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Facing a new challenge – treating brain injury during a pandemic

Dr Jenny Brooks, a consultant clinical psychologist, and Dr Keith G Jenkins, consultant clinical neuropsychologist, on supporting brain injury professionals during COVID-19.

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The current pandemic has generated varying levels of anxiety in people around becoming infected or infecting others. In extreme cases, this anxiety can be debilitating.

Overwhelming anxiety can lead to withdrawal from others, and in brain injury work settings, can cause staff members to refuse certain duties that make them feel unsafe, which can cause conflict with managers.

Feeling a loss of control can be difficult for some, whether that’s at work or at home, and this can be exacerbated by restrictions designed to minimise infection risk.

Changes in the workplace include virtual meetings, wearing PPE for client or patient encounters and working remotely.

Meanwhile, many families of those required to shield have developed decontamination rituals on returning from work, such as changing outside and immediately showering.

The challenges of working at home include loss of workplace social contact and camaraderie, and difficulties accessing adequate technology and maintaining work routines and work/life boundaries.

Moral injury

There’s also a risk of ‘moral injury’, which is the psychological distress that can occur when  a person’s actions – or lack of them – violate their moral or ethical beliefs or values.

During the COVID-19 pandemic, moral injury may occur when care can’t be provided in the usual way or to the usual standard.

If leaders or managers are seen as avoiding responsibility for events that occur during this time or are unsupportive of their staff, or if staff feel or are unprepared for the emotional and psychological consequences of any decisions that may be required of them, there’s a risk of moral injury.

Fear/anxiety can trigger instincts that magnify the sense of impending harm, which can trigger a fight or flight response.

Seeking to control these instinctive responses can come at a cost to emotional and physical wellbeing in people who don’t have adequate coping systems or strategies in place.

Research suggests that people usually recover from moral injury quickly, and are more likely to experience long-term distress when they’re confronted with numerous moral injuries that cause cumulative effects.

As a general approach to moral injury, frontline staff ought to be made aware of events that could trigger such feelings, and managers should be encouraged to seek formal support if they are troubled because they think they may have contributed to or directly caused an employee to experience moral distress.

When informal support doesn’t help, professional help should be sought as soon as possible, particularly when the moral injury effects the employees’ day-to-day functioning.

Employers of essential staff need to be aware that psychological debriefing techniques and psychological screening approaches are ineffective. Instead, they must monitor and have appropriate support for staff exposed to difficult and challenging situations that may cause moral injury or wider psychological distress.

Generally, supporting physical and emotional health should always be in the minds of employers and managers. Well functioning team dynamics are key to providing the essential social support required for workforces to cope and work well.

Change and loss

Working at home can bring its own challenges to employees, including the guilt that others are risking their health in work environments.

With the pandemic bringing threats to everyone’s wellbeing, workforces are at a higher risk of experiencing health anxiety, which can add further to emotional distress and difficulties coping.

Being able to make a valued work contribution is key to the wellbeing of many home workers and shielding colleagues, who may also be particularly at risk of physical health problems at a time when they don’t have access to leisure facilities and gyms. Some may also be more likely to indulge in unhealthy, comfort-seeking behaviours, such as drinking, smoking and eating unhealthy foods.

Employees may have lost loved ones during the pandemic – and with normal grieving rituals and social support compromised by the pandemic, feelings of grief may be exacerbated.

Grief is most commonly associated with death, but it can occur after other types of loss, including the losses brought about by Covid-19. Employees may be grieving aspects of their lives previous to the pandemic.

Not only are people now experiencing the loss of normality, but also may be anticipating greater losses to come. There may also be increased financial stress and other tensions occurring more often within families.

The familiar stages of grief, originally outlined by psychiatrist Elisabeth Kubler Riley and author David Kessler, are not meant to be a linear process. People may go back and forth between each of the five stages, rather than following a sequential timeline, while some may not experience one or some of these stages.

In the denial stage, individuals may believe a situation isn’t real. In relation to the pandemic, those experiencing grief may have not have fully digested the situation.

In the anger stage, people recognise that denial can’t go on any longer and they become frustrated or angry. During the pandemic, this may manifest as people defying the government’s social distancing guideline, for example.

The bargaining stage is where people hope they can avoid anymore grief, so they may think it’s okay to break social distancing, for example, as long as they’re careful. They may think “it’s okay to spend time with others as long as they wash their hands before they see me” or “I’ll be fine as long as I stay around people that who are healthy”

Within the stage of depression, the person recognises the impacts the pandemic will have on their life, such as not being able to see family and friends or not earning as much money.

Finally, there is acceptance. People come to realise they can’t control the outcomes of the pandemic, but accept what is in their control and find a way to move on.

Social distancing, feelings of isolation and loss of human contact, as well as changes to routines, could cause up to 50 per cent of people to experience anxiety and depression, as well as some post-traumatic stress symptoms .

People who have pre-existing mental health conditions, particularly anxiety, mood disorders, substance abuse or obsessive-compulsive disorders, may experience heightened symptoms, but it’s unclear how much this is affecting those working in the brain injury field.

The pandemic is likely taking a huge toll on the population’s mental health. Chronic stress can cause people to become physically and mentally unwell and, if it goes unmanaged, can become debilitating, or manifest as anger.

But there could also be a silver living. The pandemic has also provided people with the opportunity for personal growth.

In the workplace, sharing the experience of the pandemic is likely to bring teams together, and could improve employees’ confidence and performance.

Getting through the pandemic may help people feel more resilient, and more confident in their ability to cope under stress.

Psychological first aid

One of the ways negative and unhelpful feelings in the workplace can be overcome or supported on a day-to-day basis is through psychological first aid, which helps to provide practical, non-intrusive care and support.

It is recommended in crisis and disaster situations, such as during the COVID-19 pandemic, and in the aftermath; when it can provide a useful guide in supporting each other when experiencing feelings and reactions that may have been lurking under the surface during lockdown.

When delivering psychological first aid, it’s important that the first-aider remains calm and shows concern, and offers a confident, reassuring presence.

They need to ask questions and most importantly actively listen, and also take note of practicalities such as whether the patient is looking after themselves by taking breaks, eating and drinking.

It’s also important to understand that there might be a need for someone better equipped to help, and to act as a liaison between this person and the patient, while continuing to advocate for them.

The first-aider shouldn’t rush the person or be dismissive, or offer opinions. They also shouldn’t make promises they can’t keep or feel wholly responsible for  individual’s recovery.

For non-emergencies, there are many ways for people to alleviate the strains of the pandemic. For example, prioritising contact with family and friends through phone and video calls throughout the week.

Working at home and living

Daily routine and structure has changed for everyone during the pandemic, and this can feel very unsettling, so structure is important. It increases feelings of normalcy and a sense of control, meaning and purpose – and can reduce feelings of distress and anxiety from providing distraction/engagement.

Keeping home and work separate can be another challenge of working from home during the pandemic.

For this reason, it’s good to have set start and finish times for work, as well as a fixed area in your home that can be kept relatively separate from where you have downtime, if possible.

Another way to establish a work/home boundary is to dress for work during working hours.

It is natural to be worried about loved ones catching COVID-19, however, if these worries start to spiral, it’s always worth talking to friends or colleagues, or contacting your GP.

And anyone feeling acutely unsafe or risky yourself should go to A&E or call 999, and in non-urgent situations, consider calling a helpline, such as the Samaritans, which is open 24 hours a day on 116 123.

It’s best to approach the internet with caution, especially when seeking out Covid-19 information. Only use reliable sources, such as the World Health Organisation, NHS or UK government – and consider limiting exposure to the news.

It’s important to not work in the bedroom, as getting a good night’s sleep is vital – and some people will find their sleeping habits are disrupted by the pandemic.

This could be because of changes to bedtime, the working day, additional stresses, or not getting as much exercise. A lower mood can also contribute to disrupted sleep.

Disrupted sleeping habits can cause a poor sleep-wake cycle, which can cause tiredness and fatigue throughout the day.

This can lead to a vicious cycle where it becomes more difficult to sleep, and lack of sleep makes it more difficult to relax. Those drinking more alcohol during the pandemic may also experience a negative effect on the quality of their sleep, as alcohol disturbs sleep rhythms.

One way to improve the quality of sleep is to improve sleep hygiene, which includes going to bed and getting up at the same time each day, exercising during the day, cutting down on caffeine or nicotine and avoiding the blue light from screens in the evening.

Try to have a bedtime routine that supports winding down. What people find relaxing tends to vary from person to person – for some it may be a warm bath, for others it may be listening to music. Bedrooms must be conducive to sleep – that means considering the lighting and temperature.

During the pandemic, some people are tending to spend more time in their bedrooms, perhaps to have space away from members of their household that they wouldn’t normally spend so much time with, or because they’re having to isolate from a shielding family member.

In these instances, it’s best to sit somewhere other than the bed, so the bed isn’t associated with being awake.

During the night, try writing worries down on paper, and allocating time to address them the next day with a family or friend, if necessary, or a relevant professional.

Covid-19 is presenting an immense challenge to brain injury professionals, and is also changing many of the ways we live and work.

But we can adapt to these changes and, in doing so, may well find better approaches and strategies that prevail and offer benefits long after the pandemic is over.

This article is based on a webinar produced for ABI London (ABIL). Dr Keith G Jenkins is consultant clinical neuropsychologist at St Andrew’s Healthcare and chair of Headway East Northants. Dr Jenny Brooks is a consultant clinical psychologist working independently and a director of The ABI Team.

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Osteoarthritis: breaking the cycle

Medical technology company Ottobock shares its expertise on approaches to the condition.

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Sponsored feature

Why is Cartilage Important?

Bones that come in contact with other bones are covered by cartilage at their contact points. Cartilage does not have blood vessels – it is supplied with nutrients through movement of the joint. That’s why regular exercise is so important!

Cartilage ensures that the joint surfaces move against each other in the most efficient way and with little friction. It absorbs shock, cushioning the joint, and distributes the forces acting on the joint.

If cartilage is damaged and its gliding properties are affected, it can no longer serve its purpose and the joints range of movement can become limited.

Typical Progression of Osteoarthritis

When osteoarthritis of the knee develops due to joint malalignment, an accident, advancing age, obesity or excessive strain, the damaged cartilage is no longer able to properly fulfil its function.

This results in pain and re­duced mobility. The affected patient instinctively assumes a relieving posture to reduce strain on the knee.

However, this often leads to new prob­lems in other places, such as the hip, and reduces the supply of nutrients to the cartilage, for which movement is required – sparking a vicious circle.

The cartilage develops cracks and begins to break down. At the same time, the bone thickens at the site of the damage.

When the cartilage layer is completely worn away, the affected bones come into direct contact and rub against each other causing joint pain and inflammation.

The thickest joint cartilage is located behind the kneecap (patella). This is an area of high stress. Osteoarthritis occurring in this area is known as patellafemoral osteoarthritis

Signs and Symptoms

There are several common symptoms that signal knee osteoarthritis. They can occur individually or together. However, with the initial onset, you may not notice any of these symptoms

When symptoms appear they usually occur in the following order:

  • Cracking in the joint
  • Pain during load bearing activities, such as carrying a heavy object
  • Pain during every day activities, such as climbing the stairs
  • Reduced mobility
  • Swelling and inflammation

Non-Invasive Treatments

Joint specific exercises: with regular exercise mobility can be maintained and muscle strengthened, ensuring the cartilage is supplied with the nutrients it needs.

Temperature: with acute inflammation, cold relieves pain and reduces swelling. Heat relaxes the muscles and tendons and increases the flow of nutrients. Heat may only be applied when the joint is not inflamed.

Creams: various over the counter products are available at your local pharmacy including gels and creams that can help relieve pain.

Orthopaedic devices (braces and supports): these are applied externally to the knee, reducing pain and improving mobility.

Lifestyle: living a healthy lifestyle can help to combat osteoarthritis. A healthy diet and an active lifestyle reduces the chance of obesity, putting less stress and strain through the knee joints.

Orthotic Options

An orthotic fitting is a key component in the treatment of osteoarthritis. It can provide the following:

  • Pain relief
  • Support daily activities
  • Support during activities that affect the joint, whether at work or during sports

Did you know?

An osteoarthritis patient takes an average of around 1,200 tablets a year to manage pain. But this can lead to damage to the stomach, bowel and liver.

An orthosis from the Agilium line is therefore a good alternative. It’s worth-while for anyone with knee osteoarthritis to test the effectiveness of the orthoses themselves.

The Agilium Line

The braces in our Agilium line are designed specifically to target the symptoms of osteoarthritis of the knee.

Each works in a different way to address the various characteristics of osteoarthritis of the knee. At the same time, we placed great emphasis on their comfort and suitability for daily use.

The Agilium Freestep, the Agilium Reactive and the Agilium Softfit are used to treat unicompartmental osteoarthritis of the knee.

The Agilium Patella is used for patients with patellofemoral arthritis.

The Agilium Freestep is used to treat OA, although it is not applied directly to the knee. Instead is worn on the foot, right inside the shoe! For targeted relieve, it alters the load-line of the knee – the point where the body weight impacts the cartilage.

The Agilium Softfit is a pull on knee brace with a textile base and single upright that stabilises and relieves the knee using a three point force system to offload the affected compartment (side) of the knee.

The Agilium Reactive also uses a three point force system to offload the affected compartment (side) of the knee. However, the innovative closure system in the upper calf provides comfort while sitting without compromising the stable position when standing.

The Agilium Patella combines a textile structure and stabilising component with a dynamic re-alignment mechanism enabling it to maintain the central alignment of the knee cap, reducing pressure behind the knee cap.

Find the appropriate brace with Agilium Select.

Visit our website or go to ottobock.com/agilium-select

If you would like to know more about any of these products please get in touch via orthoticsuk@ottobock.com or visit our website for more information: www.ottobock.co.uk

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Masturbation linked to stroke in medical case study

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Doctors in Japan have reported how masturbation sparked a bleed on the brain of a 51-year-old man; as published in the Journal of Stroke and Cerebrovascular Diseases.

Doctors at the Nagoya City University Graduate School of Medical Sciences in Japan explained that the man attended hospital after orgasming, with the sudden onset of a searing headache that lasted for around a minute. This was followed by an intense bout of vomiting.

A CT scan showed an acute subarachnoid hemorrhage in the left hemisphere.

The researchers note that masturbation causes an increase in heart rate, blood pressure, and noradrenaline plasma levels – which are likely to contribute to the risk of splitting a blood vessel in the brain and result in a hemorrhagic stroke.

The man was treated with stents and coiling, two techniques used to bolster the blood vessel and maintain blood flow to the brain, and he went on to make a full recovery.

The study authors say that they found just two other cases of masturbation-linked strokes in other scientific literature.

The Japanese man survived and was discharged after nearly two weeks in hospital in an “excellent” condition.

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Engineers develop ultrasound patch to monitor blood flow

Breakthrough could help to better predict stroke and other cardiovascular conditions earlier.

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Engineers at the University of California San Diego have developed an ultrasound patch that can be worn on the skin. It monitors the blood flow through major arteries and veins deep within the body.

It is hoped that it could help clinicians diagnose cardiovascular conditions faster. It could also help to diagnose blockages in the arteries which could lead to strokes or heart attacks.

The ultrasound patch continuously monitors blood flow as well as blood pressure and heart function in real-time. Assessing how much blood flows through a patient’s blood vessels could help diagnose blood clots, heart valve problems and poor circulation in the limbs.

For many patients, blood flow is not measured during a regular visit to their doctors. It is usually assessed after a patient shows signs of cardiovascular problems.

The patch can be worn on the neck or chest and can measure cardiovascular signals up to 14 centimetres inside the body non invasively with high accuracy.

How the patch works

The patch is made of a thin, flexible polymer that sticks to the skin.

There is an array of millimetre-sized ultrasound transducers on the patch known as an ultrasound phased array.

These are individually controlled by a computer. Another feature is that the ultrasound beam can be tilted at different angles to areas in the body that are not directly below the patch.

It can operate in two modes. In one, all of the transducers can be synched together to transmit ultrasound waves which produce a high-intensity beam that focuses on one spot.

This can be up to 14cm deep in the body.

A wearable ultrasound patch on the skin

The other mode allows the transducers to be programmed to transmit out of sync producing beams at different angles.

In being able to manipulate the beams, it gives the device multiple capacities for monitoring central organs as well as blood flow with high resolution.

When the electricity flows through the transducers, they vibrate while emitting ultrasound waves that travel through the skin into the body.

When they penetrate a blood vessel, they encounter the movement of red blood cells flowing inside. The cell movement changes how the waves are transmitted back to the patch.

This change is recorded by the patch and creates a visual recording of the blood flow. It can also be used to create moving images of the heart’s walls.

The benefits:

Sheng Xu, professor of nanoengineering at the UC San Diego Jacobs School of Engineering said:

“This type of wearable device can give you a more comprehensive, more accurate picture of what’s going on in deep tissues and critical organs like the heart and the brain, all from the surface of the skin.”

Xu added: “This is a first in the field of wearables because existing wearable sensors typically only monitor areas right below them.

“If you want to sense signals at a different position, you have to move the sensor to that location. With this patch, we can probe areas that are wider than the device’s footprint. This can open up a lot of opportunities.”

The researchers say that the easy to use patch could allow patients to wear the patch and monitor the results themselves. It doesn’t depend on a technician to read the results

The next stage

The patch is not yet ready for clinical use. The researchers are currently working on a way to make the electronics wireless as it currently needs a power source and benchtop machine.

Image credit: Nature Biomedical Engineering

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