Towards integrative neurorehabilitation science - Professor Gert Kwakkel

[gcoe]

This article has just come out as the editorial in Physiotherapy Research International. There is a lot to it and includes several challenges to us all in applying research to practice and how our practice may change for the better.

Have a good read of it then contribute to a discussion. No need to contribute to all the points as there is so much to say. But choose one or two points that you may feel strongly about or that the article has stimulated think more about. I have listed some of the main points and the issues involved:


1. The Significance of Evidence-Based Medicine (EBM) in Neurorehabilitation

EBM involves the explicit, judicious and conscientious use of the best available evidence from published scientific research, which is necessary for the diagnosis and treatment of patients.

Issues:

In current practice do we do this? In some areas there is so much evidence coming available that is almost impossible to keep up-to-date. In other areas there is so little. In ten years time half of what we know will be shown to be unhelpful. The trouble is that we don’t know which half So in neurological therapy how do we best do this?

If we aren’t using EBM to inform practice, then why not?


2. The Need for Knowledge about Functional Prognosis

Issues:

Are you appraising and using prognostic evidence that is available?
Do you know how to? Do you believe it can help your patients and your decision making?

What is your experience with using this information?


3. The Role of Clinimetrics in Neurorehabilitation

Basically this is about outcome measurement, it's role and how we should be measuring.

Issues:

Do you use the ICF. In your patient assessment?

How do you apply it?

What do you think of it?

4. What Do Patients Learn?


“If we want to know the direction in which this mountain of evidence is currently shifting, we will first have to find the answer to the question: What do patients actually learn during functional improvement? As long as we lack the necessary insights into this question, we will not be able to understand the mechanisms underlying the learning process. It is precisely this understanding that could allow us to improve existing therapeutic options and develop new and more effective therapies.”

"We can only gain an understanding of what exactly patients learn by investigating whether therapy-induced and other improvements in skills such as walking, extending an arm and grasping objects are the result of recovery or restitution of the neurological functions themselves, or the result of patients learning to cope with the loss of function, sometimes referred to as substitution or compensation (Kwakkel et al., 2004). It goes without saying that the balance between these two processes is entirely determined by the nature and stage of the patient's disease..."

"...An understanding of the balance between restitution of body functions and compensatory behaviour is important for designing therapies...."

Issues:

Have we really got this balance right yet?

Do our preconceptions about what patients gain when their function improves get in the way of advancing our knowledge of how best to help our patients?

5. Is Abnormal Movement Abnormal?

Issues

Here Prof Kwakkel is really challenging some of our basic notions of the basis of what we strive to achieve in neurological physiotherapy, and whether the notion of normal movement is realistic and achievable, is actually best for our patients. Have a good read of this section and give your comments

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[gcoe]

OK folks

A number of you have looked at this post but no one has yet posted a response. So how about responding to this first point:

1. The Significance of Evidence-Based Medicine (EBM) in Neurorehabilitation

EBM involves the explicit, judicious and conscientious use of the best available evidence from published scientific research, which is necessary for the diagnosis and treatment of patients.

Issues:

In current practice do we do this? In some areas there is so much evidence coming available that is almost impossible to keep up-to-date. In other areas there is so little. In ten years time half of what we know will be shown to be unhelpful. The trouble is that we don’t know which half So in neurological therapy how do we best do this?

If we aren’t using EBM to inform practice, then why not?

It seems to me as a community we are divided into two camps: those that do and those that don't use EBM to inform practice. Of course it is not as simple as that. Well here is my thought:

However limited EBM is it is the only tool we have for ensuring our patients get the best management available. And it is only through applying EBM to practice that we are going to truly develop as a profession. Otherwise we are locked into endless cycles of discovering a new treatment and applying it without understanding the consequences, rehashing old treatments and treating them as if they are new and being limited to current fashions and fads or believing something does or doesn't work based on anecdote.