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Vital rehab role under threat



“Numbers are our biggest challenge as a profession,” says Diane Playford as she ponders the current state of the nation for rehab medicine physicians.

“Many medical specialties are small in the UK compared to our European colleagues, but rehab medicine is disproportionately small.”

November 2018 brought an end to Playford’s two- year tenure as president of the British Society of Rehabilitation Medicine (BSRM). She stepped down with the profession in which she has worked since 1995 at a crossroads.

In the UK there are currently around 180 consultants in rehab medicine, with a further 40 currently in trainee positions.

These professionals play a key role in shaping and improving rehab outcomes – yet their limited number means many patients and multidisciplinary rehab teams cannot benefit from their expertise or skills.

Various factors in the UK have resulted in the influence of the role shrinking in recent decades. Among them is the legacy of changes in the 70s and 80s that saw the two physical medicine fields, rheumatology and rehabilitation, veer off in separate directions. This shift left doctors in the latter camp focused largely on the most severe disabilities, and therefore a limited number of cases. This means patients with conditions that are managed with input from rehab medicine physicians in other countries do not receive such access to these professionals in the UK. This must change however, says Playford, or the standard of UK rehab compared to other nations could suffer over time.

“We need to articulate the role of the rehab physician more clearly. We also need to grow links with other specialties, many of whom use a rehabilitation approach but their core skills lie elsewhere.” She points to pain clinics as an example area where rehab physicians are being underutilised.

“The physicians or anaesthetists within a pain clinic will be technically very skilled at treating pain but may not be so good in the skills needed to help people function in everyday life. Rehab physicians have something to offer here, as do physiotherapists and psychologists. The more comprehensive the multidisciplinary team, the better the outcomes will be. It is relatively unusual to have a rehab physician in a pain clinic in this country but fairly common in other countries.”

Musculoskeletal rehab is another field in which Playford believes rehab physicians could and should play a greater role in patient care.

“We have very few rehab physicians working in musculoskeletal rehab. In other countries, musculoskeletal is a significant field for them; and this includes recovery from musculoskeletal trauma, management of lower back pain and vocational rehab for people with musculoskeletal conditions.

“I think there is a growing recognition that rehabilitation services for people with musculoskeletal conditions, particularly trauma, are very limited in the UK and need to be developed.

“Currently these services are largely delivered by physiotherapists, many of whom have practitioner or consultant practitioner roles and are very skilled. But when things get very complex, then the rehab physician has a contribution that at the moment is not being made.”

The historic move of rehab physicians towards only the most severe disabilities means many now work only with patients with combined physical and cognitive difficulties. As a result, members of the musculoskeletal population, whose difficulties are mostly physical, may miss out on their expertise.

This differs overseas, partly because of the impact of insurance-based systems in creating a stronger drive to get people back to work. “In other countries, rehab medicine has grown because of its very close links with vocational rehab. And that has also been very badly neglected here,” she says.

Another trend in the UK that is not widely replicated elsewhere is skilled therapists increasingly taking up the role of autonomous practitioner.

“This has many advantages, but there is also a disadvantage. The multidisciplinary team may face a complex problem that requires some of the skills of a physician, such as the prescription of medication, or consideration of medication in the context of other factors. Unless you have a prescriber on your therapy team – and there are some physiotherapy and nurse prescribers – you have to wait to get a referral to a rehab physician who has those skills.

“Alternatively, you can refer to a GP, but you can’t have that multidisciplinary conversation about the various factors contributing to spasticity and the best way that can be treated without a physician on the team.

“In not having physicians on the team, patients are missing out on prompt treatment. They are not getting the right treatment at the right time.

“I think teams that do have easy access to rehab medicine physicians really value their contribution. Many teams who’ve never had that experience would also value the opportunity of working with them.”

An example scenario could be a patient needing an expert physician to consider the impact of drugs which manage tone, but which also may have sedative, cognitive, mood and bladder function implications.

“It’s self-evident that having someone whose expertise lies in this area, amongst other things, will have a valuable contribution to make to the timely management of that patient.

“Multidisciplinary teams work well when they identify all the contributing factors to a patient’s presentation and to their function very accurately. That means they target their interventions in the right order and in the right way for that patient. That makes the team much more efficient.”

Against widespread inconsistencies, Playford believes the UK would benefit from a single, cohesive voice representing the multidisciplinary rehab team and its patients on a national level.

“It is right and proper that there are individual disciplines and professional concerns. If what patients need is access to a multidisciplinary rehab team, however, then there perhaps ought to be a voice that represents all the disciplines and all the patients.”

Stroke is an area where the collective voice of multiple professional groups has been able to influence change and improvements in care delivery, she says.

“Stroke has been strongly led by the stroke physicians, working with multidisciplinary teams. The big national meeting, the Stroke Forum, is a really successful clinical and academic gathering which is influential in the development of stroke services and
the dissemination of skills and knowledge around stroke.

“A really successful multidisciplinary environment has been created that drives the stroke agenda and this has been manifest in all sorts of things. You can see it in the nature of multidisciplinary data collection and the Royal College of Physicians’ multidisciplinary guidelines for example. We don’t have the same powerful voice for other conditions.”

Could such achievements in the stroke field be replicated more widely in rehabilitation? “You could, of course, find a voice for all traumatic brain injury, which is a very large and growing problem. You could have another for MS or Parkinson’s. But if you look at the skills required in multidisciplinary teams to treat those conditions, there is a lot of commonality.

“We perhaps need to separate generic skills that allow us to deliver treatment to large groups of patients from the very specialist skills that may need to be offered at a regional rather than district level. Some patients need a disease or symptom-specific team – but that’s a relatively small number of patients. “Ultimately, most patients want treatment close to home from a team that feels comfortable managing it. A louder and more collaborative representation of multidisciplinary rehabilitation teams
would perhaps help to ensure more patients receive this.”

Despite the many challenges facing UK rehab teams, there are plenty of reasons for optimism about future of rehab, says Playford. She is particularly enthused about advancements in neuroscience.

“This is a really exciting time for rehab generally. There is an enormous amount of interest within the neuroscience community in targeting treatments to individual patients. This will allow us to stratify patients in terms of their individual pathologies and genotypes and target the right treatment to the right patient. It also allows us to do the sort of clinical trials that need to be done that demonstrate positive results.

“At the moment, we tend to use treatments that we know will work in some patients, but we don’t know which those patients are. We therefore waste a lot of time and energy treating the wrong patients. The advances in neuroscience will allow us to match
the interventions to the patient and that’s really exciting.

“Soon we’ll be able to achieve really sophisticated imaging, enabling us to do real time analyses of, for example, EEG or polysomnography data. This will allow us to choose our drugs more carefully, based on the impact they are having on people’s cortical activity.

“They will also enable us to enhance neuro-plastic changes, allowing patients to make better recoveries.

“Then there is the technical stuff around robotics, exoskeletons and smart fabrics for lightweight orthotics. There is lots of really exciting stuff going on.”

In future Playford would welcome more research projects specifically focused on rehab. These are in short supply partly because there are so few rehab centres co- located with university hospitals, she says. Also, there are “very few” trained academic rehabilitation medicine physicians.

“There is some really good neuroscience looking at preventing disability, in the context of an acute neurological event. But there
is very little looking at how we improve treatments for people in the sub-acute and chronic phases.

“There is funding available for research into the early stages of rehab, in terms of preventing disability in the acute injury, but very little for later on. We need to meet this challenge and create more successful rehabilitation research platforms.”

Meanwhile, having stepped down from the BSRM helm in October, Playford believes the organisation remains in good health, but with a tough remit to deliver.

“The BSRM is a relatively small society which reflects the size of the rehab medicine community in the UK. I have to say I think it punches above its weight. It has produced a number of very useful guidelines and guidance and it is well represented within the clinical reference groups, the Department of Health, on national committees and at the Royal College of Physicians.

“The challenge for the society is to make sure that medical students and trainees are aware of rehab medicine as a specialty; and we are taking some steps to raise awareness of it as a fascinating career choice. Certainly it’s one I have never regretted.”

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