Rhaïa November 2016

Associate Professor Michael Pollack, Guest Editorial

Thank you to the ​Faculty for inviting me to provide this Guest Editorial. I have been asked to provide my thoughts/philosophies on research in rehabilitation. It is a great privilege to be able to express a personal opinion to a wide number of respected individuals, and, in return, I fully respect those whose opinions may well differ from my own.

I would like to start by quoting the first line of the covenant of the (modern version) Hippocratic Oath

“I will respect the hard-won scientific gains of those physicians in whose steps I walk ...”.  

Positioned here at the beginning of the oath, it is impossible to deny the value placed upon scientific research by the respected forefathers in our profession. What are we, in the field of rehabilitation medicine in Australia and New Zealand, doing to gain the respect of our students, and our professional descendants? 

In the more modern manner of training and education to become doctors and physicians, the emphasis is primarily on clinical skills. A number of specialties encourage (or even enforce) research at various levels as part of the obligatory training, but, more often than not, our clinical pathways tend to diverge from research and academic opportunities.  

It usually takes significant effort to keep even just a toe in the research pond, much less swim in the pool itself. However, I wonder if rehabilitation medicine physicians, as a whole, are providing the academic resource and scientific foundations to the same extent and quality as our colleagues in other specialties. Are we producing the sort of research that our own speciality is proud to not only quote, but even lay as the foundation for the next level of knowledge and skill base in our field of rehabilitation medicine?

If there is no research in our field, then our clinical practice stands still. If our clinical practice is actually evolving, it implies that research (that we trust) is actually occurring. If this is the case, who is carrying out this research? If we are not doing the research in our own field, then why aren’t we? The reality is that, in Australia and New Zealand at least, we, in rehabilitation medicine, do not really know what research we are producing, and where our strengths (or gaps) lie. 

What sort of research should we be doing?
Rehabilitation covers a broad church. As rehabilitation medicine physicians we usually work as part of a multidisciplinary team in clinical practice. 

We often take on a role as the leader, or the person with ultimate responsibility, for the interventions and therapies that are provided to our patients, not only by us, but by the rest of the team as well. 

Our true role however is not just one of responsibility, but our training as physicians, which differentiates us from the other team members. Undertaking research which can just as easily be carried out by members of other health professions is, no doubt, very important, and very useful, especially if the outcome results in evolution of clinical practice.  Such research, of course, furthers the knowledge required for appropriate practice of rehabilitation. This should definitely be encouraged, but as rehabilitation physicians, we have a special body of knowledge, and I wonder if this should not form the foundation of setting the priorities for an arm of research that we should be obligated to.  

As physicians, we should theoretically have a greater depth of knowledge than other team members with regards to illness, pathology, recovery, and healing. Rehabilitation (including rehabilitation medicine) requires an indepth understanding of natural healing and recovery, but especially should involve an indepth understanding of processes that enhance recovery (beyond ‘natural recovery’). This can take place at the level of the cell, the organ, the organism (i.e. the individual human), the ‘family unit’, and even at the community level, if not beyond.  

As physicians, we are uniquely trained to understand the impact of illness/disease, co-morbidities, physiology, and pathophysiology on prognosis, biologic healing and recovery, and functional recovery. Who else is trained as effectively as us to sit in this research space?  If we are not leading the research in this arena, the research is more likely to be unfocused, haphazard, slow to progress, and less likely to meet the needs of clinical practitioners.  

Who should be doing the research?
Research is carried out by people with a range of various skills – pure scientists, epidemiologists, statisticians, accountants, managers, a range of clinicians, and more. If the research is dominated by managers and accountants, we would not be surprised if our clinical processes were diverted down the pathway focused around budget and resource efficiencies. If the research was dominated by pure scientists, we could expect to have a great wealth of knowledge, but not all of it would be practical for the needs of clinicians, or their patients.  

There is clearly a definite need for clinicians to stake a strong claim in the research space if there is to be the level of research required to drive changes in clinical practice. This however does not mean that clinicians should be the only researchers, or even the dominant researchers. What is important is that clinicians are a significant part of research teams who set research priorities, determine research questions, establish research protocols, and interpret research outcomes. 

Clinicians need to be a part of a multidisciplinary team in research, just as we are part of a clinical team.

Where are we now?
As noted above, we really do not know where we as rehabilitation medicine physicians sit in the research space.  

There is no doubt that a number of our colleagues are involved with important research activities and outcomes. We do not know who they all are. We do not know all of the science that they produce, even though they are among our own colleagues. How much of our own clinical practice has evolved as a result of research undertaken by rehabilitation medicine physicians in Australia and New Zealand? Do we as individuals even know what has influenced our practice in the last five to ten years?  

Beyond this, there does not seem to be a coordinated approach to rehabilitation medicine research in our region. Various institutes, hospitals, individuals, and teams, are running research activities (often of high quality) which sit within the personal interests of the research leaders, but may or may not have relevance to the priorities of rehabilitation clinical practice, or for the patients and communities we work with.  

Such a concept however forces us to face the question – how do we determine what the research priorities might be?  

Is it, perhaps, more important to do research for the relatively low numbers but severely impacted groups such as spinal cord impairment, or more important to do research on impairment groups with very high numbers of people impacted across the country (eg, orthopaedics/trauma). Should we be looking at the impairments which impose the highest ‘cost’ on the community, or should we in fact focus on simply trying to get a better understanding of how the body heals and recovers, whether it be bone cells, nerve cells, or other body structures? It seems that it is almost impossible to ask the right question, much less provide the right answer.

Our own Faculty has decided to take some positive steps.  

It has decided to form a subcommittee of the Faculty ​Council focused on examining and supporting research activities by our colleagues. I have been given the honour of Chairing this subcommittee.  

There are a few processes and outcomes which this committee would like to achieve. Among the first of the priorities is to provide opportunities for our registrars to participate in a more structured process for their research module.  

To date, the research module has been appropriate to expose registrars to basic research insights and understanding, an imperative for any physician. Into the future, we would like our registrars to have the opportunity to have more indepth exposure to a deeper understanding of setting a research question, understanding research protocols, examining various options of biostatistical analysis of data. Also there is an expanded opportunity for exploring various interpretations while writing a paper that, hopefully, is good enough for publication, or presentation at national/international meetings.  

This will hopefully be achieved by bringing together a panel of ‘research experts’ from among our rehabilitation medicine physician colleagues, who are willing to participate in the research activities of these registrars. This would start during the Research Module phase. They will also be introduced to the network of researchers and research teams to make it easier to hold onto the research pathway, even while pursuing a clinical vocation.  

Another ​aim of the subcommittee is to identify who the rehabilitation researchers are in Australia and New Zealand, and ​bring them together into a collegiate network.  

The benefits of this are potentially tremendous. Hopefully we can have a better understanding of what research is occurring. Beyond this, networking can allow for improved collaboration, which can in turn facilitate a significant growth in research opportunities. It may even allow for coordination and perhaps even prioritisation of research, which in turn could lead to a more rapid evolution of our clinical practice and benefits to our patients. It also means that we can present a unified and coordinated face to our professional and research colleagues outside of rehabilitation medicine. This could facilitate an appropriate exploration of research planning, collaboration, broader networking, and wider opportunities.  

In this edition of Rhaïa, we are presenting a brief paper which is a first attempt at looking at how to prioritise rehabilitation research. This was carried out by the Research Working Party of the Rehabilitation Clinical Network in New South Wales (NSW) which is part of the NSW Ministry of Health’s Agency for Clinical Innovation. This survey was distributed to a range of rehabilitation clinicians (not just doctors) in NSW. I know that there is much to criticise about the paper and the process; it should however be seen only as a first step, where the purpose is to raise debate and discussion and not necessarily to accept the outcomes and conclusions.

I hope that this editorial raises questions in your mind, rather than providing answers. Most importantly however I hope that raising the awareness of the value of research will encourage all of us to consider what place research holds in our own professional lives.

Rehabilitation research in NSW and a 'how to' guide on researching

This article is a mini-compendium of some of the rehabilitation research in NSW, and a ‘how to' guide for those interested in considering research as part of their career. 

Rehabilitation medicine in NSW offers many interesting research projects and the following are a small proportion of them. These include involvement in National Health and Medical Research Council (NHMRC) funded Centres of Research Excellence (CRE) which are structured, collaborative, interdisciplinary projects aimed at developing a research community around certain themes in rehabilitation. 

Colleagues involved with CREs in the field of stroke rehabilitation and brain recovery include Associate Professor Michael Pollack’s team at John Hunter Hospital (JHH), Professor Michael Nilsson’s group at the Hunter Medical Research Institute and Associate Professor Steven Faux’s team at St Vincent’s Hospital Sydney (SVH). They are researching stroke rehabilitation, including mechanisms for neuroplasticity, the enriched environment and the use of botulinum injections following stroke.

Associate Professor Aggarwal’s team at Royal Prince Alfred Hospital (RPAH) is comparing the efficacy of structured physiotherapy verses non structured physiotherapy in reducing post-stroke spasticity related shoulder pain in patients treated with Botulinum toxin A. 

Rehabilitation physicians continue to play a key role in issues surrounding trauma. Dr Jane Wu (SVH) is examining the effectiveness of very early rehabilitation (via a mobile rehabilitation team) for survivors of critical illness admitted to Intensive Care Unit Very Early Rehabilitation in Critical Illness (VERICI) study.

Recovery from trauma is also a major focus, with Professor Ian Cameron and his team at the Kolling Institute involved in several CREs relating to trauma and frailty. His team is investigating factors involved in recovery post motor vehicle accident, including the effect of compensation on health.

Traumatic brain injury (TBI)/Acquired brain injury (ABI) is also a major area of focus. Associate Professor Ian Baguley’s team at Westmead Rehabilitation is researching causes of late mortality after TBI, as well as examining spasticity and sympathetic hyperactivity after ABI. 

Dr Clayton King’s team at Royal Rehabilitation Centre (RRC) is developing standardised cognitive assessment tools for TBI.

Holistic care of patients with Spinal Cord Injury (SCI) is being examined by Dr Bonne Lee and team at Neuroscience Research Australia (NeuRA) and Prince of Wales Hospital. They have several projects underway examining recurrent urinary tract infection, and respiratory management of patients with SCI.

There are many other research projects underway in the areas of pain medicine at Royal Prince Alfred Hospital (RPA), and ageing well by Associate Professor Chris Poulos and team at Hammond Care.  

Dr Karen Chia is undertaking research in exercise training and Pulmonary Arterial Hypertension at SVH. There are also some unique, cross-disciplinary collaborations occurring at SVH, enabling Associate Professor Faux and team to explore the use of virtual reality and 3D visualisation technology for post-stroke education. These collaborations have the potential to radically change the way we do rehabilitation in the future.
 
So, how does one become involved with some of these interesting research projects? You can decide on a topic that interests you, and find a senior colleague in that area to mentor you. In my case, I sought out specialists with an interest in Pulmonary Artery Hypertension (PAH) because I noted a gap in the literature regarding the effectiveness of rehabilitation and PAH and I wanted to answer a particular clinical question. These are some of the things I’ve learnt so far:

Tips for considering a research post-graduate degree

1. Define your topic.
Keep in mind that whatever research project you undertake, it will likely require a vast amount of reading, thinking and writing, so it helps to have a topic that really interests you.

Advantages of generating your own research question are that it’s interesting, novel and can address gaps in the literature. Disadvantages are that you will need to set up the whole project (Protocol, Ethics submission, developing collaborations) from scratch.

2. Identify why you want to undertake research.
This may be because you enjoy the mental stimulation, want to learn new skills, develop new contacts or enhance your career opportunities. Whatever your motivation, it will need to be one that can sustain you through all the difficult times but ultimately it should be fulfilling.

3. Assess your other commitments and responsibilities.
Some stages in life are not conducive to research.

4. Be prepared for ups and downs and sometimes setbacks.
The whole process is not in your control. There are many processes involved in research including ethics, governance, administration, finance and collaboration that can all delay your project by many months. Once you realise this, you can roll with it.

5. Mentally prepare yourself for an appropriate time frame to complete the research.
Whatever you decide is an appropriate timeframe, double it, and you will get closer to a realistic timeframe. (See point four above).

6. Ensure your loved ones are on board
If you have a partner and family, make sure they understand the time commitment involved. However, make sure you maintain these relationships. There’s no point completing a PhD and then realising your personal life has gone bust.

7. Be organised.
You will be dealing with vast amounts of information. Develop a filing system for all your documents related to your research, and back up every single time you work. Use a reference aid such as EndNote to help keep references under control.

8. Prioritise funding.
If you are in the rare position to have funding already available e.g. joining an established project – lucky you. If not, make sure you know when all the various grants you are eligible for are due, and prepare your applications at least six weeks beforehand. Often these grants will require numerous signatures from busy clinicians and administrators.

9. Be aware of the financial implications
It is very difficult to undertake a post-graduate research degree if you have a full clinical load. The time needs to come from somewhere, and it can’t all be done after hours without adversely affecting your sleep, health, mental state and relationships, unless you are superhuman. Be prepared to reduce your equivalent full time (EFT) workload while doing your degree.

10. Maintain balance
A research post-graduate degree is a marathon, not a sprint. You need to be in top-notch health to be efficient. Make sure you do all the things we tell our patients – eat healthily, get enough rest, exercise regularly and have enough down time. Find something that replenishes you.

Dr Karen Chia
Rehabilitation Physician
Coffs Harbour


Dr Karen Chia is a Rehabilitation physician in Coffs Harbour, involved in private practice and teaching. She is in her third year part time of a PhD supervised by Associate Professor Steven Faux. Last year she started doing triathlons for fun as a counterbalance to her work and research commitments.

Rehabilitation clinicians and consumers contribute to prioritisation of rehabilitation research

Rehabilitation is a relative newcomer among clinical specialties in the health arena. While the demand for its programs is growing, the definitions and the science underpinning rehabilitation practise are emerging from a relatively narrow foundation.  

In Australia, a number of research centres with excellent researchers and protocols are involved in rehabilitation research, however they are frequently focused on narrow arenas of special interest. 

While it is positive to see an ever increasing number of research publications in the rehabilitation field, most are the result of individuals seeking answers to specific questions. 

Overall, rehabilitation research in Australia is limited, disparate, unstructured, and lacking in coordination with the lack of a clear direction one of the most glaring gaps on a national scale. As a result, what we are seeing now are many jigsaw pieces, but no ability to put them together to create a clear overall picture. To add to the complexity, we also have multiple puzzles.

The New South Wales Agency for Clinical Innovation (ACI) Rehabilitation Network is one of 40 clinical networks of doctors, nurses, allied health professionals and consumers within the ACI. 

The Network was formed in late 2012 to drive improvements in rehabilitation care in New South Wales. It has established a Rehabilitation Research Special Interest Group to facilitate networking amongst those with an interest in rehabilitation research, with the goals of elevating interest in rehabilitation research, improving the opportunities and quality of rehabilitation research, and improving networking between clinicians, researchers (including basic scientists), administrators, funders, and consumers. 

The ultimate goal is to start a process of coordinating aspects of research in the field of rehabilitation. The Special Interest Group would like to see a pathway, or structure, which can guide decisions about rehabilitation research. One of the first steps to achieve this was to determine a broad consensus with regard to the key criteria for determining ‘priorities’ for research in the field of rehabilitation.

Process
The ACI has developed a priority-setting framework – Making Choices A framework for prioritization within ACI Clinical Networks, Taskforces and Institiues1 that aims to support fair and transparent decision-making for resource allocation within its Networks. 

This has been necessary as Network members invariably propose more projects than there are resources to complete them. 

The first requirement of the framework is clarity in the approach taken by the group. In particular, it is essential that the group articulates the criteria it uses in selecting its work program. This informs debate and supports improvement in subsequent priority-setting exercises. 

To open the discussion around priorities in Rehabilitation research, we surveyed the membership of the ACI Rehabilitation Network to determine the criteria they considered important.

Creating criteria against which proposals for work are assessed and selected by the group is complex and experience in this area is limited. The literature was explored to identify a relevant survey tool that could be used to create an initial set of criteria. Rudan et al2 described their approach to priority setting in the context of child health research, and this approach was considered suitable for our purposes. 

The criteria for prioritisation proposed in this paper were converted into a survey which was distributed by email to the full Network membership (650 members – mostly clinicians, many with a research interest), as well as some consumers. 

Members were asked to rank 15 options in order of importance. Overall 103 completed responses were received. 

The three criteria ranked highest by the network were:

  • Effectiveness (i.e. research more likely to generate/improve truly effective health interventions), ranked in the top three criteria by 87 respondents.
  • Maximum potential impact on burden (theoretical potential to reduce much larger portions of the existing disease burden than the others), ranked in the top three criteria 61 respondents.
  • Potential for translation (more likely to generate knowledge that will be translated into health interventions), ranked in the top three criteria 61 respondents.​

There were 61 respondents who ranked both effectiveness and potential for translation within their top three.

The three lowest ranked criteria were:

  • Likelihood of generating patents/lucrative products (potential for greater financial return on investments, regardless of impact on disease burden). 90 respondents ranked this in their lowest three responses.
  • Attractiveness (more likely to lead to publications in high impact journals) ,ranked in the lowest three by 60 respondents.
  • Novelty (more likely to generate truly novel and non-existing knowledge), ranked within the lowest three by 53 respondents.

Interpretation
It is difficult to draw definitive conclusions from this survey. There were many biases including the ‘casemix’ of the respondents, and the choice of survey tool (Survey Monkey). There are also many ways to report the responses. However, the broad interpretation of the results provides a clue to the direction that interested rehabilitation clinicians and consumers are looking when prioritising opportunities within the rehabilitation research compass.

Although the primary purpose of this process was to begin the discussion around research priorities, the actual process brings with it multiple opportunities:

  • giving prioritised perspective to (would be) researchers
  • allowing a more objective base for decisions around research choices
  • establishing a pathway for progressively improving processes and discussions around research prioritisation
  • facilitating a research focus rather than progressive divergence of research activities and targets.

Beyond the contribution to the field of rehabilitation research, this process was also an exemplar in itself. It has provided a practical starting point for complex discussions and conversations, as well as inviting relatively junior clinicians to participate in some of the complex conversations usually reserved for more senior colleagues. More importantly, it allows more junior professionals and other interested, but often less visible/audible participants, including consumers to have an equal and evident voice.

Conclusion
This survey was the first step towards a coordinated discussion in setting a prioritised direction for rehabilitation research. 

The outcome of our survey suggests to us that any proposals put forward to the Rehabilitation Network for consideration of support should be prioritised based on their potential ability to improve the effectiveness of rehabilitation therapies, the ability to translate the proposed research into health interventions, and the capacity to reduce the burden of disability. This now allows the following:

  • Clinicians and institutions interested in rehabilitation research have transparency around how their research proposals will be prioritised by the Rehabilitation Network and can explore if/how their proposals address these criteria.
  • If there is doubt about the validity of the process, others (or ourselves) can improve the process for the next phase.
  • Research funders/supporters (e.g. government agencies) can use this information as part of a decision making/selection process when determining which project to support (if competition is present).
  • Discussions can commence in a range of forums using the survey results as the beginning point, or merely as a talking point. Whichever, the outcome should be an expanded opinion on this important topic.
More importantly, a process has been established which can effectively include a range of participants, including those who may often feel disempowered and excluded, in a topic which should influence the future focus of rehabilitation research and in turn, potentially influence the way rehabilitation is actually delivered.

Next Steps
It is important that the results of this process are distributed widely across relevant settings, both in the clinical and research arenas. 

Further feedback and discussion regarding the suitability of the process undertaken, and steps to improve on the process should also be explored. We hope to continue to refine the process with an ongoing goal of identifying research priorities in the field of rehabilitation, and disseminating the results. 

The potential to expand the process to a national level should also be investigated to support the development of a structured and coordinated approach to rehabilitation research in Australia. 

Finally, exploration of the value of the process in improving the outcomes of consumers of rehabilitation services would be a valuable contribution to the ongoing discussion in the rehabilitation arena.


Associate Professor Michael Pollack
Associate Professor, Conjoint, University of Newcastle
Senior Staff Specialist, Rehabilitation Medicine
Area Director/Clinical Leader, Rehabilitation Medicine, Hunter New England LHD
Director, Hunter Stroke Service 

Dr Tracey Tay
Deputy Director, Anaesthetics, John Hunter Hospital, Hunter New England LHD
Clinical Lead, Innovation Support, Hunter New England LHD

Claire O’Connor
Rehabilitation Network Manager, Agency for Clinical Innovation, NSW Health

References
1 Tay T, Pares J. Making Choices: A framework for prioritisation within ACI Clinical Networks, Taskforces and
Institutes 2013. (accessed July 2014).
2 Rudan I, Gibson JL, Ameratunga S, et al. Setting priorities in global child health research investments:
Guidelines for implementation of the CHNRI Method. Croatian Medical Journal. 2008;49(6):720-733.
doi:10.3325/cmj.2008.49.720.

PhD awarded for research on hemiplegic shoulder pain

With increasing survival following stroke, there is a growing rehabilitation population of patients with stroke-related disability.  Whilst increasing attention has been directed towards motor deficits such as upper limb weakness following stroke, the common complications such as shoulder pain are often overlooked.  

Hemiplegic shoulder pain is one of the four most common complications of stroke, and has been the focus of Dr Zoe Adey-Wakeling’s PhD thesis as she explains.

Following encouragement from my supervisors, I commenced my PhD studies in 2011. The topic of Hemiplegic Shoulder Pain was chosen as it presented an opportunity to investigate an intervention in this population that could potentially inform clinical change.  Whilst challenging at times, I have enjoyed the opportunity to enhance my studies over the course of this degree.  

My thesis explores the current literature pertaining to this topic: its context within the broader upper limb deficits post stroke, its definition, aetiology and evidence for prophylaxis and treatment.
  
Building on this background, original research using data from a population based stroke incidence study provides information on the local epidemiology, and the typical characteristics of shoulder pain presentation. A greater understanding of typical presentations provides the clinician with context and understanding on which to build strategies for assessment and treatment.

Randomised controlled data provides insight into suprascapular nerve block as an effective evidence-based treatment option. Post-hoc analysis indicates that patients aged over 80 years and with more severe baseline pain are more likely to respond to this intervention. This pragmatic trial provides information which is highly relevant to patients under the care of all Australian rehabilitation units but the findings are general to all patients with hemiplegic shoulder pain following stroke.

While the experience of stroke, and pain after stroke have previously been shown to impact on quality of life, the specific impact of hemiplegic shoulder pain has not been demonstrated. Using data from the population study on stroke the impact of hemiplegic shoulder pain occurring at any time during the first year after stroke on health-related quality of life is demonstrated.  

The findings of this thesis suggest that a new approach to the assessment and management of shoulder pain after stroke could be considered and tested. A possible protocol is suggested for future evaluation. The gap between research and implementation in clinical practice is well known and a review of possible barriers and facilitators to knowledge translation is discussed. 

Hemiplegic shoulder pain after stroke affects more than one in four stroke survivors. Greater understanding of this common complication of stroke will enhance the clinical focus on appropriate evidence-based management options.

Dr Zoe Adey-Wakeling
Consultant in Rehabilitation Medicine
Repatriation General Hospital, SA


Stroke Rehabilitation Research and Rehabilitation Funding in New Zealand

Funding for clinical research in New Zealand is relatively low compared to other countries and this is especially true in the field of rehabilitation medicine. 

The Health Research Council (HRC) in New Zealand is the equivalent grant funding body to the National Health and Medical Research Council (NHMRC) ​in Australia. 

HRC distributes about NZ $75 million per annum, or about NZ $16.7 per capita. This compares to A$850M from NHMRC, or A$36.7 per capita in Australia (more than twice as much as New Zealand). Consequently, there are few active research groups supported by the HRC that are involved in rehabilitation research.

One very successful group has been the Centre for Brain Research at the Faculty of Medicine and Health Sciences, University of Auckland. 

At the Centre’s Clinical Neuroscience Laboratory, Associate Professor Cathy Stinear is leading a series of trials that examine techniques to promote neural plasticity and recovery after stroke. 

In one of their randomised trials, this group tested the idea that active-passive bilateral priming (APBP) would improve upper limb function after stroke. APBP involves a device that couples the two hands together and causes the paretic wrist to move in a mirrored way to the non-paretic wrist. 

Patients performed 500 to 1500 movement cycles over 15 minutes prior to upper limb therapy daily (except weekends) for four weeks. The control group received intermittent cutaneous electrical stimulation of the volar aspect of the paretic forearm for 15 seconds every minute for 15 minutes. 

In this study of nearly 60 patients, it was shown that more patients achieved at least 75 per cent of their maximum recovery on the Active Research Arm Test (ARAT) score by 12 weeks (79 per cent vs 54 per cent, p=0.039), although there was no difference by 26 weeks. 

Neurophysiological measures showed that APBP increases corticomotor excitability in the ipsilesional primary motor cortex. Neuronal excitability is thought to be an important precursor to neural plasticity.

While it seems that recovery can be accelerated, a bigger question is whether the extent of recovery can be increased over and above the apparent ‘70 per cent rule’. This rule refers to consistent findings that upper limb motor impairment improves by a fixed proportion, which is invariant with respect to the patient characteristics, therapy dose or degree of neurologic impairment at baseline. 

However, the rule appears to apply only to patients who have an intact ipsilesional corticomotor tract. This important observation was also made by Associate Professor Stinear’s group using transcranial magnetic stimulation (TMS) applied over the lesioned hemisphere to elicit motor evoked potentials from a forearm muscle. 

The clinical implication is that it may be reasonable to target therapies that aim to enhance neural plasticity to patients with an intact ipsilesional corticomotor tract. The technique of eliciting motor evoked potentials (MEPs) using TMS can be done at the bedside and is within the capability of clinical staff to learn.

In fact, a tool partly based on this work and designed for clinical use called PREP (Predicting Recovery Potential for the hand and arm) is currently being evaluated within a randomised clinical trial by Associate Professor Stinear’s group. 

Hopefully this trial will provide a very good basis for clinical decision making. The tool involves three steps:  

  • Assessment of shoulder abduction and finger extension strength (Medical Research Council grade 0 – 5). 
    If the combined score is eight or more, complete recovery is probable and a home exercise program is appropriate. 
    If the combined score is five to seven, repetitive movement practice is appropriate. 
    If the combined score is less than five then TMS is used to elicit MEPs. 
  • Patients with intact motor pathways have good potential for a notable recovery and should be similarly managed with repetitive movement practice.
  • For patients without elicitable MEP, the third step is an MRI scan of the brain 10 to 14 days after stroke. 
    The structural integrity of the posterior limb of the internal capsule (PLIC) is measured using diffusion weighted imaging and calculation of the fractional anisotropy asymmetry index. 
    Patients with integrity of the (PLIC) are thought to have some potential for limited recovery of the upper limb whereas patients with an asymmetry index of 0.15 or more have no potential for recovery and rehabilitation should be directed towards compensation and prevention of secondary complications (spasticity, pain, shoulder instability). 

The results of this TRIO study (clinical trials registry ACTRN12611000755932) are awaited with great interest.

Associate Professor William Taylor
Rehabilitation Teaching and Research Unit
University of Otago, Wellington

Why I’m not a 'rugby Mum': Evolving evidence about mild Traumatic Brain Injury in young people

At my boy’s school ‘SPORT RULES’… and, as we all know, RUGBY is the KING of sports. But I’m so glad I’m not a ‘Rugby Mum’.

A few months ago, a friend rang me from the emergency department. Her 14 year-old son had been knocked out in a rugby tackle. Her son is a big, gangly boy but the ​opponent who tackled him weighed about 100 kg. I went down to the emergency department to find my friend amazingly calm, considering her son was still pale and nauseated. “It’s all OK, ”she said “ just a mild concussion. I was so worried he’d miss the regional trials next week.” She really is a 'Rugby Mum'.    

I am sure the same scenario is played out in emergency departments across the country through the winter months. 

‘Concussion’ is a transient disturbance of brain function caused by an external mechanical force1. Although the term mild traumatic brain injury (mTBI) sounds more severe, the definition is really similar (alteration of brain function  due to mechanical force with loss of consciousness less than 30 minutes, post-traumatic amnesia less than 24 hours and/ or GCS 13-15 )2

In the USA nearly half a million children under the age of 14 seek Emergency Department treatment for traumatic brain injury each year, with the majority of these injuries being mild. Many of these young people will suffer ‘post- concussive’ symptoms in the days and weeks following injury: headache, dizziness, fatigue, sleep disturbance, poor concentration, memory changes and emotional difficulties. 

Although research suggests that the vast majority of young people make a full recovery within a few weeks, a proportion who suffer mTBI will have persistent symptoms that cause significant impact on function and anxiety for the young person and their family3

We are slowly learning more about the pathophysiology of mTBI and the factors involved in recovery. Studies in animal models of mTBI suggest that the initial mechanical force causes primary disruption at a cellular level that is followed by a cascade of metabolic, haemodynamic and electrical changes4

Advanced imaging techniques such as Diffusion Tensor Imaging, Spectroscopy, positron emission tomography scans and functional magnetic resonance imaging are giving us insight into these changes in patients following mTBI. A number of studies have also been published in recent years that attempt to predict who is likely to have ongoing post- concussive symptoms5. Factors considered include patient demographics, injury characteristics, imaging techniques, biomarkers, neuropsychological and physical assessments3,6

Evidence is still evolving for treatment strategies following mTBI. The importance of education and reassurance has long been recognised7. For this reason, our paediatric rehabilitation service started a nurse-led phone follow-up service for patients referred following mTBI.  

Families are sent information after referral and then receive a phone call from a clinical nurse after several weeks regarding post-concussive symptoms and return to school and activities. Where persistent problems are identified, an appointment can be made in a multidisciplinary mTBI clinic. 

The recommendations about physical and cognitive rest following mTBI are changing – prolonged rest may be detrimental to recovery and early graduated return to school and low-risk physical exercise is probably the best recommendation8. Promising treatment options for post-concussive symptoms are also being studied3.

And so, back to my friend the ‘Rugby Mum’ and the tricky question of return to high risk activities following mTBI. 

There has been a significant increase in awareness of sports concussion in recent years and changes are slowly taking place on the playing field. Sports concussion assessment tools, although so far of limited validity for research, provide a clinical framework for medical assessment and post-injury advice that can be used by doctors on the field, by general practitioners and in emergency rooms9. Consensus guidelines have been developed that include recommendations about return to play and many sporting codes have adopted these (although these guidelines are based on expert opinion rather than clinical trials)1,10. Recommendations are even being made to change the way the media describes concussion in sport, to reduce the perception that concussion is a trivial injury11

However, I am still concerned about possible long term impacts of mTBI during childhood and adolescence, a time of significant remodelling and maturation of neuronal circuits. I am concerned that acquiring mTBI during these years may be associated with neurodegenerative conditions later in life12, and by a recent small study that reported changes in cortical thickness and task performance in asymptomatic 10 – 14 year olds after mTBI13. There is still so much we don’t know about the best management for mTBI, in particular the evidence on which to base our return-to-activity advice. 

I’m relieved I’m not a ‘Rugby Mum’.        


Dr Kim McLennan – council member
Paediatric Rehabilitation Specialist, Queensland Paediatric Rehabilitation Service,
Lady Cilento Children’s Hospital



References
1. McCrory P, Meewise W, Aubry M, Cantu B et.al. 2013 Consensus Statement on Concussion in Sport- the 4th International Conference on concussion in sport held in Zurich Nov 2012. Physical Therapy and Sport. 2013, 14 (2) :1-13.
2. Carroll, L., Cassidy D., Holm L., Krause J., Coronado V. Methodological issues and research recommendations for mild traumatic brain injury: the WHO collaborating centre task force on mild traumatic brain injury. Journal of Rehabilitation Medicine. 2004; Suppl. 43: 113–125.
3. Barlow, K Post-Concussion Syndrome: A Review. Journal of Child Neurology. 2016, Vol 31(1) 57-67.
4. Shultz S., McDonald S., Vonder Har, C  et. al. The potential for animal models to provide insight into mild traumatic brain injury: translational challenges and strategies. Neuroscience and Biobehavioral Reviews. 2016. 
5. Bernard C., Ponsford J., McKinlay A., McKenzie D., Krieser D. Predictors of post concussive symptoms in young children: Injury vs non injury factors. Journal of the International Neuropsychological Society. 2016,22 793-803.
6. Kirkwood M., Yeates K., Taylor G., Randolph C., McCrea M., Anderson V. Management of Pediatric Mild Traumatic Brain Injury: A Neuropsychological Review from Injury Through Recovery. The Clinical Neuropsychologist. 2008 22:5, 769-800.
7. Ponsford J., Willmott C., Rothwell A., et. Al. Impact of early intervention on outcome after mild traumatic brain injury in children. Pediatrics. 2001 Dec; Vol. 108 (6), pp. 1297-303.
8. Wells E., Goodkin H., Griesbach G. Challenges in Determining the Role of Rest and Exercise in the Management of Mild Traumatic Brain Injury. Journal of Child Neurology. 2016 ; 31(1): 86-92.
9. Chin E., Nelson L., Barr W., McCrory P., McCrea A. Reliability and Validity of the Sport Concussion Assessment Tool-3 (SCAT3) in High School and Collegiate Athletes. American Journal of Sports Medicine. 2016 44: 2276. 
10. Ahmed O., Hall E. “It was only mild concussion”: Exploring the description of sports concussion in online news articles. Physical Therapy in Sport. 2016 ;23:  7-13.
11. Burke M., Fralick M., Nejatbakhsh N., Tartaglia M., Tator C. In search of evidence –based treatments for concussion: characteristics of current clinical trials. Brain Injury. 2015; 29 (3) :300-5 12. Crane P., Gibbons L., Dams- O’Connor K., et. Al. Association of traumatic brain injury with late-life neurodegenerative conditions and neuropathological findings. JAMA Neurology. 2016 Sep 1;73(9):1062-9 13. Urban K., Riggs L., Wells G., et. al. Cortical thickness changes and their relationship to trial task performance following mild traumatic brain injury in youth. Journal of Neurotrauma. 2016, October ( Epub ahead of print) DOI: 10.1089/neu.2016.4502.
 

Demonstrating the Benefits of Spinal Cord Injury Rehabilitation

Nicola Hunter is a Senior Occupational Therapist in the Spinal Unit, Fiona Stanley Hospital in Western Australia. She is involved in research focused on selection of outcome measures for individuals with a new Spinal Cord Injury which will quantify the benefits of a rehabilitation inpatient hospital.

In the current financial environment it is more important than ever that the benefits of a rehabilitation stay can be quantified.  

‘Clinicians recognise the need for functional measures that are sensitive to clinically meaningful change and assess functional abilities that are important and relevant to persons with Spinal Cord Injury (SCI).’ (Slavin, MD et al 2010).

At Fiona Stanley Hospital regular use of the Functional Independence Measure (FIM) is essential and used as a basis for the predicted length of a patient’s hospital stay. However, FIM scores have been noted to have missed 26 per cent of the changes detected by the Spinal Cord Independence Measure (SCIM) (Catz, A et al 1997). In addition it is noted that many other spinal units globally are using the SCIM as a more accurate outcome measure, and other rehabilitation services are also attempting to quantify the complexity of patient needs.

Outcomes for patients vary depending not only on the basis of diagnosis, but also co-morbidities, social situation and funding which influence the patients’ capacity to return to the community. A comparison of a range of outcome measures was undertaken to select which provided an accurate prediction of length of stay.

A review of 60 individuals with a newly acquired SCI, who were admitted for rehabilitation from August 2015 – August 2016, was completed. Comparison was made in regard to:

  • diagnosis and completeness of injury
  • admission and discharge scores for: FIM, Rehabilitation Complexity Scale (RCS) and SCIM 
  • length of stay.

RCS was high in the majority of cases indicating a highly complex patient load. It did consider care and equipment issues but not discharge destination concerns, nor did it quantify functional change in detail.

FIM and SCIM identified changes in function, with SCIM identifying greater change in all patient types within the spinal units. Neither considered the impact of any other influencing factors on patient outcomes.

All outcome measures could accurately predict the length of stay for those with good social supports and limited care needs. Individuals with complex needs and situations require a combination of measures and clinical knowledge to foresee the length of the patient journey.

Nicola Hunter
Occupational Therapist
Spinal Unit
Fiona Stanley Hospital, WA


References  

  • Catz, A et al 1997 SCIM – spinal cord independence measure: a new disability scale for patients with spinal cord lesions. Spinal Cord 35, 850 – 856.
  • Slavin MD et al 2010 Developing a contemporary functional outcome measure for spinal cord injury research. Spinal Cord 48, 262-267. 

Review of Spinal Cord Injury Patients with Pressure Injuries Admitted to a State Rehabilitation Service in Western Australia

There are over 1,100 people living with persistent spinal cord injury (SCI) in Western Australia with approximately 40 new cases each year. Increases in population, better survival rates from catastrophic injury and improved life expectancy for people with SCI will contribute to an increase in the prevalence of spinal cord injuries in WA.
 
These forecast figures instigated an audit on the rates and reasons for readmission following SCI treatment. 

The audit, conducted by the State Spinal Unit in WA, covered patients who sustained an acute traumatic SCI and received treatment in Western Australia between January 1971 and July 2012.

Length of stay (LOS) was calculated for each diagnostic group resulting in the following breakdown: 

  • There were 815 people identified who met the inclusion criterion Acute traumatic SCI between 1971 and July 2012 – and completed their rehab program in the state spinal unit in WA.
  • Of these, 463 (56.8 per cent) required one or more readmissions to Royal Perth Hospital, including Shenton Park Spinal Unit, since discharge from their acute episode.
  • A total of 2,722 readmissions were identified for this group.
  • The number of readmissions ranged from 1 to 40 per person.

SCI Reason for Readmission graph[] 

  • The average Length of Stay (LOS) for all was 19.05 bed days.

SCI_Length of Stay graph[

The results of the audit have shown that Pressure Injuries utilise a disproportionate number of bed days compared with other Diagnostic Related Groups. This was evidenced by the following points: 

  • There were 17 people who had an average of 11 admissions each and utilised an average of 77.3 bed days per person per year (calculated to date of death or to 30 June 2012) in the 40 years the study covered.  
  • These admissions represented 21 per cent of the bed days of all admissions.
  • 46 per cent of these admissions were for pressure injuries.

Anne Watts
Nurse Unit Manager, Spinal Rehab, State Rehabilitation Service
Fiona Stanley Hospital WA

From Melbourne to Mongolia – The Royal Melbourne Hospital Rehabilitation Team Capacity Building Activity in the Developing World

The Rehabilitation Medicine Department of The Royal Melbourne Hospital (RMH) has a long history of providing support, supervision and mentoring for clinicians and researchers. 

One of the initiatives of the RMH Rehabilitation team is the ‘Flying Faculty’ which visits various international rehabilitation centres (upon invitation) for rehabilitation education and for medical, nursing and allied health personnel, especially in developing countries. 

The team just returned from Ulan Bator, Mongolia where rehabilitation is viewed through the prism of traditional natural therapies. The team spent a week teaching a group of 76 Mongolian rehabilitation specialists, modern rehabilitation techniques and evidence-based practice.

In 2017, the team will visit Ghana, Nigeria and Morocco on a teaching program allied with local universities – University of Ibadan, Nigeria, University of Al-Qarawiyyin in Fez, Morocco, and others in the Middle East and Asia.

The RMH also has a Rehabilitation Disaster Response Team accredited by the World Health Organisation (WHO) for deployment in natural disasters such as the May 2015 Nepal earthquake. The team is drawn from a pool of approximately 10 specialists and the composition of the team is based on the type of the disaster and need for specific skills.

In the aftermath of the Nepal earthquake the team provided essential triage of people with acute spinal injuries. There were other teams on the ground from various countries, but most worked in the field of acute medicine. The commitment of the team members is obvious as they are required to pay their own way (the RMH does provide some limited funding).

In November 2015, during the Hindukush, Pakistan earthquake, the RMH Rehabilitation Disaster Response Team was fully embedded with the Pakistan military for disaster relief work. The experience resulted in some team members to be trained in disaster training courses accredited with Australian Medical Assistance Teams (AUSMAT) and the National Critical Care and Trauma Response Centre. 

The work conducted in Mongolia is under review prior to publication. From Pakistan the WHO- Global Disability – perspectives in Pakistan was published in the Journal of Rehabilitation Medicine2016) and from Nepal, Rehabilitation needs assessment in persons with spinal cord injury – lessons learnt in Nepal earthquakes was published in the International Journal of Physical Medicine and Rehabilitation 2015. 

Other published work include: Medical rehabilitation in Disaster Settings – a review (Archives of Physical Medicine and ​Rehabilitation 2015), Medical rehabilitation in Asia- Pacific Region (International Journal of Natural Disasters and Health Security 2015), Overview of Medical Rehabilitation in Pacific Islander Countries (Physical Medicine and Rehabilitation – International2016) and Neurorehabilitation in developing countries: challenges and the way forward (Physical Medicine and Rehabilitation- International – 2016).

Professor Fary Khan
Director of Rehabilitation, Royal Melbourne Hospital

AFRM President’s report

My report this edition summarises the twelve months of activities between the AFRM Annual Scientific Meeting (ASM) in Wellington last year and the RMSANZ ASM in Melbourne this year.

For those who have read my regular monthly posts in the e-Bulletin, this will cover much that is familiar, but somewhat more briefly. Dr Steve de Graaff was Faculty President until we changed over the role at the RACP Congress 2016 in Adelaide in mid-May. I must thank him for laying such a good foundation for the ongoing success of our Faculty, and the strong support that has been given to the establishment of the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ), during the two years of his Presidency. 

The very successful recent first Annual Scientific Meeting of the RMSANZ in Melbourne will be reported elsewhere; suffice to say that I thoroughly enjoyed the meeting, and everyone else I spoke with commented likewise. The Faculty and the Society are continuing to develop a Model of Collaboration between our two corporate bodies, which we look forward to completing and signing off in the very near future.

At the same time, I must thank other folk who have given me great support and advice: the other members of Faculty Executive and Council; and the AFRM Team – Dominique Holt (Manager of Faculties), Phillipa Warnes (AFRM Executive Officer) and Annette Barker (AFRM Administrative Officer), and not to forget Paul Washington, whose work underpins the successful administration of our Faculty’s regular assessments for trainees. Phillipa has now moved to another post in the Fellowship Relations Directorate of the RACP, and has been replaced by Isabel Roos.

I have written recently about Dr Shari Parker’s ‘Rehabilitation Trainee of the Future’ report, and the recent workshop in Melbourne, where we decided to work on enhancing our current FAFRM training program. An Expression of Interest request will appear shortly, for those who may wish to apply to join that group. Together with our work on the role of rehabilitation physicians in the community, both documents will then inform further work on the ‘Horizon 2030’ document, in consideration of future workforce needs and distribution.

Fellows in Australia will be aware that the roll-out of the National Disability Insurance Scheme (NDIS) continues, and that it will be a year or three yet before there is a degree of uniformity about service provided across all Australian jurisdictions. I think our New Zealand Fellows must be watching the roll-out of this scheme with some bemusement, having had similar provisions in place there for around a decade already. Plenary sessions on NDIS have featured at both the RACP Congress and RMSANZ ASM in recent months, and will be revisited at both meetings in 2017, I am sure! 

The RACP Board has been maintained in its present state and composition for the 2016 – 2018 cycle and the representative College Council has had its term extended for a further year. The Council will continue in much the same form as now, once the RACP Board  reduces in size from mid-2018 onwards. I am a member of both the College Board and its Executive, and my thanks go to Dr Jennifer Mann who will continue as the AFRM representative on College Council until mid-2018.

Colleagues will be aware that the AFRM Research Committee is off to a flying start with the able Chairing by Professor Michael Pollack, and that our links with Australasian Rehabilitation Outcomes Centre (AROC) remain very strong, with Dr Nathan Johns as Faculty lead for AROC, and Professor John Olver as AROC Clinical Director.

Apart from the various groups mentioned above, Dr Steve de Graaff continues as a member of the RACP Fellowship Committee, and the International Strategy Working Group. He and Dr Kate Langdon and Dr Elizabeth Thompson are members of the RACP’s NDIS Working Group. At different times in the year, different individuals have been involved with the College’s Educational Governance Implementation Working Group, and the Evolve consultations, identifying low-value treatments and therapies, endeavouring to improve patient care by avoiding using these. Finally, I am Deputy Chair of the College’s recently-established Euthanasia & Physician Assistance in Dying Working Group.

All told, it has been a busy and fulfilling year, and the end-of-year holidays will be upon us before we know it. May I take this opportunity to wish all and sundry a very happy Christmas, New Year and summer holiday season, with our families and friends, whilst taking every opportunity to recharge our Vitamin D levels and maintain (or achieve) healthy BMIs.

Like all of us, I look forward with hope towards even better times in 2017.

Associate Professor Andrew M Cole
President, Australasian Faculty of Rehabilitation Medicine
November 2016

Report from the Chair, Faculty Policy and Advocacy Committee

This is my first report as Chair of the Faculty Policy and Advocacy Committee (FPAC) and I am looking forward very much to working with the Committee over the next couple of years.

We most recently met via teleconference on Friday, 12 August. 

Committee Members
Along with myself, current members of the Committee are: 

  • Dr Louis Baggio (Rural and Remote representative)
  • Associate Professor Andrew Cole (Faculty President)
  • Dr Luca D'Orsogna (Western Australia)
  • Dr Monika Hasnat (Paediatric representative)
  • Dr Julia McLeod (Queensland)
  • Dr Elisabeth Sherry (Victoria/Tasmania 
  • Dr Tai-Tak Wan (New South Wales)

We recently also welcomed Dr Harry Eemon to the Committee and thank him for his commitment to be part of FPAC.

Feedback from FPAC 

The FPAC is currently working on the following issues:

1. Evolve initiative

  • Ongoing discussion is occurring regarding the Evolve initiative and the draft rehabilitation top-five list of low-value care items. The draft list is now being reviewed with the existing evidence associated with the proposed items.

2. College Policy & Advocacy Committee Archiving Process for Policy Documents

  • FPAC has continued to consider a number of Faculty policy documents that need review. These include policies on landmines, stroke units and the role of the rehabilitation physician.
  • The Rehabilitation Medicine Physicians and CPD Obligations and Rehabilitation Service Categories documents have been assessed as no longer necessary and have been archived.

 3. Integrated Care Working Party and Rehabilitation Medicine Integrated Care document

  • FPAC continues to be represented on the RACP Integrated Care Working Party and members of FPAC are working in collaboration with staff from the College Policy & Advocacy Unit to develop a draft paper related to Rehabilitation Medicine and Integrated Care using Early Supported Discharge (ESD) for Stroke as an example.
  • There has been good discussion at several recent teleconferences and a sub-group of FPAC is now progressing the document, with the aim of finalising it as soon as possible. 

 4. Guiding Principles for Telehealth Consultation in Rehabilitation Medicine

  • FPAC approved the latest version of this document and it has been submitted to CPAC for final approval and publication.

5. Other 

 FPAC has also contributed significantly to a number of recent College matters including:

  • endorsement of the National Transport Commission Assessing Fitness to Drive Guidelines – April 2016
  • submission to the Queensland Insurance Commissioner regarding the inappropriate consultation process undertaken to request feedback from the College regarding the Queensland Draft National Injury Insurance Scheme – July 2016
  • submission to Avant Mutual Group to provide feedback on its Telehealth Issues Discussion Paper – Medico-Legal Risks – July 2016

Professor Tim Geraghty
Chair, Faculty Policy and Advocacy Committee

Faculty Education Committee Report

Trainees and Supervisors
As at 4 October 2016, there were currently 206 general trainees and 12 paediatric trainees of the AFRM. The breakdown of trainees by Australian state and territory, and New Zealand is:  

  • ACT – 5 
  • NSW – 84
  • NT – 2 
  • QLD – 47
  • SA – 15 
  • TAS – 5 
  • VIC – 45
  • WA – 9
  • NZ – 5.

As at 4 October 2016, there were 254 accredited supervisors of the AFRM and 128 accredited training sites.

Sub-Committee Updates – Faculty Training Committee in Rehabilitation Medicine

Membership
The Faculty Training Committee (FTC) membership is now at full capacity. 

I would like to thank the following Committee members for their continued hard work overseeing and developing the Advanced Training program in Rehabilitation Medicine: Dr Caitlin Anderson, Dr Sharon Wong, Dr Mary-Clare Waugh, Dr Jon Ho Chan, Dr Kellie Nichol, Dr Juan Rois-Gnecco, Dr Michael Ponsford, Dr Gavin Chin, Dr Hilary Taylor-Evans, Dr Susan Inglis and Dr Louisa Ng.

Bi-National Training Program (BNTP)
To date, there have been nine Bi-National Training Program (BNTP) sessions held in 2016. These sessions have covered a range of topics such as: Illness and Injury in the Elderly, Stroke, Orthopaedics and Burns. The remaining BNTP session for 2016 will be covering Paediatric Pain. 

The Committee is currently developing the 2017 BNTP timetable, which will be more closely aligned with the curriculum and learning objectives for Advanced Training in Rehabilitation Medicine.

Accreditation Sub-Committee
The Accreditation Sub-Committee (ASC) has been incorporated as a subcommittee into the FTC rather than reporting directly to the Faculty Education Committee. The ASC is on track to complete the required assessments for 2016. I would like to thank the following members for their involvement this year: Dr Gavin Chin, Dr Miranda Jelbart, Dr Sureshbabu Subramanian, Dr Francoise Joseph, Dr Kim Dobbie, Dr Yong Hee Kim, Dr Lucy Ramon, Dr Warren Jennings-Bell and Dr Peter Flett. 

AFRM Faculty Assessment Committee

Membership
I would like to thank the following Faculty Assessment Committee (FAC) members for their dedicated involvement in developing and coordinating the AFRM Examinations: Dr Michael Johnson, Dr Sridhar Atresh, Dr Venugopal Kochiyil, Dr Lynne McKinlay, Dr Charitha Perera, Dr Vidya Ramnath, Dr Anand Kumar, Dr Rachael Nunan and Dr Shari Parker.

2016 Fellowship Written Examination (Adult)
The 2016 Fellowship Written Examination was convened in Sydney, Newcastle, Auckland, Christchurch, Melbourne, Adelaide, Brisbane, Canberra and Perth on 31 May 2016.  There were 41 candidates for the short answer paper and 37 candidates for  the  multiple choice questions (MCQ)  paper. Twenty-four of the 41 candidates passed the short answer paper (a pass rate of 58.5 per cent) and 31 out of 37 candidates passed the MCQ paper (a pass rate of 83.3 per cent).

2016 Fellowship Clinical Examination (Adult)
The 2016 Fellowship Clinical Examination was convened on 13 August 2016, at St Vincent’s Hospital, Melbourne. There were 38 candidates. Thirty-one of the 38 candidates passed the FCE (a pass rate of 81.6 per cent).

Faculty Paediatric Training Committee in Rehabilitation Medicine

Membership
The Faculty Paediatric Training Committee (FPTC) is currently working with the College to develop Terms of Reference which satisfy the workload requirements for the Committee. I would like to thank the following FPTC members for their diligent work in coordinating the AFRM Paediatric Fellowship Examinations and overseeing the training program: Associate Professor Ray Russo, Dr Adrienne Epps, Dr Lynne McKinlay, Dr Katherine Langdon, Dr Mary-Clare Waugh, Dr EeWei Lim, Dr Adam Sheinberg and Dr Jane Valentine.

AFRM Paediatric Fellowship Written Examination
The 2016 Fellowship Paediatric Written Examination was convened in Sydney, Melbourne and Perth on 31 May 2016. There were five candidates for the Short Answer Paper and five candidates for the MCQ Paper. Four of the five candidates passed the Short Answer paper (a pass rate of 80 per cent) and 100 per cent of candidates passed the MCQ paper.

AFRM Paediatric Fellowship Clinical Examination
The 2016 Paediatric Fellowship Clinical Examination was convened on 3 September 2016, at the Lady Cilento Children’s Hospital, Brisbane. There were five candidates, and a pass rate of 100 per cent.

Continuing Professional Development Committee

Continuing Professional Development (CPD) Forum
A CPD forum was held in August, in Melbourne, with great success. Some interesting topics regarding CPD and its future direction were discussed. Attendees also discussed revalidation, regular practice review and implementing CPD into every day practice.

2017 CPD Framework
The CEC has approved changes to the 2017 CPD Framework. For further information, please contact the CPD unit. 

MyCPD Program
The College’s CPD Unit is currently making improvements to the MyCPD portal, in response to feedback from Members, so that the system will be more user-friendly. It is anticipated that the improvements will be available in mid-2017.

New Zealand

There are currently nine accredited training sites: two in Dunedin, one in Christchurch, one in Wellington and five in Auckland; and five trainees. There has been difficulty in recruiting new trainees in New Zealand. Strategies to promote rehabilitation medicine as a career choice in New Zealand are currently being discussed.

Physician Education

Dr Kochiyil has continued to take the lead in organising Supervisors and Long Case Workshops including those at the Annual Scientific Meeting in October 2016.

Other News

Education Policies
The following policies have been revised: Selection into Training, Flexible Training, Progression through Training and Academic Honesty and Plagiarism. The updated versions of these policies will be implemented in 2017.

Training Requirements
The training requirements outlined in the 2017 and 2018 Handbooks for Advanced Training in Rehabilitation Medicine have also been revised. These changes have been sent to all AFRM Fellows and trainees for consultation, and are currently being finalised with the College Education Committee.

As well as mentioning all the members of our many hard working subcommittees above, I would especially like to draw your attention to the Lead Fellows and Subcommittee Chairs who work tirelessly on these crucial areas of Faculty work throughout the year. Finally I would like to thank Rachel Smith and Lanica Alonzo, members of the College Education Services Directorate, who do an enormous amount of work behind the scenes supporting the Faculty's many education responsibilities and activities.

Dr Greg Bowring
Chair, Faculty Education Committee
 

Mind Special Interest Group Report 

The Mind Special Interest Group (SIG) has had a busy year. 

We had a wonderful start with Dr Susannah Ward’s presentation on ‘Yoga and Rehabilitation’ and Dr Barbara Hannon’s work with registrars as part of the Victorian Training Weekend on ‘Manage your Mind’. Dr Phil Funnell continues his work in Junior Medical Officer training at Northern Sydney Health which includes such things as relaxation and meditation. 

Some Mind SIG members followed Dr Craig Hassad’s free online course on mindfulness after it was promoted on the Mind SIG website and in the AFRM eBulletin. Mindfulness seems to be everywhere at present and it was great to have an online window seat to Dr Hassad’s experience and knowledge. 

Dr Barbara Hannon has become an active member of the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) Organising Committee for the Annual Scientific Meeting in Canberra in 2017. She is liaising with some wonderful speakers in the ‘Mind’ space. Fingers crossed for some ‘like Minded’ speakers in 2017.

Finally, we’re excited about our final Mind SIG teleconference for the year during which we’re inviting people to share their favourite piece of research or Mind based literature. I really enjoyed Jo Marchant’s Cure and am about to start When Breath Becomes Air by Paul Kalanithi. 

Join us for a wide ranging and entertaining end of year discussion on Wednesday, 30 November at 5.30pm.

Dr Jane Malone
Chair, Mind Special Interest Group 

Paediatric Rehabilitation Special Interest Group

At our face-to-face meeting at the end of March at the Australasian Academy of Cerebral Palsy and Developmental Medicine (AusACPDM) Conference in Adelaide, Dr Kate Langdon stepped down as Chair of the Paediatric Rehabilitation Special Interest Group (SIG). 

Dr Langdon had been Chair of the SIG since 2011 and was widely thanked by SIG members for her leadership during a period of significant change.

I will step in as the new Chair, and the SIG welcomes Dr Maria Kyriagis as the new Secretary.

Members of the SIG continue to be very active in a period of change for paediatric rehabilitation. 

The SIG continues to maintain its strong links to the Faculty while intending to play a larger role in the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ), including assisting with planning for the Annual Scientific Meeting in Canberra in 2017. 

Members have used the forum to develop a national information form for botulinum toxin A injections, discuss the progress of the developing the Australasian Paediatric Rehabilitation Outcome Centre (APROC) dataset and to feedback on the impact of the National Disability Insurance Scheme in Australia for members’ practices. Supporting this ongoing work will form the majority of planned works for the SIG over the coming months.

The SIG remains, as always, keen to attract new members. Please feel free to contact me through the Faculty office at afrm@racp.edu.au if you would like to join the SIG or learn more about it.

Dr Simon Paget
Chair, Paediatric Rehabilitation Special Interest Group
 

Rehabilitation and Older People Special Interest Group

At the Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) Annual Scientific Meeting in Melbourne on Wednesday, 19 October, the Rehabilitation and Older People Special Interest Group (SIG) supported a session with the title ‘Should Older People be Excluded from Spinal Cord Injury and Severe Traumatic Brain Injury Services? Challenges or Opportunities?’ There were contributions from NSW, Victoria, South Australia and Queensland and also from Dr Gaetan Tardif. It is clear that there are differing policies between states.

The SIG also met during the RMSANZ Annual Scientific Meeting. 
The Group Executive ​meets quarterly, and also on an ad hoc basis. 

Did you know?
Did you know that there are Australian and New Zealand Hip Fracture Guidelines? There is also a hip fracture registry and work is on-going to link that to AROC.

Did you also know that there are now Australian Dementia Guidelines? These are important for rehabilitation physicians working with older people.

Professor Ian Cameron 
​Chair - Rehabilitation and Older People Special Interest Group 

 

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

The Rehabilitation Medicine Society of Australia and New Zealand (RMSANZ) held a very successful and well attended inaugural Annual Scientific Meeting (ASM) in Melbourne during October 2017. 

There was very positive feedback from delegates on the range and content of the topics that were presented, the quality and relevance and also the standard of presenters and speakers. 

Many suggestions have been received that will assist the 2017 Organising Committee to offer an even better meeting in Canberra from 16 to 20 September 2017 at the National Convention Centre. 

Please mark the dates in your calendars to attend our second ASM titled ‘The Leading Edge: Innovations in Rehabilitation Medicine’. 

In November 2018, the RMSANZ will be co-hosting the 6th Asia-Oceanian Conference of Physical and Rehabilitation Medicine of Asian-Oceanian Society of Rehabilitation Medicine AOSPRM in Auckland as part of our third Annual Scientific Meeting. 

At its Annual General Meeting (AGM) on Monday, 17 October 2016, members of the RMSANZ voted to elect Dr Lee Laycock as the President-Elect of RMSANZ. Dr Laycock will take on the office of President at the forthcoming AGM in September 2017. 

On behalf of the RMSANZ, we are all with you Lee, in offering you our congratulations in your new role and best wishes for the future.

The RMSANZ now has over 400 members and is growing in strength as a peak collegiate and representative organisation. State Branches have been formed in NSW/ACT, Victoria/Tasmania and in South Australia.  

A Private Practice Special Interest Group (SIG) has already formed and has conducted clinical meetings and reviews amongst its members. A Pain SIG is about to be formed with over 50 members already in its support.

The RMSANZ is active in its advocacy role and has recently made representation to the Deans of Medical Schools in Australia and New Zealand in support of anti-discrimination practices in the ​management of medical students with disabilities.

Dr Alex Ganora
President, Rehabilitation Medicine Society of Australia and New Zealand
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