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Action among the daffodils

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William Wordsworth urged to the world to “come forth into light, let nature be your teacher”.

He was obsessed with the natural world’s power to help, heal and nourish.

Surely then, the lake poet would have approved of the owners of his old Cumbrian bolt hole.

For they are also channelling the power of nature, in the name of rehabilitation.

On the outskirts of Keswick, down the sort of road that only the Lake District can produce – dramatic skies, looming peaks and ancient trees stretching their arms over the narrowest strip of tarmac – stands Old Windebrowe.

The finishing touches are just being put on restoring the 500-year-old tithe barn and dairy cottage when NR Times arrives on a wintry morning.

Fortunately the heating is working and, over coffee in the barn’s vast communal space, Jill Beswick updates on the progress.

She recently moved here from Shetland to take up her role as clinical lead for Calvert Reconnections, an acquired brain injury (ABI) rehab centre harnessing the great outdoors to drive better patient outcomes.

Her experiences of running a community rehab service on the remote Scottish island could stand her in good stead for rolling out her new employer’s big plans.

“I’m used to remoteness, weather and small communities that really seem to look after each other. We moved up to Shetland for a two-year adventure and ended up staying for 16 years but when I saw this job it struck me as a brilliant opportunity and I’ve been on a rollercoaster ever since.”

 We’re sitting in an area where brain injuries survivors, support workers and therapists will gather in the morning, anticipating a day of outdoorsy adventure; and socialise in the evening, windswept and glowing from the best the Keswickian elements can throw at them.

“When I show the locals round they all remember the ceilidhs they used to come to here,” says Jill. But the real historical highlight of the building is its Romantic connections.

Wordsworth’s close pal growing up was one Raisley Calvert, and their friendship continued into adulthood.

By age 21, however, Raisley had developed tuberculosis and was dying. He saw great potential in his young writer friend and wanted to help him fulfil it.

He made sure that his family’s Old Windebrowe cottage was given rent-free to Wordsworth and his sister Dorothy and they lived there for several years.

He also left him £900 in his will to afford him the freedom to write, prompting William to pen the sonnet, To the Memory of Raisley Calvert declaring: Calvert! It must not be unheard by them / Who may respect my name that I to thee / Owed many years of early liberty.

It’s fitting that the room where Wordsworth lived, and which was a launchpad for his career, will be used for life-changing interventions once more; with Calvert Reconnections developing it into a classroom for residents and staff.

The organisation believes it has created the UK’s – and possibly the world’s – first intensive ABI rehab centre focused on outdoor activities.

Residents will typically stay for three to six months, with accommodation for up to ten adults with ABI at any one time.

The centre offers a “24-hour interdisciplinary approach”, with clinical and rehabilitation support combined with various outdoor activities to challenge individuals and deliver evidence-based outcomes.

Before its £1.4m redevelopment, the property had been largely unused, save for some activities like archery. Thanks to a fundraising drive by the Calvert Trust, the charity which provides outdoor adventure holidays for disabled people, it has undergone a dramatic transformation.

The Grade II-listed building now has accessible bedrooms, a self-contained flat to help support people in their independent living, alongside a living area with kitchen and laundry facilities to encourage residents to do as much for themselves as possible.

The centre also has links to Calvert Trust’s portfolio of other facilities, including outdoor activities centres and accommodation also in the Lake District.

The facility adds much-needed residential brain injury care capacity, helping to alleviate a problem continually highlighted by neuro-rehab professionals; the chronic lack of available resources, which can jeopardise patient outcomes.

Recent research carried out by Exchange Chambers barristers and Calvert Reconnections highlighted this further.

It shows that ninety-seven per cent of senior brain injury lawyers believe there are a lack of residential- based brain injury rehabilitation units in the UK.

Also, 71 per cent say the NHS is unable to provide effective support. (Clearly this research took place before the Covid-19 crisis, and time will tell what impact the pandemic has on NHS investment in the future.)

Calvert Reconnections is helping to plug this gap in residential ABI care, while also offering a novel approach – drawing on the benefits of outdoor activity.

“The fact that we really focus in on the outdoor activities and adventure as part of our therapeutic model makes us completely unique. There is nowhere else doing what we do,” says Jill.

“The outdoor activity approach is our therapeutic medium to reach the goals that people want to achieve around things like planning, time management, social interaction and managing impulsive behaviours.”

Outdoor activities can also enhance wellbeing and confidence, Jill explains.

“The goal might not be to climb a mountain, for example, but it’s the fact that what you are doing is a challenge that matters, and this alters how you feel about yourself and your own mental wellbeing.

“If I can do this, which I never thought I could do, then what else can I do? It starts opening up other horizons.”

The outdoor element is underpinned by an interdisciplinary programme which Jill and her team build around the needs of individual residents.

“With a neuropsychologist, neurophysiotherapist and junior occupational therapist employed on-site, alongside rehab coaches with a background in enabling support or activity instruction, the team has been put together to respond to bespoke needs.”

And daily routines do not follow the norm in neuro-rehab.

“We don’t have a clinical model here,” she says. “We don’t have say, physio at 10 o’clock and speech therapy at 11. We don’t have a set programme of that kind at all.

“We work in conjunction with our participants, get to know their aims and work together to achieve them. It depends on their interests as to how we match that and also decide what therapies are appropriate.

“Certainly, we don’t have a programme that everybody has to fit into. We speak to people, find out their interests, the difficulties they have, their aspirations and what they want their future to look like.

“We can then look at how we can build that into their own therapy programme.”

An array of activities is offered to residents, depending on their individual needs and preferences. Calvert Reconnections has an adjacent horse riding centre and is also only four miles from the Calvert Lakes Activity Centre.

“Taking the access we have to the stables as an example, it’s not just about horse riding, there is equine care, stable management, repairing fences and outdoor management. We are focusing very much on the activity challenge alongside the vocational one.

“We have two people carriers which will enable us to get out and about, and we do want to work with the community and with local businesses and groups.

“The response we have had so far has been fantastic and we hope there are many opportunities for us to work together.

“We’re not a secure unit, we’ve developed this as being a part of the community, and we want people to feel able to go out into the community. Doing this helps to open up further opportunities for life experience.”

After busy and active days, the Calvert Reconnections centre itself offers a homely environment, with ten individuals bedrooms on the ground floor and a first-floor living area including a snooker table to increase the opportunity for social interaction.

The centre is designed to be both relaxing and challenging.

“If you go to most rehab units, they are a bit like hotels in that every bathroom and bedroom looks the same. But that’s not what we’ve got here. Every room is different, which gives it character, but also provides a better opportunity from a rehab perspective because it can offer different challenges.

“Depending on what type of bathroom facilities they have at home, for example, we can try to replicate them to better prepare them for the future.

“Also, with a lot of newly-built rehab units which are very accessible, but very clinical, you find that when somebody is going home, they may not have had any experience of steps, slopes or other walking challenges that occur in real life areas.

“Whereas here, while some of it is a bit quirky because it’s a very old building, we have a real life setting and we want it to challenge our residents.

“If you make things too ideal, you’re setting people up for failure when they go out into the community. Can they go to the local shop if you’ve not been practicing on stairs or different surfaces?”

The approach is also designed to support residents’ mental wellbeing, helping them to better manage the cognitive challenges of daily life.

“Often, when people are going through their acute phase of rehab and to get them out of hospital, the focus is on whether you can walk, wash and dress yourself. But actually they may not be able to manage a daily routine.

“They look good because they’re walking fine, but planning their day and managing their activities within the day is a real struggle. So we feel that to be able to work on that cognitive rehabilitation, mental wellbeing is a massive aspect that we’ll also be addressing.”

As well as focusing on the needs of her residents, Jill also hopes to help to build up the hard evidence for Calvert Reconnections’ distinct approach.

“Previously this type of service has not existed, which is why we need these evidence-based outcomes.

“But everyone we have spoken to and consulted with, whether that’s potential clients, clinicians, case managers, physicians and personal injury lawyers, is really excited about the model and feels that this is absolutely the way forward.”

And once such evidence is collected demonstrating the value of Calvert Reconnections’ approach, Jill aims to share it as widely as possible.

“We are very excited about the work we are doing and the impact this will have on the people who come to us from across the country, and hopefully on many others too,” she says.

Since our visit, Calvert Reconnections has opened for referrals. Find details here: www.calvertreconnections.org.uk.

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Insight

Astrocytes identified as master ‘conductors’ of the brain

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In the orchestra of the brain, the firing of each neuron is controlled by two notes – excitatory and inhibitory – that come from two distinct forms of a cellular structure called synapses.

Synapses are essentially the connections between neurons, transmitting information from one cell to the other. The synaptic harmonies come together to create the most exquisite music–at least most of the time.

When the music becomes discordant and a person is diagnosed with a brain disease, scientists typically look to the synapses between neurons to determine what went wrong. But a new study from Duke University neuroscientists suggests that it would be more useful to look at the white-gloved conductor of the orchestra – the astrocyte.

Astrocytes are star-shaped cells that form the glue-like framework of the brain. They are one kind of cell called glia, which is Greek for “glue.” Previously found to be involved in controlling excitatory synapses, a team of Duke scientists also found that astrocytes are involved in regulating inhibitory synapses by binding to neurons through an adhesion molecule called NrCAM. The astrocytes reach out thin, fine tentacles to the inhibitory synapse, and when they touch, the adhesion is formed by NrCAM. Their findings were published in Nature on November 11.

“We really discovered that the astrocytes are the conductors that orchestrate the notes that make up the music of the brain,” said Scott Soderling, PhD, chair of the Department of Cell Biology in the School of Medicine and senior author on the paper.

Excitatory synapses — the brain’s accelerator — and inhibitory synapses — the brain’s brakes — were previously thought to be the most important instruments in the brain. Too much excitation can lead to epilepsy, too much inhibition can lead to schizophrenia, and an imbalance either way can lead to autism.

However, this study shows that astrocytes are running the show in overall brain function, and could be important targets for brain therapies, said co-senior author Cagla Eroglu, PhD, associate professor of cell biology and neurobiology in the School of Medicine. Eroglu is a world expert in astrocytes and her lab discovered how astrocytes send their tentacles and connect to synapses in 2017.

“A lot of the time, studies that investigate molecular aspects of brain development and disease study gene function or molecular function in neurons, or they only consider neurons to be the primary cells that are affected,” said Eroglu. “However, here we were able to show that by simply changing the interaction between astrocytes and neurons — specifically by manipulating the astrocytes — we were able to dramatically alter the wiring of the neurons as well.”

Soderling and Eroglu collaborate often scientifically, and they hashed out the plan for the project over coffee and pastries. The plan was to apply a proteomic method developed in Soderling’s lab that was further developed by his postdoctoral associate Tetsuya Takano, who is the paper’s lead author.

Takano designed a new method that allowed scientists to use a virus to insert an enzyme into the brain of a mouse that labeled the proteins connecting astrocytes and neurons. Once tagged with this label, the scientists could pluck the tagged proteins from the brain tissue and use Duke’s mass spectrometry facility to identify the adhesion molecule NrCAM.

Then, Takano teamed up with Katie Baldwin, a postdoctoral associate in Eroglu’s lab, to run assays to determine how the adhesion molecule NrCAM plays a role in the connection between astrocyte and inhibitory synapses. Together the labs discovered NrCAM was a missing link that controlled how astrocytes influence inhibitory synapses, demonstrating they influence all of the ‘notes’ of the brain.

“We were very lucky that we had really cooperative team members,” said Eroglu. “They worked very hard and they were open to crazy ideas. I would call this a crazy idea.”

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Insight

Carers at risk of being forgotten

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A study has found that 68% of people believe they should ‘reach out’ to carers more often – with 60% of respondents only asking carers how they are ‘now and again’, ‘rarely’ or ‘almost never’; leaving carers at risk of feeling forgotten.

Furthermore, 72% of respondents worried that carers struggled with ‘loneliness’ thanks to the full-on nature of care leaving them little time for socialising.

Throughout the pandemic, caregivers have been at the forefront of the fight, looking after the most vulnerable in society and putting their own lives on the line to do so. In light of this, a campaign called #ReachOutAndHelpOut has been launched to encourage support for carers as they continue to deliver essential care to those in need – amidst fears that carers’ wellbeing is often overlooked.

Spearheaded by Sentai, a British technology start-up focused on helping the elderly live more independently in their own homes, the campaign looks to highlight the vital role that carers play.

Respondents, mindful of the associated health impact of winter, believe the biggest fears to be faced by carers in coming months is another ‘national lockdown’ (60%), while 53% of respondents saw ‘excessive workload’ as a primary worry. 50% also believed ‘difficulty visiting family and friends due to their care commitments’ was a central concern, while ‘juggling different responsibilities’ was a key issue according to 46%.

Other concerns included ‘lack of time’ (32.9%) and carers ‘feeling they’re not doing enough’ (25%).

Professor Ray Jones, professor of health informatics at Plymouth University and director of eHealth Productivity and Innovation in Cornwall and the Isles of Scilly (EPIC), which focuses on the provision of internet based healthcare services (eHealth) voiced his support for the campaign, highlighting the difficulties carers face.

He said: “The impact of the coronavirus crisis has been profound on almost all aspects of society. For carers though, this impact has been magnified to a far higher degree. The physical and psychological toll of caring during a pandemic is huge. We must be mindful of the burden placed on carers and do what we can to help. The service they provide is essential, and we’re all indebted to their hard work. The very least we can do then is simply ask them how they’re doing and offer whatever assistance we’re able to give.”

These sentiments were echoed by Philip Marshman, founder of Sentai and orchestrator of #ReachOutAndHelpOut, who said: “The role of a carer is often overlooked. It’s all too easy to ask how the recipient of care is without extending that concern beyond to take into account the person looking after them. Carers are people, not robots, and now, more than ever we must do what we can to consider and support their wellbeing and mental health.”

Sentai has launched a Kickstarter campaign to raise funds for the next stage of its smart device development, the success of which will see its pioneering technology brought to mass market – allowing those in need to benefit from its advanced offering.

Philip said: “The experience of looking after my own father led me to create Sentai, and it’s been developed to help both the care recipient and the caregiver. Through revolutionary voice technology it initiates intelligent conversations, helping to alleviate boredom and loneliness, while also providing helpful reminders. It’s safety properties also allow the caregiver to monitor the care recipient remotely and unobtrusively, providing reassurance that the care recipient is OK and acting as normal, thereby helping to ease stress and worry for the caregiver.”

He added: “We have everything in place to deliver a successful solution – we want to get Sentai into people’s homes as quickly as possible – whether that’s someone’s own home, or a care home. Raising funds in this way means we can stay true to our mission which is helping people live more independently, for longer.”

Further details of the Kickstarter campaign can be found via https://www.kickstarter.com/projects/sentai/sentai.

To find out more about the #ReachOutAndHelpOut campaign and the different ways to get involved, including the chance to win a well-deserved break away, please visit sentai.ai/ReachOut.

Others in the care industry who have expressed support for the #ReachOutAndHelpOut campaign, include Dr Stephen Ladyman, founder of Oak Retirement and former Minister of Health responsible for Social Care, and Shaleeza Hasham, founder of the Adopt a Grandparent scheme and head of hospitality at care home and home care provider, CHD Living.

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PhysioFunction setting the trend for telerehab

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Having been an early adopter of telerehab, PhysioFunction was perhaps less daunted than most at the prospect of responding to the COVID-19 lockdown and ensuring their clients’ needs were met.

The specialist neuro physiotherapy practice has, for the past year, used video calls to enable its clients to receive one-to-one sessions in addition to those provided in person, with its staff supporting them to install and use the technology remotely.

It is also an early adopter of the MindMotion GO, a first-of-its-kind mobile neurorehabilitation therapy system which uses gaming to support the recovery of brain injury and neuro patients.

PhysioFunction has reported strong levels of engagement and progress among clients as a result of its telerehab programme, which has increased in its use during the past few months amidst the pandemic.

From its specialist outpatient rehabilitation unit in Northampton, PhysioFunction supports patients from a 100-mile radius, which was a key driver in the adoption of virtual means of delivering therapy.

Claire Everett, clinical operations manager at PhysioFunction and a senior neurological physiotherapist, said: “For some time now, we have tried to embrace the use of online means for therapy, and it has really helped many of our clients. By doing sessions in their own homes, we see them taking ownership of their rehabilitation and it delivers benefits to them in their own settings.

“For example, we might be doing a session by video with a client on how to cope in the kitchen – but because it’s their own kitchen they’re in, that makes it even more relatable.

“It is a very useful way for some clients who perhaps struggle to get to us once a week, but cope much better with two half-hour weekly sessions by telerehab. We do carry out home visits, and will combine the remote sessions with hands-on therapy wherever we can, but some clients live quite a distance away or maybe it isn’t easy for them to get out of the house.

“By holding sessions by video, it doesn’t matter where they live, whether it’s round the corner or two hours away, and we’ve had a great response to our telerehab work. It’s changed our practice in some really positive ways.”

When lockdown came, while for many organisations a swift and seismic move to the adoption of remote communication was needed, PhysioFunction were in the enviable position of being able to build on what they had already created.

“With us already being established with many clients, we didn’t have to start from scratch, and we could look at how to build on what we had already done. By extending our telerehab programme, we could continue to support our clients effectively,” says Claire.

“The team were able to take our classes online from a very early stage, with Taher Dhuliawala and Keiran Cox very much holding the fort during lockdown. The classes followed the same format as in person, with small numbers of participants so we can easily spot if someone needs help, but we were able to increase the frequency of them. Being able to do these kinds of sessions in your own living room was really welcomed.

“With clients who were already able to use video, we also were able to introduce the MindMotion GO, which is fantastic as we can interact with the technology and, for example, increase the intensity as required. But at the start of the pandemic, we still had some clients who didn’t use video, and the fact we have supported them to use it meant they had an extra channel of communication with their family during lockdown, and that was a lovely extra benefit.

“Even aside from COVID, with the flu and winter weather coming, we are expecting further demand for our telerehab sessions. We’re currently running a blended approach of online and in-person sessions, although a few people are still choosing not to come in at all, but they have found our telerehab so effective that they’re still progressing with their therapy.”

While remote working was a ‘needs must’ for many practices during lockdown, and to help mitigate ongoing restrictions, PhysioFunction intend to continue to build telerehab as a core function.

“We are very into innovation and technology here and our team have worked really hard to do what we’ve done, I’m really proud of what we’ve achieved,” adds Claire.

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