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Carrying on regardless

Professionals involved in the care of people with brain and spinal injuries and conditions have risen to the challenge of COVID-19 in recent weeks. Deborah Johnson reports on how the rehab field is adjusting.



The way coronavirus has swept through the world has created an unprecedented situation which each country has had to adapt to.

In the UK, the total numbers of confirmed COVID-19 cases and fatalities due to the virus continue to rise and lockdown remains in place at the time of writing.

While business has had to temporarily end for many, particularly in sectors including retail and leisure, however, the situation is vastly different for those working in care.

Work must carry on to ensure patients are looked after as usual – particularly for neuro patients, whose needs are often particularly complex – with the additional challenge of protecting them, as well as fellow care professionals, from the deadly COVID-19.

The challenge for the sector is undeniably huge, but businesses are responding with commitment and determination to get through the weeks and months ahead.

Specialist care providers are adapting their ways of working in light of COVID-19, yet doing so in ways which offer the continuity their patients need.

Aliyyah-Begum Nasser, director of Askham Village Community, a family-owned care and rehabilitation community in Cambridgeshire, said her staff are doing all they can to keep morale high in these tough times.

“While everyone around us is closing down, shutting shop, staying in, our staff are continuing to show up for work and keep their smiles handy,” she says.

“Rehab requires motivation and we are doing our utmost to keep residents inspired and enthused to work hard to meet their goals.

“For the entire health ecosystem to continue to operate, we need to do our bit and keep people progressing towards their goals, and hopefully to discharge. This will enable others to come to us for rehab and thereby free up hospital beds.

“The cogs need to keep turning – despite all that is going on around us we are doing every we can to ensure the pace of rehab is not affected.”

Neurological care provider PJ Care, which operates three specialist centres across Milton Keynes and Peterborough, has implemented a raft of stringent protocols to constantly monitor the situation for the benefit of its patients, including monitoring staff and residents’ temperatures every four hours, checking staff daily for coronavirus symptoms, installing additional hygiene facilities, including new sinks at the entrance to all sites, plus identifying all high risk patients and staff and devising bespoke management plans around that.

Mark Butler, director of operations at the firm says that, while such changes were quickly introduced, the decision has since been taken to also stop visiting to the centres. Restrictions have also been imposed on staff movement.

“Sadly, we had to take the decision to stop all non- essential visitors into PJ Care centres. There are very limited exceptions to this, which only really includes end of life family visiting, GPs visiting seriously ill residents, contractors repairing essential equipment, and other such situations.

“But we do offer video conferencing facilities so residents can keep in touch with their loved ones.

“Our new protocols detail our preparedness to address escalating levels of viral invasion. Stage one, which we have currently, is when no resident or staff member is affected by the virus, with stage two to be implemented if/when we are hit by an infection.”

Fourier Intelligence, a China-based exoskeleton company which works extensively with UK rehab providers, has also seen the impact of the restrictions on movement.

A spokesperson tells NR Times: “Many of our people are around the world and they have not been allowed to return home.

“Certain procedures have been taking longer than usual due to the onset of the virus, but also, customer visits and shipping of products are being disrupted because of the fear of spreading the virus.

“These will ultimately slow down the company’s business,” he adds.

Chroma, a national provider of arts therapies to care patients, has also taken steps to restrict visiting in light of the developing situation, and is working closely with fellow providers in an attempt to map out the way forward.

Daniel Thomas, joint managing director, says: “We are working with other arts therapies organisations

and our professional bodies to ensure a consistent response, which highlights ways in which we can work together to get through the impact of COVID-19.

“We are working with our NHS and private healthcare partners to ensure the delivery of a safe and appropriate level of service, consistent with government advice and updates from each setting.”

Indeed, the recent agreement between the NHS and the nation’s independent hospitals, which will make more beds, ventilators and thousands more staff available to the COVID-19 fight, has also touched the specialist care sector.

When unveiling the new agreement, NHS chief executive Sir Simon Stevens spoke of the NHS “doing everything in its power to expand treatment capacity and is working with partners right across the country to do so”.

Care providers are also being included in this, with PJ Care revealing an approach from a CCG proposing a Mutual Working Agreement, and Chroma saying it “stands ready” to assist further in the national efforts of joint working.

While the new partnership between NHS and private hospitals has seen huge innovation on a national level, equally innovative practice can be introduced locally.

At Askham Community Village, the team quickly devised a plan around rehabilitation, in light of restrictions on movement between the units on site. “Never was a truer word spoken than ‘necessity breeds invention’,” says director Aliyyah-Begum Nasser.

“Our rehab team have come up with a super plan to ensure residents do not miss out on rehab and do not put themselves at infection risk by moving around site and mixing with outpatients.

“We have moved physio equipment from the gym into each of the specialist units to ensure that residents have access and infection risk is minimised. In some ways this has actually improved the access residents

have to rehab – every cloud has a silver lining.” For Fourier Intelligence too, the company’s innovation means it is able to assist patients with rehabilitation they can do independently, without the need for human contact.

“Unfortunately, for some of our patients, our team are unable to carry out treatment in physiotherapy centres or hospitals as it would be dangerous for them,” says the spokesperson.

“For patients who are unable to carry out their therapy treatments in the hospitals or centres, they can benefit from our home devices such as CycleMotus H1 and OT Parvos, which allow the patients to still carry out their daily treatment without leaving the house.”

Similarly, BIS Services, a community-based rehabilitation services provider, is adapting its traditional model to accommodate the challenges presented by Coronavirus.

“We’re still out in the community and are putting together a virtual program of cognitive rehabilitation provision that can be delivered with our team and in a group format,” the company says.

“Focus has moved to wellbeing and mental health, alongside retaining functional skills.”

With care companies responding with vigour to the challenges, charities are also taking measures to adapt to the developing situation, although their ability to generate income at such a difficult time poses a separate challenge.

Spinal Research, a charity which funds medical research for effective treatments for paralysis caused by spinal cord injury, says: “Coronavirus is, of course, impacting on what we do here, with many colleagues working from home, or in the process of setting up an office at home.

“While this may be an inconvenience, one of the biggest challenges we face is an expected fall in donations. As we operate as a charity, this is a particular concern as people reassess their financial priorities.

“Going forward, as the situation continues to. change on a daily basis, operators have expressed a desire for clearer guidance and direction from regulatory bodies.

“We are concerned about the lack of updated information coming from organisations like the CQC, and PHE,” adds Mark Butler from PJ Care.

“We feel, by necessity and despite clear guidance, we have devised a most sensible set of protocols that we believe in good faith will protect our residents, staff, relatives and the whole operation.”

At the law firm Irwin Mitchell, its client liaison managers (CLMs) have been adjusting the way they support people with brain injuries.

CLMs, who have nursing, occupational therapy or social worker backgrounds, support seriously injured clients throughout litigation before liability can be established.

They have told NR Times that the period of self- isolation has led to many clients feeling anxious about their financial situation and seeking benefits for the first time.

The team has been signposting clients towards helpful resources and filling in benefits forms for them if and when necessary. Other extra measures have included helping clients to utilise online grocery shopping.

One young female client, meanwhile, was rapidly discharged from a neuro-rehab setting after suffering from a brain bleed at a time when the NHS was, understandably, trying to create bed capacity.

She has a blood disorder and was therefore in the high risk category. The CLM, working remotely, helped to secure funding for the continuation of her therapy and assisted with the discharge plan. This ensured that there was support available, despite her early discharge.

Read more on the impact of COVID-19 on rehabilitation:

Charities and community rehab groups pull together  

Maintaining progress amid the madness 

The Children’s Trust: Help us to be better and stronger 

Editor’s note: Getting stuck in and challenging conditions 

Stroke concern in COVID-19 crisis

If your resolve is flagging  

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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.



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



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.



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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