Are private physiotherapy clinics only useful for MSK problems?


Neurological Physiotherapy

You have navigated yourself to this portion of the Wiki by recognising an interest you have in Neurological physiotherapy within the private setting. This section is designed to give an introduction into neurological physiotherapy, highlight the prevalence of neurological conditions within the UK, briefly discuss neurological physiotherapy services offered by the NHS with emphasis placed on two common conditions, stroke and Parkinson's disease, and conclude by outlining the benefits of private neurological physiotherapy. This will hopefully trigger questions for thought and reflection on whether neurological physiotherapy in the NHS or private practice is suitable for the career pathway you have in mind.

Firstly, we will aim to answer the basic question of "What is Neurological physiotherapy?"

Neurological Physiotherapy is a specialist area of physiotherapy focused on the treatment of individuals with neurological conditions. Neurological disorders affect the functioning of the brain, spinal cord, and nerves. Stroke, multiple sclerosis, spinal cord injury and Parkinson’s disease are common neurological conditions [1]. It also includes conditions of the peripheral nervous system such as Guillain Barre Syndrome. Neurological conditions can have a devastating impact on the lives of the sufferers, along with family and friends. Disturbances in the travelling of messages between the brain and the body can result in the loss of movement, sensation, co-ordination, and balance. Other aspects of bodily function, such as perception, speech, memory, cognition, and behaviour may also be effected. Therefore, it is important that neurological physiotherapists work in close partnership with other members of the multidisciplinary team including speech and language therapists, occupational therapist, dieticians, nurses, and doctors. Effective communication between patient, family members, and the multidisciplinary team is critical to positive healthcare outcomes following a neurological disorder [2].

The role of a Neurological Physiotherapist

Neurological physiotherapists are expeirenced and trained to treat neurological conditions with the aim to provide interventions which assist an individual to regain or maintain their maximum movement and functional independence. This is achieved by aiding in the development of new pathways through repetition and exercise.


Treatment interventions

A number of treatment approaches are used, often incorporating a selection of the following as appropriate [2]

  • Stretching
  • Strengthening
  • Balance re-education
  • Gait re-education
  • Joint mobilization
  • Electrical stimulation
  • Postural exercise
  • Spasticity management
  • Advice/Education on lifestyle, fatigue management, and exercise                             
Stop 2.jpg

                                           Time to reflect.jpg                                  .


Reflection Questions:

1. Does the role of a neurological physiotherapist still interest me?

2. Do I want to further investigate if working in the private sector would interest me?

If you have answered "yes" to the above questions, continue reading below. If not return to the career pathway in the introduction section and select another specialty that may be of interest.


Prevalence of Neurological Conditions

The Neurological Alliance [3] reported the total number of neurological cases in England to be 12.5 million or 59,000 cases per CCG in 2013-14, with a further 1 million cases in Scotland reported in the NHS QIS Clinical Standards on Neurological Health Services [4]

Neurological Conditions cases.


This table[5]represents the most common neurological conditions in England.






The image[3] below illustrates the number of neurological conditions and the distribution of cases between progressive, intermittent, stable with changing needs, and sudden onset.


Colourful splats.jpg

Within NHS Lothian, it is estimated 53,480 people are living with a neurological condition. The number of people disabled by the condition is 5,348 and an estimated 1,872 people will need assistance carrying out activities of daily living. Each year, a further 8,489 people in Lothian will be diagnosed with a neurological condition [6]. The illustration below represents the number of people affected by neurological conditions in Lothian [6].

NHS lothian.jpg

Public perceptions of Neurological Conditions

A study conducted by Sue Ryder revealed that 45% of the UK population feared being impacted by a neurological condition the most which is compared to 36% who feared getting cancer. The study highlighted the beliefs of the public with regards to neurological conditions, showing that 26% of the public felt that “nothing much can be done” for people with neurological conditions [7]. It is understandable why the general public fear being effected by a neurological condition when one takes into consideration patients poor experience with neurological healthcare. The Neurological Alliance conducted a neurological patient experience survey in 2014 [5].  

Neurological patient experience survey profile.jpg


Neurological conditions in the survey.jpg
Figure 1 illustrates the population responding to this survey


Figure 2 indicates the neurological conditions represented in the survey.



The survey stated that 58.1% (n=3402) of NHS England respondents (n=6916) have experienced difficulty accessing the service/treatment they require, 39.8% (n= 2357) of respondents had a 12-month waiting period from the time of observation of the first symptom to seeing a neurologist specialist, 31.5% of respondents (n=2140) had 5 or more GP visits related to the health problems experienced due to their condition prior to being referred to a neurological specialist, and 71.5% (n=4603) of respondents were not provided with a care plan to help manage their condition [5]

Waiting times for NHS Neurological Services


The 2005 National Service Framework for Long-term Conditions [8] identified the need for prioritising an accurate and rapid diagnosis of neurological conditions, highlighting the importance of early diagnosis within this clinical population to reduce neurological damage, delay disease progression, elevate survival numbers, and enhance patient’s quality of life. However, it appears in 2014 that this call to action had not been achieved with 3,402 respondents to the neurological patient experience survey [5] voicing concerns regarding challenges experienced trying to access the treatment and services they needed.

Quote 1.png




Respondents opinions emphasized the concern of long waiting times especially transitioning from general practice to specialist care settings.

In December 2011, a survey of NHS Physiotherapy waiting times[9] in the UK was published, showing that in neurology departments, the longest wait reported was 2-4 weeks and 83% of neurological patients were seen in 8 weeks or less. The shortest wait was less than a week and the longest wait was 18-20 weeks.






NHS patient involvement in decision making 


Only 34.1% of Clinical commissioning groups which responded to the quality of commissioning audit, utilise mechanisms to involve patients in decision-making processes and only 33% obtain important feedback on the services they provide. Taking into consideration the NHS principle of “no decision about me without me[10], the NHS must actively incorporate patient views in the design and provision of services. The chart below [5] highlights the high number of neurological patients receiving no information from healthcare professionals on various aspects of patient care. Without crucial information, how is it possible for patients to make educated, informed decisions about their healthcare?


Patient satisfaction with the provision of information

Stroke

What is a stroke?

A stroke is a type of cerebrovascular disease. A stroke occurs when the blood supply to part of the brain is disrupted, depriving brain cells of oxygen and nutrients.

Stroke 2.jpg

 
The two types of stroke are [11]:


1. Ischemic stroke: A blood clot interrupts the blood supply to the brain. Blockages may be due to atherosclerosis, small vessel disease, arterial dissection, or a heart condition. A blood clot may be treated with thrombolysis, which is a clot busting medication. Thrombolysis needs to be given within 4.5 hours of the onset of the first stroke symptom in order to have the optimum effect. This medication can break down and disperse a clot, helping to regain the blood supply to the brain.


2. Haemorrhagic stroke: This type of stroke occurs when a blood vessel ruptures causing bleeding in the brain. The bleeding may occur within the brain, known as an intracerebral haemorrhage or blood can leak into the subarachnoid space, known as a subarachnoid haemorrhage. Symptoms of an intracerebral haemorrhage may include loss of consciousness, nausea, muscle weakness on one side of the body, or severe headache, a subarachnoid haemorrhage causes a sudden onset of symptoms, including a severe headache, loss of consciousness, vomiting, or neck stiffness. A ruptured blood vessel may be caused by high blood pressure, cerebral amyloid angiopathy, an aneurysm, anticoagulant medication, or drugs such as cocaine. A haemorrhagic stroke may need surgery to stop the bleeding, relieve pressure, or remove blood around the brain. This operation is known as a craniotomy. 

Below the left scan shows an infarct represented by the black areas and the right scan shows a haemorrhage indicated by the white areas [12]
Scans.jpg

A transient ischemic attack is similar to a stroke but the symptoms last less than 24 hours. It acts as a warning sign for being at risk of a full stroke.

How is a stroke diagnosed?

A stroke is usually diagnosed using a brain scan, either a magnetic resonance imaging scan or a computed tomography scan. If the patient has had a subarachnoid haemorrhage, a lumbar puncture may be carried out in addition to a brain scan to remove fluid around the spinal cord to determine if any blood has leaked into it [13].

Stroke prevalence in the UK

A stroke occurs every 3 minutes and 27 seconds in the UK, totalling approximately 152,000 strokes a year [14] . There is a high prevalence of stroke in Scotland due to the risk factors linked with the condition, including hypertension, smoking, inadequate exercise, high levels of alcohol consumption, and a poor diet. The Scottish Health survey 2014 revealed a shocking figure of 3.3% of males and 3.1% of females reported to have suffered from a stroke. In 2014/2015, 10,306 females and 10,310 males were discharged from hospital with stroke in Scotland. The percentage of stroke patients surviving 30 days or more after first emergency admission has improved very slightly from 81.6% in 2005/2006 to 84.9% in 2014/2015.[15] Scotland has the highest percentage of stroke survivors, meaning a large population of people requiring support and therapy post-stroke. This places addtitional stress on resources within NHS Scotland [14] .

Stroke survivors in Scotland 2016.jpg

Within Lothian, it is estimated that there are 1,698 first or recurrent strokes per year, along with a further 340 people experiencing a transient ischemic attack, and 6,112 people living with stroke [6].

NHS Stroke services

The NHS Physiotherapy waiting times, workforce and caseloads survey in the UK in 2010-2011 asked the question “Do you provide a stroke service?”. Sixty-seven respondents answered the question to show overall that 42% provided an inpatient stroke service, 34% did not provide any physiotherapy for stroke, 16% provided both community and inpatient stroke services, and 8% only provided a community stroke service.
The Scottish Stroke Care Audit 2015 [16] identified clear standards for stroke services in Scottish hospitals to achieve. Standard one states that at least 90% of stroke patients should be admitted to the stroke unit on the day they arrive or the day after. The table below shows the Scottish hospitals that did not meet standard one in 2014.

HOSPITALS 2.jpg
A large systemic review of organised stroke unit care showed evidence to indicate that stroke patients have better clinical outcomes in terms of independence, survival, and returning home. Stroke Unit care can decrease the risk of death and disability following a stroke. Admission to a stroke unit is the optimum choice of treatment, however it is not always feasible due to Scotland’s geographically scattered population. Suspected stroke patients can often present to rural, remote hospitals which lack a stroke physician. Smaller hospital may have generic rehabilitation services rather than an organised stroke unit. Research favours a stroke specific ward over a general medical ward or mixed rehabilitation ward, with fewer patient deaths and less patients remaining dependent [17]

Deficits of neurological physiotherapy in the NHS

There are a number of key issues within neurological physiotherapy in Lothian that have been identified within the NHS Lothian Neurological Care Improvement Plan 2014-2017 [6].


• Improvements need to be made with regards to accessibility, including inequality of access, problems of physical access and transport for people with more complex disabilities, lack of clear, identifiable pathways and possible duplication.
• There are currently only eight qualified neurological physiotherapists within Lothian. This service capacity needs to be increased.
• The quality of care needs to be more consistent, improving on the current situation of irregular bouts of excellent practice and expertise.
• Further encouragement needs to be provided to consider a single point of referral for neurological physiotherapy, which would supply information on demand.

A study conducted by Verpillat et al 2015 [18] examined the management of ischemic stroke in West Scotland. This study showed that out of 101 patients, 45.5% sought further physical therapy during the 1-year follow-up period. Often, within the NHS, the provision of physiotherapy is based on achieving goals within an expected timeframe. Unfortunately, if progress is limited, the continuation of physiotherapy may be questioned and focus may shift towards self management of the condition with less frequent physiotherapy sessions [19]

Do patients get enough therapy in hospital?

Rehabilitation is evidence based medicine utilised “to reach and maintain optimal functioning in physical, intellectual, psychological and/or social domains, according to the World Health Organisation [20].

It has been recognised that many patients in stroke units feel they do not receive enough therapy during their hospital stay. The SSNAP [21] reported that physiotherapy is required by 85% of stroke patients. Despite this, patients who need physiotherapy only receive 32 minutes on average on just over 50% of their days in hospital. This is one of the NHS's downfalls as patients should be obtaining the equivalent of 45 minutes of physiotherapy per day for 5 days a week. These are the opinions of stroke survivors regarding the care they received in the UK by the NHS in 2013-2014, highlighting some key areas of concern.[21].

Quote 4.jpgQuote 6.jpgQuote 5.jpg

This graph [21]  shows the number of hours of physiotherapy given throughout the year, April 2013- March 2014 in comparison to the target number of hours which would have been given if each patient who needed physiotherapy received 45 minutes, 5 days a week during their as an inpatient. 
Target hours of physio.jpg



The NHS does not have sufficient resources to provide long-term physiotherapy treatment for stroke survivors. Instead, the focus is placed on the initial period following a stroke. Pressure can be felt by patients within the hospital setting to reach targets fast in order to reach their recovery potential within a specified timeframe and some patients are led to believe that after 6 months, recovery stops. It is essential to know that stroke can potentially be a deteriorating condition as patients who do not continue treatment may become stiffer and less mobile. Also due to pressures on hospital beds, patients may get an early supported discharge with continuation of treatment at home [15], as shown in the illustration below. However, treatment at home may be delayed, reduced in intensity, and hence hinder recovery. 




What happens when I transfer home?

What happens when you go home.jpg

Early supported discharge can lead to better outcomes for patients, but The Second SSNAP Annual Report[12], 2015 highlights certain areas in the UK where this service is unavailable, leaving patients isolated with limited therapy at home.

 Quote 3.jpg 

Benefits of using private practice for stroke care

For the reasons highlighted above, having the option to go for physiotherapy for stroke care at a private practice can be of benefit to numerous people to eliminate pressures related to timescales and improve accessibility to therapy. Patients can receive a higher volume and frequency of therapy which is criticial, especially in the early stages post stroke. Evidence shows that spontaneous recovery tends to occur mostly within the first 3 months [22]. Motor impairment is the focus for stroke rehabilitation of physiotherapists [23]. In the first 30 days following a stroke, the largest improvement in motor recovery occurs. However, significant progress is still seen up to 90 days’ post stroke in patients with more severe deficits [24] [25] [26]

Private neurological physiotherapy services in the UK have experienced significant improvements in the functioning levels of patients with a stroke beyond the first 6 months. Neurological physiotherapists re-educate the brain and body through movement that allow further progression in rehabilitation to be achieved [27]

Parkinson's Disease

Parkinson’s disease is a chronic, progressive movement disorder affecting an estimated 127,000 people in the UK [28]. Parkinson’s disease sufferers have inadequate levels of dopamine, which is the chemical needed to send messages to an area of the brain that controls coordination and movement. The primary motor signs of Parkinson’s disease are a tremor, bradykinesia, rigidity, and impaired balance and coordination [29]

Youtube video [30]

NHS Parkinson's disease care

Parkinson’s disease (PD) is the second most common neurological condition in the UK. The NHS Lothian Neurological Care Improvement Plan 2014-2017 states that medical care alone is insufficient for this disease. In spite of this, patients with Parkinson’s disease frequently have no access to allied health professionals. The Edinburgh Parkinson’s Assessment Clinic (EPAC) is led by therapists to provide people diagnosed with Parkinson’s access to advice from a physiotherapist. However, the EPAC offers all newly diagnosed patients of parkinsonism a once-off assessment by a physiotherapist to provide education on self management. Following the initial assessment, there is no standardised pathway of care to therapeutic services. It has been highlighted that the NHS Lothian physiotherapist service needs specific PD staff training, an intranet page dedicated to Parkinson’s physiotherapy to improve communication between professionals, a system to review staff competencies in PD regularly, a system to review patient education throughout their journey frequently, and an evaluation of PD community exercise programmes [6]. Based on this information, the Lothian physiotherapist service for patients with PD is inadequate and requires improvements.

Physiotherapy aimed at rehabilitating patients with PD focuses on posture, upper limb function, transfers, balance, physical capacity, and gait. Supporting evidence in recent years for the inclusion of physiotherapy in the care of Parkinson’s disease has increased [31]. Management guidelines such as the National Collaborating Centre for Chronic Conditions: National clinical guidelines for diagnosis and management in primary and secondary care of Parkinson's disease [32] and the Royal Dutch Society of Physical Therapy's practice recommendations [33] have supported physiotherapy, leading to an increase in the number of referrals to physiotherapy. A systemic review and meta-analysis completed by Tomlinson et al. 2012 [34] showed that physiotherapy resulted in significant outcomes for gait speed, balance, and the unified Parkinson’s disease rating scale.

However, the 2015 UK Parkinson’s Audit [35] showed that only 50% of patients with PD are referred to a physiotherapist within two years of diagnosis, as shown in the table below.

Time between diagnosis and physiotherapy referral.jpg

This Patient Reported Experience Measure (PREM) collected the views from patients with PD and their carers regarding their PD service. There were a total of 5,835 people with and carers for PD who responded to the questionnaire. The pie chart below represents the quality of physiotherapy service offered [35]. The APPG launched an inquiry to examine the availability and quality of health and social care for patients with PD and their carers. This inquiry revealed evidence emphasising the benefits of early and ongoing access to therapy services including physiotherapy, which is less likely considering the two year wait to be referred to physiotherapy following diagnosis. A preventative approach to PD care is cost effective by reducing admissions to hospital and supporting patients in the community for an extended period of time. Unfortunately, evidence showed these interventions in many areas are unavailable until a later stage in the illness, which is too late or not at the frequency needed to be beneficial. For the limited amount of patients who received access to therapy services, some patients highlighted that they were only receiving short periods of therapy before being “signed off”, despite the long term requirement for support associated with the nature of the condition [36] .
Pie chart.jpg

Physiotherapist's role in PD care

Physiotherapists play a key role in the care of patients with PD. Physiotherapy is the most common non-drug treatment recommended for PD [37] [38] and physiotherapy is recommended by national guidelines as a mainstay of management. Some of the physiotherapists objectives are to improve the patient’s quality of life by increasing or maintaining the patients level of independence, wellbeing, and safety. These aims may be achieved by preventing falls and inactivity, reducing the patient’s activity limitation, and enhancing functional activity.

Parkinson’s disease can be divided into three phases, with the patient requiring physiotherapy in each phase. The early phase is characterised by little or no patient limitations. The physiotherapists goals are to prevent inactivity, prevent the fear to move or fall, and improving exercise capacity by providing information, advice, and exercise. The mid phase is recognised by balance issues, restrictions in performance of activities, and an increase fall risk. The therapeutic intervention is focused on body posture, gait, balance, reaching and grasping, and transfers. The late phase is identifiable by the patient’s confinement to a wheelchair or bed. The physiotherapist treating a patient in this phase is focused on preservation of vital functions and prevention of pressure sores and contractures.

The figure below is the International Classification of Functioning, Disability, and Health[20] associated with PD [39]

ICF KASMA.jpg

The impairments linked with PD that fall within the scope of physiotherapy are [40]

Table 6.jpg

The ParkinsonNet model

Bloem and Munneke [41] recognised that PD is a condition where patients require long term support to manage, hence described the benefits of a model of integrated care incorporating a network of specialists. ParkinsonNet is a scheme established in the Netherlands to tackle problems such as inadequate interdisciplinary collaboration and communication, lack of specific training and expertise in PD, treatment focus on suppression of symptoms via drugs, and that referrals to allied health professionals such as physiotherapy being arbitrary. This model developed regional networks of inspiring, motivated, specialist health professionals to whom patients are referred for treatment long term [41]. Parkinson’s UK and the Parkinson’s service have been advocating the ParkinsonNet model, however as highlighted by the NHS Lothian Neurological Care Improvement Plan 2014-2017 [6], this model has yet to be established in Scotland. In 2014, the Chair of the Lothian Parkinson’s Service Advisory Group, Dr Conor Maguire sought approval for the appointment of a Specialist Parkinson’s Physiotherapist to lead the development of a multidisciplinary model such as ParkinsonNet to help decrease geographical inequalities and standardise the provision of multidisciplinary care within Lothian. This process is ongoing currently [6], meaning the patients with PD in Scotland are not receiving the benefits of this model.

How private physiotherapy can aid in the treatment of PD

Due to the long waiting period between diagnosis and referral to physiotherapy as highlighted in table 12 above, private physiotherapy can aid in reducing shortfalls in early therapeutic and preventative interventions.

Speech bubble.jpg




Bhanu Ramaswamy, a consultant physiotherapist in Derbyshire, shared the significance of early referral to physiotherapy in the treatment of PD to help avoid complications such as falls. She reiterated the importance of early intervention stating: [36]





Quote 9.jpg



Private physiotherapy can provide early intervention to delay the decline in a patient’s conditions and help maintain or improve a patient’s quality of life, confidence, and mobility. A person with PD responded to the APPG’s inquiry by saying [36]:




This patients experience with poor NHS accessibility highlights significant unmet needs. Private neurological physiotherapy can meet these needs providing early intervention following diagnosis, allowing patients to benefit from a preventative approach to care[36] .

Overall benefits of private physiotherapy for Neurological Conditions.

Private UK neurological physiotherapy clinics such as Neurolink [42] in London provide specialist physiotherapy for neurological conditions such as Stroke, Parkinson’s Disease, Traumatic Brain Injury, Multiple Sclerosis, and Spinal Cord Injury.


At Neurolink, the majority of clients attend x3 sessions a week, addressing issues proactively to prevent long term complications from developing. For progressive neurological conditions such as PD, the clinic aims to provide treatment and advice at each stage of the condition. A major benefit to private physiotherapy is on achievement of a client’s short term goals, focus shifts immediately to longer term maintenance and progression through a combination of neurophysiotherapy and the use of FES machines, neuro pilates, personal training, and massage therapy.


Many private clinics purchase state-of-the-art equipment. Neurolink uses a number of large Functional electrical stimulation machines including the RT-600 aimed at increasing the percentage weight bearing capacity of a client’s body through their legs, the RT-300 allowing for leg and/or arm cycling whilst seated, and the RT-200 providing arm and leg therapy and offering high cardiovascular demands. These machines are typically used with the aim of building up to daily 1 hour sessions. Neurolink also houses a five piece Integra wheelchair accessible gym, a five piece pilates equipment system, and a Medimotion leg bike [42]. With longer and more frequent treatment sessions privately, patients can really experience benefits using advanced, up-to-date technology.

Following an interview with a physiotheraist treating neurological conditions in Edinburgh, it is clear that private physiotherapy for neurological conditions plays a pivotal role in helping clients achieve a threshold level of mobility and gain confidence and competence with exercise in order to support the transition to a local leisure club or community-based activity groups. The physiotherapist describes the role of a private physiotherapist, in addition to providing an incredible opportunity for improvement, is to help a client reflect on important outcomes from functional perspective to quality of life using careful documentation and involving family members. He believes this offers the client time to make a decision independently as to whether a change in functional status is possible and help shape their ideas about future management of their long term condition.

To quote an experienced physiotherapist in the field of neurological conditions:



Seans quote.jpg




This statement highlights the need for private physiotherapy to help neurological patients reach personal aspirations and higher goals, which take more time and effort to achieve.












Receiving regular physiotherapy not only improves patients physically, but also psychologically, building patient and family members confidence, positivity, hope, and belief. A private neurological physiotherapy clinic in California known as the Challenge Center, [43]provides long term physiotherapy for neurological conditions for people who are no longer eligible to receive physiotherapy from the health system as they have reached their insurance coverage limit. For people who had run out of hope, this private physiotherapy clinic raises money through fundraisers to provide scholarships to clients needing continuous therapy. This scholarship is in addition to patients financing therapy independently. The video[44] below describes the physical and psychological benefits private physiotherapy brings to the lives of people with a neurological condition and their family members.



References

  1. NEUROLOGICAL ALLIANCE OF SCOTLAND.,2016. Neurological conditions factsheet [online]. [viewed 31 October 2016]. Available from: http://www.scottishneurological.org.uk/content/res/Neurological_Conditions_Factsheet.pdf
  2. 2.0 2.1 NEUROLOGICAL PHYSIOTHERAPY., 2016. Neurological physiotherapy [online]. [viewed 31 October 2016]. Available from: http://neurologicalphysiotherapy.com Cite error: Invalid <ref> tag; name "Neurological_Physiotherapy" defined multiple times with different content
  3. 3.0 3.1 THE NEUROLOGICAL ALLIANCE., 2014. Neurological alliance neuro numbers [online]. London: The Neurological Alliance. [viewed 31 October 2016]. Available from: http://www.neural.org.uk/store/assets/files/381/original/Final_-_Neuro_Numbers_30_April_2014_.pdf
  4. NATIONAL HEALTH SERVICE QUALITY IMPROVEMENT SCOTLAND., 2009. Neurological health services: Clinical standards.
  5. 5.0 5.1 5.2 5.3 5.4 THE NEUROLOGICAL ALLIANCE., 2015.The invisible patients: revealing the state of neurology services [online]. London: The Neurological Alliance. pp. 1-69.[viewed 31 October 2016]. Available from: http://www.neural.org.uk/store/assets/files/495/original/Invisible_patients_-_revealing_the_state_of_neurology_services_final_14_January_2015_.pdf
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 NATIONAL HEALTH SERVICE LOTHIAN., 2015. Lothian neurological care improvement plan 2014 to 2017 [online]. [viewed 31 October 2016]. Available from: http://www.nhslothian.scot.nhs.uk/OurOrganisation/Strategies/Documents/NHS%20Lothian%20Neurological%20Care%20Improvement%20Plan%202014-2017%20-%20Final.pdf
  7. SUE RYDER., 2016. Public fear getting a neurological condition [online].[viewed 31 October 2016]. Available from: http://www.sueryder.org/media-centre/news/2016/june/public%20fear%20getting%20a%20neurological%20disorder
  8. DEPARTMENT OF HEALTH., 2005. The national service framework for long­term conditions. Leeds: NSF.
  9. JJ CONSULTING., 2011. A survey of NHS Physiotherapy waiting times, workforce and caseloads in the UK 2010-2011. London: CSP.
  10. DEPARTMENT OF HEALTH., 2012. Liberating the NHS:No decision about me, without me. London:NHS
  11. STROKE ASSOCIATION, 2015. What is a stroke? [online].[viewed 1 November 2016]. Available from: https://www.stroke.org.uk/what-stroke/what-stroke
  12. 12.0 12.1 ROYAL COLLEGE OF PHYSICIANS., 2015. The second SSNAP annual report: Is stroke care improving?[online]. London: SSNAP.pp. 1-30. [viewed 2 November 2016]. Available from: https://www.strokeaudit.org/Documents/Results/National/Apr2014Mar2015/Apr2014Mar2015-AnnualReport.aspx
  13. NEUROSCIENCE., 2010. Subarachnoid haemorrhage [online]. Bristol: NHS Trust. pp. 1-10. [viewed 1 November 2016]. Available from: https://www.nbt.nhs.uk/sites/default/files/attachments/Subarachnoid%20Haemorrhage_NBT002126.pdf
  14. 14.0 14.1 "STROKE ASSOCIATION., 2016. State of the nation: stroke statistics [online]. [viewed 1 November 2016]. Available from: https://www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf Cite error: Invalid <ref> tag; name "2016_stroke_statistics" defined multiple times with different content
  15. 15.0 15.1 NATIONAL HEALTH SERVICE SCOTLAND., 2016. Scottish stroke statistics [online]. [viewed 1 November 2016]. Available from: https://www.isdscotland.org/Health-Topics/Stroke/Publications/2016-01-26/2016-01-26-Stroke-Report.pdf
  16. NATIONAL HEALTH SERVICE SCOTLAND, 2015. Scottish stroke care audit: public summary of 2015 national report [online]. Edinburgh: ISD Scotland Publications. pp. 1-37. [viewed 1 November 2016]. Available from: http://www.strokeaudit.scot.nhs.uk/Downloads/2015_report/SSCA-summary-2015-web.pdf
  17. SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK., 2010. Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning. Edinburgh:SIGN.
  18. VERPILLAT, P., DOREY, J., GUILHAUME-GOULANT, C., DABBOUS, F. and ABALLEA, S., 2015. Ischemic stroke management in West Scotland: a chart review.Journal of market access and health policy [online] September, vol. 3. [viewed 1 November 2016]. Available from: http://europepmc.org/articles/PMC4802692
  19. ASHFORD AND ST PETER'S HOSPITALS NHS FOUNDATION TRUST., 2014. Physiotherapy for stroke patients [online]. viewed 2 November 2016. Available from: http://www.ashfordstpeters.nhs.uk/physiotherapy-for-stroke-patients.
  20. 20.0 20.1 World Health Organization, 2001. International Classification of Functioning, Disability and Health: ICF. World Health Organization.
  21. 21.0 21.1 21.2 ROYAL COLLEGE OF PHYSICIANS., 2014. How good is stroke care?:first SSNAP annual report [online]. London: SSNAP. pp. 1-39. [viewed 2 November 2016]. Available from: https://www.strokeaudit.org/Documents/Newspress/SSNAP-Annual-Report-(April-2013-March-2014).pdf
  22. KRAKAUER, JW.,CARMICHAEL, ST., CORBETT,D. and WITTENBERG, GF., 2012. Getting neurorehabilitation right: what can be learned from animal models? Neurorehabilitation and Neural Repair. vol. 26, pp. 923–931.
  23. LANGHORNE, P., COUPAR, F. and POLLOCK, A., 2009. Motor recovery after stroke: a systematic review. The Lancet Neurology. vol. 8, pp. 741–754.
  24. DUNCAN, PW., GOLDSTEIN, LB., MATCHAR, D., DIVINE, GW. and FEUSSNER, J., 1992. Measurement of motor recovery after stroke. Outcome assessment and sample size requirements. Stroke [online]. August, vol. 23, no. 8, pp. 1084–1089. [viewed 3 November 2016]. Available from: http://stroke.ahajournals.org/content/23/8/1084.long
  25. DUNCAN, PW., GOLDSTEIN, LB., HORNER, RD., LANDSMAN, PB., SAMSA, GP. and MATCHAR, D., 1994. Similar motor recovery of upper and lower extremities after stroke. Stroke [online]. June, vol. 25, no. 6, pp. 1181–1188. [viewed 3 November 2016]. Available from: http://stroke.ahajournals.org/content/25/6/1181
  26. DUNCAN, PW., ZOROWITZ, R., BATES, B., CHOI, JY., GLASBERG, JJ., GRAHAM, GD., KATZ, RC., LAMBERTY, K. and REKER, D., 2005. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke [online]. September, vol. 36, no. 9, pp. 100-143. [viewed 3 November 2016] Available from: http://stroke.ahajournals.org/content/36/9/e100.full
  27. HEADS UP NEURO REHAB LTD., 2016. Neurological physiotherapy for long term strokes [online].[viewed 2 November 2016] Available from: http://headsup.co.uk/neurological-physiotherapy-for-long-term-strokes/
  28. NHS CHOICES., 2016. Parkinson's disease [online]. [viewed 2 November 2016]. Available from: https://www.parkinsons.org.uk/sites/default/files/appg_report_please_mind_the_gap.pdf
  29. PARKINSON'S DISEASE FOUNDATION., 2016. What is Parkinson's disease? [online]. [viewed 2 November 2016]. Available from: http://www.pdf.org/en/about_pd
  30. PARKINSON'S UK., 2016. What is Parkinson's? [online video]. [viewed 2 November 2016]. Available from: https://www.youtube.com/watch?v=ODX2-C2uEAs
  31. KEUS, SH., MUNNEKE, M., NIJKRAKE, MJ., KWAKKEL, G.and BLOEM, BR., 2009. Physical therapy in Parkinson's disease: evolution and future challenges. Movement Disorders. vol. 24, no. 1, pp. 1-14.
  32. THE NATIONAL COLLABORATING CENTRE FOR CHRONIC CONDITIONS., 2006. Parkinson’s disease: national clinical guideline for diagnosis and management in primary and secondary care [online]. London: Royal College of Physicians. pp. 1-534. [viewed 2 November 2016]. Available from: https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0008867/pdf/PubMedHealth_PMH0008867.pdf
  33. KEUS, SH., BLOEM, BR., HENDRIKS, EJ., BREDERO-COHEN, AB. and MUNNEKE, M., 2007. Evidence-based analysis of physical therapy in Parkinson’s disease with recommendations for practice and research. Movement Disorders [online]. November, vol. 22, no. 4, pp. 451-460. [viewed 2 November 2016]. Available from: http://onlinelibrary.wiley.com/store/10.1002/mds.21244/asset/21244_ftp.pdf?v=1&t=iv143vsw&s=93baac2479c4103cb2114bcf8151168c0f24ca54
  34. TOMLINSON, C., PATEL, S., MEEK, C., HERD, C., CLARKE, C., STOWE, R., SHAH, L., SACKLEY, C., O DEANE, K., WHEATLEY, K. and IVES, N., 2012. Physiotherapy intervention in Parkinson’s disease: systematic review and meta-analysis. BMJ [online]. August, vol. 345, pp. 1-14. [viewed 2 November 2016]. Available from: http://www.bmj.com/content/bmj/345/bmj.e5004.full.pdf
  35. 35.0 35.1 UK PARKINSON'S EXCELLENCE NETWORK., 2015. 2015 UK Parkinson’s Audit Summary Report [online]. London:UK Parkinson's. pp. 1-43. [viewed 2 November 2016]. Available from: https://www.parkinsons.org.uk/sites/default/files/audit2015_summaryreport.pdf
  36. 36.0 36.1 36.2 36.3 ALL PARTY PARLIAMENTARY GROUP FOR PARKINSON'S DISEASE., 2009. Please mind the gap:Parkinson’s disease services today [online]. pp. 1-40. [viewed 2 November 2016]. Available from: https://www.parkinsons.org.uk/sites/default/files/appg_report_please_mind_the_gap.pdf
  37. KEUS, SH., BLOEM, BR., VERBAAN, D., DE JONGE, PA., HOFMAN, M., VAN HILTEN, BJ. and MUNNEKE, M., 2004. Physiotherapy in Parkinson’s disease: utilisation and patient satisfaction. Journal of Neurology [online]. June, vol. 251, no. 6, pp. 680-687.
  38. STOCCHI, F. and BLOEM, BR., 2013. Move for change part II: a European survey evaluating the impact of the EPDA Charter for people with Parkinson’s disease. European Journal of Neurology [online]. March, vol. 20, no. 3, pp. 461-472 [viewed 29 October 2016]. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1468-1331.2012.03876.x/epdf
  39. KAMSMA, YPT., 2002, Functional reorganisation of basic motor actions in Parkinson's disease: problem analysis, development and evaluation of a compensatory strategy training. Groningen.
  40. KNGF., 2004. Guidelines for physical therapy in patients with Parkinson’s disease [online]. Netherlands: Royal Dutch Society for Physiotherapy. pp. 1-86. [viewed 29 October 2016]. Available from: http://www.appde.eu/pdfs/Dutch%20Parkinson's%20Physiotherapy%20Guidelines.pdf
  41. 41.0 41.1 BLOEM, B. and MUNNEKE, M., 2014. Revolutionising management of chronic disease: the ParkinsonNet approach. BMJ [online]. vol. 348, pp. 1-8 [viewed 29 October 2016]. Available from: http://www.west-info.eu/files/Revolutionising-management-of-chronic-disease_-the-ParkinsonNet-approach-_-BMJ.pdf
  42. CHALLENGE CENTER., 2011. About us [online]. [viewed 3 November 2016]. Available from: http://challengecenter.org/about-us
  43. CHALLENGE CENTER., 2015. Challenge center video 2014 [online video]. California: Challenge Center. [viewed 3 November 2016]. Available from: https://www.youtube.com/watch?v=TDGETLa4Bm8