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Building bridges is all in a day’s work for OTs

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Working as an OT, with individual’s who may have physical, sensory, cognitive, emotional and behavioural difficulties, can vary hugely from day to day. 

I liaise closely with other therapists within our centre, particularly in Physiotherapy and Speech and Language therapy on a daily basis. The team and I also have strong relationships with other community teams/resources and various local NHS hospital based therapy teams. This helps us here at The Bridge to be able to offer trulyholistic support to our patients, from preparing for their arrival to after they leave; and it means a lot of work goes on beyond the boundaries of the traditional core function of OTs.

Christine’s* story offers a prime example of this. Christine came to us having had a stroke in her early fifties which had had a serious impact on her function in multiple ways.

At the time Christine was living in a house which was wholly unsuitable to meet her complex needs moving forward.

Christine was around 18 months post-stroke when she arrived, so was unlikely to make many significant functional improvements. However, there was still much work to be done in enabling her to be as independent as possible.

Christine’s main goal was to go home. This was her sole focus and we kept that at the forefront of our work throughout her time here. A plan, to be delivered via a multidisciplinary approach, was put in place built around this goal, plotting the way ahead and mitigating the risks.

We also focused on providing an environment in which she could feel safe. One difficulty she faced was hemianopia, a common visual impairment post-stroke where the eyes are still technically working but there is a problem with the visual processing within the brain. When we first met Christine, she couldn’t see past the mid line of her visual field – the rest of the environment on her right hand side simply did not exist in her world. Now, she is blind to less than a quarter of the normal field of vision.

To help achieve this progress, we used scanning techniques with basic repetition during functional tasks like washing and dressing, or when moving in her wheelchair up and down the corridors on the unit. For example, I would put post-it notes along the corridor and she had to find them all, turning her head to compensate for her visual deficit. Similarly with washing and dressing, we would place the items she needed in different areas of the room. This strategy meant she had to move and turn her head to locate the objects, an important action in preparing for a more independent life.

As the goal we were working towards was allowing Christine to live in her own home, I worked very closely with her allocated social worker and housing provider to firstly assess her current property, which was deemed not suitable for her to return to. I then assessed a further property jointly with the local housing provider and identified that this new bungalow was better suited to Christine’s needs but required some adaptations to be fully meet Christine’s longer term needs.

After a Disabled Facilities Grant was made on my recommendation, we implemented adaptations to the bathroom and installed a ramp to allow wheelchair access. Kitchen counters were also lowered to make them more accessible, enabling Christine to make a cold drink. Hot drinks were not possible due to the risks involved, but being able to make cold drinks was another step towards independence.  

There was a lot of work between all parties to put the right equipment into the house and to devise and implement the strategies to best manage Christine’s cognitive and behavioural difficulties. Great effort was required in securing her a larger then standard package of care to support her needs on discharge home, but we achieved that and Christine was able to return to a much more suitable home environment with the appropriate level of care to support her needs.

Today she has support from her family and a package of care through which she is visited four times per day with additional carer input overnight which will be reviewed and hopefully reduced over time once Christine settles further into her new home environment.

This is a vast improvement on her situation compared to when Christine first came to us needing close monitoring by staff every few minutes and significant periods of one to one care to ensure her safety. If not for the aforementioned interventions, people like Christine all too often end up in nursing homes, with none of the independence she enjoys today. 

Crucial to this outcome, alongside the care and rehabilitation Christine received whilst at the Bridge, was the close collaboration we were able to foster between our team and the various community partners.

Pauline Matthews is an occupational therapist at The Bridge Neurological Centre in Middlesbrough, which is operated by Elysium Healthcare.

*Name changed for anonymity.

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Repeated head injuries linked to depression – study

Repeated head impacts may be associated with depression symptoms and worse cognitive function later in life, new research suggests.

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It’s well established that a traumatic brain injury (TBI) can cause memory and cognitive problems, as well as depression, but now, researchers have looked at the consequences of repetitive head impacts.

They found that people exposed to repetitive head impacts may be more likely to experience difficulties with cognitive functioning and depression years later.

The researchers analysed data from the Brain health Registry on 13,000 adults, five per cent of whom reported having had repetitive head impacts through contact sports, abuse or military service.

They were asked about depressive symptoms and completed cognitive tests.

The paper, by researchers at Boston University and the University of California, San Francisco, reveals that participants who’d had repetitive head impacts and TBI reported greater depression symptoms than those who hadn’t.

Repetitive head injuries were a stronger predictor of depression than TBI, and those who had a history of repetitive head impacts and TBI with loss of consciousness reported the most depressive symptoms.

“The findings underscore that repetitive hits to the head, such as those from contact sport participation or physical abuse, might be associated with later-life symptoms of depression.

“It should be made clear that this association is likely to be dependent on the dose or duration of repetitive head impacts and this information was not available for this study,” said Michael Alosco, associate professor of neurology at BU School of Medicine (BUSM).

Those who’d experienced repetitive head impacts or TBI also performed worse in some of the cognitive tests.

“It should be noted that not all people with a history of repetitive hits to the head will develop later-life problems with cognitive functioning and depression,” says Study author Robert Stern, professor of neurology, neurosurgery and anatomy & neurobiology at BUSM.

“However, results from this study provide further evidence that exposure to repetitive head impacts, such as through the routine play of tackle football, plays an important role in the development in these later-life cognitive and emotional problems.”

The researchers point out, however, that one limitation of the research is that researchers didn’t have data on the extent of participants’ injuries.

Last year, BUSM researchers found that longer someone was exposed to tackle football, the higher the risk of developing the degenerative brain disease chronic traumatic encephalopathy.

For every year of exposure to the sport, footballers had a 30 per cent increased chance of having the disease.

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City dwellers “more likely to die in hospital” after stroke – US study

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Compared to those living in urban areas, stroke patients treated at rural hospitals were one third less likely to undergo a procedure to remove a blood clot that caused the stroke and were more likely to die of stroke before leaving the hospital.

Researchers examined national data on almost 800,000 adults hospitalised after a stroke between 2012 and 2017.

In their paper, published in the American Stroke Association’s Stroke journal, the researchers warn that this urban-rural divide may be getting worse. This gap, the paper states, could be caused by the slower take-up of newer treatments and technologies, and because rural hospitals are less well-resourced and have poorer access to specialist care. Rural hospitals may also be more likely to lack specialised clinical support, such as dedicated stroke units.

Other causes for poorer stroke care could be a lack of clinical expertise in urban areas, due to difficulties attracting and retaining experienced staff, and poorer access to emergency services and longer responses to emergency calls due to distance.

“The lack of access to specialists is often a limiting factor in adequate care for rural stroke patients, and in this case, that could mean a neurologist to guide the initial care, an interventional neurologist or radiologist to do a procedure, or having a neurosurgeon available for backup in case of any complications,” said Gmerice Hammond, author of the study and a cardiology fellow at Washington University School of Medicine.

“Clinicians need to work to improve access to high-quality stroke care for individuals in rural areas. That means partnerships between hospitals for rapid transfer, as well as telehealth when appropriate. And clinical leaders and policymakers should prioritize improving access, care and outcomes for stroke in rural communities.”

The study had some limitations, including a lack of data on the severity of patients’ strokes, or factors that would determine whether a patient received advanced therapies, sich as the size of the clot and where it is located.

Karen Joynt Maddox, senior author of the study and assistant professor of medicine at Washington University School of Medicine, calls the differences in care, and the lack of improvement over the five-year period, ‘striking’.

“Future studies using more detailed clinical data will be important to follow up on our findings and to determine why patients in rural areas aren’t receiving advanced therapies. Is it because their stroke severity is different? Or because delays in getting to the hospital meant they weren’t eligible by the time they arrived?

“Those questions can’t be answered with administrative data, but they’re very important to look into so that we can develop effective solutions.”

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One charity’s challenging move to online group sessions

Since lockdown began in March, many people recovering from brain injuries have had to adapt to remote sessions with health workers.

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But it’s not just outpatients that have seen a change. One neuropsychologist in York is trying to sustain momentum with her support group, but navigating the new online world with patients has brought its challenges.

Just before lockdown, Diana Toseland, consultant clinical neuropsychologist, was celebrating. Her charity, Café Neuro York, became officially registered. Café Neuro is a social support network that allows people with long term neurological conditions in York to learn new skills, help others and learning to be mindful, after they’re discharged from health services.

Group members were meeting face-to-face for morning and evening meetings, and once a month on Thursday evenings there was an interactive presentation for members to enjoy. When lockdown began, Toseland wanted to continue her twice-weekly sessions online.

But adjusting hasn’t been easy – Toseland had built up a loyal user base, but sessions were very much based offline. Adjusting hasn’t been easy.

“People need this in York. People with a neurological condition need ongoing support,” Toseland says. “People with brain injuries found it helpful to come along to meet people without having to explain – they can just be who they are. It’s about what people can do, not about their condition or disability.

Since lockdown, Toseland has been struggling to know how to support people.

“I’ve got up to speed with Zoom. This week we had six people call in, but their difficulties are quite profound and they’re finding it hard to get onto Zoom. Some call in late because they forget or find it difficult, others call in with help from families.”

Toseland has found there are many technical difficulties to overcome before the sessions can begin.

“You need so many things – good internet connection, distraction-free environment, working microphones and speakers.

“One woman managed to set it up herself, her career before the injury was IT, but then she didn’t have sound. Then she tried headphones, which worked, but then she took them off and couldn’t get the microphone on the computer to work without the headphones – she was the most successful in that meeting.

“Another has poor signal so she has to sit under a tree in her garden, which means she can only do it when the weather’s good.”

Once the call is up and running, Toseland says some members find it difficult to navigate the conversation, which has entirely different unspoken social rules than offline conversations.

“They’ve found it difficult because you can’t have two people having a conversation, it’s got to be one person at a time, which requires intense concentration. People can’t sustain that level of attention long enough to fully participate in the conversation.

“Some go quiet, it leaves people with headaches, it’s fraught with disaster. They might dominate the conversation and not pick up on cues; one finds it’s too much stimulation, so she closes her eyes.”

But Toseland hopes to continue the groups, as when it does work, it works well.

“On the other hand, for those who have joined it, they’ve used it as a bit of a lifeline.”

But Toseland is looking forward to getting meetings back into the real world. She’s been runnin Café Neuro for over a year and a half, and she’s seen more progress in some members than they ever made coming to her clinical practice.

“It’s made a difference in ways I couldn’t have predicted, and an impact wider and quicker than I could’ve possibly hoped for,” she says.

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