Rehabilitation in Multiple Sclerosis

Update asked Dr. Seymour, Consultant in Rehabilitation Medicine at Woodend Hospital, to let us know about her work. Over the last 10 years specialist rehabilitation services in Grampian have
expanded and there are now a number of gateways to Department of Rehabilatation Medicine.
We felt her article was so informative that we have printed it on a separate insert for you to keep.

I would like to thank you for the opportunity to write about rehabilitation possibilities for people with multiple sclerosis living in Grampian. Can I start with a quote about the way neuro-rehabilitation was done two thousand years ago? Although it relates mainly to stroke, it remains an inspiration to all of us working on behalf of individuals with neurological impairments.

‘Advice was given on general management, on nursing techniques (including the use of catheters), and on physical treatment and the use of machines. After massage with aromatic vegetable oils, or with ointments composed of medicaments with real or imagined virtues, the limbs were warmed and exercised, perhaps in the waters of a hot spring, or by rolling on sun-warmed sand wrapped in a calf-skin rug. Paralysed fingers were softened in wax for manipulation, and weights, drawn over pulleys, were used to extend contractures and to exercise relaxed limbs, the patient being encouraged to join in the effort himself. Practice in rising from a chair, in standing, and in walking was part of systematic instruction, making use of a forerunner of the modern walking chair. Other walking aids described were wooden hurdles to step over and ditches providing variable inclines. Weights were added a few ounces at a time to the patient’s shoes, and the walking pace was increased gradually. Bathing in warm springs or in the sea was assisted by inflated bladders attached to the paralysed limbs to reduce the effort of swimming’. SORANUS OF EPHESUS (AD 90 – 138) ‘From: Cerebrovascular Disability and the Ageing Brain: G.F.Adams’

I love this quote because it speaks of the contribution of neuro-rehabilitation across two millennia. The importance of targeted rehabilitation for different problems is recognised together with a hint of ancient Greek hedonism as their clients lay wrapped in skins on warm sand by blue sea. The dark ages for rehabilitation followed with charms and spells, bleeding and leeches. It is only in the 20th century that a true renaissance for neuro-rehabilitation began. In the ten years that I have been in post, there have been huge changes in the interventions that we offer and the way we deliver services.

GUIDELINES

Members of the MS Society and readers of Update will be well aware of the publication of the recent NICE guideline in England and Wales (copies ordered via tel: 0870 1555 455 and on line information via www.nice.org.uk). ‘Multiple Sclerosis: Management of Multiple Sclerosis in Primary and Secondary Care’ provides important guidance for all health care staff about best clinical practice for people with the condition. For those of us in Rehabilitation, two key priorities set out by NICE are firstly that everyone with MS should have access to specialist rehabilitation services (especially when anything new occurs) and secondly that there should be thorough problem assessment provided in a systematic way. There are many other guidelines that provide us with further advice on how to do the best we can for patients, including publications produced by your own society, by the British Society of Rehabilitation Medicine and by the Royal College of Physicians in Scotland. The Specialist Rehabilitation Services in Grampian have devoted time to training and development to ensure that we have the range skills required of a modern service. Anyone with MS whose symptoms are causing difficulties is a potential client and there should be no delay in seeking help. The Scottish Office of Public Health’s Needs Assessment Programme published four years ago predicts that there are 1066 people with MS in Grampian and 789 of these individuals are likely to have moderate or severe impairment from their MS.

SPECIALIST REHABILITATION SERVICES

  • MARS (Mobility and Rehabilitation Service)

MARS provides wheelchair and seating services including specialist seating and specialised splints (orthoses). We have acquired techniques of using custom-made, plastic splints to enable selected patients to stand and take steps for certain types of mobility difficulties. Neuro-orthotics is a highly specialised area and requires close collaboration between neuro-physiotherapists and technicians. Referral to MARS is through general practices. One of our consultants (Dr Alastair Cozens) has a special interest and expertise in management of posture, spasticity and walking difficulties.

  • Environmental Controls

For individuals who have difficulties using their hands to guide wheelchairs or to use equipment there are technologies available under the generic heading of ‘Environmental Controls’. These can be supplied to someone’s home to enable them to do a range of tasks from using a computer to operating various aspects of their house (the door, television, telephone etc). New SMART technologies that are coming along will be feeding into this area of expertise and one of the consultants specialises in this area (Dr Helen Gooday).

  • Inpatient Provision

Many people with MS will remember Maidencraig from a different era when it provided mainly residential and respite facilities. All admissions to Maidencraig are now for specialist rehabilitation and most inpatient stays for people with MS are for about two to three weeks. A highly specialised multidisciplinary team addresses any issues highlighted such as spasticity, pain, problems with bowel and bladder, difficulties with mood and/or memory, problems with swallowing etc. The exercise is collaborative with patients and their families. The aim is to identify a range of treatment options to improve quality of life. Some of the treatments may involve therapy, others may involve medication or seeing other services either within Grampian or elsewhere in Scotland.

  • Rehabilitation Outpatients

Any GP can refer someone with multiple sclerosis and rehabilitation needs to the weekly General Rehabilitation Outpatient Clinic at Woodend Hospital. Dr Ruth Seymour is the rehabilitation consultant with a specific interest in MS. There is a move to set up an occasional clinic in Elgin and a joint, multidisciplinary clinic with neurology at the Horizons facility. Referral to the Outpatient Clinic is via the GP.

  • Horizons

This unique outpatient facility opposite Woodend Hospital provides skilled multidisciplinary assessment and therapy for neurological impairments and disabilities together with its social work partners. There is social work provision for clients from Aberdeen City. GPs are welcome to refer directly to this setting. The NHS team within Horizons is a therapy one and there is no rehabilitation doctor on site. If GPs wish a consultant opinion then a separate referral can be made to the Outpatient Clinic

  • Community Rehabilitation Nurse Team

Two senior nurses provide a Grampian-wide service for patients with nursing needs in collaboration with district nurses. Direct referral is possible through healthcare staff and the CRN office is in the Horizons facility.

  • Consultations

The Department of Rehabilitation Medicine can provide an outreach consultation service both in hospitals and in the community for individuals who hare particular difficulties because of their MS and cannot travel to an Outpatient Clinic. Referral is via a GP or a Consultant.

RESOURCE AND MANAGED CLINICAL NETWORKS

One of the current themes within the NHS is the development of Managed Clinical Networks (MCN’s). This involves identification and linking of key services so patients journey through health systems in a more stream-lined way and are not ‘forgotten’. Services dealing with cancer and stroke patients are already advancing along this route. Those with multiple sclerosis have a strong case for inclusion in an MCN. Recent moves to establish an MS register will help with a more detailed understanding of needs across Grampian region and will also provide opportunities for rehabilitation research and disease-modification trials.

A Managed Clinical Network for MS may present all of us with an opportunity to work together in new ways to build relevant, geographically equitable services and to do some thinking about how to match need with the very limited man- and woman-power resource we have to offer at present. It would be good if this process could be innovative and positive, perhaps with a hint of the pleasurability that was evident on the shores of the Aegian Sea two thousand years ago. I look forward to meeting with people with MS and members of the MS Society over the next few months and I am keen to hear about ideas that you may have for improving rehabilitation services.

I wish you all a Happy Christmas.

Dr R M Seymour
Consultant in Rehabilitation Medicine
Woodend Hospital