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Specialist services at
OZC
Andrew Bateman
PhD MCSP
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Ian ‘personal construct’ outcomes Work hard and achieve 1 2 3 4 5 6 7 “GO OFF”, not things achieve Happy and making 1 2 3 4 5 6 7 A problem for others others happy Head injury as the main 1 2 3 4 5 6 7 One of the human thing in my life race – just like every- one else Feeling confident 1 2 3 4 5 6 7 Loss of confidence
Pre-Injury selfIdeal self Change in ‘present self’ from start – end programme
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History
Centre founded by Prof Barbara Wilson, opened November 1996
Modelled on Adult Day Hospital, Phoenix Arizona & Oklahoma programme
Lifespan NHS Trust, Anglia & Oxford NHS Executive & MRC
National Service Influenced by work of Prigatano, Ben-Yishay & Christensen
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Who was Oliver Zangwill ?
Professor of Experimental Psychology, Cambridge University, 1952 - 1982.
1940’s Edinburgh working with war injuries.
Major influence on British rehabilitation. First to apply neuropsychological
knowledge to rehabilitation.
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Mission Statement
To provide high quality rehabilitation for the individual cognitive, social, emotional, vocational and physical needs of people with non-progressive brain injury
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Oliver Zangw ill Centre Team
R e sea rch O T R e se arch F e llow
R e sea rch A ss is ta n t
D irec to r o f R e sea rch
C lin ica l S p ec ia lis t O T
S en io r I O T
T h era py A ss ista n t
H E A D III O T
S p ec ia listS A LT
S p ec ia list S A LT(B IR T )
L ea d S A LT
C lin ica l P sych o lo g ist C lin ica l P sych o lo g ist
P sych o lo gy A ss ista n t P sych o lo gy A ss ista n t
L e ad P sych o log ist
C o urse A d m in is tra to r R e sea rch A ss is ta n t
A d m in A ss ista n t N eu roP a ge
S u pp or t M an ag er
C lin ica l M an ag er
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Andrew Bateman
Neuro Rehabilitation Clinical Lead
Jill Winegardner
Clinical Psychologist, (B8) P/T
Barbara Wilson
P/T (1/7)
Cat Ford
Clinical Psychologist
(B8A) F/T
(Clinical/Supervision 02 3/7)
Research 2/7 AIMS
CLAHRC
Research student at Uni.Cambridge
Jackie Galway
Clare Keohane
Head Specialist Speech & Language Therapist
(8A) P/T 3/7. Mon, Tues, Thurs
CCS, Stroke
E.C. & F
City & South, Huntingdon
Michelle Young
Support Manager
(B5) P/T 30hrs 5½ days
Leyla Prince
Specialist Speech & Language Therapist
(B7) F/T
Diana McCollum Specialist Speech
& Language Therapist
(B7)
Seconded manager of
paediatric team
(P/T 1/7) Mon - Weds
(2 Paed) 1/7 ozc clinicall
Fiona Ashworth
Clinical Psychologist
(B7) F/TEmma
Rehab Psychology Assistant
vol) Temp, F/T
Leah Bousie
Rehab Psychology Assistant
(B4) F/T
Chantel Williams
Rehab Psychology Assistant
(B4) F/T
Supervise all admin
Sharon McEwing
Personal/
Administration Assistant
(B3) F/T
Rachel Everett
Marketing & Courses
Administrator
(B3) P/T 20hrs
2x full days (Mon, Tues),
1x½ day (Weds)
Donna Moore
NeuroPage Administrator
(B2) P/T 15hrs
Full – Mon, Part Weds/FriBand 3 (?F/T)
(Amy Rideout)
(new student)
Psychology Research Assistant
OZ (F/T)
(Voluntary) 1/7CBU
Anna Piasceka
Psychology Research
Assistant OZ (F/T)
Gemma Hardy
Research Assistant
MRC-CBU (F/T)
Eve Greenfield
Research Occupation
al Therapist
MRC-CBU (P/T)
April – 4/7 Clinical/SPM
1/7 CLAHRC
3/7 Clinical/SPM
2/7 CLAHRC
TEMP
Helen Howe
Bank admin
P/T 12hrs
Am – Tues, Thurs, Fri
April
Sue Brentnall
Head Occupational Therapist
(B8A) P/T (5½ days 28)
Donna MalleyOccupational
Therapist Clinical Specialist
(B8A)
Band 7
Maria Martin Saez FT
Carolyne Threadgold
Rehabilitation Assistant (B4) P/T
4/7
Band 7 (vacant) F/T
Rachel Harrison
Occupational Therapist (B5) F/T
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The Team
3 Clinical Psychologists 2.6 (w.t.e.) Occupational Therapists 1.6 (w.t.e.) Speech & Language
Therapists 3 Psychology/rehabilitation Assistants 1 Clinical Manager 4 Administrators Visiting Neuropsychiatrist (0.1 w.t.e) Access to Neurologist & Physiotherapy
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Principles of rehabilitation approach Holistic approach Addresses cognitive, emotional and social
consequences of ABI Hierarchy of stages (engagement,
awareness, mastery, control, acceptance, identity)
Safe environment
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5 activities of OZC
Assessment Rehabilitation Research Education NeuroPage service
+ neurorehab management for CCS
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Assessment and Rehabilitation
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Sources of Referrals
Private: Self-referral, relative, solicitor, insurance company.
NHS: G.P, NHS clinician, Consultant Weekly preliminary assessments Fortnightly detailed assessments 4 intakes per year for full programmes Referrals to Andrew Bateman, Clinical
Service Manager.
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Referral criteria Adults with non-progressive acquired brain injury Medically stable - +/- 18 months post injury Not demonstrating severe disruptive behavioural
disorders or marked physical disability Capable of managing in community B&B or self-
catering accommodation. Require IDT for cognitive, psychological and
social issues restricting their participation in daily life
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Client DemographicsGender
Female27%
Male73%
N=95
Age16-24 19%
25-3442%
35-44 22%
45+ 17%
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Client DemographicsMonths Post Injury
<=1 year15%
1-2 yrs23%
2-3 yrs15%
3-4 yrs12%
4-5 yrs14%
5+ yrs 21%
N=95
CHI77%
CVA8%
Anoxia6%
OHI3%
Other6%
Aetiology
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Living arrangements
Local B&B or Hotel accommodation Self-catering or rental Travel reimbursement for people
receiving benefits Care support Own evening meal
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Stages of Assessment
Preliminary Assessment:• 1 day• 1 clinician and assistant psychologist• Neuropsychological screening assessments &
discussion with client & significant other• Future actions agreed
Detailed Assessment:• 8 days • Formal neuropsychological assessments• Functional discussion & observation • Experience aspects of the programme• Future actions agreed
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Assessment Holistic neuropsychological assessment by experienced
clinical team cognitive functioning, incl. attention, memory &
executive skills perceptual skills speech & language skills, incl. social communication assessment of mood & behaviour independent living skills, incl. vocational aspects social context, incl. family & environmental
considerations
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The role of ‘formulation’ The process of deriving hypotheses concerning the
nature, causes and factors influencing current problems or a client’s current situation.
Considers the multitude of possible influences on an individual’s level of functioning and psychological state
Helps clinician, clinical team and the client to understand the problems.
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The role of ‘formulation’ Range of assessments and treatment
interventions carried out by different professionals.
Opportunity to bring together results of these assessments into a single coherent formulation
Promotes a shared understanding of problems - visual element useful
Aids team working
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Brain pathologyStroke, head injury, etc
Cognitive Impairmente.g. MemoryPerceptionLanguageAttentionExecutive
Affecte.g. DepressionAnxietyAngerConfidenceMotivation
Physicale.g. HemiplegiaSensory lossDysarthriaPain
Functional consequencese.g. WorkADLLeisureDriving
LossInsight
Pre-morbidfactors
e.g. coping style
Family/socialsupport
Evans, Wilson et al 2009
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Brain pathology
Aneurysm
Cognition & communication MemoryProblem solvingDual tasking
AffectDepressio
nWorry &
rumination
PhysicalHeadacheFatigueBody image
Personal beliefsFamily factors
A biopsychosocial model (Evans, 2002)
Loss of roleIdentity: who am I now?
Functional consequencese.g. Avoidance of childrenavoidance of anything that highlights difficulties
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Holistic Neuropsychological rehabilitation aims to: enable the client to gain awareness and understanding of the consequences of his/her brain injury, facilitate acceptance and adjustment to the consequences of brain injuryenable the client to adopt compensatory strategiesTherapeutic encounters are structured around the clients’ goals that will relate to functional daily activities, participation and vocational domains.
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Aims of rehabilitation
Our rehabilitation aims are to: • Improve social participation• Enable engagement in meaningful
activity in the home and community• Improve acceptance and
understanding of the consequences of brain injury
• Promote wellbeing of client and family
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Sel
f-car
e
Institutio
nal
Phy
sica
l
Cultural
Social
Productivity
Leisure
Spirituality
Cognitive Physical
Affective
From Enabling Occupation: An Occupational Therapy Perspective, © CAOT 1997
Environment
Occupation
Person
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Personality assessmentsInterviewsEuropean Injury QuestionnaireBrain Injury Community Rehabilitation Outcomes
Personality assessmentsInterviewsEuropean Injury QuestionnaireBrain Injury Community Rehabilitation Outcomes
Pre-morbid personality and life style
Pre-morbid personality and life style
Nature of brain injury?Severity?Extent?Location?
Nature of brain injury?Severity?Extent?Location?
Neurological investigationsImagingMonitoring over time
Neurological investigationsImagingMonitoring over time
Theories of recoveryCause of brain damage?Studies of changes over time
Theories of recoveryCause of brain damage?Studies of changes over time
How much recovery to expect?
How much recovery to expect?
Current problemsCognitiveEmotionalPsychosocialBehavioural
Current problemsCognitiveEmotionalPsychosocialBehavioural
ReassessmentReassessment
Assess to identify these in detailAssess to identify these in detail
Models of cognitive functioning
LanguageReadingMemoryExecutive FunctioningAttention
Models of cognitive functioning
LanguageReadingMemoryExecutive FunctioningAttention
Emotional and Psychosocial Models
e.g. models from Cognitive Behaviour Therapy
Effect of affect on memory, attention, etc
Emotional and Psychosocial Models
e.g. models from Cognitive Behaviour Therapy
Effect of affect on memory, attention, etc
Behavioural Models
e.g. SORKC
Behavioural Models
e.g. SORKC
Behavioural assessmentsObservations
Self report measuresinterviews
Behavioural assessmentsObservations
Self report measuresinterviews
Natural settings Simulated settings
Questionnaires ChecklistRating scales
Decide on treatment (negotiate goals with patient, family and staff members)Decide on treatment (negotiate goals with patient, family and staff members)
Will you focus onImpairmentsDisabilities orHandicap?
Will you focus onImpairmentsDisabilities orHandicap?
How will you teach/achieve this?(Refer to theories of learning)
How will you teach/achieve this?(Refer to theories of learning)
How will you evaluate success or otherwise?
How will you evaluate success or otherwise?
Will you try to Restore lost function?Encourage anatomical reorganisation?Use residual skills more efficiently?Find an alternative means to the final goal?Modify the environment?Use a combination of the above?
Will you try to Restore lost function?Encourage anatomical reorganisation?Use residual skills more efficiently?Find an alternative means to the final goal?Modify the environment?Use a combination of the above?
What evidence is there for the success of these approaches
What evidence is there for the success of these approaches
Following evaluation may need to revise approach
Following evaluation may need to revise approach
Neuropsychological assessment
PsychometricLocalisationCognitivetheoretical
modelsExclusion
modelsEcologically
validmodels
Neuropsychological assessment
PsychometricLocalisationCognitivetheoretical
modelsExclusion
modelsEcologically
validmodels
Patient and family
Patient and family
From Wilson 2009
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Core Components (our reply to Prigatano core components) Therapeutic milieu Compensatory strategies Involvement of family Psychological therapy Functional & vocational meaningful
activities Shared team understanding
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Stages of the Rehabilitation programme
Full Rehabilitation programme• 24 weeks total• Intensive & integration phases• 1:1 & group sessions
– Cognitive group
– Understanding Brain Injury group
– Mood Management group
– Communication group
– Psychological Support group
– Other groups
• Client-centred goal planning
Reviews 3, 6 & 12 months post-programme
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IPC
Allocated at DA & for Programme/Reviews Main liaison with family and other
professionals/services Oversees programme for participants Weekly contact Co-ordinates reports & referrals
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Goals Starting point at assessment with question
‘What are your goals for rehabilitation?’ Other tools used are the COPM, Rivermead
Life Goals questionnaire and individual interviews.
A team meeting is used to establish ‘SMART’ wording.
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Goal Categories Understanding Brain Injury
E.g. Show an accurate understanding of her difficulties and be able to explain these to 2 relatives and 2 members of the Centre staff
Managing Daily Activities Independently E.g. To be able to prepare a simple evening
meal for the family on a weekly basis with supervision using identified strategies
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Goal Categories Recreational Activities
E.g. Will be engaged in 2 chosen leisure activities on at least a weekly basis (playing pool and wood-work).
Work or Study Plans E.g. Will be engaged in a work trial and have
an identified plan for return to paid employment within 6 months.
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Outcomes
Goal Achievement Standardised Questionnaires
EBIQ DEX CSI EuroQuol
COPM
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Research
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Research Professor Barbara Wilson OBE
Clinical team Development, application & evaluation
of developments in rehabilitation research.
Current research programme Recent presentations & publications Links with MRC
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Feeling hopeless about the future
Feeling lonely
Feeling inferiorFeeling lonely, even when with othersFeeling life is not worth living
Threshold map for depression subscale of EBIQn=226 patients (baseline)
Feeling sad
Feelings of worthlessness
Preferring to be alone
Crying easily
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EBIQ Depression subscale Four items with significant mis-fit therefore
removed leaving robust 5 item scale before and after data person location data
entered into t test n=44 start mean score 9.95; discharge
8.64; t = 3.4; p<0.01
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Impact of rehabilitation on self rated responses to EBIQ item 9,(feeling hopeless about the future)uniform differential item function, n=44; F=4.12, p<0.05
Differential item functioning - before and after rehab.
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F=4.08; p=0.04
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Markers of recognition & success at OZC
Client outcomes and feedback Visiting scholars 2008-9 from Thailand, Granada
and Madrid, Toronto, Sao Paulo Published RCP guidelines for stroke Published peer-reviewed articles Published book Invited papers/conference speeches (?how many) New scholarship/learning to meet objectives eg
anatomy (ongoing) vision (workshop, collaborations ongoing)
New PhD students Lectureship in University Cambridge CLAHRC practitioner researchers
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Courses
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Courses
A series of courses & workshops are run each year
Can offer courses specific to needs in topics related to neuropsychological rehabilitation
Further info. on current courses go to www.ozc.nhs.uk
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NeuroPage
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NeuroPage Currently 40 people using service regularly Useful for people with memory difficulties,
and dysexecutive difficulties Evidence based service recent text to voice development - ideal for
those who can’t read Text messaging developments, new
“generations” of phones (eg video/image messages)