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Sy Syms School of Business, Washington Heights, Manhattan ​[Music] thank you for being here thank you for having me yes officially it's it's 8 o'clock at night for me I feel like I'd much rather glass of red wine right now actually but bear with me I speak fast anyway so maybe it will slow me down hopefully so yes so I'm I'm down Brown I'm a HIV specialist physiotherapist and I'm very lucky to work at the Chelsea Westminster Hospital so I'm going to be telling you about our outpatient specialist HIV physiotherapy service so I'm first we're going to be giving you a bit of an overview of the service and how it works I'm going to be talking about some of the two-year service evaluations that we've conducted so the first one I'm going to tell you about is about our clinic and the second I'm going to rehash some of the data that I presented at the last forum in 2014 just to give you a bit of an overview I'm also going to do a shameless plug about an app that we have created and there are some Flyers outside but I'll be telling you lots more and then I'm going to be talking about some of the future opportunities that we've got so first of all where are we where we're located in the London central London in fact we're located in the borough of Kensington and Chelsea the most affluent part of the United Kingdom now our service the Chelsea and Westminster Hospital has a satellite clinic next door to it called the toddler clinic so my outpatient HIV physio service will accept referrals either from people they have been an indication on our ward Rondon someone been in the cobra clinic or in fact our other satellite services so for example 56th industry well renowned in central London in Soho our new clinic 10 Hammersmith Broadway which is just moved from Charing Cross Hospital into the centre of Hammersmith and we've also just expanded as a trust we've actually merged with another hospital with the West Middlesex Hospital and so now we have HIV services across Hounslow and we've also expanded even further have HIV services across Hartford share which is north of London I won't go into the complexities of finding between health and public health behaving and sexual health are separate so in half a chair we just have HIV so my service will accept referrals from anywhere across those parts of the trust so the service itself contains two key components the first is the clinic this is a one-toone clinic with myself a clinic is twice a week Thursdays and Fridays afternoons and the cocoanut rehabilitation class this is a rehabilitation intervention so what we've done is from October 2013 we've conducted a two-year service evaluation trying to find out first of all who is accessing this service what interventions are they being provided with and what's the outcome of receiving HIV specialist physiotherapy and we've done this in four key ways so first of all we did a retrospective audit looking in the demographics of people that are coming in the interventions that they received we also use the World Health Organization International classification of diseases icd-10 online version to identify what with the current home abilities that people were living with we also used the World Health Organization ICF international classification of function disability and health ICF checklist as a retrospective tool to identify what was the level of function and disability that people were living with and then lastly Richard Harding mentioned this earlier about the eq-5d we use the eq-5d the Yuriko eq-5d 5 out of that means that instead of the 3 L that Richard mentioned earlier we've used the later version which used five levels for determining health status and the point of using this is to measure change over time what is the effect of having physiotherapy it's a small service so over this two-year period we had 137 patients and on average people were aging in HOV median age 50 to 83% were male 80% living with HIV for longer than 10 years and 97% had an undetectable viral load so on paper mostly gay white men which is very crisp that's basically our cohort living well with HIV and on paper living well with their numbers how did they present we know that people were accessing the service from across London and further afield but you can see here in the red circles is where the most common locations that people were accessing the service from and unsurprisingly it was the locations around the hospital but what you can also see is that people are coming from far and wide across London they're travelling long distances and in fact some people even coming from far afield as South Somerset to access his service now we haven't been gone into this in detail as to what that may mean it could be that people are not able to access the rehabilitation services that they potentially need and so therefore are travelling long distances to access a very specialized service or it could be they would prefer to see a specialized service rather than their local services so who came to the service 87% of people that access this service were inactive and not meeting UK recommendations for regular physical activity 71% living alone 64% living locally to the hospital and 61% were unemployed we also know that on top of living with HIV people who live on average with five additional comorbidities and that we showed as well is there 87% of people that were accessing the service can be defined as complex comorbid so basically what that means is living with HIV and two or more additional chronic

conditions in two or more different body systems for example an HIV positive I have COPD and I have osteoporosis so when we were looking at the icd-10 looking at the common comorbidities that people were presenting with this is what was most common depression was the most common comorbidity for people accessing the physiotherapy service but also chronic low back pain probably quite unsurprising when you think about traditionally what people see physiotherapists but then also think that peripheral neuropathy we saw that most of the cohort have been living with HIV for a long time and may have been on antiretrovirals from a long time ago that may have caused neural of cause disturbances bone and joint health problems high blood pressure and high cholesterol interestingly every last single one of these things has very good evidence base for physical activity as an intervention when we subgroup these disease of the musculoskeletal system and connective tissue for the most common and again I go back to most people perceive outpatient physiotherapists is dealing with musculoskeletal conditions but also mental behavioral disorders and decline nutritional and metabolic disorders and diseases of the nervous system again all areas where rehabilitation has a really good evidence base so when we use the ICF checklist who is able to identify not only what the body function impairments were what the body structure impairments were but also the account activity limitations and social participation restrictions were and also the environmental factors so whether they be positive or negative towards them I've got the numbers there but in summary people are presenting the pain they're presenting the problems moving their joints they're presenting with mobility issues challenges to the numerated employment and challenges to participating in community life and what's really interesting with this is when we compare this to other data from other parts of the world this is pretty much exactly the same as the experience in sub-saharan Africa except in sub-saharan Africa there are more challenges with self-care see the ability to wash and dress so what about when we looked at the eq-5d so as mentioned earlier the eq-5d has five different domains of health status and mobility self-care usual activity pain and discomfort and anxiety and depression their self-reported by the individual what we did is we compared how people's self-reported were they presented to HIV physiotherapy which is the dark blue compared to Richard study which was HIV outpatients in the UK and then compared to the UK general population and what we showed is that there was significantly higher self-reported problems across all domains in those people who are being referred to physiotherapy is this the tip of the iceberg of people that are living with the most amount of disability that are potentially accessing rehabilitation interestingly the eq-5d also gives us an index value this index value enables us to compare to other populations and we was able to compare two elderly adults in Europe who were at risk of hospitalization and mortality our index value indicated the patients who are presenting to physiotherapy had a worse index value than elderly adults in Europe at 12-month risk of hospitalization our index value was also nearly as bad a 24-month risk of mortality there's been lots of talk today about frailty is this another potential determiner frailty we have an ageing cohort who are at risk of hospitalization living with multiple health conditions and have functional challenges so what interventions were people being provided with so they can be safe and so on physiotherapy with me in my clinic well they can have a combined approach so basically what we do is we'll either refer them on to a local service well refer them into the cocoa rehab class or we'll be able to advocate for them in their local area because we know that often people that may be independently mobile won't be able to access community rehabilitation services so I often fight tooth and now to make sure other people get it now when it comes to the copra trade hub class 37% of patients require the cocoa rehab class so they come see me in clinic I assess them we find out through a shared decision-making process what it is that you would like and instantly go get straight into the cocoa class however 53 percent of people overall accessed our group rehabilitation intervention now when we look to the e key 5dn change over time what we showed is that from a self-reported measure there were significant improvements in people's self-reported mobility ability to perform usual activities pain and discomfort and anxiety and depression what we also showed is that there was improvements in median scores of us autumn including self-care and actually our index value significant improved so it took us outside of that range of being a risk of hospitalization so what's our group we have intervention well it's a supervised group exercise twice a week with physiotherapists it takes into consideration all the evidence is reduced produced in the Cochrane reviews around making sure that we do cardiovascular exercise progressive resistance training neuromotor exercises that's balanced gait I've got one minute oh my god I'm never going to do that flexibility training and also guided relaxation now I was really pleased to hear the talked earlier about self management because we have a self management program within the co2 rehabilitation class it's a group discussion that lasts for about half an hour 40 minutes by different people professionals as you can see so we've got ot psychologists dietitians we've got not advanced nurse practitioners sleep physiologist psychologists community organisations that come in and talk to us about the charitable stuff so equivalent to eight service organizations over here stopping smoking community organizations such as the YMCA that does group exercise programs as well intimacy and relationships as well as confidence and pain management and these are group

discussions they're not didactic that the collective need of the group that drives the discussions but are after different measurements of a look at height weight body shape resting heart rate people's walking ability with a six-minute walk test people's strength of upper limb and lower limb we look at the health-related quality of life like in the Farhi flexibility and we do gas goals so what people's own personal goals its attempt week programs people start at week zero we measure them again at week ten but we don't drop them off the end of the cliff at the end of that we allow them to return or restart with flexibility depending on their own health challenges and their own health needs and we know that people that come to the service significantly improve their locomotive performance so on average 86 meters further which actually exceeds clinically important differences with people with COPD community-dwelling older adults stroke survivors as well strength in all of our muscle groups health-related quality of life through physical well-being and emotional well-being at a trend towards functional well-being flexibility and I think the most important of all is 64% of people achieved all of and on average people were setting three goals with most common in body image concerns wanting to participate in more social roles and to feel healthier and fitter by doing regular physical activity now this is a shameless plug it's not gonna work you had a video by Chelsea and Westminster Hospital NHS Foundation we can here may help you be comforting live well and achieve repose where they go you heard my voice so we've got an app we developed this app it's called bu plus there's a load of social media revenues that you can get here so basically bu + @ vu + more on Facebook we have a website we have a fire me account where you can watch our three and a half minute video the whole point of this app is moving away from a biomedical approach of supporting people to live well with HIV it's not just about your cd4 a cd4 count your viral load anymore it's about living well is about maintaining self-control it's about achieving your personalized goals and the whole point of this app is it enables you to do that gain that reliable accessible convenient information is specific to living with HIV in 19 a vagator around the app itself so that if you're interested in looking at cardiovascular disease and HIV it will then navigate you to smoking navigate you to die at navigate you to exercise but also it navigates you externally to the app so you can get that reliable information and set your own goals so our future opportunities quite a lot the coppola rehab class we're hoping it's going to be published very soon in AIDS care also some collaboration so after the last forum we managed to collaborate with marks directly from the London School of Hygiene and Tropical Medicine and a multi-stakeholder needs analysis on the Popol rehab class which hopefully can be published soon looking at research so not only are we using Kelly's hdq HIV disability questionnaire at over 50s clinic at the Chelsea and Westminster we've also got in the Dean Street cohort study which is everybody newly diagnosed at Main streets who diagnoses one in five people living with HIV in the UK are now having the hdhd Q completed also after the Cobra rehab class papers hopefully it's exceptive going to hopefully look forward to moving forward into an HR application to look at a feasibility study on that and also looking expansion because obviously the trust is expanded and we need to ensure that were providing an equitable service and part of that may be using technology not only apps but also other types of technology so that people can start to record their own health data so in a nutshell we provide a physio Service Fund to run a group and people attending of presenting with complex comorbidity they're aging well with HIV but they're presenting functional disabilities and by attending either the ones month clinic all go rehabilitation into intervention you can improve a raft of different functional and disability measurements and the app is available to now on iOS so download it now if you want Android soon [Music] Modern Orthodox Judaism.