2004 - 2007 - Cicely Saunders Institute - King's College London

In focus 3.1 –
Cochrane Reviews
The Cochrane library was set up in the 1980s to provide
a database of randomised controlled clinical trial
evidence which is regularly reviewed and updated.
Whilst RCTs may not always be possible, or even
appropriate, to answer all the questions that need to be
answered, Cochrane reviews form an important contribution
of the literature.
In rehabilitation, the major part of our Cochrane
programme has been undertaken in collaboration with
colleagues in Melbourne, Australia – Dr Fary Khan and
Professor Peter Disler, who is an honorary Visiting
Professor within our department. During this three-year
period we have completed four Cochrane systematic
reviews:
• Exercise for peripheral neuropathy 35
• Multi-disciplinary rehabilitation for acquired brain
injury in adults of working age 165 .
• Multidisciplinary rehabilitation for adults with
multiple sclerosis 327 .
• Rehabilitation interventions for footdrop in
neuromuscular disease 336 .
The two reviews of multidisciplinary rehabilitation for
Acquired Brain Injury (ABI) and for MS were large
systematic reviews incorporating 14 and eight trials
respectively. Pooling of data for meta-analysis was
prohibited by heterogeneity in the trial methods, but
both reviews used a novel ‘synthesis of best evidence’ to
assimilate the trial findings.
• The ABI review provided strong evidence that patients
with moderate to severe brain injuries recover faster
with more intensive rehabilitation programmes, and
that continued out-patient rehabilitation can help to
maintain these gains.
• The MS review also showed strong evidence that
patients with MS can benefit from an inpatient
programme, and can function better, even though
their underlying impairments do not change. Also that
out-patient and community-based programmes can
improve quality of life.
Cochrane reviews are also underway to assess:
• The effectiveness of non-pharmacological interventions
in the management of breathlessness.
• The effectiveness of antidepressants in the
management of depression in physical illness
(Hotopf et al).
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Clinical Services
There are well established clinical palliative care services
at both King’s College Hospital NHS Trust (KCH, one
hospital palliative care team) and at the Guy’s Foundation
and St Thomas’ NHS Foundation Trust (GST, two hospital
palliative care teams and two community palliative care
teams). The services provide a seven day a week visiting
service and consultant-delivered integrated 24-hour
telephone advice across both Trusts and the University
Hospital Lewisham.
Two of the clinical consultants have honorary academic
contracts with the Department of Palliative Care, Policy and
Rehabilitation – Dr Polly Edmonds (lead clinician at KCH)
and Dr Rachel Burman (KCH) and of course Professor
Higginson is a consultant (honorary), primarily for KCH, but
in on call integrated across all units. There are joint monthly
clinical update meetings between the KCH palliative care
team and academics from the Department of Palliative
Care, Policy and Rehabilitation, in order to share key
clinical issues, especially where they relate to policy and to
update on research projects, and a joint journal club. The
clinical services lead the delivery of the undergraduate
curriculum – this is discussed more fully in section 5.4.
4.1 Improving Care for People Affected by
Multiple Sclerosis (MS): Translation of Study
Outcomes to the Clinical Setting
During its evaluation phase the new MS service saw 94
patients, assessed by the referrer to be severely affected
by their MS. Most of the people referred for assessment
of symptom control problems had other specialist
palliative care issues identified on assessment by the
clinical service. This was less likely where referrals were
made for other reasons. No patient required more than
three visits by the clinical team, and only a minority of
people (n=15, 16%) were subsequently referred on to
community specialist palliative care services for ongoing
management.
Drawing on the lessons learned as part of this project,
and following a detailed option appraisal, it was decided
that the most realistic and sustainable option for the
future was that of a step-down service leading to full
integration of the MS palliative care service with the
generic King’s College Hospital Palliative Care Team. In
addition, a new referral pathway was developed (see
figure 4.1).
There are many examples where the research findings are
influencing local, national and international clinical
practice, but two specific local examples are given below.
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