Dysphagia is an all-too common adversary of neuro-rehab patients, and the professionals who care for them.
Some studies suggest the swallowing disorder is experienced in as many as 93 per cent of people admitted to brain injury rehab centres (Hansel et al, 2008).
It will affect around one in two stroke survivors, according to the Stroke Association, and roughly at least a third of people with MS.
Meanwhile, over 80 per cent of people with Parkinson’s may be affected (Suttrup et al, 2016).
Its impact on the patient can be profound. Not only does it reduce life quality and independence – those key indices of rehabilitation – but can also complicate medication intake and cause malnutrition.
It is also implicated in infections such as aspiration pneumonia which can be fatal.
After a brain injury, damage to the main swallowing centres of the brain or to the nerves and muscles controlling swallowing can cause dysphagia.
But the brain injury can influence swallowing in other ways too, as brain injury charity Headway explains in its dysphagia factsheet:
“If the senses of taste and smell are impaired then the oral preparatory stage will be affected and the production of saliva will not be stimulated.
“This stage can also be affected by severe cognitive issues.
People may not understand what food is or have an awareness that they are about to eat.
“The effects of brain injury can also mean that people sometimes aren’t aware of problems such as food going down the wrong way, because their choking reflex doesn’t work.
This is known as silent aspiration and is one of the reasons that aspiration pneumonia can occur.”
Speech and language therapists employ a range of therapy techniques aimed at triggering the swallowing reflex and strengthening muscles needed for chewing and swallowing.
Once the patient is in a residential care or community setting, carers and loved ones may also have a key role to play in minimising the impact of the condition.
“Dysphagia can mean that mealtimes become a struggle,” says Helen Willis, dietitian at Wiltshire Farm Foods.
“Not only is eating a slow process, but it can also be a scary one.
“The risk of choking or aspiration, the inhaling of food into the lungs, is high and can lead to frequent chest infections and pneumonia.”
A texture-modified diet may, therefore, be required to counter these risks.
But home-blended food brings with it its own problems, on top of reduced appetite caused by illness and apprehension about swallowing.
Helen says: “Being presented with a puréed meal that doesn’t resemble food that a patient is used to can make the eating process even harder.
“People with dysphagia still eat with their eyes so if a meal is not visually appealing then it can fail to trigger salivation, further hindering an already-weakened swallowing process.”
Density of nutrition, or rather lack of it, is a major factor too.
“Adding water to aid the blending process of food at home can dilute the nutritional content, meaning patients need to eat a higher volume of food to achieve the same nutritional intake at a time when they are more likely to have a reduced appetite.
“Often patients with dysphagia struggle to get the calories and nutrition they need, meaning each bite they do take needs to be packed with as much protein, calories, vitamins and minerals as possible.
“Serving larger portions with fewer calories does little to improve mealtimes for dysphagia patients since the meal may appear more intimidating and is unlikely to be finished.”
In her role as an in-house dietitian at Wiltshire Farm Foods, Helen is tasked with finding solutions to such problems.
One alternative to home-blended food for dysphagia patients she has influenced is the PuréePetite range, part of the Softer Foods range of texture modified meals.
They provide smaller, and therefore more manageable, portions. Yet deliver the same nutritional value as a standard-sized dish.
They are “energy dense” to serve up a similar calorie and protein content as larger dishes, containing a minimum of 500 calories at least 20g of protein.
They are also suitable for patients requiring a Level 4 Puréed diet in line with the recently introduced IDDSI (International Dysphagia Diet Standardisation Initiative) food and drink texture standards.
Crucially, dishes in the range are shaped to look like a non-blended meal – “making them more appealing, encouraging patients to eat”, says Helen.
Another weapon in the fight to mitigate dysphagia’s impact is the oral nutritional supplement (ONS). Fortifying or adding an ONS to the patient’s diet can deliver high levels of protein or calories in a low volume.
Whichever option is taken, the power of good nutrition in rehabilitation should not be underestimated, or compromised because of swallowing difficulties, says Helen.
“Eating a well-balanced meal that meets the patient’s nutritional needs whilst being at a safe texture can lead to improved recovery times and a better quality of life.
“Healthcare professionals should consider all options when it comes to providing the best diet for their dysphagia patients, and always be aware of the potential challenges of home-blended meals.”
To discover a range of Softer Foods products that are IDDSI compliant and designed to help your patients and residents with dysphagia visit www.specialistnutrition.com to request a brochure or book a tasting session with Wiltshire Farm Foods.
Adventures in online conferencing
Merryn Dowson, of rehab goal-setting platform Goal Manager, on why the virtual conference should endure long after COVID-19’s limitations are gone.
Just in case you hadn’t noticed, the last year has been a little bit different from previous years and by ‘different’ I, of course, mean ‘online’.
Conferences have been no exception. Instead of arriving at a large hall, picking up the first of the day’s seven coffees and scanning the room for the best pens on offer, we are finishing off our morning routines and setting our out-of-office email only to sit in the same chair and log in to an online virtual conference.
In March we may have hoped that these conferences would actually happen in person and that the world would quickly get back on its axis but we soon realised that this would not be the case.
We were to access it all from our computers, perched wherever we can manage in our homes.
In August, I had my first taste of this unprecedented, socially- distanced, new-normal approach to conferences by logging on to that of the American Psychological Association (APA).
For many, a previously inaccessible conference due to travel and registration fees, this year it was beamed on to my laptop at a comparatively low cost.
Not only that but, unlike at physical conferences, I did not have worry about rushing from room to room, all of my belongings slung over my arm (including a tote bag of the aforementioned pens), hoping to make it on time to the next talk I had circled in the programme.
I was able to click freely between ‘rooms’, catching the end of the talks while the kettle boiled in anticipation of the next speaker. I made notes from the comfort of my desk, no balancing a free notepad on my knee.
It was refreshing. Even if I missed a talk because I dipped back into some work (another luxury of the online conference), I was safe in the knowledge that it remains online for the rest of the year to be viewed at my leisure.
I had the privilege of seeing this from the presenter side too. In October, Dr Penny Trayner, Dr Andrew Bateman and I delivered an instructional course on best-practice goal setting in clinical practice at the annual conference of the American Congress of Rehabilitation Medicine (ACRM).
Although a complex presentation involving multiple presenters and real-world video examples, unusually, there was no sense of trepidation about everything going to plan because, like the other presenters, we had already submitted a video of the entire workshop to be broadcast right on time.
There was simply a sense of calm excitement. We were able to join the attendees in the live discussion chat, respond immediately to questions and follow the buzz on Twitter.
We were even able to ask participants to log in to Goal Manager, a cloud-based platform for facilitating the key processes of goal setting, and ‘follow along’ with a case example by filling out a patient profile using the knowledge and skills developed during the course.
This would not have been as accessible had everyone been gathered in a room, rather than sat at their computers. At the end, we hosted a live Q+A with the workshop participants and it truly had that sense of community that we all attend conferences for, connecting everyone with a shared interest live from their living rooms across the globe.
This continued throughout the conference including the poster presentations. As we well know, posters are often presented in the same room as a substantial lunch and, occasionally, complementary wine. This can make it slightly difficult to having a meaningful discussion with someone about their life’s work and the next huge contribution to neurorehabilitation.
Instead, this year’s posters were displayed on screen with a short pre-recorded narration of key themes and findings.
Dr Trayner and I presented an evaluation of real world systemic interventions run within Clinical Neuropsychology Services and we were able to give much more of an insight into the bootcamp we ran, the parenting course we delivered, and the DJ skills programme that Dr Trayner has helped to coordinate.
We were able to answer questions on these interventions both during the poster presentation and for a while afterwards on social media as people continued to revisit all of the posters long after each session. This meant that we too were able to see others’ posters and ask them questions. Everything was at our fingertips.
Of course, I describe all of this understanding its overwhelming sense of novelty.
While I have very much enjoyed learning about the latest developments in our field while wearing considerably more comfortable trousers than I would permit myself to wear in public, I would love to be in a room with the innovators, pioneers and trailblazers of neurorehabilitation, each eager to share new ideas (not forgetting the free pens – have I mentioned those?).
Networks are built at these events that go on to forge lasting collaborations and amazing developments.
Whereas academia and specialised clinical work can often exist in silos across the country, continent and world, conferences bring everyone together.
I look forward to the next event that is held in person however I do hope that not everything from this new world is discarded too quickly. This year has shown us how so many barriers to access can be broken down just by a few additions. The option for online attendance has provided entry to previously inaccessible events; the ability to re-watch talks for months afterwards has taken away the pressure of cramming hours of content into a few days while abandoning all other commitments. More people have access to the discussions and ideas shared than ever before. I hope the concessions that allow this to happen remain long after the many advantages to physical conferences resume.
In the meantime, however, I enjoy the literal home comforts that this new age of conferences brings.
As you read this article, I will have recently attended the Time For Change Online Summit by the UK Acquired Brain Injury Forum (UKABIF) with my cat on my lap and my favourite mug in hand.
At least for the time being, that is something to be enjoyed. Until I run out of pens.
Editor’s comment: Onwards and upwards in 2021
In a former life in newspapers, it was at this time of year that the dreaded churn of annual reviews and previews came…
Ups and downs of the months gone by and ill- informed soothsaying for the year ahead served only to plug the festive news glut.
Pity the junior reporter seeking their highlights of 2020. This year feels less a series of chronological news events and more a mighty tempest that has shaken our entire reality off course.
There are some positives shining through the storm, but their longevity can barely be contemplated before we’ve worked out exactly what 2020 was all about.
There has been much talk of the great technology embrace; and telemedicine and digital health purveyors have certainly been among the winners this year.
New ways of working have emerged and now feel like they’re here to stay, with hours spent travelling to meetings replaced by a few moments positioning laptops and checking audio.
Other silverlinings of the year include fresh investment in health innovation and greater respect for key workers in all their many roles.
Perhaps the most widely felt positive of 2020, however, is its hammer-blow reminder of the importance of human interaction. Smiles hidden behind masks. Embraces blocked by glass. Conversations hindered by dodgy wifi. Each momentary expression of COVID life reminds us of what we’re missing – and hopefully what we can look forward to in 2021.
Neuro-rehab professionals have fought hard to preserve what remnants of direct human interaction they safely can in the lives of their clients.
Many facilities have moved heaven and earth to enable safe visiting of family members, and the crucial interactions with the cast of professionals helping them on the road to independence.
And this is no mere sentimentality or what corporate speak terms a ‘nice-to-have’. It is borne out of a recognition of the pivotal input of people, both family members and professionals, in the rehab journey which no amount of machinery or bandwidth can replace.
I wish all our readers the very best for 2021 – a year which is loaded with optimism and an eagerness to move on from 2020’s challenges.
As the Blairite anthem goes, things can only get better!
Andrew Mernin is editor-in-chief at NR Times.
Hydrotherapy pools at home – are they necessary?
By David Withers, partner at Irwin Mitchell.
In serious injury cases, the parties can often disagree about whether an injured person has a need for a hydrotherapy pool. The installation, and subsequent maintenance, costs of a hydrotherapy pool are significant. This is often one of the most contentious heads of loss that arises in a serious injury case.
In tort, the principle of “restitution in integrum” applies. This means that insofar as is possible the injured person should be put back in the position that they would have been in but for the negligence [see Livingstone – v – Rawyards Coal Co (1980) 5 App Cas 25]. This is often known as the full compensation principle.
There is no financial limit. The consequences for the Defendant of a high award of damages are not considered [see Lim Poh Choo – v – Islington Area Health Authority (1980) AC 174].
The general rule is that “he who asserts must prove” [see Robins – v – National Trust Co (1927) AC 515.
More recently, the concept of proportionality has been developed in the context of assessing damages in high value cases. For example, in Whiten – v – St George’s Healthcare NHS Trust  EWCH 2066 (QB), Swift J stated that when considering whether actual or proposed expenditure is reasonable, she had regard to proportionality as between the cost to the Defendant and the extent of the benefit which would be derived by the injured person.
In Ellison – v – University Hospitals of Morecambe Bay NHS Foundation Trust  EWHC 366 (QB), Warby J rejected the argument that an injured person should not recover the cost of a particular item if the cost was disproportionately high in comparison with the benefit achieved.
Therefore, in summary, if an injured person has a need for hydrotherapy which cannot be met in any other way realistically, the cost of a hydrotherapy pool will be allowed.
If an injured person has a need for hydrotherapy but that need can be met realistically in some other less expensive way, the cost of a hydrotherapy pool will probably not be allowed.
The costs of a hydrotherapy pool are likely to be allowed if:
- an injured person has a daily need for hydrotherapy;
- this is supported by the relevant medical experts and the physiotherapy expert;
- the injured person reports feeling much better after the sessions;
- there is a track record of engagement with hydrotherapy provision if possible, evidenced in the notes and in invoices; and
- there is evidence that alternative provision either does not exist or is completely impractical.
Although each claim is of course fact specific and bespoke to the injured person, if there is a clinical need for hydrotherapy, identified by the relevant medical expert(s) and the physiotherapist and the need arises frequently (the authors would say on at least a weekly basis), the costs associated with a hydrotherapy pool should be recovered.
There is, however, a mix of case law and no guarantees about recoverability can ever be made. For example, in Robshaw – v – United Lincolnshire Hospitals NHS Trust  EWHC 923 (QB), the cost of a hydrotherapy pool was allowed, whereas in JR – v – Sheffield Teaching Hospitals NHS Foundation Trust  EWHC 1245 (QB), the cost of a hydrotherapy pool was disallowed. In JR, the annual sum of £1,925.00 was instead allowed on the basis that the injured person would have 35 visits to a local pool each year. This equates to c.67% attendance each week.
The Judge, Davis J, found:
“The final issue in relation to accommodation is whether a hydrotherapy pool should be provided at JR’s home. It would not be reasonable or proportionate. JR likes the water and is relaxed by it. He would enjoy having his own pool. But this is a case in which I can and should take an approach similar to that which I took in HS v Lancashire Teaching Hospitals  EWHC 1376 QB, namely make provision for the cost of visiting a local hydrotherapy pool (of which there are several) on a regular basis.
In JR, the Judge was not persuaded to allow the costs of a hydrotherapy pool. This case highlights the challenges that injured people can have in recovering the cost.
An important point of good practice is to plead the claim in the alternative. In the event that the claim for a hydrotherapy pool and the associated costs fails, the injured person should be able to seek the additional cost of care, travel, aids and equipment, pool hire and insurance which will likely arise if using a local pool.
These costs can easily be quantifiable if the injured person has in fact been hiring a local pool. If there is no such past evidence, the physiotherapist will quantify these costs based upon their experience of arranging such provision for injured people.
Evidence and mitigation of loss
The starting point should be the frequent use of a hydrotherapy pool if the injured person has access to one. If the injured person is frequently travelling to use a hydrotherapy pool and is reporting benefit from doing so, the argument becomes much stronger.
There is a requirement for medical and physiotherapy evidence to underpin the importance of hydrotherapy. This could be, for example, to assist with controlling spasms, to prevent contractures or to provide cardiovascular exercise.
Defendant teams will often assert that it is unreasonable for the injured person to have a hydrotherapy pool in their garden on the basis that they can travel to one close by. The Courts can be persuaded by these arguments. The issues that need to be weighed up are as follows:
- The distance from the injured person’s home to the hydrotherapy pool;
- The availability of the hydrotherapy pool;
- The number of times per month that the injured person needs to reasonably use the hydrotherapy pool;
- The cost of arranging for the injured person to go to the hydrotherapy pool;
- Whether there are adequate changing facilities at the premises of a local pool;
- Whether there is access to a hoist in a local pool if required;
- Whether the water is at an appropriate temperature;
- Whether the pool is too noisy;
- Whether the pool can be hired.
If the injured person has a need for hydrotherapy once a month, it will be a steep uphill battle to obtain damages to install and subsequently maintain a hydrotherapy pool at home.
If a hydrotherapy pool is sought, the following expenses will need to be born in mind by the lawyers:
- The actual pool and any replacement cost;
- The capital cost, and the subsequent maintenance costs, of building or extending the property to house the pool;
- The additional equipment, running and maintenance costs such as heating and treatment of the pool.
In summary, although it is certainly possible to obtain the costs associated with a hydrotherapy pool, it is probably fair to say that it is one of the most challenging heads of loss to prove and the need for specialist lawyers and evidence is vital.
David Withers is a Partner of Irwin Mitchell LLP and a Solicitor-Advocate, leading a team specialising in serious injury cases in excess of £250,000.
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