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Delivering at-home physio during lockdown – the challenges and opportunities

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For those providing rehab services, lockdown has presented many challenges in how to continue treatment in light of ongoing restrictions. Here, Ben Ruby, owner of Ben Ruby Neuro Physio, discusses how he has adapted his way of working to ensure his clients continue to benefit and how telerehab can help people discover new possibilities.

“Provision of therapy services since March 2020 has shifted due to COVID-19 and the restrictions put in place by the government. Working within the private sector and providing specialist neurological physiotherapy input, I often spend prolonged periods of time within my clientshome.

Providing rehabilitation within peoples homes can generate fantastic results as its possible to make treatments specific to the individual’s needs and is more relevant to their day to day lives. This is something that cant always be replicated within a rehabilitation unit, for example.

Restrictions put in place during lockdown meant I had to adapt to the climate and seek ways of providing similar input to those who needed support.

Due to the population of individuals I treat, a proportion of them fall under the at riskcategory. Because of this, carrying out clear risk assessments and wearing the appropriate PPE is essential to protect them and myself. PPE in itself has had an impact on communication with my clients, as a mask and visor hide not only your mouth, but also your facial expressions which people often use for reassurance and respond accordingly in conversation.

I have had clients who have moved to online sessions, which at first was a challenge to adjust to. Being a physiotherapist, you are so used to working with people in close proximity and being able to analyse and interpret movements in person. Relying on camera angles and WiFi connection can make things harder to respond to in real time.

Despite this, there are certainly some positives to this way of working other than the reduced risk of COVID-19 transmission. There are times when you have been working with clients for some time, that they can become dependent on your presence to move or carry out other tasks during the day.

I have found that being removed from them has enabled them to a degree. Where someone may not have had the confidence to stand without having me there before, they have attempted this whilst following my instruction via a Zoom call.

There is a degree of risk associated with this, and utilising family members when able to reduce this risk helps. This in turn has had a positive impact on family members who may have been anxious about helping someone move. Rehabilitation takes many forms and is not only about the person being treated, but also those around them and how they interact.

The neuro population can be very vulnerable and even in normal times experience isolation due to not being able to get out of the house or a lack of support network around them. Being able to communicate with them via technology and seeing a familiar face can make a huge difference to their mood and motivation.

While there are limitations in what I am able to deliver online from a physical standpoint, it can help in other aspects of our role which as therapists we do all the time but may not be so aware of.

Things have got easier since March partly because of adaptation, and due to guidance from governing bodies being a little clearer, which has enabled me to make more face to face contacts for sessions.

I still have those who I see online, which works well, especially if someone is located in a higher risk area and have greater restrictions in place. This enables me to continue seeing them without increasing my exposure risk and continue to see my other clients.

When you are not working within the NHS, you must rely on the guidance from your governing body, other therapy colleagues but also common sense. I am not given specific rules to follow from a manager because I am my manager!

I have friends and colleagues who have continued to work within peoples homes throughout lockdown and who follow the same procedures I do when entering peoples homes. Knowing what to look out for and risk factors involved with COVID-19, you are able to continue to deliver a good service, even if it might look a little different to normal.”

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Abnormal proteins unleash latent toxicity in neurodegenerative diseases

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Most neurological diseases have one thing in common: an accumulation of abnormal proteins around neurons. Researchers agree that these improperly fabricated proteins become progressively more toxic by interacting with healthy proteins, disrupting their functions. This picture, however, may be incomplete, according to a study.

In a recent study published in the Journal of Cell Biology, scientists from Daegu Gyeongbuk Institute of Science and Technology, Korea, have discovered the mechanism of action by which abnormal proteins actually unleash the inherent, but normally latent, toxicity of a natural protein in neurons, causing defects in dendrites (branched parts of a neuron that connect to the next neuron). Therefore, their results provide some clarity as to what actually goes on in diseased neurons. Though the researchers focused on Machado-Joseph disease (MJD), the implications of their results are relevant to other diseases as well.

First, they screened existing data to find candidate genes that were abnormally expressed in MJD patients and mice models. Then, based on the results and using MJD flies as animal models, they identified a problematic transcription factor–a protein that controls and regulates the transcription from DNA of other proteins–called NF-κB. Though this transcription factor is essential for the proper functioning and development of dendrites, the researchers found that something went awry with it when abnormal MJD proteins were around.

Through multiple subsequent experiments, they elucidated a long chain of inhibitory/promoting interactions between native proteins that, at a certain point, clashes with the accumulated abnormal proteins and cascades into a “deregulation” of NF-κB. In turn, this improper regulation unlocks the latent toxicity of NF-κB.

Professor Sung Bae Lee, who led the study, remarks: “Our results open-up a new avenue toward finding cures for neurodegenerative diseases by creating inhibition-based drugs that target improperly regulated latent toxic factors.” Such new potential treatments would directly target the early stages of neuron damage, stopping neurological disorders right on their tracks.

This study lights a beacon of hope for many countries that are struggling to deal with the problems of an aging society. “Korea will become a super-aged society in the near future and establishing an appropriate social system to care for and treat people with neurodegenerative diseases is turning into an urgent social issue,” comments Professor Lee. This might be the first step in a completely new road toward treating these chronic age-related diseases.

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Individualised brain stimulation therapy improves language performance in stroke survivors

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Canadian scientists are pioneering the use of individualised brain stimulation therapy to treat aphasia in recovering stroke patients.

Aphasia is a debilitating language disorder that impacts all forms of verbal communication, including speech, language comprehension, and reading and writing abilities. It affects around one-third of stroke survivors, but can also be present in those with dementia, especially in the form of primary progressive aphasia.

“Aphasia can be very isolating,” says Dr. Jed Meltzer, Baycrest’s Canada Research Chair in Interventional Cognitive Neuroscience and a neurorehabilitation scientist at Baycrest’s Rotman Research Institute (RRI).

“It can negatively affect people’s personal relationships, and it often determines whether or not someone can continue working.”

In a recent study published in the journal Scientific Reports, Dr. Meltzer and his team tested language performance and used magnetoencephalography (MEG) to measure brain waves in 11 stroke survivors with aphasia before and after they underwent brain stimulation therapy.

The scientists found that the participants had abnormal electrical activity in brain regions close to but outside the area destroyed by the stroke. This abnormal activity was mainly a shift to slower brain waves, a pattern they have also observed in individuals with dementia.

“We mapped that abnormal activity and targeted it using non-invasive brain stimulation,” says Dr. Meltzer.

“We found that the stimulation made the activity more normal – that is, faster – and improved language performance in the short term.”

Previous research has demonstrated that brain stimulation can improve language performance in aphasia patients. However, this study is one of the first to link this performance improvement to changes in the brain activity surrounding the tissue destroyed by stroke.

In other words, this study suggests not only that brain stimulation works in aphasia patients, but also that the reason it works may be because it addresses abnormalities in the brain surrounding the destroyed tissue.

Another novel aspect of this work is that the scientists targeted each individual’s abnormal brain activity with the stimulation treatment. In contrast, the standard approach in previous studies has been to use the exact same treatment, targeting the same brain areas, on every patient.

“Our results demonstrate a promising method to personalise brain stimulation by targeting the dysfunctional activity outside of the destroyed brain tissue,” says Dr. Meltzer.

“Aphasia patients are highly variable in terms of where their brain damage is and what part of the brain should be stimulated for therapy. By mapping individuals’ brain waves, we are finding ways to target the right area to improve their language performance.”

While the participants in this study were stroke survivors, individuals with dementia have similar dysfunctional tissue in their brains, and the scientists are also examining the use of brain stimulation in this group.

Dr. Meltzer and his team looked at the immediate effects of single stimulation sessions in this study. As a next step, they have received funding from the Heart and Stroke Foundation to conduct a full-scale clinical trial looking at the longer-term impacts of repeated stimulation for stroke survivors with aphasia.

However, this study has been suspended because of the restrictions on in-person research participation due to the COVID-19 pandemic. In the meantime, the scientists have pivoted to optimize other aspects of aphasia treatment.

With additional funding, the researchers could test different types of stimulation with more patients over more sessions, allowing them to make faster progress in developing this treatment for individuals with aphasia.

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Living with a spinal cord injury and maintaining good mental health during lockdown

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In conjunction with Mental Health Day 2020, Irwin Mitchell organised a webinar offering valuable insights into maintaining good mental health for those affected by Spinal Cord Injury (SCI).

The speakers were a mixture of professionals and people living with a SCI.

Dr Parashar Ramanuj, Consultant Psychiatrist gave an in depth clinical insight as to what a person who has recently sustained an SCI may be dealing with and what ‘coping’ really means

Sophie Lester, a case manager and spinal occupational therapist provided some really helpful guidance on how to maintain good mental health alongside rehabilitation and sustaining a healthy balance.

Ian Younghusband and Anne Luttman-Johnson provided first-hand insight into specific challenges of living with SCI and offered tips, advice and practical strategies to develop coping mechanisms in support of you and/or your loved ones.

The webinar offered some invaluable tips, but after seven months of different degrees of lockdown there were two key points that struck home with me. These were firstly the importance of reaching out to friends, family and charities and secondly keeping to some sort of daily routine and structure which includes hobbies, interests and exercise.

Lockdown was difficult for everyone, but especially for those who were deemed to be high risk. For those living with a SCI, a common cold has the potential to be life threatening. Most people with a SCI live with suppressed immune systems and/or possible respiratory issues, and so the possible impact of coronavirus has the potential to be devastating. Accordingly, people with a SCI were considered to be potentially high risk and were advised to shield.

For anyone who was asked to shield, in order to protect themselves, they were advised to isolate and effectively cut themselves off from their families, support networks and normal daily routines. This would have undoubtedly had an impact upon their mental health and wellbeing.

#TogetherInIsolation

In response to the growing situation, a number of positive and innovative projects have been launched to support the tens of thousands of SCI people who were isolating.

The Spinal Injuries Association (“SIA”) set up a movement, Together in Isolation. The SIA along with other charities and partners, joined forces to support and provide advice to those living with a SCI.

This included weekly inspirational blogs, an online drop-in café at 3pm every Wednesday with SCI Nurse Specialists and Horatio’s Garden providing gardening tips. Back Up, another national SCI charity also set up an online BackUp Lounge for people to just chat.

NeuroKinex is a not for profit organisation which in usual times, provides hands-on activity based rehabilitation for those living with an SCI. They continued to provide therapies and treatment virtually for a number of their clients, providing continuity of their rehabilitation, treatment and routine.

Online accessible experiences

Accessible exercise and fitness and wellness experiences have also become available online, to assist wheelchair users to continue to access exercise from home.

AirBNB launched their ‘experiences’ back in 2017, but when travel had to stop, these converted to virtual experiences with the option of filtering your results to those designed for accessibility. The experiences which have been featured include seated fitness and wellness experiences including Cardiobox, seated adaptive yoga, wheelchair dance and fitness, Mindfulness and Positive thinking with Paralympic heroes. Back Up moved their national wheelchair skills to virtual videos.

Additionally a number of free accessible exercise videos have been shared on social media. Ella, a GB U25 Wheelchair basketball player created Ella’s Wheelchair Workouts, a page on YouTube and Facebook offering and sharing exercise videos to do at home. She does this in conjunction with GymPossible an accessible gym in the North East who then started to produce adaptive fitness videos online.

Looking forward

The last seven months have been tough for everyone, and I am sure that it has had a huge impact on mental health across the country. But I am encouraged by the innovation and sense of community fostered by the use of online and virtual communication which has been sparked by this pandemic, and hope it has assisted some people to be able to continue with accessing their support networks and connecting with others, while participating in their hobbies and exercising from home.

Having access to positive experiences, friendships and exercise virtually when we can’t be there in person helps maintain good mental health. And although it doesn’t replace face to face in person experiences, I am hopeful that this positive community movement continues when life returns to what will be our new ‘normal’.

For those who are interested, I would really recommend watching the webinar recording which gives practical tips and guidance. This can be seen below:


Written by Jessica Bowles, a solicitor specialising in serious injury with a specific interest in Spinal Cord Injuries and rehabilitation at Irwin Mitchell.

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