We are keen to regularly profile rehabilitation-related research conducted within NZ. Please contact us if you would like us to profile a published paper, poster or conference presentation email@example.com
This month we can celebrate some excellent outcomes for rehabilitation-related research funding in NZ!
HRC Emerging Researcher Grant:
HRC Feasibility Grant:
Congratulations to all of these funding recipients, and we look forward to hearing more about your projects in due course.
The NZRA is now calling for applications for the NZRA Emerging Rehabilitation Research Leader studentship.
This award is offered on a biennial basis with a focus on growing rehabilitation research capability in New Zealand. It recognises NZRA objectives to provide leadership, advocate for excellence, and promote interest in and support opportunities for research in rehabilitation in New Zealand.
The award makes it possible for an early career researcher to undertake seeding work which helps them to advance their rehabilitation research programme. The $6,000 stipend can be used to appoint a student to work with you to advance your research programme. See more HERE.
The submission deadline is 08 July 2019. Complete the application form and return to firstname.lastname@example.org
Applicants need to be a NZRA financial member by the submission deadline – if you are not a member, you can join HERE ($25 annual fee).
This month, a handful of kiwis attended the 12th World Congress of Physical & Rehabilitation Medicine in Paris. Quelle chance! For me, this was in part about my work with Cochrane Rehabilitation. Prior to the World Congress, I hosted a two-day meeting in Paris with 18 rehabilitation experts from 12 different countries to workshop a series of projects examining methodological issues in the development of a scientific evidence base for rehabilitation. Specifically, we were discussing the challenges associated with systematic reviews and meta-analysis of clinical trials about rehabilitation interventions. This two-day meeting was funded in part by a Catalyst Seeding grant from the Royal Society Te Apārangi. We had a strong contingent from New Zealand attending this workshop including: A/Prof Jean Hay-Smith, A/Prof Will Taylor, A/Prof Nic Kayes, Dr Rachelle Martin, and myself. One outcome from this meeting will be a series of papers for a Special Issue of the European Journal of Physical & Rehabilitation Medicine to be published early next year. Keep an eye out for it. :-)
[A/Prof William Levack, A/Prof Nic Kayes, and Dr Rachelle Martin embrace the spirit of gonzo journalism at the trade display stands in the`12th World Congress of the International Society of Physical and Rehabilitation Medicine]
One thing that is always fascinating at these large international conferences are the trade displays on offer (see our YouTube video above). Increasingly these trade displays feature the very latest products on the market for robotics, virtual reality, computer games, and other technological devices to aid rehabilitation. There appears to be four main arguments that the developers behind these products propose as reasons to purchase their goods. Firstly, they argue that these technological aids help increase the amount of therapy time for patients. (However, they often still require supervision to implement.)
Secondly, it is proposed that 'gamification' of therapy, i.e. making therapy into a computer game, makes rehabilitation more interesting and engaging for patients, so sustains their attention longer. (This is an assumption worth testing: Is interest in these games really easier to sustain over the long term in comparison to standard exercise regimes?)
Thirdly, these technologies often offer increased precision. So, a robotic exoskeleton on a treadmill with overhead sling suspension might be able to alter the amount of weight that a patient takes through their legs by half of one percent, while providing data, to the minutest of degrees, on how much work a patient is actually investing in the activity. (Again it is worth questioning assumptions: Is this level of control over movement actually beneficial for recovery in the long run, or is it simply important to just be doing something of anything to make gains in rehabilitation.)
Fourthly, some of these technologies are designed to aid movement when patients are too impaired to even initiate any muscle activity - the example of the robotic exoskeleton and sling suspension once again. While "more" is almost always better in rehabilitation, we are yet to see really compelling evidence to indicate the patients using these fancy technologies actually achieve better health outcome in comparison to good ol' fashioned therapy with trained rehabilitation providers. For instance, the Cochrane reviews on both a) treadmill training with body weight support and b) virtual reality based therapy for people with stroke are equivocal in their findings. Treadmill training does not seem any better outcomes overall in comparison to tradition physical rehabilitation after stroke when it comes to regaining the ability to walk independently. Although treadmill training may result in improvements walking speed and walking endurance after stroke (for people are already able to walk a bit), these benefits are really quite small, and not sustained in the long term. Therapy based on virtual reality interventions are also not more beneficial that conventional therapy if offered in the same amount and intensity. If virtual reality activities are used to provide MORE therapy for individual patients (i.e. on top of conventional therapy) - surprise, surprise - this results in better health outcomes. The same however could be reasonably expected of MORE conventional therapy on top of conventional therapy. As noted above, in the case of rehabilitation, more is often better.
Nevertheless, there are some really interesting and innovative ideas being proposed by technology for rehabilitation. Anything that extends therapy opportunities is surely good. The question to ask is what extra benefit is being gain from the money being spent and are their other things, (more therapist hours? community gym membership? peer mentoring?) that might be equally worth spending money on.
William Levack is an Associate Professor of Rehabilitation at the Rehabilitation Teaching & Research Unit, University of Otago, Wellington, New Zealand. Twitter: @DrLevack
Today, I responded to an article in Stuff that was critical of the concept of cultural consultation in research. The article, which you can read here, stated that the Treaty of Waitangi has 'no place in scientific endeavour'. The article was also critical of the University of Otago's requirement for all researchers to incorporate consultation with Ngāi Tahu when planning and implementing research activities. (In fact, researchers at the University of Otago will also consult with local iwi in any region where they conduct research, not just Ngāi Tahu). The author, Bob Brockie, stated that: "I am astonished that a Māori iwi has the audacity to impose these heavy-arm rules on scientists, and more astonished that Otago University has acquiesced in these proscriptive, inquisitorial demands. The only researchers to speak out about these issues seem to be retirees. Young researchers dare not question these moves for fear of being labelled racist and putting their careers at stake."
It's not fear, Bob; it's education. So, in response to this article, I wrote a four-line comment, in Stuff, as follows: "Science is knowledge. Knowledge is power. Power is political. If you think science is not political you are naive. OR you are in power and it suits you to maintain this myth. Retired researchers who complain about positive social change lack education in contemporary perspectives on colonialism. Younger researchers don't want to perpetuate the oppression and arrogance of the older generation."
There were a number of misinformed and misleading responses to this article in general, but in response to my comment, I received the following from Richard Treadgold: "Your comments raise more questions than they answer. What has changed about scientific principles that requires input from Maoris? What scientific heritage justifies an invitation to Maoris to join the discussion? Why are Maoris invited above the Dutch, Korean, Chinese, Irish or any other of our national groups? Why do you call this racist invitation to Maoris based solely on their claimed race as "positive social change" and how can it improve science? Why are younger researchers concerned with the older generation (their elders) more than with the science they study? Why are scientific qualifications insufficient to judge the worthiness of research projects?"
It is impossible to answer all these questions, even superficially, in the 200 word limit of a Stuff.co.nz comments box. And so, here is my 1000+ word response, which I will send a link to via Stuff:
What has changed about scientific principles that requires input from Māori?
Nothing has changed about the physical laws that govern the universe. Of course! But science doesn’t occur in a social vacuum. Nothing is stopping you from building your own fusion engine in your basement, using your own money. But if you are using society’s money to undertake this research (as Universities do) then it is reasonable for that society to set some processes and policies about how that money is spent. Our last National government for instance introduced the ‘National Science Challenges’ and tied this to research funding, which is an example of an explicit political effort to change the direction of research in the country from ‘researcher-led’ to ‘mission-led’ research. Governments have always influenced the direction of research by saying what they choose or do not choose to fund: HRC and MBIE both do this. This is not new.
Here, in New Zealand, we have this founding document called the Treaty of Waitangi, which establishes a partnership between two groups of peoples: the indigenous population and a colonial group. The Treaty of Waitangi remains an important legal, social and political contract, despite there being extended periods of history when the colonial group (incidentally, my ancestors – albeit very indirectly) did not honour it. It is outside the scope of this blog to provide an in-depth discussion of the Treaty or its implications. Suffice to say that when dishing out research funding it is reasonable to have robust process to consider the conduct of that research from the perspective of the Treaty: partnership, participation, and protection. This consultation is not about how to do your statistical calculations, how to run to your DNA sequencer, or how to analyse your histology slides. Instead, this consultation is about asking who benefits from the research, how it will be used, by who, and to what end effect. This is the bit of science that has changed – not the nuts and bolt of ‘doing science’, but the social accountability of the actions and activities of scientists.
What scientific heritage justifies an invitation to Māori to join the discussion?
This question implies that you, Richard Treadgold, believe that you have gained your ‘right’ to engage in science on the basis of what science your ancestors conducted – and perhaps not your direct ancestors even, but people with similar skin colour to you, who were very, very vaguely related to some of your ancestors. This is sounding a teeeeeny bit racist. What social heritage justifies an invitation to Māori to join discussion of the use and application of science in New Zealand? Easy. The Treaty of Waitangi, which established the governance of New Zealand as a partnership between two peoples: see above.
Why are Māori invited above the Dutch, Korean, Chinese, Irish or any other of our national groups?
One: The Treaty of Waitangi. See above. Two: In my area of research, which is in the health sciences, Māori have MUCH worse health outcome than non-Māori. Lower life expectancy. Higher hospitalisation rates. Higher levels of morbidity for pretty much any major health condition. Healthcare is about so much more than popping pills and doing surgery: it is about health systems, health literacy, community engagement, interpersonal relationships and so on. It is perfectly reasonable for Māori to expect to be involved in discussions about health science research intended to improve Māori lives.
Why do you call this racist invitation to Māori based solely on their claimed race as ‘positive social change’?
One: It’s not racist, it’s moral thing to do. Two: In my area of research at least (health care), it produces better research, with more meaningful, translatable results for a group who is less well served, in terms of health outcomes, by New Zealand society. Three: It’s a positive social change because it is about confronting and addressing 170+ years of injustice. I look at race issues in the US and see a dominant colonial group who are too afraid, too arrogant, or perhaps too naïve to openly acknowledge and address the consequences of slavery in their nation. I strongly suspect this has significantly contributed to the failure in the US to address race-based conflict. They suffer as a nation as a result. The situation for the indigenous population in the US is even worse! I am proud of the Treaty we (non-Māori New Zealanders) have with our indigenous population in New Zealand, and when I look to countries like Australia and the US, I am proud of the efforts (however incomplete) being made to confront and rectify problems with it. New Zealander benefits enormously from Māori people and Māori culture. Let's not shit on them.
How can it improve science?
In my area of science – health science – consultation with Māori can and has helped people live longer, healthier lives. It helps by ensuring that interventions designed by non-Māori people can be implemented in the real world of Māori communities. It helps by ensuring that research findings relevant to Māori lives are disseminated to Māori communities. It helps by empowering Māori to lead their own research. It helps through the development of new methodologies to conduct better, more impactful research. How much more ‘improvement’ do you want??
Why are younger researchers concerned with the older generation (their elders) more than with the science they study?
Younger researchers are not concerned with the older generation more than with the science they study. This question can’t be answered because it contains false assumptions, so doesn’t make any sense to begin with.
Why are scientific qualification insufficient to judge the worthiness of research projects?
The ‘worth’ of a research project can be judged on the basis of: a) the quality of the science, b) its ethical implications, c) the potential cost-benefit of its possible outcomes, d) the meaningfulness of the research question being asked. Ethics committees and research funders consider all these things when judging the 'worth' of a research proposal. It is a REALLY bad idea to judge the worth of a research project just on the basis of whether or not the scientist has a qualification. Do I really need to give example of where this went horrendously wrong in history?
In summary, the practice of science changes over time because society changes. Science should not be above the laws and mores of a society. New Zealand society is structured, in part, around the Treaty of Waitangi. This Treaty established a formal agreement between two groups of people to work in partnership, and to protect the indigenous population, and agreements ought to be honoured. Besides, even if we did not have a Treaty, New Zealand (and New Zealand research) is enriched, not diminished, by engagement with our indigenous communities.
Goal setting in rehabilitation is a topic that I have written a lot about of the past ten plus years – both in term of research publications and textbooks. It’s a topic that has a lot of currency with health professionals, and is something that I’m frequently asked to talk about at conferences and workshops. (In fact, I developed a distance-taught postgraduate paper for people wanting to develop their knowledge and skills in this area of clinical practice.)
One aspect of goal setting that I’m often asked to comment on is the use of goal attainment scaling (GAS) as an outcome measure in rehabilitation. In fact, I have a number reservations about goal attainment in general as an outcome measure. My opinion is that goal setting is an extremely important part of the rehabilitation process, but is probably more important for communication of expectations, shared decision making, and motivation of patients and health professionals than it is for demonstrating the effectiveness of rehabilitation services. We have other tools for evaluating health outcomes – namely psychometricallyvalid, standardised outcome measures.
So, recently when I was asked to contribute a chapter on goal setting for the 4th edition of Physical Management for Neurological Conditions (due to be published in 2018), I took the opportunity to explore the topic of using goal achievement as an outcome measure in more detail. Below is a video that I put together to summarise the key points that I raise on this topic in the book chapter. For a more detailed discussion of these issues and for my other latest content on goal setting in neurorehabilitation, I encourage you to get hold of a copy of this textbook when it come out later next year.
(Footnote: The sound in this video is a little sketchy because I filmed it in my home, in a room with a lot of echo, and on an old family camera. There's only so much fixing of sound and image quality one can do after filming it turns out. I'm still learning how to be a rehab YouTuber!)
Earlier this year I attended the 11th World Congress of the International Society of Physical & Rehabilitation Medicine (ISPRM), held in Buenos Aires, Argentina. My primary reason for attending this conference was to contribute to a symposium on the work of Cochrane Rehabilitation and the inaugural meeting of its Advisory Board. I will be reporting back on my work with Cochrane Rehabilitation at our upcoming New Zealand Rehabilitation Conference, in Christchurch next month. However attending international conferences like this one provides an amazing opportunity to find out about some of the cutting-edge research and technological developments in rehabilitation going on around the world.
One of the most fascinating presentations at this ISPRM conference was by Professor Michael Boninger, Medical Director of Human Engineering Research at the University of Pittsburgh. Professor Boninger presented his team’s very latest research into brain-computer interfaces. His research unit has been working extensively over many years to develop brain implants that allow people with complete high-level spinal cord injury to operate robotic arms with their thoughts alone. These implants are neuro-surgically attached to a person’s cerebral cortex and connect to a computer via a large plug on the top of the person’s head. Five years ago, the University of Pittsburgh released a video of a woman with tetraplegia using this technology to feed herself chocolate. Currently, Dr Boninger’s team is able to give a person in excess of 12 degrees of movement with a robot arm using this approach.
Most astounding, they have now added sensory feedback to this brain-computer interface, meaning that not only can a person with tetraplegia control a robotic arm to perform functional tasks – they also can receive the sensation of movement in their brain when the arm is moved in particular ways. In the video below, a man with tetraplegia uses this neuro-prosthetic to detect, while blind folded and with 100% accuracy, which finger of a robotic arm is being moved by the researcher.
Of course, this type of technology is extraordinarily expensive. This is million dollar technology that requires a team of people to re-calibrate it every day - so it is only ever offered to one or two people at a time. In other words, this is research for the sake of knowledge creation – not research that is going to available to all people with tetraplegia any time soon. Indeed, one thing I appreciated about Professor Boninger’s presentation was that fact he went out of his way to address this limitation in his talk, and to highlight other research he is involved in, which is more immediately important to people with spinal cord injury – but which draws smaller crowds at conferences. One example of this other work was research into training strategies to help people with spinal cord injury learn to use wheelchairs for the first time. Professor Boninger promoted an organisation that had focused on this other type of work – the International Society of Wheelchair Professionals. Practical, low cost solutions for everyday challenges are going do a lot more for improving the quality of life of people with spinal cord injury worldwide than the fancy-pants, Star Trek-level technological ones.
Nonetheless – using a million dollar brain implant plus robotic arm to feed yourself chocolate is still pretty cool.
I read today about Dr Lance O'Sullivan's proactive steps to interrupt a screening of anti-vaccine documentary Vaxxed in Kaitaia this week in order to tell organisers that they are contributing to the deaths of children. Dr O'Sullivan (2014 New Zealander of the Year) has invested considerable time, effort, and creativity into addressing health disparities in the rural north. The video of his plea for reason around vaccination is well worth watching. While vaccination is not directly related to rehabilitation (other than in terms of preventing long term chronic health conditions and disability), I want to highlight Dr O'Sullivan's actions, which I fully support. This is a terribly important issue for New Zealand, as it is around the world. To be clear: vaccines prevent deaths and do not cause autism. Vaxxed is a dangerous, misleading, and potentially harmful movie.
To take just one vaccine: Prior 1980, BEFORE a vaccine for measles was first introduced, measles was killing an estimated 2.6 million people every year - mostly babies and small children. Today, worldwide, measles results in 130,000 deaths each year. According to the World Health Organization:"During 2000-2015, measles vaccination prevented an estimated 20.3 million deaths." However, due to some misinformed (and maybe unscrupulous) individuals, there has been a rise in the incorrect belief that measles wasn't all that bad, that vaccines are not needed, and that vaccines do more harm than good. All these beliefs are incorrect.
Movies like Vaxxed, and advocates for them, do incredible amounts of harm. One example of this has been the recent, and highly predictable, outbreak of measles among Somali immigrants in Minnesota - the biggest outbreak in the USA in decades. This group of immigrants was specifically targeted by anti-vaccination proponents, who directly contributed to a plunge in vaccinations rates in this population from 92% in 2004 to 42% in 2015. As of this month, at least 50 individuals had been affected in this latest outbreak, many of whom were hospitalised. It is not inconceivable, if we were to let our guard down, that this kind of outbreak could happen in New Zealand. The people who would suffer most would be the most vulnerable - children and babies; people with poorest access to healthcare services.
As such, Dr O'Sullivan is absolutely correct to take such strong action against the spread of misinformation about vaccines. We should all do more to follow his lead in fighting for a health-literate public and for evidenced-based healthcare services in our country.
On 6 February this year, the World Health Organization (WHO) launched a new initiative: Rehabilitation 2030 – A Call for Action. This initiative begins with a recognition of the "substantial and ever-increasing unmet need for rehabilitation worldwide". While the WHO has highlighted the particularly pressing need for development of rehabilitation services in low and middle income countries, this call for action is intended for all countries. Even within relatively well-resourced countries, such as New Zealand, access to rehabilitation is often insufficient or restricted by cost. Thus the emphasis of WHO is on accessible and affordable rehabilitation for all people worldwide. This call for action links closely with other WHO objectives around a global strategy for managing our aging populations, the WHO's Mental Health Action Plan, and the push for Integrated People-centered Health Services. The WHO website includes a number of associated resources, including background papers on the need to scale up rehabilitation, the cost of failing to provide rehabilitation, and examples of efforts to implement the WHO recommendations for rehabilitation in Germany, Pakistan, and Philippines.
The WHO writes that “barriers to scaling up rehabilitation indicate a need for greater awareness and advocacy, increased investment into rehabilitation workforce and infrastructure, and improved leadership and governance structures”. They highlight that addressing these barriers to necessary rehabilitation services will required investment of people, finances, and technical tools. They also highlight the need for the political will to make such investments. In New Zealand, actions related to the Rehabilitation 2030 initiative could usefully include:
So, I encourage you to raise awareness of the Rehabilitation 2030 initiative in your local regions. Get active, get political, and get involved.
More information on the World Health Organization's guidelines on rehabilitation in health systems is available in this video below:
I first wrote a column about the Stay Up Late campaign for the NZRA back in 2007 (when our newsletter was just a word doc sent out by email). Recently I've been writing a review of the literature on working aged adults with neurological impairments who end up in geriatric residential facilities for one reason or another, and the challenges that emerge from this around creating individualised, flexible, person-centred care for people who need 24 hour support. All this made me think of the Stay Up Late movement once again. In a nutshell, Stay Up Late is a grassroots UK charity originally initiated by Heavy Load – a UK punk band consisting of musicians with intellectual disability or mental health issues and their support staff. The movement boils down to putting a halt to people with support care needs having to leave clubs and music gigs early because their staff finish their shifts at 10pm.
I have to say, I love everything about this movement. I love the punk aesthetics. I love the music. I love the challenging of the status quo; the drive to have fun and maybe be a little bit badly behaved sometimes. I love the enthusiasm and momentum of the people behind it all. Since I last looked at this group in 2007, they have just grown in strength and numbers. The website is intensely active, there is such clear pride in the work, and the charity has pushed into other areas of independent living that need a bit of cage rattling. This is what we need more of in rehabilitation and disability sector.
Check out the website, or if you just want to enjoy the wall of sound that is Heavy Load, checkout the video from back in 2007 below. Rock on, dudes.
Coming up with a definition of rehabilitation that everyone agrees on is super difficult! A good definition should clearly and comprehensively describe what is and what is not within scope of rehabilitation. Does rehabilitation include the management of cerebral pressure in the acute stages of management of traumatic brain injury? Is ice for an ankle sprain rehabilitation? Is cognitive behaviour therapy a form of rehabilitation in all or just some contexts, or it is never actually rehabilitation? Does rehabilitation extend beyond the formal health services to include things like getting back to one's bridge club meetings, going to the beach or pub for the first (or tenth?) time after spinal cord injury, or starting up with wheelchair rugby? At what point is 'rehabilitation' just people getting on with their lives again?
Some might say that rehabilitation is defined by the process involved. If it is goal directed, does that make it rehabilitation? (Football is goal directed: Is that rehabilitation?) Does rehabilitation require the involvement of formally trained health professionals? It is rehabilitation because it is provided by a rehabilitation service (a tautological definition)?
In the business case to establish Cochrane Rehabilitation, we referred to the World Health Organization's (WHO) current definition of rehabilitation which is: ‘a process aimed at enabling [people with disabilities] to reach and maintain their optimal physical, sensory, intellectual, psychological and social functional levels. Rehabilitation provides disabled people with the tools they need to attain independence and self-determination’. In 2001, WHO also included the view that: ‘The rehabilitation process does not, however, involve initial medical care’ (p.290). I suspect some people disagree with this extra criteria to define rehabilitation however, which might exclude initial management of spasticity after brain or spinal cord injury for instance. It also raises the question about when 'initial medical care' ends. Nonetheless, this is the definition my colleagues and I used in our review of goal setting in rehabilitation (Levack, 2015) to help make decisions about papers that were and were not ‘in scope’ for the review. Of note, we used this definition to include papers from the mental health sector as well.
One additional thought I have on this topic however is that I’m increasingly questioning the idea that the primary focus of rehabilitation should be on maximizing independence. For people with complex disabilities, I’m wondering whether rehabilitation should be more about maximizing people’s opportunities to fulfill their personal preferences, which may or may not include maximizing independence. It may also include maximizing interdependence. It could also include making decisions to pass control of some aspects of one’s life over to other people.
This is not actually an incredibly radical idea. Being someone with very little hair, I am 'independent' in getting my two weekly haircut. (I just shave my own head.) Others however choose to get help with their hair. They pass control of their hairstyle over to trained professionals. When the hairdresser says 'what would you like me do for you today', the individual in question could in fact say 'I don't know. You decide. Surprise me.' Interestingly, this is not considered 'being dependent on others' (considered a poor outcome in rehabilitation), but rather this is considered to be people exercising their right to choose.
From this perspective, rehabilitation for people with complex conditions should be primarily about reinvention of oneself rather than primarily about regaining independence. Restoration of one's prior skills and abilities is still part of this perspective on rehabilitation, but simply not the sole focus. This position in fact aligns nicely with Amartya Sen and Martha Nussbaum 'capabilities theory', which focuses on 'the moral significance of individuals' capability to achieve the kind of lives they have reason to value'. It also fits nicely with a focus on strength of positive self-identity as primary outcome from rehabilitation rather than using measures of functional independence as the main way to judge the 'success' or otherwise of rehabilitation programmes.
In 1624, John Dunne wrote: "No man is an island/Entire of itself/Every man is a piece of the continent/A part of the main." In doing so, Dunne reminds us that none of us are independent; none are separate from the thoughts and actions of others. Maybe it is time to re-define rehabilitation to incorporate a more holistic, interdependent view of functional lives.
Levack, W. M. M., Siegert, R. J., Dean, S. G., McPherson, K., Hay-Smith, E. J. C., & Weatherall, M. (2015). Goal setting and activities to enhance goal pursuit for adults with acquired disabilities participating in rehabilitation. Cochrane Database of Systematic Reviews, Issue 7, Art. CD009727.
World Health Organization. (2001) The UN Standard Rules on the Equalization of Opportunities for Persons with Disabilities. II. Main Report. Geneva: World Health Organization.
© 2015 New Zealand Rehabilitation Association, Inc.