (AMSTAR-2) was used to critically appraise the selected reviews. The Grade of Recommendation, Assessment, Development and Evaluation (GRADE) tool assessed the quality of evidence for each outcome in terms of risk of bias, inconsistency, indirectness, imprecision (random error) and publication bias. The quality of evidence was classified as: ‘high-quality’, ‘moderate-quality’, ‘low-quality’ or ‘very low-quality’ based on the difference between the effect estimate and true effect. 

Overall, 12 systematic reviews (n = 101 studies, 87132 PwL) fulfilled review inclusion criteria, evaluating three broad categories of rehabilitation interventions (physical modalities, nutrition, and complementary medicine). Most reviews were of moderate to low methodological quality. The findings suggested moderate-quality evidence for exercise programs for improved fatigue and sleep disturbance; low-quality evidence for exercise therapy alone and Qigong/Tai chi for improved symptoms and overall quality of life, and an inverse association between sunlight/ultraviolet radiation exposure on NHL incidence, low-quality evidence for beneficial effects of yoga for sleep disturbances, and inconclusive evidence for the association of physical activity and lymphoma risk.

Despite established guidelines, standardised protocols for acute management of PwL and specific guidelines on structured rehabilitation programs are yet to be published. There was significant heterogeneity amongst the included systematic reviews in terms of primary studies involved, lymphoma patients, intervention protocols, rehabilitation settings, and the outcomes measured. Many of the evaluated interventions were too broadly described; specifically exercise interventions, without sufficient details (optimal settings, type, intensity and duration of therapy, cost-effectiveness) to enable replication of these interventions. Participant characteristics were heterogeneous amongst the studies regarding characteristics of lymphoma (type, lesion location and area, time since lymphoma, other comorbidities, age) that resulted in variability of findings. Further, the primary trials within the included reviews varied in their description of control arms, assessment time points, length of follow-up and outcome measures used. Therefore, pooling data for quantitative analyses was not possible, and a best-evidence synthesis was described using qualitative analyses.

This is the first review to systematically evaluate evidence from published systematic reviews to determine the effectiveness of rehabilitation interventions in PwL that aim to assist and guide treating clinicians in choosing an appropriate treatment approach. Despite a range of rehabilitation modalities used in this patient population, high-quality evidence for many is sparse. Some beneficial effects of exercise programs were noted for fatigue, psychological symptoms, and quality of life. The existing gaps in research and practise identified a need to be addressed in future robust studies.

Dr Bhasker Amatya, MD MPH DMedSci & Professor Fary Khan, FAFRM
Royal Melbourne Hospital & Peter MacCallum Cancer Centre, VIC

References:

  1. Amatya B, Khan F, Lew TE, Dickinson M. Rehabilitation in patients with lymphoma: An overview of Systematic Reviews. J Rehabil Med 2021; 53: jrm00163.
  2. Mugnaini EN, Ghosh N. Lymphoma. Prim Care 2016; 43: 661-675.
  3. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2018; 68: 394-424.
  4. International Agency for Research on Cancer. Global Cancer Observatory (GCO) 2020  [cited 2020 16 Sep]; Website: https://gco.iarc.fr/
  5. Allemani C, Matsuda T, Di Carlo, et al. Global surveillance of trends in cancer survival 2000-14 (CONCORD-3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population-based registries in 71 countries. Lancet 2018; 391: 1023-1075.

Walking after spinal cord injury: Fact or fantasy?

To walk again - this is the ultimate goal that every person with spinal cord injury (SCI) yearns for.  As clinicians working in spinal rehabilitation medicine, we are always asking the question: How far are we from finding a “cure” for SCI?

Most recently, I had the privilege of chatting with a special guest, Professor Simon Gandevia, who is pioneering the world’s first randomised controlled study on transcutaneous spinal cord stimulation and walking in SCI.  

Professor Gandevia (MD PhD DSc FAA FRACP) is an internationally renowned clinical neurophysiologist and researcher in the area of human movement and motor impairments.  He is also the Deputy Director and co-founder of Neuroscience Research Australia (NeuRA), a leading institute on brain and nervous system research.

Professor Simon Gandevia

Professor Simon Gandevia

Professor Gandevia, thank you so much for your time today. Can you tell us about your current research? 
The primary new work going on at NeuRA is eWALK, a special trial involving transcutaneous (surface) spinal cord stimulation to see if this can help people with thoracic paraplegia to walk better. It is a chronic intervention lasting 12 weeks with stimulation sessions, three times a week. It’s a big commitment from the research team and even more so, from the participants.

e-WALK Trial

e-WALK Trial

What makes your trial unique? 
The critical thing is that our trial has a sham stimulus. So, it is a proper randomised controlled trial. And this is a world first. The researchers, the assessors, almost everyone has no idea whether the intervention is being delivered, or not delivered. And that is crucial to us.

Congratulations, that sounds like a real breakthrough!  For those of us not involved in research, can you explain why randomised trials are so important? 
You need proper trials; you don’t want to just hear dramatic case reports of something that may have caused the patient to move better. You’ll find that there are whole groups of people who are clearly desperate in favour of things working. So, you need proper research to find the rehab therapy that actually works. That is the focus for research spending.

Are you able to provide us a sneak preview, and tell us what your preliminary results are so far? 
I can share with you that the trial is going surprisingly smoothly. There have been no unforeseen issues. This is good because it’s not trivial to move someone in and out of the gym, lifting them up in harnesses and using body weight support and treadmills.

Has COVID affected your trial? 
It certainly changed how we did things. During this year, we needed appropriate protective gear for the therapists and participants. As in most medical research facilities, we insist on a high degree of vaccination coverage, so the risk for both the participants and staff is reduced.  Surprisingly, in the midst of COVID, we got the trial up and running. We’re hoping to accelerate dramatically in January. 

Well done! What other spinal cord injury research are you involved in?
We’re looking at different forms of training to help people with spinal cord injury cough better, because the likelihood of dying from pneumonia is about 150 times greater than that of the general population. There are other trials to see whether surface abdominal stimulation can enhance breathing, coughing, and bowel function in SCI.  And some colleagues are doing work on virtual reality to see if that can enhance the sensory experience of people with functionally complete SCI.

Do you think there will ever be a “cure” for spinal cord injury? 
Over my career, unfortunately, I’ve only seen ‘smallish’ improvements. I’m not an expert in cellular and various gene-based therapies. But it has been somewhat disappointing. There are many clues about therapies that may work in small animals, such as mice and rats. But it’s different translating that change into the much larger human spinal cord, where the circuitry may be more complex.

The therapy that appears to show most promise at the moment is some form of electrical stimulation.  That is, activating the circuits that have survived and sending inputs to them, either from below or top down. The aim is to promote some degree of neuroplasticity and reprogramming to achieve some functional improvement.

Is it difficult to do SCI research in Australia? 
It is extremely difficult to get rehabilitation type trials funded on the national stage for spinal cord injury. It is considered a niche area, not necessarily affecting a lot of people, but even a small improvement in a single patient’s function can make a huge difference to their life.  A small gain can be amplified into a bigger effect. Spinal Cure Australia have been funding our current research.

Simon, what made you study medicine? 
I got into medicine because I wanted to do something in science, and I came from a medical family.  I also wanted to do something in law, but that wasn’t possible back then, which shows you how old I am! Halfway through medicine, I stopped and I did a PhD in physiology and went back into medicine. It exposed me to physiology, neurophysiology, and clinical medicine and I was able to blend these things together.

How did you get into the area of spinal cord injury research? 
In my early days, when I was a PhD student and even as a medical student, I did research in Ward One at Prince Henry Hospital on people with spinal cord injury. So, my interest goes back a long way.  And it’s been seriously reactivated in the last few years when we set up the Spinal Cord Injury Research Centre at NeuRA.

I just wanted to find out what you do in your spare time, if you have any extra time with everything you do! 
Yes, it is important to have spare time. I do a lot of things actually, but the easiest one to describe is I sculpt stone and wood. I started shortly after I graduated from medicine and I’ve kept it going.  I’ve even had a sculpture exhibition and sold pieces.  It is a creative outlet, and sometimes I have something pleasant at the end.  

Creative outlets give you some time when you can lose yourself and think about other things. It can be helpful to thinking about a particular patient or a particular problem. All of that processing can be quietly going on while you are chiselling away at a bit of wood.

May we see one of your masterpieces? 
Hardly masterpieces - this one I like is called “Torso”.  It’s a little bit spinal-ish as well!

Simon Gandevia sculpture: “Torso”

Simon Gandevia sculpture: “Torso”

Wow, this is amazing! It’s very beautiful and medically themed, I think I see a belly-button.

Simon, if people have questions about your work or trial, how can they best contact you? 
Email for those interested in more information about the eWALK trial: ewalk@neura.edu.au

To view links to key studies that are currently underway, visit the Spinal Injury Research Centre at NeuRA

Thank you so much for your time, Simon. You’ve given us such fascinating insight into your work and life. And thank you for all the research you do for our spinal patients. Both clinicians and patients appreciate it. We wish you the best of luck with your eWALK trial and look forward to the results.

Monica Ling FAFRM
Spinal Rehabilitation Medicine Specialist
Prince of Wales Hospital, NSW

New Zealand Spinal Cord Injury Registry: The journey thus far

Spinal Cord Injury (SCI) is rare, but complex. SCI can occur at any age and due to medical advancements, most people who have sustained SCI have near normal life expectancy. This brings progressive complexity. SCI management requires specialised multidisciplinary and coordinated approach of care from initial presentation through to life in the community. In Aotearoa New Zealand (AoNZ), adult acute care, rehabilitation, and follow up services for people with SCI are provided by the two supra-regional services. These are located in Christchurch under the Canterbury District Health Board (CDHB), and in Auckland under the Counties Manukau Health (CM Health).

Registries have been identified as key instruments in improving patient care and helping achieve optimal social, economic, and quality of life outcomes. Registries also assist health care planning, establish clinical research priorities, and allow international comparison of data. The need for a New Zealand SCI Registry (NZSCIR) was first identified in 1968. It was felt that a registry would be ideal to collect high-quality prospective data, with the potential to inform clinicians of the contributions of acute care, rehabilitation, and community interventions towards longer term patient outcomes. Various attempts to establish a registry in AoNZ have been unsuccessful in the past. Various researchers have published several challenges arising from the absence of a structured SCI registry.1

The NZ Spinal Cord Impairment Action Plan (2014-2019) was developed with the aim of achieving the best possible health and well-being outcomes for people who sustain SCI.2 Establishing an AoNZ SCI registry was a core objective of this action plan. A 12-month feasibility pilot study was undertaken in 2014 by CDHB, Accident Compensation Corporation (ACC), and Burwood Academy of Independent Living (BAIL) to investigate the implementation processes required to set up a SCI registry and provide the foundation for a business case. As part of the study, two registries were analysed and compared. These registries compared were The Rick Hansen SCI Registry (RHSCIR) and Victorian Spinal Injury Database. The RHSCIR was identified as an established, well-resourced national registry, with a high level of acute and surgical data, longitudinal follow up and having internationally standardised data sets and links with other international registries. This registry also provided the ability to partner with Rick Hansen Institute (RHI), with minimal cost for utilisation of a developed registry platform.3

NZSCIR was established in 2016 in partnership with the RHI, ACC, CM Health and CDHB, following the pilot study.1 It took eight months to develop and has been ongoing since 1 August 2016. An implementation plan was set up with RHI and protocols were developed including entry of non-traumatic SCI data (which was not part of the RHI data set) and adjusted to meet ethics requirements.3 A governance group was formed with representation from consumers, researchers, clinicians, funders, and managers. A registry coordinator at each site was established. Since inception, the NZSCIR publishes an annual report that is publicly available. 4

The most recent annual report is for the 2019 calendar year.4 Prior to establishment of NZSCIR, incidence of SCI in AoNZ was estimated at 30 per million, with approximately half being traumatic SCI. Based on NZSCIR 2019 annual data, the 2019 incidence was 45 per million (traumatic and non-traumatic SCI, inclusive of cauda equina) with 30 per million for traumatic SCI alone (Figure 1).

Traumatic and non-traumatic SCI

Figure 1: Percentage of traumatic and non-traumatic SCI

The leading cause of traumatic SCI in people aged 46 and above in 2019 is falls (Figure 2). The proportion of SCI from a fall increased from 17 per cent in the 0-30 age group to 82 per cent in the >76 years category. Transport followed falls as the next common cause of traumatic SCI, representing the leading cause of SCI in those under the age of 45 years. Most sport injuries included water sports (diving into pools or rivers).

Causes of traumatic SCI

Figure 2: Causes of traumatic SCI

Vertebral column degenerative disorders were the most common cause of non-traumatic SCI (29 per cent) (Figure 3). Further non-traumatic SCI causes included malignant neoplasms (19 per cent), vascular disorders (17 per cent), infection (14 per cent), and other (21 per cent).

Causes of non-traumatic SCI

Figure 3: Causes of non-traumatic SCI

Using the Ministry of Health prioritised ethnicity reporting, across all participants, most were of European descent (59 per cent), followed by Māori (19 per cent) and Pacific people (17 per cent). Pacific people includes Samoan, Tongan, Niuean, and Cook Island Māori. People may choose more than one ethnicity and categories are not exclusive (Figure 4).

Ethnicity by SCI type

Figure 4: Ethnicity by SCI type

NZSCIR also captures length of stay (LOS) in acute and rehabilitation settings (Figures 5-8). The median LOS in 2019 was 16 days in acute care (down from 17 in 2018) and 55 days in rehabilitation (down from 63 in 2018). Those with tetraplegia spent more time in acute and rehabilitation settings (median 72 days) than those with paraplegia (59 days). Combined median LOS (not shown on graph) in rehabilitation for those with tetraplegia is down trending (2019 - 52 days; 2018 - 57 days; 2017 - 76 days).

Auckland Acute - 2019 LOS (days) distributions

Figure 5: Auckland Acute - 2019 LOS (days) distributions

Christchurch Acute - 2019 LOS (days) distributions

Figure 6: Christchurch Acute - 2019 LOS (days) distributions

Auckland Rehabilitation - 2019 LOS (days) distributions

Figure 7: Auckland Rehabilitation - 2019 LOS (days) distributions

Christchurch Rehabilitation - 2019 LOS (days) distributions

Figure 8: Christchurch Rehabilitation - 2019 LOS (days) distributions

The average age of NZSCIR participants was 51 years (Figure 9). Of those with traumatic SCI, the international trend of bimodal age distribution included the first peak occurring in young adults between 15 – 29 years, and the second peak occurring amongst older adults. AoNZ’s second age peak occurs between 45 – 60 years, which is younger than international trend. The number of those with non-traumatic SCI tend to steadily increase with age, peaking at age 60 – 75 years.

Age group by SCI type

Figure 9: Age group by SCI type

The rates of surgery are higher in traumatic SCI compared to non-traumatic SCI (72 per cent vs. 66 per cent). On discharge, 36 per cent were independently walking in the community (able to walk 100 metres unsupervised with or without aids). Those with non-traumatic SCI were more likely to be walkers in the community (42 per cent vs. traumatic SCI 34 Per cent). Seventy per cent of discharges are to private residences in the community.

Secondary complications include pain, infections, and pressure injuries. On discharge, 72 per cent were receiving treatment for pain. Thirteen per cent of participants had urinary tract infections (UTIs) during their acute stay and 34 per cent during their rehabilitation phase. Respiratory complications occurred in 26 per cent of participants during the acute phase and 19 per cent during rehabilitation. Those with traumatic SCI were much more likely to have respiratory complications compared to those with non-traumatic SCI. Pressure injuries occurred in acute care in 12 per cent of cases and during rehabilitation phase in 22 per cent of cases.

NZSCIR has full Health and Disabilities Ethics Committee approval and report regularly to the Committee. The data access process is robust and requires researchers to undergo a rigorous request and review process before they gain access to de-identified data. Dashboard aggregate data can be collected for conference presentations, quality improvement activities within supra-regional spinal services, and service analyses. Clinicians have access to their own patients’ data for audits. Protocols can be assessed using NZSCIR data, such as the timing of traumatic SCI participants admitted to specialist centres and surgery.

Setting up and maintaining NZSCIR has not been without its challenges. Recruiting and consenting patients has been one of the challenges. Potential participants are approached for consent and if declined, a minimal data set is obtained as per the ethics approval. Consent rates have partially improved with increased allocation of workforce resources. Work is underway to assess the reasons why patients are declining the full data set for the registry. Issues with incomplete data entry were addressed by providing education and dedicated non-clinical time to clinicians for data entry. Securing long term funding for maintenance of registry is an ongoing challenge. Limited resources have delayed commencing and continuing with community data collection and entry. Follow-up of some participants has also been difficult. Despite these challenges, there are definite benefits of the NZSCIR in improving the understanding and management of SCI in AoNZ, whilst facilitating the translation of research into clinical practice. One of the key limitations of the NZSCIR is the absence of collection of any data for patients with SCI that have not been seen by either CM Health or CDHB supra-regional Spinal Services. 

Dr Bensy Mathew, Dr Suresh Subramanian, Dr Dawn-Louise Adair
Auckland Spinal Rehabilitation Unit, New Zealand

We would like to acknowledge Tracey Croot (nzscir@cdhb.health.nz), BSU site NZSCIR coordinator and Jessica Ozumba (nzscir@middlemore.co.nz) ASRU NZSCIR site coordinator for their contributions to this article.

References:

  1. BSU SCI Registry Development Project (2015). Website: https://www.burwood.org.nz/bsu-sci-registry-development-project/
  2. New Zealand Spinal Cord Impairment Action Plan 2014-2019. Website: https://www.health.govt.nz/publication/new-zealand-spinal-cord-impairment-action-plan-2014-2019
  3. Howard-Brown C et.al. Establishment of the NZSCIR and its challenges. 2018 - Poster Presentation.
  4. New Zealand Spinal Trust. NZSCIR Annual Report 2019. Website: https://www.nzspinaltrust.org.nz/i-need-information/new-zealand-spinal-cord-injury-registry-nzscir/nzscir-statistics-and-information/

Ben's long and winding road to medicinal cannabis - Story by Ian Baker (Australian Quadriplegic Association)

(Reproduced with permission)

After years of awakening early and in pain, Ben Gruter swallowed some cannabis and slept for 10 hours. The former policy advisor to government now takes cannabis daily - and legally.

It has been 85 years since an American anti-marijuana propaganda film warned parents about the “Reefer Madness” that lay in wait for their children.

It has been nearly 30 years since former US President Bill Clinton denied he inhaled the marijuana that he had admitted to trying.

And it is a little more than five years since the Access to Medical Cannabis Act 2016 passed in Victoria, making it the first Australian state to legalise therapeutic use of the controversial drug. Other states have followed.

In Victoria, any doctor may apply to prescribe cannabis for any condition. However, it is not likely that your local GP will do so, and for three main reasons.

Firstly, almost no cannabis preparations have been registered as prescription drugs. Secondly, little is established about what ailments cannabis might help with, and how.

Thirdly, a common ingredient of medicinal cannabis, THC, is classed as a Schedule 8 poison and a drug of addiction like morphine, methadone, and amphetamine. A doctor must therefore seek authorisation before prescribing it for you and may perceive the approval process to be very onerous.

Nevertheless, a Senate inquiry was told early last year that more than 19,000 Australians had been prescribed medicinal cannabis, and there is evidence that the number has risen rapidly since.

Persistent pain

One such Australian is former academic and state government policy adviser Ben Gruter, 65, who has been living with paraplegia from an incomplete T5 spinal cord injury since 2012.

When he resolved to try medical cannabis, Ben had spent seven years experimenting with other treatments for his persistent neuropathic pain, which arrived with his injury. He experiences the pain as located in his right leg, extending from his hip to his foot.

“It’s pain caused by damage to the nerves,” explains Ben, who is a peer mentor with Australian Quadriplegic Association (AQA)/Spire.

“It feels like the most intense pins and needles you’ve ever felt. Some people describe it as burning.

“It’s constant from the moment I wake up until the time I go to bed. Stress will make it worse; being relaxed makes it better.”

Surveys indicate that more than half of people living with spinal cord injury live with neuropathic pain.

Prior treatments

Ben spent 16 months in treatment and rehabilitation after his injury, which arose from a bleed in his spinal column. Initially, he was given Panadol for his pain and when he sought more relief, he was prescribed an opioid, Oxynorm, and a pregabalin based anti-anxiety drug, Lyrica.

“By 12 months, it was pretty clear that not only weren’t these drugs working, but I was having terrible side effects,” Ben reported.

Under the care of a pain team at the Austin Hospital, he tried alternative opioids, three anti-depressants and ketamine, an anaesthetic. He said that his pain remained very troubling, except when ketamine put him to sleep.

Subsequently, Ben was treated by a multidisciplinary team at the hospital’s outpatient Pain Clinic, finding some relief in hydrotherapy and in the cognitive behavioural therapy offered by the team’s psychologist.

“Unfortunately, they could only have me as a patient for six months”, he explained, “because it’s a high demand service.”

Marital conflict

When he was injured, Ben had been married for just four and a half years, to Christine.

“The partner or other family members of someone with a spinal cord injury are also severely affected by it,” Christine observed.

“I think for me, the worst of it has been Ben’s pain. Seeing him in pain has just been horrific.

“And the effects of a lot of the medication he was given have been awful.”

Memory loss is a recognised side-effect of pregabalin. Christine says conflicts arose at home from Ben’s memory lapses.

“We would have a specific conversation about something and the next day, Ben would deny that we even discussed it,” she revealed. “I actually just thought he was being difficult.”

I know a friend

Ben said that he sought to reduce side-effects and cut his risk of addiction by decreasing his consumption of painkillers, in consultation with his GP.

For a few months, he took no drugs at all. Today, he takes no pregabalin and no Oxynorm, instead using an alternative opiate, Tapentadol, in a slow-release formulation.

“When Ben did go off all the drugs, it wasn’t living,” Christine said.

“The pain was so consuming; he just couldn’t do anything. He didn’t want to go out. He didn’t want to communicate with anyone. He couldn’t stand the grandkids coming in because they were noisy.”

It was Christine who suggested to Ben that he might try cannabis. The topic had come up in conversation with a friend whose husband also had a spinal cord injury.

“My friend said it had been helpful,” Christine recalled. “And her husband said it was helpful.

“So we met up and had a discussion, the four of us.”

Absolutely fantastic

“I’d seen the press reports,” says Ben, who like Christine had been exposed to the recreational use of cannabis when he was younger.

“Some medical practitioners said it’s very helpful. Other practitioners said it’s not helpful, and all the evidence isn’t in.

“I went into it with an open mind.”

At bedtime one evening, Ben used a dropper to administer himself a small dose of black-market cannabis oil, orally.

“For years, I’d been sleeping about three hours each night before I woke up in pain,” he said of the result.

“That first night when I took cannabis, I slept for 10 hours.

“It was absolutely fantastic.

“I got a little high and I got a dry throat. I didn’t get munchies.”

Christine added: “And he woke up like a human, instead of a pain unit.”

Obtaining medicinal cannabis

At the beginning of 2019, Ben sought a prescription from his GP for medicinal cannabis. He says his doctor told him he would help, but then concluded that the application for approval would be too burdensome. Instead, the GP wrote a referral to the specialist clinic that had treated Ben’s acquaintance.

Medicinal cannabis typically comes in two forms, only one of which contains THC - the component credited with producing euphoria. The active ingredient of the other form is CBD, which does not produce a high but is believed to have therapeutic value.

After interviewing Ben and reviewing his history, the clinic prescribed him CBD, advising him to increase the dose each week until it was effective.

“When I wasn’t getting a good enough effect, they added THC,” Ben reports.

The cannabis comes from a Melbourne compounding pharmacy in tablet-sized resin lozenges, by registered mail. The lozenges are packed in small plastic containers that carry Ben’s prescription details (the medication is available in other forms).

He takes half a CBD lozenge orally twice a day and then a THC lozenge at bedtime.

“My understanding is that a typical joint is about 10 milligrams of THC,” Ben said, referring to the recreational user’s cannabis-infused cigarette. “I take 6.25 milligrams of THC. So this is probably a little bit more than half a joint.

“On the dose that I take, I don’t get high. If I was taking a lot more, I would.

“It does make me drowsy - both the CBD and the THC make you drowsy. It tastes terrible. And I have a dry throat.

“I don’t know what would happen if I tried to really suppress the pain and take a lot more of it. I don’t want to try that, because I think I’d just fall asleep. So what’s the point of that?”

Hello Singapore!

From Christine’s perspective, the therapy has been transformative.

“I would say within two or three weeks, Ben was engaging,” she says. “He was engaging with me whereas he had been quite withdrawn before. He was engaging with the grandchildren. He was engaging with friends. We were going out. We were socialising.

“Within six weeks of him starting it, we had our first overseas holiday. Our first in seven years!”

The couple spent a week in Singapore, testing Ben’s capacity to make a flight twice as long to The Netherlands, where he was born.

“We had such a wonderful time. We were out every day. We couldn’t take the cannabis with us, but it took four days to wear off and then Ben still had his opioids.”

Prior to starting his cannabis therapy, Ben said: “I wouldn’t have dreamt of doing that trip.”

And he said the benefits have continued.

“The way I would describe it, is that it’s like the pain has been moved a bit away from you. So you are not focused on the pain anymore.

“The pain’s still there, perhaps level four rather than level six on a scale of 10, but it’s better. It’s not in your face.”

“And it’s not on his face,” Christine said. “He’s a lot more relaxed.”

A drug is a drug

Medicinal cannabis is not subsidised under the Pharmaceutical Benefits Scheme and Ben’s prescription costs the couple about $500 a month. That’s significant for them, and they’re aware it would be out of reach for some people.

They would like to see medicinal cannabis become available more cheaply and more readily. Ben would also welcome changes to traffic law.

Driving under the influence of THC is illegal and unlike alcohol, no threshold is specified.

“I’ve heard stories of people who won’t take THC because they’re afraid for their licence,” Ben said.

He added: “I take a very, very small dose, and that’s also worth saying. It is possible that I will need a higher dose in the future. But I don’t need it now.

“And I’ve got to say that although I’m a fan of cannabis - it’s probably the most benign of the drugs that I take for pain. It would be nice to get to a stage where I didn’t have any drugs and could just rely on physiotherapy and psychological pain management systems.”

Commentary by Dr Andrew Nunn – Medical Director of the Victorian Spinal Cord Service

Thank you Ben for your measured personal insight on your careful use of cannabis for pain following spinal cord impairment. Your personal account raises some issues for us all, and maybe very necessarily opens up this can of worms.

It is important that we do this, but it is also tricky. We need to develop a balanced view so that people with spinal cord injury, and those prescribing and funding the use of medicinal cannabis are well informed. The legislation on medicinal cannabis seems to be ahead of the science and a spectrum of issues and views.

Here is some commentary on the topic from the Australian Pain Society, a multidisciplinary not-for-profit organisation that seeks optimal access to pain prevention and management for all people (date reviewed: 19 March 2021).

“Cannabis-derived products are now available for use with therapeutic intentions in Australia and New Zealand. By far the most common reason for their use is chronic pain, however there is a critical lack of evidence that it provides a consistent benefit for any type of chronic non-cancer pain. More than 90 per cent of Special Access Scheme – Category B (SAS-B) approvals have been for chronic pain of various types.

The evidence available is either unsupportive of using cannabinoid products in chronic non-cancer pain (CNCP) or is of such low quality that no valid scientific conclusion can be drawn. Cannabidiol-only [CBD] formulations have not been the subject of a published randomised controlled trial (RCT) for pain indications, yet they are the most prescribed type of product.

In addition, evidence of harms does exist, particularly in relation to sedative effects, interactions with other medications, and neuropsychiatric effects (for products which contain tetrahydrocannabinol [THC]).

Given the above, the clinical use of cannabinoid products cannot be ethically recommended outside a properly established and registered clinical trial environment until high-quality evidence for specific indications is published.”

I see in this cautious approach legitimate concern about the possibility we will create a new problem relevantly similar to the over-prescription of OxyContin and other opioids for pain management in the United States, if with less florid complications. So we must think broadly.

Our Spinal Cord Service explored evidence and trial protocols with the industry pre-COVID, and we hope to understand this better through starting a trial on therapeutic use for spasticity.

Here are 12 points that deserve our attention:

  • There are well over 1000 cannabis strains available, plus now many plant hybrids.
  • Production methods for therapeutic use are variable, with many derivatives for each plant depending on fractionation method and even synthetic THC available.
  • Cannabis formulations usually combine CBD and THC, and these can be supplied in many different proportions.
  • Physiology is complex. There are many receptors in every body system, hence multiple applications (pain, spasticity, sleep and so on).
  • Cannabis can have many positive and negative effects, so a balance is needed.
  • Smoking is clearly not the best way to administer and other options such as oral, nasal or skin absorption contribute variability in both absorption of the medication and duration of action. 
  • There are many types of spinal cord injury, so the optimal dose will be very individual and time of action variable, plus placebo effects must be considered.
  • Cannabis would often be used in combination with other agents. As Ben has recognised, it is important that we look at eclectic approaches and resist the assumption that we can procure a “quick fix”.
  • Commercial drug costs and marketing are becoming a major influence.
  • Prescribing cannabis is tricky and is subject to laborious follow-up requirements.
  • Use of medicinal cannabis has functional considerations for driving and work.
  • Research trials show varied results and for limited number of participants.

I believe we need to bring fresh eyes and an open mind as we consider the many views that are out there as well.

Dr Andrew Nunn
Director Victorian Spinal Cord Service, Austin Health VIC

Rehabilitation and older people – Geriatric rehabilitation

AFRM has been an international leader through its syllabus in rehabilitation and older people for many years. The syllabus was developed about 20 years ago and has been refined on several occasions. It should be revised again because of the explosion of literature about frailty, and post COVID-19 rehabilitation for older people.

In Australasia, we generally use the inclusive term rehabilitation and older people. However, in many countries, the other label “geriatric rehabilitation” is used.

There is much interest in Europe in this topic. An interdisciplinary group including rehabilitation physicians, geriatricians, nursing home physicians and other health professions is working to define geriatric rehabilitation specifically. The definition that has been formulated is – geriatric rehabilitation is a multidimensional approach of diagnostic, therapeutic and rehabilitative interventions, with the purpose of optimising functional capacity and independence, promoting physical activity, and preserving social participation in people with frailty and disabilities.

In Australia, we have COVID-19, an ageing population, the Royal Commission into Aged Care Quality and Safety and the recent Australian Institute of Health and Welfare Report on the prevalence of dementia as current issues. All suggest that rehabilitation and older people is a critical topic.

Professor Ian Cameron, FAFRM
Hornsby Hospital, NSW
John Walsh Centre for Rehabilitation Research
Chair in Rehabilitation Medicine, The University of Sydney

Osteosarcopenia and ageing

Osteosarcopenia is a musculoskeletal syndrome characterised by concurrent low muscle mass and function (sarcopenia), and low bone mineral density (osteoporosis). This “hazardous duet” has shared common risk factors and biological pathways.1 Osteosarcopenia has a strong association with impaired physical performance and balance, increased risk of falls and fractures.

Osteoporosis

Osteoporosis is a microarchitectural loss of bone tissue leading to decreased density and bone fragility. The preferred method of testing is a dual-energy x-ray absorptiometry (DEXA) scan of the central skeleton to measure bone mineral density (BMD) of the lumbar spine and hip (T scores). The World Health Organization (WHO) criteria for diagnosis of osteopenia and osteoporosis are T-scores of below -1 and below -2.5, respectively.

Risk factors for osteoporosis include older age, female gender, high alcohol intake, current smoking, obesity, menopause (females), low body weight, living in residential aged-care facilities, and low mobility and function. Peak bone mass is reached by the end of the third decade, and declines thereafter, more so in females. Between 24 and 49 million individuals over 50 years in North America, Europe, Japan, and Australia have osteoporosis.

The common consequences of osteoporosis are vertebral fractures and fragility fractures of the hip, wrist and humerus. Vertebral fractures are often clinically silent, with a higher risk of severe fracture in women than men over 70 years, but a higher risk of mild vertebral fracture in males. Fifty per cent of all low trauma fractures are non-hip and non-vertebral. All result in an increased risk of subsequent fracture, and all are associated with an increased risk of premature mortality.

With ageing, there is an imbalance between bone resorption and deposition, leading to accelerated loss of bone mass, and significant marrow fat infiltration.2 Women lose almost 50 per cent of trabecular bone and 30 per cent of cortical bone mass with oestrogen depletion following menopause, whilst men lose 30 per cent of bone mass during their lifetime.

Sarcopenia

The term sarcopenia is derived from the Greek: sarx = flesh and penia = loss, and refers to loss of muscle mass associated with ageing. However, sarcopenia is not only a disease of ageing, but shares common mechanisms with sarcopenia in chronic diseases (e.g., COPD, cancer) and endocrine diseases (e.g., diabetes, thyroid disease).3 This condition was recognised with separate ICD-10-CM code. Sarcopenia should not be defined solely on loss of muscle mass. Although muscle weakness is an inevitable consequence of sarcopenia, skeletal muscle becomes intrinsically weaker in old age, and the relationship between age-related reduction of muscle mass and strength is often independent of body mass (e.g., sarcopenic obesity).

The prevalence of sarcopenia increases with age; it is present in 10 per cent of people aged 60-70 years, and 30 per cent of those aged 80+ years. Sarcopenia has negative health consequences with a fourfold higher risk of mortality in people aged 79+ years, a threefold higher risk of functional disability, a significant association with risk of falling, a higher risk of hospitalisation, and prolonged hospitalisation.

Contributing factors to sarcopenia are changes in the nervous system and in muscle. With ageing, a loss of spinal motor neurons due to apoptosis results in a drastic reduction in muscle fibre numbers and size. In addition, there is a decline in neural organisation, an impaired capacity for reinnervation of denervated muscle fibres, and structural alterations in the neuromuscular junction. At the muscle level, there is a glycolytic-to-oxidative shift (i.e., a fast to slow twitch muscle transformation). This differs from the muscle changes associated with disuse atrophy, where there is a slow to fast twitch muscle transformation. Other features of sarcopenia are impaired muscle protein synthesis, impaired metabolic pathways, and fatty infiltration affecting mainly type II fibres.

Sarcopenia in spinal muscles is an independent predictor of vertebral compression fracture. Severe sarcopenia is associated with substantial increases in vertebral compression in the thoracic spine and shear loading along the whole spine.

Screening and assessment

Osteoporosis/osteopenia is diagnosed by DEXA. Fracture risk algorithms include the FRAX and QFracture (UK), the Garvan algorithm (Australia), and the CAROC (Canada).4 Whilst fragility fractures of the hip, wrist, and humerus have a clear clinical presentation, vertebral fractures are often silent. These may be identified through monitoring of height over time (a prospective height loss of >2cm), rib-pelvis distance (distance between costal margin and pelvic rim) for lumbar fractures, and occiput to wall distance for thoracic fractures.

The SARC-F tool5 is a screening tool for sarcopenia and clinical assessment should include measurement of handgrip strength, and the Short Physical Performance Battery (strength, function, balance). Muscle mass may be estimated using DEXA (reference standard), bioelectrical impedance (a surrogate measure), and CT or MRI.

Diagnostic criteria for sarcopenia vary among reference groups. The Consensus of the European Working Group on Sarcopenia in Older People6 recommends diagnosis based on documentation of criterion 1 plus criterion 2 or 3:

  1. Low muscle strength – probable sarcopenia
  2. Low muscle mass (appendicular skeletal muscle mass (kg)/height2 less than two SD below mean of reference group) – confirms diagnosis
  3. Low physical performance – severe sarcopenia if all criteria met

Management of osteoporosis and sarcopenia

Antiresorptive drugs such as bisphosphonates, denusomab or selective oestrogen receptor modulators are the first line approach for osteoporosis. However, fracture risk reduction with drugs is modest because the microstructural deterioration is not reversed. Anabolic agents (e.g., Teriparatide) and Romosozumab (humanised monoclonal antibody) enhance osteoblast activity.

There are no pharmacological treatments for sarcopenia. Non-pharmacological treatments include ensuring adequate calcium, vitamin D and protein intake, and limiting coffee and alcohol consumption and tobacco use. However, resistance exercise is a key evidence-based recommendation for management of osteosarcopenia and a number of trials have shown it to be beneficial in improving balance, bone health, and muscle.7,8

Professor Mary Galea AM PhD FAHMS
University of Melbourne, VIC

References:

  1. Crepaldi G, Maggi S. Sarcopenia and osteoporosis: A hazardous duet. J Endocrinol Invest 2005; 28(10 Suppl):66-68.
  2. Hirschfeld HP, Kinsella R, Duque G. Osteosarcopenia: where bone, muscle, and fat collide. Osteoporos Int 2017; 28:2781-2790.
  3. Borba VZC, Costa TL, Moreira CA, et al. Sarcopenia in endocrine and non-endocrine disorders. Eur J Endocrinol 2019; 180:R185-R199.
  4. Leslie WD, Lix LM. Comparison between various fracture risk assessment tools. Osteoporos Int 2014; 25:1-21.
  5. Malmstrom TK, Morley JE. SARC-F: a simple questionnaire to rapidly diagnose sarcopenia. JAMDA 2013; 14:531-532.
  6. Cruz-Jentoft AJ, Bahat G, Bauer J et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019; 48:16-31.
  7. Watson SL, Weeks BK, Weis L et al. High intensity resistance and impact training improves bone mineral density and physical function in postmenopausal women with osteopenia and osteoporosis: the LIFTMOR randomized controlled trial. J Bone Mineral Res 2018; 33:211-220.
  8. Liu CJ, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev 2009; (3):CD002759.

April 2021

Editor's Introduction

Swinging into 2021 – with the year probably already well underway by the time of publication – I hope you have all remained safe and well this year and carrying on with new, exciting activities/projects as best possible. I would like to welcome all of you to our first Rhaïa eBulletin for 2021, which features our Fellows sharing their stimulating opinions, perspectives and experiences within the areas of upper limb prosthetics, spasticity management, and the use of technology in rehabilitation. 

Both Dr Greg Bowring and renowned Alfred Health (Melbourne) plastics surgeon, Mr Frank Bruscino-Raiola highlight more creative technological advances in the realm of upper limb prosthetics and the use of targeted muscle reinnervation (TMR). Our foremost spasticity experts: Associate Professor Barry Rawicki, Associate Professor Ian Baguley, Dr Yuriko Watanabe and Dr Warren Jennings-Bell draw our attention to key and current aspects of spasticity management. We have interesting and excellent articles by Associate Professor Ray Russo and Dr Timothy Scott discussing the increasing use of robots and adaptive technology to help facilitate recovery in rehabilitation patients. 

Once again, I would like to express my sincere thanks and appreciation towards our contributors for providing their time and efforts in writing these articles. I hope you will thoroughly enjoy reading this edition as much as I did.

Dr Krystal Song
Editor

AFRM President’s Report 

I would like to share observations about technology and rehabilitation, particularly in the field of upper limb prosthetics. Upper limb prosthetics is being revolutionised by technological advancement, offering a window into how technology might to be used in parallel fields in the future (e.g. spinal cord injury, brachial plexus injury etc.). We need to incorporate these technological innovations into the comprehensive rehabilitation we offer to patients with disabilities.

Most of you will remember the cable and harness body-powered prostheses that you learnt about in outpatient clinics or during upper limb amputee training courses. These designs have changed little since the late 19th century and, although passionate advocates argue that their function has barely been surpassed by the modern battery-powered myoelectric alternatives, the improved performance and cosmesis of myoelectric hands is winning the hearts of the amputee community; soon, they will exceed the function of the previous devices by a wide margin. Cost is the major drawback.
 
Myoelectric upper limb prostheses have been in use since the 1950s (invented in Germany in the 1940s). These two-site control, battery operated, single axis ‘hands’ improved gradually over the next 50 years. Powered wrist rotators were added and although powered elbows were also available, they were rarely used because control systems made the combined prosthesis too cognitively demanding for most amputees to tolerate.

The USA’s large number of injured veterans from 2002 onwards included thousands of amputees because body armour and rapid resuscitation techniques could often save a life despite massive injuries. The rehabilitation needs of these veterans drove the political will to fund major research and development in upper limb prosthetic technology to improve the outcomes. This was funded by the US Defence Department’s Defence Advanced Research Project Agency (DARPA) via its ’revolutionising prosthetics’ project – a multi-billion-dollar research effort directly targeted at improving upper limb prosthetics.

Multifunction hands, with a myriad of grip patterns, began appearing from 2007 first in the UK, then subsequently in the US, Germany, and most recently Aotearoa New Zealand. The oddly named “i-Limb” hand from Touch Bionics (not Apple!) in the UK was the first of the multifunction hands and its latest generation continues to lead the market. There are now at least half a dozen multifunction hands in the world market, though in Australia – only four have been used. Of these, the i-Limb (now owned by Ossur), the Bebionic (now owned by OttoBock) and the Aotearoa New Zealand designed Taska (the newest entrant) are the three most popular models, with the Michaelangelo (OttoBock) being less popular. 

In the USA, one of the early DARPA funded products was the so-called ‘Luke’ (as in Luke Skywalker) hand by the Deka Corporation, which is seen in US research and promotional videos. Another is called the MPL (modular prosthetic limb). Neither are available in Australia yet.

Ultimately, the improved hands needed better control systems to fully utilise the potential of their multiple group patterns. A major breakthrough came with Targeted Muscle Reinnervation (TMR) designed for trans-humeral amputees. TMR involved the identification of the now disconnected median, ulnar, and distal radial nerve branches and re-attaching them to slips of muscle (one head of biceps, one head of triceps, and brachialis if present). This enables the previous two-site control systems to be increased to four or even five separate sites providing intuitive control of hand function in a transhumeral amputee rather than relying on the previous two-site control which utilised musculocutaneous innervated biceps and radially innervated triceps as the only control signals to control a powered elbow, wrist, and multifunction hand. This was indeed a great breakthrough and made the use of multi-powered limbs far more realistic and practical. However, two-site control has other problems – the prosthetic electrodes must be sited precisely over the strongest surface electromyography (sEMG) signal and the patient must learn to activate agonist and antagonist separately and accurately. When a person needs to learn four-site control with similar ’purity‘ of signal, it was quite a difficult thing to achieve reliably.

Pattern recognition was a conceptual shift in myoelectric control. This concept dated back to at least the 1970s, but no one had tried incorporating it into control systems for commercially available prostheses until the TMR work at The Rehabilitation Institute of Chicago (RIC) in the early 2000s, in collaboration with the University of New Brunswick School of Biomedical Engineering. Pattern recognition sampled all the muscles around the limb simultaneously when movements were attempted, and the computer ‘learned’ what the pattern of activation represented; in terms of what movement the patient desired in the elbow, wrist, or hand. Pattern recognition is much easier to use in a multi-powered limb and in a transradial level myoelectric hand. It also offered movement control beyond what even our multifunction hands could deliver.

Adding sensory perception to upper limb prosthetics is the major missing component to enable prostheses to reach their potential as a replacement for the lost upper limb. Fortunately, while TMR was performed in Chicago, some sensory reattachment occurred fortuitously and was detected by the patients who described areas of skin overlying the TMR which when touched, produced the sensation of touch on part of their missing hand. Targeted Sensory Reinnervation (TSR) was then deliberately carried out as part of the TMR procedures to create areas of skin that were portals to the cortical areas mapped to the missing hand, particularly the fingers and thumb – sensors on the prosthetic fingers and thumb could enable the person to genuinely ‘feel’ objects with the prosthetic hand. Although this has been done in a limited number of cases in research settings, it has never moved into general use. 

The implication that prehensile function is dramatically improved by the ability to feel an object is not in doubt, nor is the improved ‘embodiment’ of the prosthetic limb. An additional bonus is the prospect of a reliable treatment for phantom limb pain – a cortical deafferentation phenomenon with dysfunctional neuroplasticity.

Subsequent to the TSR experiments, a separate DARPA funded group has demonstrated sensory reattachment via implanted nerve cuffs placed around sensory nerves and direct stimulation of the nerves from touch sensors on the hand. The cuffs remain viable without injury to the nerve for periods of at least five years. While these experiments reported in 2017 held great promise that a commercially available sensory system would soon be available, further technical difficulties have not been overcome.

Implantable motor systems have been utilised in research settings for at least the last five years. Groups in Gothenburg and Utah have implanted leads into muscles replacing the previous surface EMG electrodes and can demonstrate a more stable system. These have not been made available commercially yet.

Osseointegration is the direct skeletal attachment of prostheses. This was pioneered by Dr Rickard Brånemark in Gothenburg, Sweden in 1990, building upon the work of his pioneering orthodontist father who discovered that bone would bond to titanium a generation earlier. Dr Brånemark’s work was designed to provide a method of attachment for amputees who could not wear sockets, and the initial cases were typically short transfemoral and short transhumeral amputees, as well as some cases of thumb amputation. Dr Brånemark’s system, using a threaded barrel-shaped implant, requires two surgical stages and a slow, graduated weight-bearing protocol to achieve the most reliable outcome.  Press-fit implants were developed later by other orthopaedic surgeons utilising hip replacement technology. This enabled much earlier weight bearing by comparison. 

The world is currently seeing a minor proliferation of Osseointegration programs, with at least five or six different approaches available but these can generally be grouped into Brånemark-type threaded barrel implant or press-fit implant. Debate continues about whether single stage or two-stage surgery has better outcomes. All approaches carry the risk of sepsis because of the open stoma which remains in all the designs. Other complications include implant loosening and periprosthetic fracture. Implant removal may require further loss of limb length. Trauma patients are the most commonly implanted, with vascular disease generally contraindicated.

In Australia, the Melbourne group based at the Alfred Hospital has used the Brånemark system since 1995 and the current team led by plastic surgeon, Mr Frank Bruscino-Raiola, prides itself on its meticulous stoma formation, striving to minimise any ooze from the stoma and thus reduce the risk of infection. This requires a two-stage procedure. At the Macquarie University Hospital in Sydney, a group headed by Associate Professor Munjed Al Muderis, currently the world’s most prolific osseointegrator, uses its own proprietary press-fit system and takes a single stage approach. 

Ultimately, osseointegration provides advantages for transhumeral amputees by preserving more of the normal shoulder ROM, especially in presence of a shorter remnant. It also provides a more secure fixation when a heavier, multi-level powered prothesis is utilised. 

The upper limb prosthetic experience demonstrates the great strides that have occurred in connecting the human nervous system to robotic componentry, both at a motor and sensory level. These advances offer tantalising evidence that similar re-connection could be offered to patients with different diagnostic problems. The upper limb prosthetic neural interfaces have generally utilised peripheral nerves and peripheral muscles because it is technically easier to utilise signals that are already large enough to detect and specific enough for purpose. In research settings, direct control of devices from the brain has also been demonstrated, with both directly implanted systems and electroencephalogram (EEG) based surface systems. These are often grouped under the name brain machine interface or brain computer interface. By comparison to peripheral signals, brain signals are smaller and more difficult to separate out from the background noise. The intense research interest in this field would suggest that control systems will continue to evolve and may offer future neural reconnection for spinal cord and brachial plexus injuries.

Dr Greg Bowing
AFRM President 

Faculty Policy & Advocacy Committee update

2021 is now well underway and the policy and advocacy work of the Faculty Policy & Advocacy Committee (FPAC) continues chugging along. As is the pattern of all policy and advocacy work, tasks of FPAC move between urgent requests for consultation with very short response times (those that members won’t generally hear about until after they have already happened) all the way through to the ‘slow burn’ projects, those projects that require considerable ongoing work to reach their goal (those that you keep reading about in these reports). I always think that the ‘slow burn ‘projects are the most challenging as it is hard to keep sight of the long term goal and to maintain enthusiasm, so my thanks go out to those members who continue working on those projects. 

Working Groups

Bariatric Rehabilitation Position Statement: By now you all should have received and hopefully completed a survey for members relating to bariatric services. The results of that survey will assist the working group in development of the Faculty position statement.

Stem Cell Therapy for Children with Cerebral Palsy Position Statement Review: Work continues on this position statement. Now with valuable consumer representation included in the group, we will be looking to complete this document in 2021.

Guiding Principles for the Management of Patients with Multi-resistant Organisms (MROs) in Rehabilitation Units Position Statement: As the members of this group are located in Victoria, COVID-19 put a halt to their work in 2020. With things settled (and hopefully to stay that way) they will be recommencing their project in 2021.

Prehabilitation: This is currently still on hold as we focus on completion of other projects. But watch this space in Rhaïa later this year for updates.

Other work

COVID-19 and rehabilitation
The AFRM COVID-19 Rehabilitation Group has recommenced regular meetings to update and discuss current issues relevant to Faculty members. It is a valuable opportunity to discuss current issues at a binational level. Members are welcome to join the group. The Faculty continues to have a representative on the RACP COVID-19 Expert Advisory Group (ERG) and discussions/advice from our COVID-19 Rehab Group can help inform the RACP COVID-19 ERG about COVID-19 issues from a rehabilitation perspective. 

Australian Council on Healthcare Standards (ACHS) Clinical Indicators
The revised recommendations for rehabilitation clinical indicators were submitted to the ACHS for their review. If accepted, these are expected to replace the current indicators used by ACHS by 2022.

Interesting reading

Finally, there are often other issues that come up from time to time that the Faculty may or may not directly work on, but I will note in this article as they are potentially of interest to members.

Review of National Disability Insurance Scheme (NDIS) Assessments
You will be aware of the extensive reviews being conducted of NDIS processes. It is worth members keeping an eye on this review as items do come up that are relevant to rehabilitation physicians. For example, there has been recent review work underway of how NDIS assessment processes are conducted. There are many opportunities for both individuals and organisations to submit views to the review. Link: Access and eligibility policy with independent assessments | NDIS

Royal Commission into Aged Care Quality and Safety Report
By the time of this publication the Commission should have released their final report. In the interim report released in late 2020, several recommendations were made regarding access to rehabilitation services for the aged and for young people in nursing homes. I’m sure the final report will be worth a read. Royal Commission into Aged Care Quality and Safety

Dr Jennifer Mann
AFRM President-elect
Chair, FPAC

Adrian Paul Prize

The Adrian Paul Prize is awarded annually for the best scientific work in the field of rehabilitation medicine submitted as part of the AFRM Advanced Training Program.

2020 Recipient – Dr Petria Carter

Dr Petria CarterDr Petria Carter recently completed her Master of Medicine (Clinical Epidemiology) at the University of Sydney. She completed her postgraduate MBBS at the University of Sydney in 2012 after graduating with first class honours in Science (Psychology). Petria is a final year rehabilitation medicine trainee, most recently positioned at St Vincent’s Hospital in Sydney. She has been a national representative for Australian universities in rowing and developed her keen interest in musculoskeletal medicine because of this. Petria is also interested in neurological rehabilitation, developmental psychology, research and quality improvement.

The 2019 recipient was Dr Tim Butson.

The Prize was established by the AFRM in 1986 through a donation by the late Mrs Nancy Paul, wife of the late Dr Adrian Paul, the Director of the Department of Rehabilitation Medicine of the Royal Alfred Hospital.

Targeted Muscle Reinnervation: An update

Major limb amputations result in significant long term functional disability, pain, psychological and social problems amongst amputee patients. Over the past 30 years, surgical developments in the area of bone anchored prosthesis and residual nerve management have reinvigorated optimism in this field. 

In 2016, The Alfred Hospital in Melbourne established a multidisciplinary Advanced Surgical Amputee Program (ASAP)* to specifically treat major limb amputees. Simply summarised, this service provides a trifactor of: 

  1. Osseointegration (OI)
  2. Residual nerve management
  3. Soft tissue management.

OI was discovered by Swedish Professor Per-Ingvar Brånemark in the 1960s. The Alfred performed the first femur OI in Australia in 2000. Our major indication for OI remains failure of standard socket prosthesis, usually in transhumeral and transfemoral amputees. OI eliminates the socket and its related problems especially to the skin residuum. It improves comfort, simplifies, and expedites prosthetic attachment. It also improves range of motion, gait and decreases energy expenditure. It provides a conduit for sensory feedback (osseoperception). Not surprisingly, prosthetic use improves by four-fold in our patients.

These benefits must be balanced against the risks. These risks will vary depending on three factors:

  1. the system used 
  2. the team using it
  3. patient selection. 

This is reflected in the wide range of reported complications within the literature (Table 1).

Table 1: Risks reported in the literature.

 Risks  Failure rate 
 Componentry failure (abutment) 10-60% 
 OI failure 10-20% 
 Pain 10-40% 
 Deep infection 10-40% 
 Superficial infection 15-100% 
 Fractures 0-10% 

We use the Osseointegrated Prostheses for the Rehabilitation of Amputees (OPRA™) Implant System, a Swedish two-stage procedure three to six months apart. Although The Alfred performed the first femur OI in 2001. It was not until 2016, following the establishment of the multidisciplinary service, that significant changes were made to our protocol (Figure 1).

Figure 1-Alfred Osseointegration protocol
Figure 1: Alfred Osseointegration protocol with OPRA™ Implant System.

Abutment fracture is a mechanical failure. Although not a major complication, this requires a trip to theatre to replace the abutment. During this time, the patient will be off the system. This was a major issue with the OPRA™ Implant System (up to 60%) until modifications were made in 2017; since then we have had no abutment issues (0%). Risks for OI failure (15%) in our cohort are smoking, being overweight (>90kg), and poor compliance with the rehabilitation program. Infection reflects soft tissue instability at the soft tissue metal interface. Due to our extensive soft tissue reconstruction, our risks are relatively small (12%). Pain (40%), as expected, was a significant issue following any stump surgery in amputees, but this problem has been resolved with the addition of TMR in all our patients in stage 1 (0%). Fractures have not been an issue in our patients. 

Although placement of the fixture (intramedullary titanium rod) is important, the vast majority of the surgery is spent on the soft tissue. It is critical to provide a stable soft tissue metal interface to avoid discharging sinus, commonly associated with superficial infections, exposure of bone, and eventually osteomyelitis/deep infection. Also important as part of the soft tissue management is to deal with the residual nerves to reduce or avoid phantom limb pain and residual limb pain. 

Figure 2 - second stage x-ray
Figure 2: Second stage X-ray.

Figure 3 - Metal soft tissue interface (transhumeral)
Figure 3: Metal soft tissue interface (transhumeral).

Figure 4 - Metal soft tissue interface (transfemoral)
Figure 4: Metal soft tissue interface (transfemoral).

Targeted muscle reinnervation (TMR) is a recent surgical technique designed to improve myoelectric prosthetic control in upper limb amputees. The procedure was first performed in 2002 at Northwestern Memorial Hospital, Chicago (Illinois, USA) and reported in the literature in 2004. Simply stated, TMR results in the formation of multiple strong, reliable and independent EMG signals to allow intuitive use of myoelectric prosthesis (Figure 5). Nerves that control a specific movement in the amputated limb will trigger a similar movement in the myoelectric prosthesis.

Figure 5 - TMR and use of myoelectric prosthesis
Figure 5: TMR and use of myoelectric prosthesis.

For example, in a transhumeral amputee, TMR will allow intuitive six-degree myoelectric control, negating the need of switching mechanisms (Graphs 1 and 2). The Alfred performed the first successful TMR in a transhumeral amputee for myoelectric control in 2016.

Graph 1
Graph 1: Shows increase in EMG signals in transhumeral non-acute patients post TMR.

Graph 2
Graph 2: Shows increase in EMG signals in transhumeral acute patients post TMR.

To undergo TMR (Figures 6 and 7), a patient must satisfy the standard criteria for a general anesthetic, avoid smoking and be cleared of proximal nerve injuries (brachial plexus). There needs to be soft tissue and skeletal stability, as well as enough muscle present or able to be harvested to provide targets for the residual nerves. Consideration needs to be given to the age of the patient.

Our experience is that early TMR performed in the acute post-injury stage and prior to fitting of a prosthesis allows for greater preservation of muscle mass, maintenance of neuromuscular junction receptivity, improved pain control and a more intuitive and expedited training process.

Figure 6-Proximal transhumeral amputation
Figure 6: Proximal transhumeral amputation. Divided nerves identified. Each nerve will be given a muscle target.

Figure 7-Tranhumeral amputation
Figure 7: Tranhumeral amputation. Nerves identified with potential muscle targets.

An extensive rehabilitation process including pre-prosthetic virtual reality training and a pattern recognition system are essential to achieve optimal results (Figures 8 and 9). 

Figure 8 - virtual reality training
Figure 8: Virtual reality training.

Figure 9 - COAPT pattern recognition system with TASKA prosthetic hands
Figure 9: COAPT pattern recognition system with TASKA prosthetic hands.

Post amputation pain can be simply categorised into Phantom Limb Pain and Residual Limb Pain. This has been reported in up to 85 per cent of amputees. To date, no single treatment has proven consistently effective for pain control following major limb amputation. Many theories have been postulated as to the cause and an array of surgical and non-surgical treatments advocated over the years. A biproduct of TMR for myoelectric control has been a significant improvement in post-amputation pain. As a result, nerve surgeries like TMR and Regenerative peripheral nerve interface (RPNI) are now becoming more routine in specialised centres.

TMR gives the regenerating nerve fascicles somewhere to go and something to do. It provides a distal nerve receptor for the nerve to innervate and therefore attempt to heal. It is important to understand that these procedures are not a silver bullet, but a big step in a process. A thorough assessment in a multidisciplinary setting to identify the cause and contributing factors to the pain is essential. This includes assessing the distal end of the nerve, the nerve in transit and the central nervous system including patient characteristics that may predispose them to pain syndromes. We use MRI and US guided injections routinely in our work up.

Our experience suggests that TMR in the acute setting (following amputation) would offer better pain control presumably by preventing abnormal neural pathways and cortical re-organisation. In the chronic setting, results are extremely encouraging but ideally, this surgery should be done at time of initial amputation.

Mr Frank Bruscino-Raiola MBBS FRAC
Director of Plastics, Hand & Faciomaxillary Surgery Unit 
The Alfred Hospital


*ASAP incorporates The Alfred Hospital Melbourne Plastics, Hands and Faciomaxillary Surgery Unit, Epworth Hospital Rehabilitation (Melbourne) and Promotion Prosthetics.

Medical management of spasticity: A current approach

In this short article, I will only be able to give an overview of the medical management of spasticity.  It goes without saying, of course, that medical management without appropriate and expert physical management will always lead to suboptimal outcomes.

The two decisions that need to be made are: firstly, should the spasticity be treated and secondly, are you dealing with focal, multifocal, regional, or general spasticity. It should be noted that spasticity of primarily spinal origin is usually regional or general in nature, and that spasticity of primarily cerebral origin is often focal or multifocal – although may be regional and occasionally general. Spasticity of primarily cerebral origin is almost always associated with dystonia and should usually be considered as a spastic dystonia rather than pure spasticity.

Medication

There are several medications that can be used for the treatment of regional and generalised spasticity. I will rarely, if ever, use systemic medications for the management of focal or multifocal spasticity. Although we don’t have time or space to discuss the pathophysiology of spasticity and dystonia, there are strong theoretical and experiential reasons to avoid oral medications when treating primarily cerebral origin spastic dystonia.

Baclofen, the most commonly used oral medication, is a GABA-B agonist that inhibits the release of excitatory neurotransmitters. It has a short oral half-life. The most frequent errors in baclofen prescription are inadequate dose and inadequate regime. It should be given at least tds and preferably qid (making compliance a problem) – in therapeutic doses always of course, considering side effects.

Diazepam acts at the GABA-A receptor site increasing the efficacy of endogenous gamma aminobutyric acid (GABA). It can be taken bd.

Clonidine is an α2 agonist, therapeutically very similar to the unavailable in Australia – Tizanidine. Careful consideration should be given to dosing above 300mcg/day as it does have some α1 activity and may cause an increase in spasms.

Dantrolene acts at the sarcoplasmic reticulum to prevent Ca++ release. It works primarily by weakening muscle, both spastic and unaffected. It exerts its anti-spasticity effect by also acting on the intrafusal fibres of the muscle spindle. I reserve its use to people with severe general spasticity who have little voluntary function where weakening will not be a great problem.

Gabapentin, despite its name and design does not act like GABA, or on the GABA-A or GABA-B receptor site. Its mechanism of action is unknown, although it possibly acts as an α2 agonist. I personally have been unimpressed with its use for spasticity, although it is arguably and currently the most popular medication. I note that there is limited current literature available.

Medicinal cannabis consists of varying combinations of THC and CBD. The THC component (the bit that makes you stoned) has been shown to be useful in the management of spasticity associated with multiple sclerosis (MS). It is not difficult to access. The jury is certainly still out with respect to benefits and side effects.

Botulinum Toxin (BoNT-A)

There are two commercially available Pharmaceutical Benefit Scheme (PBS) approved preparations of BoNT-A, Botox, and Dysport. Xeomin is available but not PBS-approved for treatment of spasticity. Despite BoNT-A having been used in Australia and world-wide for spasticity management since the early 1990s, there is no consensus on dose or dilution. There is reasonable consensus on the need to localise the specific muscle to be injected. Rehabilitation physicians tend to use either ultrasound or muscle stimulation, whereas neurologists tend to use EMG. In my opinion, ultrasound is far superior to either of the other two methods. The art and pleasure in using BoNT-A is in the clinical assessment and muscle selection and a great deal of experience and expertise is necessary to achieve optimal results. Despite the temptations to be an injector, the worst results and least benefits are those of the occasional injector.

Phenol

Phenol has been used for spasticity management since 1965 (tibial nerve). Phenol is injected perineurally (unlike BoNT-A, which is intramuscular). It causes patchy demyelination of the nerve slowing down both afferent and efferent traffic in a mixed nerve. Average duration of benefit is around 12 months. It affects all muscles in the distribution of the nerve, so is best suited to nerves that innervate multiple muscles performing the same general function. The main complication is dysaesthesia so is best used for nerves with limited sensory function. The obturator nerve is by far the most commonly injected nerve. Other nerves that are frequently injected are the axillary and musculocutaneous nerves.

Intrathecal Baclofen (ITB)

The principle behind ITB is that baclofen is given directly to the subarachnoid space, bypassing the systemic circulation. The average dose of ITB is around 400mcg/day compared to an oral dose of say, 80mg (80,000mcg)/day, which is usually ineffective compared to the ITB. ITB is indicated for generalised and especially lower limb spasticity and is much more effective for trunk and lower limb than upper limb spasticity, irrespective of the placement of the catheter. A knowledge of cerebrospinal fluid flow and dynamics explains this. ITB is a highly specialised but invaluable tool in the management of difficult to treat generalised or regional spasticity.

Associate Professor Barry Rawicki
Rehabilitation Physician
Associate Professor Medicine, Monash University

Spasticity: When I was a medical student

When I was a medical student 400 or so years ago, ’spasticity’ was easy: easy to recognise and easy to treat. 

Easy to recognise because it was essentially a spot diagnosis – if the person walked with a stiff knee or equinovarus foot and/or had their arm up around their ribcage then they had spasticity. 

I could do a quick knee jerk test with my tendon hammer and detect hyperreflexia – case closed. 

Easy to treat because there were only a few oral medications available that either had a risk of addiction (diazepam), hepatotoxicity (dantrolene), or cognitive impairment (baclofen). Motor point blocks existed but were time consuming and required a high degree of skill to be successful. Consequently, most pharmacological treatment failed, and few patients would persist with splints or AFOs. Thus, spasticity for the clinician was something to document in the notes and for the patient was something to endure. Treatment was largely supportive or targeted at redirecting the patient to think about things that could be achieved. 

As often happens with science and medicine, things have got a whole lot more complicated. This was largely the effect of the development of more powerful interventions such as botulinum toxin and intrathecal baclofen. These medications also allowed us to better explore the nature of the condition, and to rethink what we were trying to achieve.

In my first few years of injecting, I had some wonderful successes (I remember one gentleman who returned to playing the piano six weeks after Botox), but many more cases where treatment was beneficial but not as good as I would have liked. In thinking about it over the following decade or two, it became evident that ’spasticity‘ was not one thing. 

I would argue that Lance’s ground-breaking 1980 definition of spasticity is largely irrelevant for rehabilitation medicine – I don’t want to know what happens on an EMG or a passive stimulus (such as that from a tendon hammer). I want to know how sensorimotor dyscontrol impacts upon the person’s ability to undertake movements during active function. Hyperreflexia is clearly real, but by itself it does not necessarily limit function. This observation has caused confusion in some clinical circles who interpret the absence of a ’spasticity angle‘ during Tardieu testing, for example, to either mean the muscle is irreversibly contracted or that pharmacological intervention is not indicated. It ignores other drivers of positive upper motor neuron (UMN) features such as abnormal postural reflexes or action dystonias, just to name two.

There had also been considerable confusion at a government level, with ’irrational rationing’ of access to BoNT-A creating an accidental funding apartheid of those who qualified versus those unworthy of injection. I was proud to work with Alex Ganora in his role leading the Botulinum Toxin Expert Working Group (run by the Rehabilitation Medicine Society of Australia and New Zealand) for my one foray into medico-political activism. After submissions and meetings with a subgroup of the Therapeutic Goods Administration (TGA) over a couple of years, we were successful in helping the TGA see the need to broaden accessibility for people with focal spasticity from acute neurological disease, rather than just stroke and cerebral palsy. While still not perfect, it was refreshing to see that the system was open to logic and sensible revision.

Without apology, rehabilitation medicine focuses on the individual, and by corollary, their family and carers. These days, in describing the UMN motor consequences to patients, I refer to muscles that won’t switch on (the negative features) and muscles that won’t switch off (positive features, or what I would have confidently called ’spasticity’ in my younger years) when you want them to. In a spasticity clinic context, my assessment goals now focus on what drives the second part of this dyad. 

Associate Professor Ian Baguley OAM
Brain Injury Rehabilitation Service
Westmead Hospital 

Obturator Nerve Blocks with Phenol for Adductor Spasticity Management

Botulinum toxin type-A (BoNT-A) is the most widely used treatment for focal spasticity. In Australia, it has finally become available on the PBS with the patient co-payment. However, the PBS S100 Botulinum Toxin Program has ongoing restrictions for some conditions such as MS (e.g. maximum treatment periods per year and maximum BoNT-A units per session). 

Obturator Nerve Blocks (OBNs) are an alternative option for hip adductor spasticity/spasms, in order to improve pain, gait, posture, lower body dressing, and/or perineal hygiene. ONB with phenol are significantly less expensive (AUD $75 for 600mg/10mL) than BoNT-A injections and effects can last up to 12 months (or more). If clinically necessary, BoNT-A can be additionally used to other muscles such as hamstrings, gastrocnemius and soleus. There are consensus guidelines, protocols and workshops of BoNT-A injections; however, in contrast there is limited literature to guide how ONB can be used in a spasticity clinic setting. 

So how did I start doing ONBs?      

Technique

There was a rotating pain fellow who worked in our rehabilitation ward four to five years ago. He was an anaesthetist in his country and had performed ONB. He taught me the distal approach with ultrasound and electric stimulator guidance, and I have been using this approach since. To place a transducer at the inguinal crease and block the anterior branch (between the adductor longus and brevis) and posterior branch (between the adductor brevis and magnus) of the obturator nerve. However, positioning the patient and placing the transducer at inner groin can be very challenging due to limited abduction and involuntary adductor spasms. Anatomical variations of the obturator nerve and echogenic muscle changes make visual anatomical landmarks more difficult. When I see the muscle twitching with minimum current (1-2 mA), I am sure ONB will work.             

Doses

I perform ONB with local anaesthetic (LA) (0.5% bupivacaine, max 5 mL per leg) first to see if the patient achieves the treatment goals. We can see the results within 15 minutes, which I find fascinating. We can see huge differences (before vs after ONB) during one consultation if adductor spasticity was a main contributing factor, unlike BoNT-A that takes a couple of days to work. As the effectiveness of bupivacaine lasts up to four hours, patients are encouraged to do their usual activities (e.g. toileting) at home. If patients are happy with the changes from LA, ONB with phenol is then organised. At our hospital, only one preparation (6% phenol aqueous) is available. I use 240-300mg of phenol per leg based on body weight and age (not exceeding 600mg in total). 

Side effects

From my experiences, one patient developed dysesthesia that continued for six weeks and two patients reported light-headedness/dizziness that improved within two hours.        

Searching for educational opportunities 

I have only six to eight ONB procedures per year, in comparison to 60 to 70 BoNT-A injections. I am keen for more educational opportunities (e.g. workshops) to further develop my anatomical and practical skills (my current teacher = YouTube). I am certainly interested in hearing from the experiences of other rehabilitation colleagues in this area.

Patient example

This patient with MS received ONBs with phenol and BoNT-A to both hamstrings followed by an intensive rehabilitation program. Post intervention, he was able to manage lower body dressing independently (photographs used with consent). 

Image 1
Pre-treatment 

Image 2 
Post treatment

Dr Yuriko Watanabe
St Vincent’s Hospital Sydney

Setting up and running a spasticity service: an experience worth sharing 

From 2008 to 2020, I was involved in setting up and running a spasticity management service at the Royal Hobart Hospital, Tasmania’s only tertiary referral hospital. Spasticity management, in particular botulinum toxin (BTX) injections, is the area of my career that I enjoy most. It is extremely rewarding to see the clinical benefits, but there are aspects that are extremely challenging. My hope in this brief is to share aspects of our system and you can consider for yourself what kind of system to run.

When I started as a registrar, the administrator of our spasticity service was an occupational therapist. She organised clinics and even provided the occasional piece of advice to medical staff as to where to point the needle. It wasn’t long before she moved on. I was then given a handwritten A4 sheet of paper with patient names and medical record numbers and told to organise the clinic. The first thing that needed sorting was a database. Given I’m no expert, Excel was my database of choice. It was sufficient to record names, medical record numbers, diagnosis, source of toxin funding, and how many procedures had previously been performed. The upside of the administrative responsibility as a registrar means one learns quickly the ins and outs of a spasticity service. The downside is the time it takes to record data and organise the correspondence with patients, clinics, pharmacy and allied health. It takes significant time away from traditional registrar time, perhaps to one’s detriment.

Fortunately, an outpatient spasticity management clinic was already in place. This was a once-per-month multidisciplinary pre-assessment and review clinic only with the capacity to see about eight patients. Some centres choose to have an all-in-one clinic model, where the patient turns up, is assessed by the multidisciplinary team and then the medical staff perform the injections. This model can run well, but in my opinion, can be restrictive in public practice. Once everyone assesses, has their say, addresses goals, and the procedure is performed, it becomes a lengthy process. In my opinion, it is difficult to scale up this model to cope with demand due to cutbacks in allied health staffing. Our outpatient pre-assessment and review model was also limited, eight patients assessed/reviewed per month, which was less than the number of patients injected with BTX per month – it’s unsustainable.

Figures from the Stroke Foundation illustrate the future demand on our spasticity management services. More than 56,000 strokes experienced by Australians this year, more than 475,000 Australians currently living with the effects of stroke and more than 1,000,000 living with stroke by 2050. Further, the literature states that approximately 30 per cent of stroke survivors develop spasticity. In my mind, those figures suggest that our traditional ways of assessing, treating and reviewing patients with spasticity in our multidisciplinary clinics need reviewing, particularly because those figures are just for stroke. In 2008, I was handed a sheet of paper with about 30 names on it. By 2020, we ran a database with more than 120 patients actively receiving BTX across Tasmania. 

My approach was to increase the number of assessment/review clinics and the number of injection clinics. Over the space of 13 years, we went from performing BTX injections for approximately three patients/week to 10-12 patients/week in three separate injection clinics. Each of our physicians still ran a monthly multidisciplinary pre-assessment/review clinic, but this was usually set aside for more complicated patients. Patients with relatively straight-forward spasticity were seen by the physician alone on a weekly basis, with assessments and management plans developed without allied health present. Referrals were then sent to allied health so that pre-injection assessments and reviews could be arranged in their time, thereby maintaining the multidisciplinary nature of the model. It was by no means a perfect system, but it allowed us to meet demand. If we had stuck to the system of the single monthly multidisciplinary appointment or trialled the model where assessments and procedures are performed on the same day, we would not have treated as many and patients that needed our help would have gone without.

Whichever way our services run changes will be necessary. Demand is outgrowing supply. The turnover of allied health in public hospitals is generally out of our control, but somehow more therapists with experience in spasticity management are required. Administrative support should be available to manage services. Although there are advantages to a registrar-run administration model, I do not think it is fair to leave all those duties with trainees. Last but certainly not least, training for our current and future physicians is vital. This training needs to be of excellent quality and occur frequently. If it is not, then I believe patients will suffer and the demand on our health services will not be met. Training needs to be in assessment and procedural. As physicians, we ought to be able to carry out the more difficult aspects, perform an accurate assessment and implement an effective management plan. The procedural side requires further training with localisation techniques, but in my opinion, this is easier than assessment and management. Unfortunately, a once-per-year workshop is not quite enough.

After 13 years in Hobart, my family and I decided it was time for a change, so we moved to the Sunshine Coast in Queensland. Here we have decided to open a private spasticity management service and after five months of preparation we should be ready to open in one more month. Having experience in setting up a public service has been useful for setting up a private service, but it doesn’t mean it has been simple. Important steps included writing the business plan, securing finance, finding suitable real estate, fitting out the office, brand and business registration, organising a website, setting up practice management software, organising practice and ultrasound accreditation, a Medicare Location Specific Provider Number, ordering consumables, stationery, a BTX ordering and delivery system, a reliable vaccine fridge with a backup power supply, setting up professional connections, writing practice policies and guidelines – the list goes on. If I can offer advice here, it is that though the process seems daunting and overwhelming, aim to tackle one issue at a time and it will come together. It has taken longer than I initially anticipated, so it is worth expecting a lengthy process. Patience is a virtue; I better work on that.

Dr Warren Jennings-Bell FAFRM, MBBS, B Med Sc, B Sc
Rehabilitation Physician
NeuroRehabilitation, Sunshine Coast QLD

Robotics in rehabilitation medicine

As clinicians in neurological rehabilitation, we are often fighting against the natural history of the disorders we are managing. Most commonly, this occurs in stroke and traumatic brain injury in the adult sector, and traumatic brain injury and cerebral palsy in paediatrics. 

In many studies, intensity of therapy is identified as a critical factor for maximising change in functional outcome.1,2 However, achieving the intensity needed to prevent deterioration and promote functional improvement is often elusive, given the amount of therapy input needed to bring about recovery. An exciting area that could help fill this gap is robotic technology. 

Robots are machines capable of carrying out a complex series of actions automatically and are typically programmed by a computer. Robotics is the branch of technology that deals with the design, construction, operation, research and application of robots. There has been a shift in the use of robotic technologies away from helping individuals cope with their environment, to one of interactive robots used to directly help facilitate recovery.3 The critical elements for neuroplasticity and motor learning are not only for intensity of therapy, but for repetition, task specific training and motivation as well as tactile, visual and auditory feedback for self-monitoring and learning.4 Robotic technology has the potential to provide these requisites and contribute to an intensive rehabilitation program. 

We are currently investigating the role that robotic technology can have in children with neurological disability through The Little Heroes Foundation Centre for Robotics and Innovation at the Women’s and Children’s Hospital in Adelaide, South Australia. We have conducted one randomised controlled trial in traumatic brain injury and a feasibility trial of robotics in fragile oncology patients post-chemotherapy, with the aim of improving fitness and functional outcome. Our findings to date indicate that there is feasibility to these technologies both in efficacy and acceptance by our paediatric patients that seems to be primarily related to improved motivation, repetition of tasks and overall dose of therapy, as well as improvements in sensory feedback where motor learning is optimised.

An example of the advantage of sensory feedback provided by the robots is illustrated in a case study. We assisted a 10-year-old boy with cerebral palsy whose goal was to improve his gait efficiency and endurance. Even before this treatment in robotics, his physiotherapist was trying to teach him to isolate his quadriceps muscles on the right, a difficult task for him due to poor selectivity and difficulty understanding the therapist’s instruction. It was not until he got a visual feedback loop from the Lokomat® robotic gait orthosis, having seen a 'peak' on the graph noting knee extension, that he finally understood what “contract your quads on the right” really meant. Once he understood this action, he was able to generalise this through practise in land-based physiotherapy more efficiently and improve the quality of his gait, which was documented objectively in his Gross Motor Function Measure.

There is concern that robotic technology has several deficiencies, such as the cost of providing robotics, the lack of variability of movement within the machines, and a lack of research evidence demonstrating efficacy to the point where the cost of the robotic technology can be fully supported. With ongoing research, this view is changing such as the cost equivalency of robotics with conventional therapy as demonstrated in one study.5 However, there are advantages to the application of robotics, such that this technology is likely to be a valuable adjunct to rehabilitation therapies into the future. 

Associate Professor Ray Russo PhD, MBBS, FRACP, FAFRM 
Head of Research, Paediatric Rehabilitation
Women’s and Children’s Hospital

References
1. Horn SD, DeJong G, Smout RJ, Gassaway J, James R, Conroy B. Stroke rehabilitation patients, practice, and outcomes: is earlier and more aggressive therapy better? Archives of Physical Medicine and Rehabilitation. 2005; 86(12):101-14.
2. Damiano DL. Activity, activity, activity: rethinking our physical therapy approach to cerebral palsy. Physical Therapy. 2006; 86(11):1534-40.
3. Krebs HI, Dipietro L, Levy-Tzedek S, Fasoli SE, Rykman-Berland A, Zipse J, Fawcett JA, Stein J, Poizner H, Lo AC, Volpe BT. A paradigm shift for rehabilitation robotics. IEEE engineering in medicine and biology magazine. 2008; 27(4):61-70.
4. Esquenazi A, Packel A. Robotic-assisted gait training and restoration. American Journal of Physical Medicine & Rehabilitation. 2012; 91(11):S217-31.
5. Lo AC, Guarino PD, Richards LG, Haselkorn JK, Wittenberg GF, Federman DG, Ringer RJ, Wagner TH, Krebs HI, Volpe BT, Bever Jr CT. Robot-assisted therapy for long-term upper-limb impairment after stroke. New England Journal of Medicine. 2010; 362(19):1772-83.

Shameless wearable technology: Impact on assistive technology for people with disability

As a 10-year-old boy, my difficulties in reading the blackboard at school brought the need for corrective glasses. I was a boy who was very self-conscious and I was a non-compliant wearer. Seeing other children in my class getting glasses at the same time did not change my resolve. Sensitivity to my appearance to others limited me and was further fueled by comments from my peers (“Do you have to wear those now?”).

I am a Kids Rehab Doctor with a strong interest in use of technology for innovation in reducing disability. I have always been acutely aware of my own situation as a boy and the things that we ask children to bear (even something as simple as wearing an ankle foot orthotic [AFO]). One of my kindergarten age patients was asked by a peer “Are you a robot?” on sighting his plastic AFO. A term that I heard in the 1990s associated with optimising assistive technology compliance was that it must not be a 'badge of disability'. 

Since the 1990s, there has been a proliferation of wearable technology for mainstream consumer use. This is changing our perception and acceptance for wearable technology. Shamelessly, people in the community are increasingly wearing their devices such as Bluetooth earphones, smartwatch, fitness tracker and safety wearables (including call alarms). Smart garments embracing the convergence of textiles and electronics into e-textiles and smart glasses, to provide an access to data with the potential for augmented reality, have been emerging. Such progress builds a new state of play for children (and adults), with differences embracing assistive technology and its, more recently, increasing 'cool factor' in the broader community. 

A key element in such a factor is appearance (underlined in my own experience above). The term “uncanny valley” was introduced by Mori in Japan in 1970 (Figure 1). It mainly refers to human likenesses in robotic technology. It is also applicable to adaptive technology such as prostheses, exoskeletons, and brain-machine interfaces. Mori wrote “I have noticed that, in climbing toward the goal of making robots appear human, our affinity for them increases until we come to a valley, which I call the uncanny valley”. This is the point at which the likeness is almost but ’not.quite.right’. It produces a feeling of eeriness and becomes uncanny. This progression is shown in the figure below. The valley shown in the curve becomes steeper and deeper when movement of the robot is introduced.

Figure 1 - The uncanny valley graph.tif
Figure 1: The uncanny valley graph created by Masahiro Mori: As a robot’s human likeness [horizontal axis] increases, our affinity towards the robot [vertical axis] increases too, but only up to a certain point. For some lifelike robots, our response to them plunges, and they appear repulsive or creepy. That’s the uncanny valley.

Our response to this as rehabilitation technologists can take one of two divergent approaches with both having merit. Firstly, we can use our innovation to progress our technology to the right of Mori’s curve by more closely emulating natural systems and appearances. The development used in prostheses of incredibly lifelike silicon skin with matching pigment and hair is an example. This is a slowly progressing combination of cosmetic aspects of technology and societal change which is, nonetheless, likely to remain asymptotic to the goal. 

Secondly, we can abandon the goal of being lifelike and embrace the difference by moving to the left of Mori’s curve. Existing prosthetic examples might include the Greifer hand or the running blade. In these cases, the differences are worn confidently as a badge of honour this time. Here, the commitment to function and play supersedes concern for the appearance of differences. This is an outcome of a gradual progression in attitude of the individual and the community where the achievements of people with differences can be paramount and celebrated.

In my own journey, wearing glasses eventually became a part of my life (although I do enjoy contact lenses at times). I accepted the changes it would make to my appearance and, perhaps, I have become a little more resilient. I can laugh with the ophthalmologist when he likens my glasses to the bottom of soft drink bottles (albeit feeling the comment perhaps just a little inappropriate from an eye professional). My father in recent years had a cataract operation that relieved him of his lifetime requirement (to that point) to wear really thick glasses due to an intraocular lens replacement. Recently, on seeing me wearing my glasses, stated animatedly “They’re really thick glasses you’re wearing”. All I could do was shrug, smile and reflect on my own journey. For the individual, growth and change is personal. Others may not understand another’s journey, and this is okay. By appreciating this fact, effective growth and acceptance of change, including emerging assistive technology, without the need for the approval of others, will allow the individual to flourish. 

Dr Timothy Scott
Paediatric Rehabilitation Specialist
Rehab2Kids, Sydney Children’s Hospital 


References
1. https://spectrum.ieee.org/automaton/robotics/humanoids/the-uncanny-valley 


George Burniston Oration

The George Burniston Oration is our keynote lecture. It was named soon after our incorporation into the RACP, to showcase our history and pay homage to our founders.

Learn more about the George Burniston Oration, including a list of keynote speakers from 1994.


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Australasian Rehabilitation Outcomes Centre (AROC)
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RMSANZ is the professional body for rehabilitation physicians and trainees in Australia and New Zealand. The Society offers a stimulating and supportive environment of professional development, continuing education and policy review and is committed to improving the quality of care for persons with impairment and disability.


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