Rhaïa July 2016

Rhaïa June 2016 – Editorial 

Dr Damien Daniel

The National Disability Insurance Scheme (NDIS) is coming to a health service near you - you must prepare. The NDIS has now been rolled out in four locations around Australia (each aimed at diverse populations), and will rollout throughout Australia from July, with full take-up planned for 2019. This edition of Rhaïa is dedicated to the NDIS. We have articles from rehabilitation physicians directly involved in two of those early 'test' regions. We also have a commentary piece by outgoing Australasian Faculty of Rehabilitation Medicine (AFRM) President Dr Steve de Graaff, who has personally been involved with the NDIS for a number of years. 

There is no doubt Australia needs to change how it treats people with disabilities. Australia’s overall performance in outcome and cultural terms for people with a disability, their families and carers has been poor. Australia ranks 21 out of 29 ​Organization for ​Economic ​Cooperation and ​Development (OECD) countries in employment rates for people with disability and 27th out of 27 countries, when it comes to relative poverty risk for people with disability.1

Rehabilitation physicians will undoubtedly play an integral role in the NDIS, but the specifics of that role are yet to be determined. As Professor Michael Pollack and Dr David Kellett (Hunter region, NSW) state in their article, “certainly, there is a very complex interaction that has developed between Health and Disability services, and Rehabilitation sits at the intersection.” This concurs with The Conversation’s  article Sorry, Not My Department. It may be a role we need to forge for ourselves, and for our patients. Another effect of the NDIS has been significant extensions in length of stays in rehabilitation or transition care wards while patients endure long delays in the administration and implementation of their NDIS care plans. 

The experience in the Barwon region, Southern Victoria, echoes that of the Hunter region according to our article by Dr Michael Bennett. There seems to have been a universal underestimation in the level of take-up from the community by the National Disability Insurance Agency (NDIA - the agency that administers the NDIS), and a resultant blow out in costs. A reactionary “tightening of the belt” is now being felt. Thus, inconsistencies in approvals of plans have led to unrest among many consumers of the NDIS, though you will not find this in government publications.2 I have joined the NDIS Grassroots Discussion Facebook group seeking a balancing view. It is worth a perusal.  

Through Dr Steve de Graaff and Associate Professor Andrew Cole (now AFRM President) the AFRM has been heavily involved in offering guidance to NDIS administrators. The RACP has also set up an NDIS Working Group led by Professor Robyn Wallace. This degree of involvement should ensure our voice is heard at the highest level. 

Everyone agrees that change in disability care in Australia is necessary. How that change is implemented is the issue. So far the experience of the NDIS, for both health providers and consumers, has been mixed. This makes the input and influence of rehabilitation physicians even more important at every stage of development. As Dr de Graaff concludes, “there is still a lot of work to do.”

1. http://www.theaustralian.com.au/national-affairs/health/australia-ranks-among-worst-in-oecd-on-needs-of-disabled/story-fn59nokw-1226209606132
2. http://www.ndis.gov.au/news/enewsletters-archive

National Disability Insurance Scheme (NDIS) – Changing the environment we work in

Dr Stephen de Graaff
Immediate Past-President, AFRM

The National Disability Insurance Scheme (NDIS) aims to provide a new model of care and support to people with disability, helping them to participate and contribute to their community, over their lifetime. The NDIS recognises that people with disability have the same right as other members of the community to realise their potential. It acknowledges and respects the roles of families and carers by supporting the pursuit of their goals and planning the delivery of the resources necessary to achieve them. 

1 July 2016 is targeted as the day that the NDIS will ‘roll out’ throughout Australia. By July 2019, it is estimated that 460,000 people will transition to the NDIS. It is important to note that State/Territory Government funded clients will transition ahead of new participants. As multiple trial centres have been functioning throughout Australia, it has become apparent that the rollout needs to be in a staggered manner. 

To accommodate the cultural change that the NDIS brings to our community, the rollout will now occur over a period of three years, rather than just on 1 July 2016, to allow a smoother transition. In fact, the Western Sydney region has commenced its participation in the NDIS program just recently.

The Faculty and wider College continue to actively engage with the relevant administrative departments and the National Disability Insurance Agency (NDIA). Associate Professor Andrew Cole and I have met twice yearly with NDIS administrators, in particular Mary Hawkins. These meetings have certainly assisted the Faculty in guiding the NDIS towards a more proactive, earlier intervention model in acquired brain injury (ABI) and spinal cord injury management, as well as providing expert opinions on difficult clinical scenarios.

The NDIS will fund organisations that enable participants to undertake daily living activities. This includes the provision of non-clinical supports, aids and equipment, and in specific situations, nursing care. It will not support health aspects including diagnosis and clinical treatment of health conditions, supports linked to maintaining or improving health status, rehabilitation following a medical or surgical event, nor medications and pharmaceuticals.

The College has set up an NDIS Working Group led by Professor Robyn Wallace. This group has given insightful feedback on a number of issues relating to the NDIS already. Three Faculty Members (Dr Kathryn Langdon, Dr Elizabeth Thompson and I) are on this working group so AFRM has excellent representation. One of the priorities of the working group is to ensure the interface between Health and Disability is not lost. 

The working group provided advice to the College recently concerning the challenges faced and ramifications of the potential closure of The Centre for Disability Health, in South Australia. Issues with the divestment of The Slow to Recover Program in Victoria are also a concern.

The RACP NDIS Working Group, with the support of the RACP Paediatric Division, hosted an NDIS workshop at this year’s Congress. This is the beginning of more comprehensive dialogue between the College and National Disability Insurance Agency (NDIA). There are many challenges ahead but there is clearly goodwill between the RACP and the NDIA to ensure that the NDIS provides the best outcomes for our patients.

I was fortunate to attend a workshop organised by The Young People in Nursing Homes Alliance and Spark Strategy in November 2015 and February 2016. These are national cross sector engagement meetings involving many groups that will have an impact on, or will be impacted by, the NDIS rollout. There is global goodwill to have the NDIS succeed, as evidenced by these meetings. I encourage you to read the following articles by Associate Professor Michael Pollack and Dr Michael Bennett outlining their experiences in the Hunter Valley and Bellarine Peninsula. There is still a lot of work to do.

National Disability Insurance Scheme (NDIS)  The John Hunter Hospital Rehabilitation Medicine Department Experience

Associate Professor Michael Pollack and Dr David Kellett

Translating policy into action presents numerous challenges. For the NDIS, a major challenge is creating operational definitions of disability that reflect the true requirement for disability care across Australia. Do the people with disability who need help get it? Our experience as part of NDIS Hunter trial site has been one of ‘hits and misses’, provision for some has been generous and for others, not forthcoming. 

To better understand how disability has been operationalised by the National Disability Insurance Agency (NDIA) you can read the guidelines available on the NDIS website

In examining the NDIS operational guidelines, one can already see that there may be comparisons and contrasts between the NDIS approach, and that of a Rehabilitation service.  It is not then surprising, that gaps exist between the service provisions as delivered by the health system, and those delivered by the NDIS.

Certainly, there is a very complex interaction that has developed between ‘health’ and ‘disability’ services, and rehabilitation sits at the intersection. This complexity reflects potential differences of definition, and also differences in prioritisation, organisation, and coordination.  In practice, navigating these complex interactions in the Hunter region between health services and NDIS has been a challenge, and remains a work-in-progress.

The trial experience in the Hunter has been further challenged by early oversubscription of allocated NDIS places reflecting a significant underestimate of reality by NDIA.  Need, may be determined either by the specific number of people who perceive that they deserve access to the scheme, and also potentially assessed by the cost of providing services to those accepted into the scheme (at both an individual and at an organisational level). Underestimation has seen progressive tightening (possibly even restrictions) of the level of support that is available to people applying to the scheme.  In the early days, approval was available for people who required 24 hour-a-day support services in their home setting. Recently, we have been informed by NDIA that scheme participants would typically not require more than four to five hours per day of support.

There is no doubt, despite the issues identified above, that there have been significant positives as a result of the establishment, delivery, and access to NDIS in the Hunter region including:

  • more rehabilitation patients able to return or remain in the community, rather than an Aged Care facility
  • facilitation of increased community participation, as well as improved independence and quality-of-life (QOL) in the home setting
  • improved carer opportunities.

This has been achieved through improved access to support services, equipment, and technology.

The above advantages and benefits however, do not come easily. The infrastructure and administration required to deliver these have so far resulted in a process that seems to lack agility. It takes time for the NDIA to receive, consider, decide, and then deliver on the programs that it oversees. The workforce within NDIA has had to be garnered from a community that has not yet had time to fully train for the needs and demands of the service and its initiatives. NDIA timeframes have not coincided with the priorities of inpatient settings in particular.  

The establishment of NDIS has been accompanied by the withdrawal of other public health support services (home and community care) and has highlighted significant gaps. Whilst the needs of people with major/permanent significant disabilities in the community are being addressed, the needs of people with moderate, temporary disability would appear to be less well recognised. Many of these individuals tend to fall into the gap and are still struggling to identify where they can turn to receive their support programs.  Where the limiting conditions are seen clearly to be health related (including many with chronic disease conditions), there is often a struggle to have efficient services delivered.

So far the introduction of the NDIS into the Newcastle region has had implications for:

  • defining and identifying those with a disability in our community
  • shifting attitudes regarding the value of disability care
  • the roles and responsibilities of health and other disability service providers.

There have been significant impacts on individuals and the public health system which have seen:

  • some people who required support services, which would have been provided previously, now miss out
  • a significantly increased length of stay in hospital for many people
  • an increased workload on the multidisciplinary team (administration, communication, justification, advocacy, and more) and a change in the work role of some team members
  • a whole new NDIS workforce, which demands a new learning curve.

Our concerns moving forward include ensuring that new or evolving definitions of disability do not result in inappropriate exclusions. It must also be ensured that the impact on health services is not detrimental to the needs and priorities of individuals and the health system.

Building the plane whilst flying it – McKellar Centre/Barwon Health’s test flight of the NDIS

Dr Michael Bennett

Here is what I witnessed two years ago on an overseas sabbatical designed to study neurorehabilitation in a foreign system. A thirty-three year old labourer with a moderate to severe closed head injury was discharged home after only three weeks. He had a gastronomy tube, required a heavy two person transfer, was non ambulant and probably still in post-traumatic amnesia. He was taken  to his mother’s home which was up three flights of stairs. He had minimal local nursing assistance, and his family was expected to hire cheap unskilled labour as carers.

The country – USA. The city – New York. The hospital - elite and world renowned.

Universal access to assistance for people with disabilities is a goal to be lauded, valued and supported. The National Disability Insurance Scheme (NDIS) implemented by the National Disability Insurance Agency (NDIA) is pursuing that goal, set for national implementation in June this year.

The stated goal of the NDIS is ‘Individualised support for eligible people with permanent and significant disability, their family and carers.’ Their website also suggests that the disability “stops you from doing everyday things by yourself” although whether this is an admission criterion is unclear.

The scheme aims to provide “reasonable and necessary supports that help you achieve goals such as therapies, equipment, home modifications, mobility equipment, taking part in community activities…”.
This article will discuss the opportunities and challenges presented to the Barwon region as one of the four test sites for the NDIS from July 2013. Our trial age was less than sixty-five.

Barwon Health is the major health care provider for the Barwon region in Southern Victoria.  The acute service is three hundred and seventy beds at University Hospital Geelong, and inpatient subacute care 100 beds at McKellar Centre, North Geelong.
The positives

We have many people living independently in the community purely because of NDIS funding for carers and equipment. When the trial was in its infancy, the generosity with equipment provision was almost breathtaking. Whatever was asked for was given - $40k wheelchair with standing facility; $10k gait aid (never used). Financial constraints are now much more in evidence.

Our experience would suggest:
Time delays are very significant. After an application for acceptance to the NDIS it will be 21 to 28 days before you hear back. This applies to inpatients too. Start early.

Ensure a support coordinator/case manager is appointed. If you don’t have a named contact, communication is fraught. Consider asking your managers to push for an NDIS representative to be allocated to your service, as for Veterans’ Affairs.

For your inpatients, the case worker/support coordinator will come to the ward for a planning meeting with the client. Try to ensure your staff is invited to contribute.

If accepted, NDIS will ask for a care plan. Sort out a pro forma for your team as soon as possible. It is very time consuming. Our occupational therapists are increasingly being asked to revise care plans, particularly for home modification costings, and are spending literally hours getting quotes for “cheaper tiles”, or “cheaper taps”, ​and more.

The first twelve months was beset by a lack of trust, that is, prognostication from skilled clinicians. An application on behalf of a 32 year old with a devastating stroke was met with “get back to us in 12 months when you know if the disability will be permanent.” This is changing but may need ongoing advocacy.

Applicants or supporters require high levels of health and computer literacy. Information is online. A phone number is given, but you need to be able to access the website to get it.

The NDIS specifically states it does not provide rehabilitation. Determining where rehabilitation ends and maintenance starts is subjective, imprecise and confuses clients.

NDIS will employ private provider’s, ​for example allied health professionals, and if public allied health workers are also involved with active rehabilitation, communication between all the parties is almost impossible. In addition, your health service may lack private providers with requisite skills such as carers and neurophysiologists.

Support coordinators are not always health trained, and my allied health colleagues have advised me that these coordinators have no leave cover.

At the time of writing, a contested claim is reviewed by the same person who declined the request in the first instance. I am not aware of a clinical panel that reviews contested claims.

For the very disabled inpatient, who can only get back to private accommodation with either considerable home modifications, a new home and/or complex care provision, NDIS will not fund interim accommodation. If you decide to move the patient to transitional or residential care whilst awaiting suitable private accommodation, you will be relying on the NDIS driving the process for getting that person out of care. Personal discussion with Professor Michael Pollack in the Hunter region trial site suggests that they had young clients who did not emerge from long term care as planned. As a result I understand their average length of stay for such clients is 160 days, whilst they keep the patients on their ward and advocate for completion of the discharge.

Someone has to decide what is “reasonable” and “necessary”. This is 'Wisdom of Solomon' territory and I fear may be budget dependent. Rapid entitlement of patient mindsets doesn’t help. Mr A. thinks $200k to modify a bathroom in a heritage building is now his right. Mr B. wants not just a wheelchair modified vehicle, but a modified van, with portable hospital bed and room for equipment for a weekend away. He wants the van modified for the wheelchair to sit in the front passenger area, because “why should ​he have to travel at the back – non-disabled people travel in the front, and they have weekends away.” Is this reasonable? Is it necessary?

In summary, this is a scheme of ​which intent we should be very proud. We may be inconvenienced and even frustrated as the plane gets built. I think it will keep flying, but the legroom may get very tight unless we are prepared to pay for “reasonable” and “necessary” comfort for those who need and deserve it.

Immediate Past-President's report

Dr Stephen de Graaff
Immediate Past-President, AFRM

As my term as AFRM President approached completion, I reflected on what has been a productive time for the Faculty.

The 2014 Annual Scientific Meeting (ASM) in Adelaide was an outstanding conference. The organising committee produced a high quality educational program that highlighted the great work that is being undertaken by our Fellows and trainees. The bar was set higher for the 2015 ASM in Wellington. The 2015 organising committee, in association with the New Zealand Rehabilitation Association (NZRA) produced an exceptional meeting with strong research and educational components as well as being fiscally robust. The responsibility for future ASMs will lie with the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) but the Faculty will continue to assist with the educational components of these meetings. There will also potentially be an increased role for the Faculty in College Congress.

The Call for a New Zealand Rehabilitation Strategy’ was launched at the Wellington ASM. I am pleased to advise that the Faculty is in discussion with the New Zealand Ministry of Health to have this Strategy incorporated prominently into the overall New Zealand Health Strategy.

In the past two years, the Annual Trainees' Meetings have become a priority on the education calendar. These meetings have been extremely well attended with enthusiasm abounding and a clear desire for more educational events for trainees where possible. I am grateful to the Fellows who put in the precious time at these meetings to assist in the education of our trainees.

It is reassuring to see that RMSANZ is evolving and we are now in the process of developing a Memorandum of Collaboration on behalf of the College. Alex Ganora and the RMSANZ Committee have been great to work with over my two years as President. Discussions will continue to make this relationship strong and productive.

Work continues on the Horizon Report and Trainee of the Future Document. There has been some feedback into these important works and planning is in process for an all day workshop prior to the RMSANZ ASM in Melbourne in October, to ensure we keep ourselves influential and relevant in the health environment.

Every year the AFRM Council looks at its strategic plan. Over the next couple of years there will be an emphasis on setting up a Rehabilitation Research Network.

National Disability Insurance Scheme (NDIS) discussions continue. It is pleasing to note that the NDIA do come to us for advice. Hopefully we can continue to influence the rollout of this critical community program. This edition of Rhaia highlights the importance and implications of the NDIS for the Faculty. 

I had the privilege of participating in the College Ceremony on Sunday, 15 May 2016. This is an extremely important role for the Faculty President. We were able to welcome 25 new Fellows in 2016 and I was able to participate in the presentation of the 12 new Fellows who were able to attend the Convocation.

It was an honour to present Dr Alaeldin Elmalik with the 2015 Adrian Paul Prize. Another great thrill was the awarding of the RACP Medal for Clinical Service in Rural and Remote Areas in 2016 to Associate Professor Adam Scheinberg, one of our outstanding Paediatric Rehabilitation Physicians.

AFRM Congress 2016 medal winners

Left to right: Associate Professor Adam Schenberg, Associate Professor Andrew Cole (incoming AFRM President), Dr Stephen de Graaff (Immediate Past-President, AFRM), Professor Timothy Geraghty (incoming AFRM President-Elect)

I handed the Presidency of the Faculty to Andrew Cole as of 16 May 2016. Andrew has been a tremendous support to me and I will be eternally grateful to him for his advice and discussion. The Faculty will be in good hands with Andrew, and Tim Geraghty at the helm.

Finally, as this is my last Rhaia report, I would like to thank all Fellows and trainees who have worked tirelessly on AFRM Council, committees and special projects on behalf of the Faculty. Your efforts do not go unnoticed and are appreciated.

Also thank you to Dominique Holt, Phillipa Warnes and Annette Barker for all the work you do. You are the engine room of the Faculty and your input makes our roles much easier.

I look forward to the next phase of the Faculty.

Policy & Advocacy Committee Report May 2016

Associate Professor Andrew Cole
Outgoing Chair, AFRM Policy & Advocacy Committee​

The Australasian Faculty of Rehabilitation’s (AFRM) Policy & Advocacy Committee (FPAC) met for the last time in the current two-year membership cycle on 6 May 2016. The College has supported the development of the Evolve project, where all major sub-specialties are being encouraged to identify five or more low-value procedures in each area of professional practice. An initial set of suggested procedures/therapies in the area of rehabilitation was presented for discussion, and will be circulated in an upcoming future eBulletin for comment and additional items, from Fellows.

The Australian Council on Healthcare Standards (ACHS) Rehabilitation Medicine Clinical Indicators are in process of being reviewed by Australasian Rehabilitation Outcomes Centre (AROC).  Suggested changes were discussed at length by FPAC, particularly in regard to the expertise of medical staff involved in supervising rehabilitation programs, the development of rehabilitation plans in multidisciplinary settings, and suspension/interruption of these, in relation to defining completed rehabilitation episodes for counting purposes. Comments were returned to AROC, to assist in preparing the next draft update.

A final draft document for Telehealth Consultations in rehabilitation medicine was reviewed, and will be circulated to Fellows for comment and finalisation. Jeremy Christley and the Working Group are to be thanked for the very large amount of work put into developing this document.

A College Working Party has been continuing to work on developing models for integrated care, including input from AFRM Fellows, with examples of interdisciplinary care, including of stroke patients.

As this will be my final report as Chair of FPAC, I wish to place on record my thanks to the whole Committee for work done in the last two years. Special thanks to the following members, who have now stood down from membership: Drs Jennifer Mann, Kim McLennan, Jeremy Christley, Luca D’Orsogna, Julia McLeod and Professor Maria Crotty.

Faculty Education Committee Report May 2016

Professor Tim Geraghty
Chair, Faculty Education Committee​

2016 has well and truly commenced for the Faculty Education Committee (FEC) and its sub-committees, and exam season is approaching rapidly.  The FEC held its first meeting for 2016, on Thursday, 25 February in Sydney and its second on 20 May.

There have been a number of changes to the FEC membership since my last report to Rhaia. Dr Samir Anwar stepped down as New Zealand representative and we thank him for his significant contribution to the FEC. Dr Toni Auchinvole has recently been appointed the New Zealand representative and we welcome her to the FEC. 

Dr Greg Bowring has joined the Committee in the position of Deputy Chair, while Dr Ruth Marshall will be concluding her time as CPD Lead on FEC. Ruth has held the position for nine years and I would like to sincerely thank her for her great work in the role. Her experience and knowledge will certainly be missed on the FEC. 

Rachel Smith, AFRM Education Officer, continues to provide great support to the FEC. Lanica Alonza has also recently commenced to provide additional secretariat and Education Officer support, reflecting a recognition of the large amount of work undertaken by the Committee and sub-committees. 

As at ​June 2016, there were 199 registered general adult trainees and nine registered paediatric trainees of AFRM. The breakdown of trainees per state is:

  • ACT – 4
  • NSW – 82
  • QLD – 43
  • SA – 15
  • TAS – 5
  • VIC – 45
  • WA – 8
  • NT – 1
  • New Zealand – 7.

As at 9 May 2016, there were 260 accredited supervisors of Australian Faculty of Rehabilitation Medicine (AFRM) and 127 accredited training sites.

This will be my last report as Chair of the FEC and I would like to sincerely thank all the FEC members for their interest and dedication to the work of the FEC. For those who are not aware, the vast majority of the day-to-day work of the FEC is performed by its sub-committee Chairs and members and by other working groups that assist with a variety of things such as exam preparation and more. These roles and activities now involve a very large number of Fellows and without these people, the extremely important work of the Faculty in educational and CPD activities would not be possible. 

I would also like to acknowledge the great assistance and support of all the Education Office staff who provided ongoing help to the FEC and sub-committees during my time as Chair – Sally Timmins, Isabel Roos, Rachael Smith, Neelam Huda, Paul Washington, Anne-Marie Van Roie and more recently Lanica Alonzo. Dominique Holt, Phillipa Warnes, and Annette Barker from the AFRM Executive Office have also assisted me greatly throughout my term. And of course, Steve de Graaff and Andrew Cole whose vast years of experience as FEC Chairs, I have drawn upon on many occasions. Greg Bowring will be taken over as Chair, FEC and therefore, I know that the Committee will be in great hands.  

CPD Update

Associate Professor Ruth Marshall 
Outgoing AFRM CPD Lead

Reflecting on nine years wearing the "hat” as your Lead for Continuing Professional Development (CPD).

It is hard to believe that I started in this role in February 2007 after undertaking the Learning Evaluation and Planning (LEAP) framework trial run by the Royal Australian & New Zealand College of Psychiatrists (RANZCP). It was really hard and I was one of the few across all the Colleges who completed it (and I almost didn’t).  

The LEAP framework program was a year-long trial focused on improving my professional development by creating a personal learning plan and tracking the results. It forced me to examine my own CPD and realise how limited it had been. I hadn’t reflected enough, I went to conferences but not to journal clubs, I taught registrars and got them to develop learning plans but hadn’t set my own.

As a result of my involvement in this program, I became very interested in what it really means to be involved in personal continuous professional development, and how we could ensure that rehabilitation physicians are at the forefront of this process. I therefore, agreed to become the Chair of the committee.

Nine years have passed really quickly. I have been trying to give up the position for more than three years only to be prevailed upon to stay until we had completed the move from the Australasian Faculty of Rehabilitation Medicine (AFRM) CPD program to the RACP MyCPD program. During that time I have written an article for every issue of Rhaia (a feat in itself) and chaired countless teleconferences and many face-to-face meetings of the AFRM CPD sub-committee, until it was disbanded two years ago.  I have also attended multiple teleconferences and face-to-face meetings of the various iterations of the RACP CPD Committee. I chaired the RACP ‘My Resources Gateway’ Working Group and I'm now a member of the RACP Practice Review Support Working Group. I have become the 'grand old lady' of the RACP CPD Committee team.  

Most importantly, I was there when our Faculty became the first group in the College to have our CPD program on line. I chaired our CPD committee as we examined how our CPD program would need to change to move to the College MyCPD program, and then supported its transition.

I became actively involved in the activities of the RACP CPD committee, which has been intellectually stimulating (albeit with mountainous amounts of paperwork to read) and enjoyable in a way that I did not expect.  I also represented our Fellowship on the AFRM Faculty Education Committee (FEC), regularly reminding my colleagues that they must  recognise the learning needs of our Fellows as well as our trainees.

During my time as the Lead AFRM Fellow for CPD, I have learnt to reflect even more on my own learning needs. I have, I suspect, become increasingly critical of passive learning situations (the sort that see me falling asleep in a lecture theatre). However, in active learning situations, I am engaged in discussion, and asking myself questions, actively seeking information and making changes to my practice as a result.  As physicians an awareness of our learning styles and needs, and the development of our own personal learning plans are important if we are to achieve continuing excellence in our practices. This is coupled with a degree of critical thinking or questioning about what it is we need to know, need to learn and want to achieve. 

The role of the CPD lead has evolved over the last nine years, for example there is no longer an AFRM specific CPD subcommittee. In lieu of this, it will be important for the new AFRM CPD lead to liaise closely with our regional committees to remain informed about the CPD needs of our Fellows. Possibly also, from time-to-time, lead an AFRM CPD Working group with representatives from all regions to deal with CPD issues that affect AFRM Fellows specifically. The ongoing education of our rehabilitation physicians is every bit as important as the training of our registrars and this must be recognised as a priority for the Faculty. It is essential that strong communication is facilitated between the regions, the Faculty Education Committee and AFRM Council and the CPD committee to achieve this. 

I would like to say that standing down from the AFRM Lead Fellow in CPD means that I have more time to smell the roses, go to concerts, sing, cook, go to the gym and walk the dog. But alas, I seem to fill the hours with too much work and not enough time to sit and reflect.

I continue to have a heavy clinical and managerial load, teaching medical students and trainees, undertaking research, co-authoring papers and book chapters, chairing other committees, attending hospital mortality meetings and so on.  Recently, I was thrilled to be invited to participate in a special new RACP course on Diagnostic Errors and attend the recent RACP Congress. I feel I need to continually upgrade my general medical as well as my general rehabilitation and sub-specialty knowledge, as our specialty increasingly takes care of patients with medically complex issues.  

After nine years and three months as your CPD Lead, I now bid you farewell. I look forward to catching up with you at meetings along the way, but please stop calling me to ask into which section of MyCPD your various CPD credits belong, ask my successor, your local CPD rep if your branch has one, a member of your local regional committee or contact the RACP CPD unit.

Finally, don’t wait until 29 March 2017 to start inputting your credits – start doing it now.

Best wishes to you all, and signing off as your ex-CPD Lead.

AFRM Trainee Committee Report

Dr Emma-Leigh Synnott
Chair, AFRM Trainee Committee and ATM Organising Committee, 2016​

In 2015, the Australian Faculty of Rehabilitation Medicine (AFRM) Trainee committee determined two key priorities for the year ahead, the successful delivery of the Annual Training Meeting (ATM) and supporting formal teaching sessions for AFRM trainees. 

The AFRM ATM was held on 5 and 6 March at Royal Melbourne Hospital, with 65 trainees in attendance over the weekend. Incidental feedback over the weekend was highly positive from trainees and Fellows alike, however the committee determined to send out a formal survey designed to garner feedback to improve the program and structure of the 2017 meeting.

The survey indicated that all respondents believed they got value for money at the ATM, which was something the committee set out to achieve. The speakers were also considered to be engaging and knowledgeable, with overall content being highly relevant to their training. The most highly rated topics of the weekend were the urodynamics, gait analysis and stroke overview sessions. 

The following topics were suggested as future sessions, and will be considered by the Committee in planning for 2017: 

  • acquired/traumatic brain injury 
  • pain management 
  • spasticity/botulinum toxin injections (with an emphasis on a non-concurrent, practical session) 
  • cancer rehabilitation 
  • spinal rehabilitation/spinal cord injury 
  • cardiac management 
  • Nerve Conduction Studies (NCS) / Electromyography (EMG). 
If you are a Fellow with an expertise or interest in one of these areas and would be willing to speak at our 2017 ATM, please contact me through the Faculty office on AFRM@racp.edu.au. We would love to hear from you.

Trainees have noted that they felt concurrent sessions were equally important and did not want to miss any of the topics. A full two day program may be considered next year to overcome this issue. The committee is also planning to invite an Education Officer as it is an excellent opportunity to answer trainee queries in person.  

The ATM remains a priority for the Faculty Trainee Committee, with planning already underway for 2017. We would also like to take the opportunity to thank all Fellows who gave up their valuable time to speak over the weekend, it was greatly appreciated by all. 

Another focus of the Trainee Committee is in relation to the formal learning opportunities for trainees via local, state and national teaching sessions. The Trainee Committee is aware these sessions are regarded as an important opportunity for trainees to learn curriculum based information from Fellows, medical specialists, and allied health professionals. With this in mind the Committee continues to liaise with other Faculty committees to better coordinate these sessions to maximise the educational benefit from these opportunities.

We encourage trainees, and Fellows alike to give formal or informal feedback on these sessions. This can be done via contacting the AFRM on AFRM@racp.edu.au, via written feedback following local sessions, or through the Bi-National training feedback link in the ​monthly AFRM eBulletin.

Yoga as medicine

Dr Susannah Ward
Rehabilitation registrar
RACP Board Member
College Trainees' Committee Member
Member of the MIND SIG

Yoga is a Sanskrit word meaning union1. Yoga may be seen as a philosophy, a way of living or an ancient set of skills. These skills evolved from the need to survive the human condition, evolve spiritually, gain mastery over fluctuations in the mental state and to reach a state of calm2. The term yoga does not dictate subscription to a religion or a god1.

The syncing of the breath to body movement is the foundation of yoga as a form of mindfulness3. Movement is purposeful and draws the practitioner’s attention to the breath to bring focus and quiet the mind. Voluntary regulated breathing techniques provide a conscious way to regulate mental and emotional states. This is suggested to have many benefits such as improving attention, memory, reaction time, dexterity and calmness3. Mediation practices, including yoga, have effects on the autonomic and endocrine systems, and areas of the brain involved in emotion regulation, attention and executive functions3.  

Yoga is increasingly recognised by western culture as a holistic health intervention for a diverse mix of illnesses including pain, chronic diseases, cardiac rehabilitation and mental illness4. As a result there is a growing body of research looking into the health benefits of yoga. This suggests that yoga programs of similar composition and duration improve exercise capacity and health related quality of life (HRQOL) among patients with chronic diseases. They may also be a beneficial adjunct to conventional rehabilitation interventions to improve balance, strength, flexibility, and exercise tolerance. Evidence also suggests yoga increases feelings of calm and connection, thus reducing anxiety and depression4

Mindfulness-based interventions, including yoga, have sound conceptual underpinnings and growing empirical support for aiding addiction treatment, prevention and recovery5.  A review on yoga for low back pain found strong evidence for short-term effects on pain, back specific disability and global improvement, long-term effects on pain and moderate evidence for a long-term effect on health related quality of life6. Yoga has strong beneficial effects on distress, anxiety and depression, moderate effects on fatigue, general HRQOL, emotional function and social function7.

To date there is a dearth of large quality studies on the benefits of yoga. If yoga is going to establish a place in medicine, research must ensure rigorous methodology and reporting. Comparisons need to be made to current therapies and analysis is required of the separate components of yoga to improve the understanding of the underlying mechanism of its health benefits.

In New York Dalia Zwick, a physical therapist and Iyenger yoga teacher incorporates yoga poses into her rehabilitation programs to improve standing postures in disabled patients8. Standing yoga poses have assisted her patients relieve habitual postural patterns, improve postural control, increase symmetrical weight distribution, improve steadiness and strengthen reflexive muscle activation.  Ms Zwick teaches traditional standing yoga postures using a tilt table or standing frame or in the supine or sitting position transitioning standing over time. She believes the use of yoga asana in her therapies also contributes to a sense of wellbeing, body-mind awareness and calm in her patients8.

Yoga can be seen to be a useful adjunct to conventional medicine with the view to reduce lifestyle related illness, lessen the impact of impairment and disability and to improve quality of life and mental health. Yoga is suggested to have strong beneficial effects on distress, anxiety and depression and moderate effects on fatigue, general HRQOL, emotional function and social function.  Incorporating yoga into rehabilitation medicine is an exciting and emerging field and I look forward to hearing more about it and being a part of its evolution in my own practice.


1. Gordon T, Theorizing yoga as a mindfulness Skill, Social and behavioural sciences 2013;84:1224-1227.
2. Telles S, Singh N, Science of the mind. Psychiatric clinics. 2013;36(1):93-108.
3. Khanna S, Greeson J, A narrative review of yoga and mindfulness as complementary therapies for addiction. Complementary therapies. 2013;21:244-252.
4. Desveaux L et al. Yoga in the management of chronic disease. Medical care. 2015;53(7):653-661.
5. Khanna S, Greeson J, A narrative review of yoga and mindfulness as complementary therapies for addiction. Complementary therapies. 2013;21:244-252.
6. Cramer et al. A systematic review and meta-analysis of yoga for low back pain. Clinical Journal of Pain. 2013;29(5):450-460. 
7. Feild T, yoga clinical research review, complementary therapies in clinical practice.
8. Zwick D, Dunn M. Integrating yoga into rehabilitation. Therapy insider 2007. October 10-12.


Associate Professor Steven Faux
Chair, AFRM NSW/ACT Committee

This year the Australasian Faculty of Rehabilitation Medicine (AFRM) NSW Regional Committee determined to act as the state committee for both the AFRM and the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) in separate capacities. The executives have decided that, for the next 12 months, consecutive NSW committee meetings will be held for AFRM and RMSANZ . 

AFRM NSW members’ activities included, a continuing medical education (CME)  on Complementary Medicine in Patients with Disability, presented by Dr John Wardle (UTS) last November. A combined meeting of the Faculty branch and the society was also held at the AFRM Annual Scientific Meeting (ASM) in Wellington last year with attendance of more than 40 members. A topic of conversation was ideas for restructuring the training program in the context of the Rehabilitation Medicine Trainee of the Future report. 

Dr Faye Un and Greenwich hospital have agreed to facilitate the registrar selection advisory group meetings for appointments of trainees to public hospitals terms for 2017. This will be held in early September 2016. 

NSW Saturday morning sessions and the Bi-national Training Program have been supported through the AFRM Training Committee with two extra sessions being added in April due to popular demand by trainees. 

In the next six months priorities of the NSW/ACT committee include increasing the  use of social media platform Yammer by NSW trainees, as well as supporting the ongoing development of the Agency for Clinical Innovation rehabilitation research group. Further CME activities at the college premises and a neuro-rehabilitation CME weekend, will be planned for later in the year.

I would like to formally thank the committee including Tim Ho, Emma-Leigh Synnott Malcolm Bowman, David Skalicky, Faye Un, Yan Zhang, and Tai Tak Wan.

AFRM South Australian/ Northern Territory update

Dr Adrian Winsor
Head of Unit, Department of Rehabilitation Medicine, The Queen Elizabeth Hospital, Central Adelaide Local Health Network

Dr Andrew Wilkinson
Department of Rehabilitation Medicine, The Queen Elizabeth Hospital, Central Adelaide Local Health Network

Dr Faye Jansen 
(AFRM Trainee), Hampstead Rehabilitation Centre, Central Adelaide Local Health Network​

Transforming Health
The South Australian Government, under the banner ‘Transforming Health’ is attempting an unprecedented revision to the public health sector. Their stated aims are to improve patient care and improved efficiency. At the same time the new Royal Adelaide Hospital is approaching completion and an Electronic Patient Record (EPAS) is being rolled out.  With a large quantum of change in a short time frame clinicians have identified risks and raised concerns.   For sub-acute services including rehabilitation medicine, the concerns centre on poor and inadequate modelling for in-patient bed numbers, uncertainty regarding the commitment for increased Ambulatory Services and the quality of EPAS and the method of its implementation. Fellows continue to meet with the South Australia Health Minister, South Australia Health administrators, our hospital managers and interested politicians to use appropriate public and industrial forums to advocate for quality and access in rehabilitation services.
AFRM SA/NT Regional Committee matters
The AFRM South Australia regional committee is progressing smoothly, and we have filled all of our state branch committee positions for next year. An Australasian Rehabilitation Outcomes Centre (AROC) benchmark data workshop day, was held in Adelaide on Friday, 8 April. At the workshop, local data and national benchmarks were presented by Jacqui Capell. In the afternoon, regional teams provided short presentations about how they are utilising AROC data. In terms of trainee matters, the popularity of rehabilitation medicine as a career in South Australia is growing year upon year with more competition for places, than ever before. This year we have five first year trainees, taking our total number of AFRM trainees in South Australia and the Northern Territory to 17. 
AFRM SA/NT training 

We have a busy schedule of teaching sessions planned with the Bi-National Training Program, thanks to our dedicated consultants. We are looking at ways for the Northern Territory trainees to access these teaching sessions via video-link, however, the availability of suitable facilities at South Australia health sites is an ongoing challenge. We hope that the Transforming Health process will bring the development of new health sites and services in South Australia and increased access to videoconferencing equipment. 

AFRM New Zealand update

Dr Cynthia Bennett
Chair, AFRM NZ Committee

Rehabilitation Medicine specialists in New Zealand continue to work to advance the specialty and the recognition of opportunities for rehabilitation inclusion in all aspects of New Zealand health and well-being.  The New Zealand Health Strategy has been finalised and released with limited, but noted comments regarding the need for rehabilitation, primarily within the scope of chronic health conditions.   The NZ Spinal Cord Impairment Action Plan 2014 – 2019, a collaborative national service initiative for people with spinal cord impairment continues to gain acceptance with a formal destination policy for people who sustain a traumatic spinal cord injury.  

A Northern Regional Amputee Rehabilitation Pathway has also been developed and is in a final draft. The pathway identifies collaborative, interdisciplinary, rehabilitation medicine focused provision of best-practice and support for people with traumatic and non-traumatic limb amputations. 

Work on the advocacy plan for the Call for a New Zealand Rehabilitation Strategy (the Strategy) continues. Discussions have been undertaken with various stakeholders within the health sector and the ministries including the Director General. The response to the Strategy has been very positive and it is widely recognised that the paper aligns well with many current national healthcare concerns being addressed through other work within New Zealand.

New Zealand continues to face a shortage of Rehabilitation Medicine trainees and practicing Australasian Faculty of Rehabilitation Medicine (AFRM) Fellows. Recent discussions with Accident Compensation Corporation (ACC) and the Ministry of Health have resulted in identification of program which may be able to encourage and entice medical students and junior doctors to consider rehabilitation medicine as a specialty. Discussions at the New Zealand regional annual members meeting in February regarding the possible development of a national, rather than regional, recruitment and training program, were positive. We continue to welcome any expressions of interest for rehabilitation medicine training in New Zealand. 

The 4th New Zealand Rehabilitation Medicine Symposium was held 27 February in Auckland.  AFRM trainees and Fellows’ presentations included research and findings, unusual educational cases, examples of best rehabilitation medicine practice and practice opportunities in New Zealand. The third Dr Boris Mak Rehabilitation Medicine Trainee Awards for best presentation were awarded to Dr Sarah Hawkins as the first place winner and also to Dr Dawn Adair. Next year’s symposium will be extended to a full day program in conjunction with a half day NZ AFRM regional meeting. 

AFRM Queensland update 

Dr Tracey Symmons
Outgoing Queensland Regional Committee Chair

As this is the end of my term as chair, I would like to sincerely thank the outgoing Queensland regional committee for their hard work, especially Dr Gillian Nadler for her role as secretary. I would also like to extend this gratitude to the very patient and organised Australasian Faculty of Rehabilitation Medicine (AFRM) staff, Phillipa Warnes, Dominique Holt and Annette Barker.  

In Queensland, the state-wide Spinal Cord Injury report and the state-wide Brain Injury reports have been completed. The state-wide Rehabilitation Clinical Network had a very successful meeting in November and there is continued enthusiasm for the network with a number of further activities and initiatives on the radar. 

The AFRM QLD Regional Committee thanks Dr Ben Chen and Professor Timothy Geraghty for their work as Co-Chairs, as well as on the steering committee. The state-wide Rehabilitation Clinical Network is a very exciting initiative as it will provide a greater voice for rehabilitation medicine in Queensland. 

There has been continued success with the Queensland selection and matching process for registrar recruitment. This year, all 33 positions have been filled across Queensland and two health services in northern NSW. The same process is planned for 2017. Our sincere thanks to Dr Gan for her hard work in coordinating this process over the last two years 

The Queensland Resident Medical Officer (RMO) campaign will close on Wednesday, 6 July and the RACP matching process closes on Friday, 12 August this year, with selection interviews planned for Friday, 2 September. Please don’t forget these important dates.

The National Disability Insurance Scheme (NDIS) is also being rolled out in a number of pilot sites across Queensland, with important lessons to be learnt from our southern counterparts who have already begun this process.  

MIND Special Interest Group (SIG) update

Dr Jane Malone
Chair, MIND SIG 

The MIND Special Interest Group (SIG) has had a great start to the year with a wonderful presentation from Australasian Faculty of Rehabilitation Medicine (AFRM) trainee Dr Susannah Ward on ‘Yoga and Rehabilitation’. Many members of the MIND SIG practice yoga, and a fruitful discussion on the benefits and impact of yoga followed Dr Ward’s presentation. This presentation is available on the Mind SIG website for all to enjoy. Dr Craig Hassad also presented a free online course on Mindfulness which was well attended.

AFRM MIND SIG members are actively involved in education of trains. In NSW Dr Phil Funnell has been involved in junior medical training (JMO) that includes topics such as relaxation and meditation. In Victoria, Barbara Hannon presented Manage Your Mind at the Annual Trainee Meeting (ATM) in March. This included an overview of research and up to date mindfulness strategies.

The MIND SIG is now looking forward to a 'book club' style discussion of one of the hottest titles in the field at present, Cure, by Jo Marchant. The SIG will be discussing this as well as the latest evidence in the ‘Mind’ space in September. Please join our email list or stay tuned to the website for updates on how to get involved. Later in the year we’re also hoping to secure a presentation from one of the treating physicians on the paralympic team to Rio. 

Paediatric Rehabilitation Special Interest Group (SIG) update

Dr Katherine Langdon FRACP FAFRM, 
Outgoing Chair, Paediatric Rehabilitation SIG  

The Paediatric Rehabilitation Special Interest Group (PRSIG) met in Adelaide at the Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM) in March 2016, and I stepped down as Chair of the PRSIG after four years. Dr Simon Paget was elected as Chair and Dr Maria Kyriagis elected as Secretary of PRSIG. My thanks and congratulations go to Simon and Maria. It was excellent to see so many Fellows and trainees present. 

Members of PRSIG sought clarification about the various roles being undertaken by Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) and the Australasian Faculty of Rehabilitation Medicine (AFRM) and the benefits of having membership of both.  Dr Alex Ganora, President of RMSANZ has now kindly agreed to a meeting with members of the PRSIG executive to discuss paediatric representation on RMSANZ. The PRSIG noted their support for the 2016 RMSANZ Annual Scientific Meeting (ASM) program as it appears to have strong paediatric content. The process for paediatric consent for botulinum toxin injections was also discussed with dissemination of forms in use around the country to follow. 

The need for documents to support the process of credentialing hospital doctors has become critical. The Paediatric Rehabilitation Scope of Practice document is being reviewed by the RACP Policy and Advocacy Committee (CPAC) in order to address this issue.  The PRSIG is keenly awaiting the outcome of this review. 

The process of Australasian Rehabilitation Outcomes Centre (AROC) collecting paediatric data has been made a reality due to funding to being secured by Dr Priya Edwards and the group from Queensland.  The data set has almost been finalised, following wide consultation from paediatric rehabilitation service providers and PRSIG members across Australia.
Professor Dinah Reddihough, Head of Developmental Disability and Rehabilitation Research at Murdoch Children’s Research Institute (MCRI), and lead investigator of the project, has announced that Australia’s first clinical trial of stem cell infusions from cord blood, a possible treatment for cerebral palsy, has commenced in Melbourne. The first study is a safety trial, recruiting nationally, with the intervention to take place at the Royal Children’s Hospital in Melbourne. It is looking at changes in motor skills in the recruited patients. PRSIG members are actively supporting this important study. 
Dr Kim McLennan, the PRSIG representative on the AFRM Policy and Advocacy Committee, is stepping down from this role after making a major contribution in this area for more than four years. We thank her for your contributions over the last six years. 

I would like to extend my thanks to Dr Simon Paget for his wonderful support as Secretary of the PRSIG since 2012, Dr Kim McLennan and also Annette Barker from the RACP, for her administrative support.  Being Chair of PRSIG has been a great experience. I wish Simon and Maria the very best of luck in their new positions.     

Rehabilitation and Older People Special Interest Group (ROP SIG) update

Professor Ian Cameron
Chair, ROP SIG

The Rehabilitation and Older People (ROP) Special Interest Group is meeting quarterly. The current Executives are Jill Collins, Tai Tak Wan, Pushpa Suriyaarachachi, William Bong, Maria Crotty, Ben Chen and myself as Chair.

Recently the SIG has been planning ​a session for the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) Annual Scientific Meeting in October 2017, titled Should older people be excluded from Spinal Cord Injury and Severe Traumatic Brain Injury Services? Challenges or opportunities? The SIG has identified that there are differences in admission policies between states which will be highlighted during this session

The clinical syllabus for the training program, which is titled Illness and Injury in Older People, is regularly reviewed and updated. Other relevant issues are addressed by the SIG as they arise. 

The SIG is seeking additional members, and suggestions for further discussion and investigation topics at their meetings.

Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) update 

Dr Alex Ganora
President, RMSANZ

There is no better time for Australasian Faculty of Rehabilitation Medicine (AFRM) Fellows and trainees to join the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ). Substantial savings can be achieved on annual membership fees and registration to the 2016 Annual Scientific Meeting (ASM) by joining before 1 July, 2016. Those who join before 1 July 2016 will be financial members of RMSANZ until 30 June 2017.

The Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ)  now has 363 members, including 89 trainee members. It is estimated there are about 100 active Fellows who have not yet joined the Society.

If you have not already, please register to attend the inaugural Annual Scientific Meeting of RMSANZ, Change, Challenge and Opportunity, Sunday, 16 to Wednesday, 19 October 2016 at Crown Promenade, Melbourne. This year will be the 35th Annual Scientific Meeting of Rehabilitation Physicians in Australia and New Zealand.

The Society has recently established a Private Practice Special Interest Group to facilitate discussions amongst interested members. An Annual Members Meeting (AMM) for this group is being arranged for the October ASM when a committee can be elected according to the terms of reference and By-Laws of committees of the RMSANZ.

RMSANZ has been working closely with the RACP to draft a Model of Collaboration that defines the relationship between the two parties and we are pleased to agree with the general principles of the collaboration as we continue discussions.

Our trainee members of RMSANZ are the life blood and future of the society and we are keen to identify activities that will encourage and support their involvement. Now that a membership fee has been established for trainee members, the Trainee Members Committee of RMSANZ, chaired by Dr Kong Goh, will be looking for opportunities to communicate with trainee members about their interests and needs. Fellows are asked to encourage trainees to put their thoughts forward to the Society.
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