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Why the Arni way is up

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Dr Tom Balchin’s mission to help UK stroke survivors was forged in tragedy. In late 1996, his twin brother Alex died aged 21 after falling from a building during a night out in London.

Three months later Tom suffered a serious subarachnoid haemorrhage stroke, which he believes may indeed have been triggered by the stress of losing his sibling.

“I wasn’t coping very well before the stroke and there was a lot of grief I just couldn’t get out,” he says.

He was initially paralysed down his left side and weighed just nine stone when he left hospital in a wheelchair six months later. His journey to independence taught him a lot about what really works in rehab; and shaped the ARNI Institute, which has helped thousands of stroke survivors since Tom founded it in 2002.

“I wanted to get out of hospital as soon as I could and I just went for it. I got hardcore about it! At home, I remember hauling myself upstairs on my behind, step by step, to prove that I didn’t need a stairlift.

“I used combinations of all sorts of exercises I found for myself, including piano finger playing exercises – but the best thing in those early days was to try to get back to my DJ decks, put my paretic hand on the platter and try and move it back and forward, beat matching. I even turned the decks backwards initially, before my fingertips were able to grip into the grooves of a record, and made special surfaces for records which assisted my fingers and thumb to move where I wanted them to go.

“The headphone was held on the side of my brain which had suffered the stroke. I progressed to being able to control the cross-fader, equalisers and samplers, take records out of and back into sleeves with my good arm and hand. It was intensive… at least four hours per day, for a number of years. The other big thing was that I was evaluating my performance in relation to my action control each time by recording what I was doing. I made some terrible tapes.

“I would encourage anyone with spasticity in their upper limbs to consider this kind, or any kind, of intensive dosage of fun ‘hobby’- type training. It’s very hard for patients to find the right thing to do, but anything they can do to ramp up the number of hours of rehabilitation, the better.

“Back then there was nobody around to tell you not to do something, which was good, in a way. I had to innovate. Over the last 18 years or so, I’ve seen patients time and time again being told not to move for fear of doing bad movement. But in most areas, particularly lower limb rehab, this is wrong and out-of-date.”

ARNI – or Action for Rehabilitation from Neurological Injury – works with stroke survivors “stuck in limbo” after their therapy programme ends.

Via a network of specialist instructors and therapists across the UK, they learn ARNI’s functional “retraining” strategies aimed at enabling them to take charge of their own recovery.

It offers intensive one-to-one sessions in the home, some group classes and training manuals and DVDs which encourage stroke survivors to continually work on their rehabilitation. Classes are paid for by the client, although often at a reduced rate.

Balchin, however, has always been a volunteer in his own charity and has never taken any payment for his input. The programme is designed to speed clients from the stage where an NHS therapist becomes unavailable, to making recommended activities part of their daily life as they work towards more independence.

Its therapists and professional instructors meet the standards of the Stroke-Specific Education Framework. Clinical Commissioning Groups and charitable and local authorities provide community- based ARNI training for stroke survivors, which has been positively received.

The approach is now the adopted model for combined rehab and exercise after stroke for a number of UK areas.

“My big mission when I launched ARNI in 2002 was to get one ARNI qualified, appropriately insured and DBS-checked trainer within five miles of every stroke survivor who needed help, wherever that was in the country. I now have about 120 trainers on the books and am almost there. We haven’t quite got to everyone yet, but we’re getting there.”

Stroke survivors on the ARNI programme are matched with personal trainers and physical therapists; their focus is on helping people with partial paralysis to make as full a recovery as possible.

Results are achieved through various activities, including education in exercise principles after stroke and the establishment of an independent home-based exercise programme.

ARNI also develops skills in goal setting, functional problem solving and self- monitoring. It is a personalised programme, with substantial one-to-one training to ensure individual tailoring of activities, feedback and progression, and encouragement to work “at the edge of personal capacity”.

The approach has become increasingly well evidenced since 2007. In one small study, reported at the World Stroke Congress, involving 24 stroke survivors at the ARNI stroke gym at Chaul End Centre in Luton in 2011/12, participants reported improved mobility, range of movement, fatigue and confidence. Service audit data reported 24 ambulance call-outs for fallers during the year preceding intervention.

In the year of the intervention there were zero call outs, with an ambulance service saving of £7,200. This particular statistic was mirrored the following year.

Further savings of £5,482 came from the reduction in care packages, nursing input, catheter care, respite care, appliance support and medications.

Another small-scale study in 2014, supported by the NHS and the charity Different Strokes, revealed that all participants showed ARNI-powered improvements over a span of clinical measures.

A number of bigger randomised controlled trials have been undertaken, including one supported by Stroke Association, entitled ‘Retrain’. This was conducted by the University of Exeter and published in 2017.

It involved 45 patients and showed that ARNI is feasible, acceptable and safe. It also showed that key techniques involved in it could successfully support patients with one-sided loss, including those with multiple comorbidities (eg with lower limb amputation).

This year, an upper limb research study is taking place at Brighton and Sussex Medical School, looking at the efficacy of use of ARNI upper limb task training by patients and families in the clinic.

The ARNI programme involves task-specific functional movement training, development of physical management strategies, stroke- specific resistance training with adjuncts such as technology and pharmacological inputs recommended as appropriate. It was borne out of Balchin’s own rehab experience. He credits part of his success to an “innovative” physio who, in the early days after his stroke, taught him the importance of regaining self- reliance as quickly as possible.

Martial arts were also hugely influential. Despite the remnants of partial paralysis on one side, he powered through the coloured belt classes of aikido, karate, taekwondo and hapkido in the years after his stroke.

He also learned Teukgong Moosool, the official martial art of South Korea’s special forces. In 2008, he was awarded the grade of 3rd Dan by Grand Master Lee (8th Dan), Head Grand Master of the International Teukgong Moosool Federation.

Balchin also became a serious power-lifter and strength athlete, regularly working with non-stroke trainees. He added strength training into the mix from the initiation of his project for stroke survivors, at a time when the majority of UK therapists were not introducing it for fear that it would exacerbate tone.

It was difficult to find the evidence for strength training for stroke in the very early days, he says, but eventually did, academically justifying his project and implementing it successfully.

He honed his mental strength and capacity after his stroke too. He went back to university to finish his first degree and then taught for two years in a primary school.

He then went on to complete a masters degree and Phd and spent three years as a research fellow/lecturer in gifted education at Brunel University, London. Following that, he worked as an MA course leader in gifted education at Reading University.

He says: “Through my training, I regained nearly all my functional movement, and continued to perfect it twenty years later using ARNI-developed techniques.

“I still train all the time as it’s the only way to stave off limitations from stroke; and I’m still dealing with drop foot.

“The biggest weapon you already have on your side is definitely neuroplasticity. I learned that from Professor Nick Ward who runs the UK’s first specialist upper limb clinic. A very early supporter of ARNI, he helps me run the ARNI functional rehabilitation course for therapists and trainers.”

In the case of stroke, brain plasticity could allow certain lost functions, such as speech and language, to re-emerge as the result of intensive rehab. The ARNI system contains techniques designed to prime the body for task-related practice.

Often, therapists help stroke survivors to get to their feet and walk again after brain injury and many achieve great successes in the very short time they have to work with them in the acute/chronic stages.

However, ARNI works with many stroke survivors who find it hard to move on from sticks, orthotics and other aids to functional movement. Many feel they could achieve better function in their weaker hand, for example, if given a chance to do so by an ARNI instructor.

The benefits of rigorous training beyond the standard allocation of post-stroke therapy sessions are wide ranging, according to ARNI. They include balance and posture correction, improved timing, better flexibility and greater muscular, tendon and ligament strength.

These in turn can boost self-sufficiency, confidence, self-esteem and productivity in employment or hobbies. In ARNI’s case, clients are encouraged to work “on the edges” of their current ability to stimulate maximum neuroplasticity. Instructors teach progressively more advanced exercises.

A core part of the ARNI approach is to teach clients how to cope with falls; the most dangerous part of the balance problems caused by stroke.

Trainees (many of whom have the functional use of just one arm) learn how to get down to, and up from, the floor without any kind of external support to pull themselves up with.

They also learn other innovative strategies such as turning, step and ramp navigation and emergency action techniques. Balchin also teaches what he calls “gait-tactics”.

Upper limb retraining is a large part of the syllabus, with no coping or compensation allowed for the patients in this area: they are taught creative stretches to access, and then extend time, on discreet and progressive tasks, with spasticity decline being a focus.

“You have to develop strategies that are workable for the individual. You can give them the tools they need but clients need to be able to personalise them. Also, a key to good recoveries that I worked out straight away is that you can’t tell people they can’t do things. That’s absolutely critical.”

Balchin believes the rise of ARNI is timely, given current trends in UK healthcare. He points to the “sad fact” that effective rehab is generally unavailable from the NHS once sufficient movement to simply get around has been achieved.

At the same time, neurophysio and occupational therapy services are stretched, he says, while he believes stroke classes that promote active task-related functional movement and resistance training are non-existent.

“Most physical after-stroke classes that do exist are fitness-focused and many attendees report that these are, in conclusion, unable to provide them with the specific and custom tools they need to rehabilitate functional limitations or effectively cope with the rigours of their daily lives.

“This is especially the case if extra problems persist such as epilepsy, aphasia or fatigue. Most report that they need external help to guide balance control or spasticity decline for example, but that their essential cardio fitness can, in the end, be done better at home.” Meanwhile, global research findings have backed up the ARNI way for years, he believes.

Home visits and outpatient exercise programmes have been shown to improve gait speed. Research into ARNI techniques show that in a number of activities, performance is retained and built upon.

Balchin cites the example of the Dutch researchers Kollen, Kwakkel & Lindeman who, in 2006, reviewed all available published, clinical stroke rehabilitation trials, of which at the time there were 735.

They selected 151 studies including 123 randomised controlled trials and 28 controlled clinical trials. The rest did not meet the inclusion criteria as they lacked quality or statistical validity.

They wrote: “Traditional treatment approaches induce improvements that are confined to impairment level only and do not generalise to a functional improvement level”.

In contrast, they stated that: “More recently developed treatment strategies that incorporate compensation strategies with a strong emphasis on functional training, may hold the key to optimal stroke rehabilitation.”

In summing up their findings, they reported that “intensity and task-specific exercise therapy are important components of such an approach”.

Balchin says: “There is a good range of interventions with strong evidence of both efficacy and effectiveness now. Cochrane reviews have found that electromechanical gait training, treadmill training, circuit training, physical fitness training, repetitive task training, CIMT, mirror therapy and FES are also effective.

“You’ll notice that all of these interventions require that you DO something. So many stroke survivors do what is essentially a homeopathic dose of what is required to recover well.”

The delivery of ARNI’s services usually relies on the goodwill of others. While individuals pay for one-to-one sessions, the session costs are low – around £45 to £55 an hour.

The charity’s overheads are partly covered by physios paying to become qualified trainers and serious rehab training sessions at ARNI’s headquarters in Lingfield, Surrey.

The charity also gives full bursaries to students and runs a trainer sponsorship programme which enables any organisation, family or carer to sponsor an instructor through the ARNI qualification. The course fee is partly paid back by the instructor in the form of free lessons to the survivor. The charity also often gives away helpful material such as copies of The Stroke Survivor Manual and its stroke survivor DVD set.

“It’s a fact that a lot of stroke survivors just don’t know what to do when their clinical physio ends because they haven’t been set up properly to do better. What they probably need is an evidence-based, innovative and personalised programme of training strategies, a low-cost means of trainer or therapy support as they do it and to be guided to access helpful local community services or other specialist services.

“It’s really important that survivors are guided to autonomous retraining efforts if possible, in order that they may fulfil goals and thrive rather than decline, become dependent on others or just re-enter the care pathway.

“This is really hard to achieve, but one by one, over the years, ARNI has helped a vast amount of people. I’m proud of this and of the way that, by its sincere efforts, ARNI has gained the trust and support of professionals in neurorehabilitation over the years.”

Balchin describes the charity as his life’s works and passion. “Stroke has driven me to get better, and it continues to drive me to make the effort to help people affected by stroke to do better,” he says.

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Update:concussion in sport

A run through the latest developments in concussion in sport research and protocols.

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A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.

Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.

“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.

“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”

Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.

Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.

Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.

Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.

“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”

The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.

The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.

Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.

These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.

The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.

Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.

“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”

A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.

There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.

A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.

EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.

This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.

This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.

SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.

“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”

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Stepping up the fight against alcohol-related brain injury

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Alcohol-related brain injury (ARBI) is becoming more widely recognised, but specific rehab services for the condition are surprisingly rare.

With few dedicated units for patients with ARBI, many patients in need of specialist care instead find themselves in a hospital or even an elderly care home.

ARBI is characterised by prolonged cognitive impairment and changes in the brain due to chronic alcohol consumption.

The average age of diagnosis in men is 55, and only 45 for women – following at least five years of excessive alcohol consumption, of around 50 units per week in men and 35 for women.

ARBI is not a degenerative condition, with up to 75 per cent of patients recovering to some degree with the correct support; and the first three months following diagnosis are recognised as key in a person’s recovery. Access to appropriate provision, therefore, is even more crucial at this time.

In February, UK-wide charity Leonard Cheshire opened a residential unit in Northern Ireland to help some of the many patients in need in the country. It is the first facility of its kind on the island of Ireland. 

The 14-bed unit, near Belfast, opened inconveniently – after years of planning – just as the COVID-19 crisis was emerging.

Its work goes on, however, with the centre taking patients from across the country, though initially from the capital and surrounding areas.

The residential centre aims to support residents over a two to three-year period, although that can be shorter for some patients. It helps them to live independently, by building the life skills and confidence to do so. 

Naomi Brown, clinical lead at the centre, joined Leonard Cheshire late last year to oversee the opening of the facility, following an extensive career in brain injury work and in being part of multidisciplinary teams.  

She says: “The background here in Northern Ireland is that the acquired brain injury (ABI) service is really well structured and established but for ARBI, often the person wouldn’t meet the criteria for addiction services, but their needs would not be such that they needed to be admitted to hospital, or even fulfil the criteria for ABI services, so they would fall through the cracks.

“The provision they receive would often come from the care sector, but to end up in a care home at what could be a very young age is not appropriate either.

“There is a real lack of options. Their care managers recognise they aren’t in the appropriate setting for them, but through a lack of alternatives, it is very difficult.

“A lot of symptoms are very similar to those under the influence of alcohol, difficulty with balance and memory for example, which can make ARBI difficult to diagnose.

“Often it can be something like liver failure that gets them into hospital, but then it becomes obvious there are cognitive issues there too.

“Our centre only has 14 beds, which we don’t pretend is going to answer the scale of the problem, but the decision to restrict it to that number is that we don’t want quantity over quality. To try and accommodate huge numbers would risk the patient-centred approach that we are really proud of, so we wanted to keep it on a small scale.

“But there are 14 places here at any one time for people to get access to the specialist rehabilitation they need, so we are really pleased to be able to offer this.”

With the centre’s goal being the independent living of its patients, a resident-led rehab plan is created for each individual, based around their individual goals and aspirations.

It is delivered by Leonard Cheshire’s team of rehab assistants, supported by clinicians, occupational therapists, physiotherapists, speech and language therapists and neuropsychologists who come in to hold sessions with the residents, and overseen by Naomi. 

“From the minute someone is admitted to us, we are already planning for their discharge, even though that may be a long time and a lot of work away.

“From the very start, it’s about the individual, it’s absolutely not a generic approach, even though the ultimate outcome for everyone may be the same. Most people who move in do want to live independently, so if that’s their goal and we will do all we can to help them achieve that, with a plan individualised for them. 

“Some people will come to us and we realise they won’t be here very long as they do very well very quickly, but for others, they are going to be with us for two or three years.

“Some people arrive and love it here and say they don’t want to leave, which is a great reflection on the work we do and the centre we’ve created, but the ambition is that the point will come where they realise they don’t need us anymore.

“Through the work we do and our interventions, we can make very good progress. We’ve had some people here already who have been in quite an acute state but the progress they make brings joy into my heart.”

One such patient is David* who, despite only being with the centre for a matter of weeks, has made significant progress in his recovery.

Prior to moving to Leonard Cheshire, he lived in a nursing home for two years.

Before his arrival, Naomi remembers he had low mood, minimal spontaneous conversation and spent long periods of time in his bed sleeping.

He had no clear weekly routine and lacked any scheduled therapeutic or recreational activities.

Naomi says: “David initially required a significant amount of support to initiate activities, engage with others or even leave his room. He has slowly adjusted to the active therapeutic programme in the unit and his mood has improved significantly.

“His mobility and exercise tolerance has greatly increased, he participates in group activities, is now more spontaneous in conversation and has developed facial expressions. David has been able to self-identify rehabilitation goals and discovered a new love for playing the drums and guitar. 

“He is in the very early stages of his rehabilitation but having spent three months in the ARBI unit, the change is his quality of life is already dramatic.

“He engages in an individual, weekly timetable which includes activities of daily living, physical, cognitive and social activities, and is reportedly very happy in his current placement. Once the COVID-19 restrictions are lifted, we very much hope to begin reintegrating David to the local community and making future plans for his discharge.”

David’s experience is one which the unit is keen to replicate, by engaging patients from the earliest stages of their arrival at Leonard Cheshire in building a new and healthier daily routine.

“We are always keen to introduce routine, as that is so important in the longer-term. Where some people have maybe traditionally watched TV all night then get up into the afternoon, we try to create a new routine with lots of support services available in the morning. A healthy routine is what we want them to have when they go back home,” says Naomi.  

“We encourage people to do things for themselves – to get up, make yourself breakfast, maybe do some gardening or help with the cleaning, all things which promote the ability to do things independently.

“If they put the washer on, they’ll need to go back to it when it’s finished. We have rehab assistants on-hand to support them, but we do actively encourage independence.”

Everyone has an individual timetable for the week based on their own interests, combined with their clinical requirements, which centres on promoting reintegration into the community.

“It’s very individualised, so if someone wants to do an online course or learn how to cook for themselves, or learn a musical instrument, we’ll focus on that. We have a fantastic team here who will turn their hand to anything for the benefit of our residents,” says Naomi.

“As well as activities in the centre, we do a lot in the community, or rather we did before COVID-19, but that will resume when it’s safe to do so. We did sports activities, yoga classes, bowling, it’s not just your classic physio. We want people to be engaged and comfortable with the world outside. 

“We will always ensure residents have support once they leave us, and are setting that up long before they go.

“If there was someone who was with us who wasn’t from Belfast, we would use resources we knew were transferable to where they lived, so they didn’t leave us and not know how to access support.

“We build up these links with community services in the relevant discharge areas, so ideally the person will already be confident at being independent and will have the added assurance of knowing they continue to be supported.”

The Leonard Cheshire centre’s launch came amid changes to Northern Ireland’s legislative backdrop with the implementation of the Mental Capacity Act (NI) 2016. This has new deprivation of liberty regulations, a significant new introduction for the country and its approach to capacity and consent.

Naomi says: “When planning for the opening of a new centre, a global pandemic wasn’t on the radar, and for it also to coincide with the new mental capacity legislation meant it was a really busy time for us in the early stages, the COVID-19 aspect of which we could not have foreseen. 

“The pandemic did present challenges for our residents, many have a certain level of confusion so it’s difficult for them to always remember that they can’t be close to someone else, they have to regularly wash their hands. There is a lot of prompting which leads to a certain amount of frustration. While they are watching these things on TV about how COVID is affecting the world, it’s hard to relate that to everyday life.”

New referrals continue to arrive during the pandemic, from both hospital discharge and moving from a care home environment, although happily the Leonard Cheshire unit has remained COVID-19 free.

“We were keen to admit new residents and take referrals from hospitals and care homes, subject to extra measures being in place to protect ourselves and our residents.

“We wanted to continue to support hospitals and free up beds, but also to offer the appropriate care to people whose specific needs through their ARBI diagnosis meant they would be better in our centre than a hospital environment or care home.

“This has certainly been a challenging period in which to start our ARBI unit, but we have come through it well together so far and we look forward to continuing to develop ourselves as we come out of the pandemic and go into the future.”

*Name changed for anonymity.

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Neurobehavioural rehab in aggression management after TBI

Changes in personality following TBIs are often more problematic than neurocognitive, functional deficits or even physical disabilities. Dr Grzegorz Grzegorzak, consultant neuropsychiatrist at St Peter’s Hospital, South Wales, explains why taking a neurobehavioural approach to treating TBI can be highly effective.

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Personality changes are sometimes referred to as neurobehavioural disability (ND), especially when associated with social difficulties.

The concept of ND involves impairments of numerous aspects of functioning including the abilities to self- monitor and self-regulate, to control frustration, anger and aggression, to tolerate delay in gratification, and to self-motivate.

These impairments can lead to a sense of being overwhelmed when facing situations requiring control and management of internal impulses or coping with social situations or tasks.

Impulsivity, disinhibition and aggression all have significant potential to interfere with rehabilitation efforts, jeopardize recovery and become a major obstacle to successful functioning in social roles.

Research estimates the prevalence of aggression in survivors of TBI as being as high as 33.7 per cent.

Addressing aggression as soon as it arises is critical to the individual’s recovery.

Sometimes aggressive behaviour is so intense and frequent that its management takes priority over all other aspects of care and rehabilitation.

Neurobehavioural rehabilitation (NR) was introduced in the late 1970‘s as an attempt to improve functional abilities of TBI patients.

NR stems from recognising that people who survive TBI can still learn new skills to self-regulate and to modify their behaviour.

The basis of NR is embedded in learning theory and thus the success of NR is reliant on the patient’s ability to make use of new information and experiences.

Therefore, NR is only suitable for the post-acute phase of recovery from TBI, and in fact is intended as a medium to long term rehabilitation programme.

​NR interventions are composed of comprehensive and multidisciplinary efforts to create a user-friendly, supportive and encouraging social environment which facilitates therapeutic interactions and activities.

Specific goals and detailed routines are constructed for each patient individually, based on structured collection of data informed by behavioural analysis.

The process of designing and implementing the interventions puts emphasis on personal autonomy.

Clinical formulation is preferred over medical diagnosis. The attitude of the MDT should always be positive, embracing a strong belief in the patient’s ability to achieve their goals, improve and recover.

Carefully managed feedback and positive reinforcement are an essential part of NR.

Consistent interactions with every member of the team are of utmost importance, given that neurobehavioural intervention should not be limited to scheduled activities but in fact incorporated in every interaction.

Over the last forty years the model has been implemented by many neurorehabilitation services worldwide.

Several case studies describing recovery pathways through NR paint a very positive picture, and our own experience at St Peter’s of adopting a neurobehavioural approach has demonstrated it can produce real and measurable outcomes for both our patients andtheir families.

Case Study: Mehmet

On admission to St Peter’s Hospital, Mehmet presented with extreme challenging behaviours including serious assaults on staff, destruction of environment, verbal abuse and shouting.

Mehmet has frontal lobe dysfunction as a result of a head injury he sustained. For the previous 18 months he had been in a general hospital.

At St Peter’s a bespoke positive behaviour support plan and activity plan were developed with Mehmet’s input and reflecting his cultural needs which, under the supervision of his MDT, promoted positive changes to his social interactions, routines and activities.

Over nine months Mehmet’s challenging behaviours reduced significantly and he now enjoys a wide range of activities including regular community visits and has strengthened his relationship with his family.

Dr Grzegorz Grzegorzak is one of the consultant neuropsychiatrists at St Peter’s Hospital a specialist 39-bed Neuropsychiatric facility in Newport, South Wales run by the Ludlow Street Healthcare Group. www.saintpetershospital.co.uk

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