Five brain injury professionals spanning dietetics, case management, physiotherapy and speech and language therapy share what they’ve learnt from to shift to virtual therapy.
At the start of the pandemic, many statutory rehab services were redeployed, and some independent therapy teams closed or therapists moved back into frontline work within the NHS and community.
A group of private therapists in the North West of England started keeping in touch on social media and in weekly group support sessions to share their fears and concerns, and identify the strengths that helped them survive in such challenging times.
They shared a desire to maintain a therapeutic relationship and meaningful rehab for their patients, all living with complex neurological conditions, while delivering remote therapy sessions online. This is what they – a dietitian, a speech and language therapist, two physiotherapists and a case manager with an occupational therapy background – learnt during that time.
As therapists and health care practitioners, our hands are often our primary tool; we use them to direct, feel, inform, instruct, measure. The inability to see our patients face to face took away these vital tools.
We knew we had to adopt a positive attitude of creativity, innovation, and practicality, and decided to continue as much as was practically possible, albeit remotely.
The pandemic thrust us into a new world where we soon learnt that we have a wide range of diverse skills beyond the use of our hands – as educators, problem-solvers, movement and task analysts, communication specialists and counsellors.
For some of us, the beginning of the COVID-19 pandemic saw a reduction in caseload by up to half, which affected morale as we tried to manage personal and professional stress and anxiety. For others, our case load dramatically increased as we maintained routine and aimed to prevent safety concerns around swallowing and malnutrition.
Working remotely by virtual platforms has required therapists to re-evaluate their roles and responsibilities and redesign pathways of rehab, all without a guidebook and almost overnight.
Sharing the challenges we were facing enabled us to embrace the new era of therapy provision, ensuring that a calm, professional and positive approach paved the way as we guided our teams and patients through what would become months of change.
Embrace core values
As we continued to meet regularly, we began to understand we were united by our shared views and values regarding duty of care, therapeutic relationship and safe and ethical practice.
Our common commitment was our duty of care to providing continued therapy input to our patients. We could develop novel approaches to practice quickly to reduce negative impacts on clients’ physical and mental wellbeing.
As independent health providers, we were able to rapidly try out new service delivery techniques and begin to rebuild a new virtual therapist identity to ensure ongoing rehab, delivered in a safe and realistic format.
One of the key factors enabling our speedy response was not being tied to a specific platform. Recognising the frustrations technologies can cause, however, administrative team members assisted families to ensure an effective technology connection to avoid this impacting on the therapeutic relationship.
The freedom of being at the helm of smaller, independent practices placed us in a position to respond quickly and invest time and resources into developing a new way of working, but this was not without financial risks. Our weekly group meetings helped identify the need for a supportive framework for professional staff to share and explore what we meant by ethical and safe practice.
Be innovative, creative and dynamic
Therapy is not a desk job, it’s active and engaged. Teams invested time working out the positioning of devices and how to use selfie sticks to ensure the optimum viewing angle.
We taught relatives and support workers techniques and assessment tools separately to the patient to ensure that they understood their responsibilities in the session. During physiotherapy, people reportedly became used to observing themselves on the video link, so they could see what the therapist meant when they were talking about making postural changes.
In dietetics, the continued use of eHealth communication apps maintained frequent dietetic communication, giving real-time feedback, accountability and encouraging confidence, control and mindful eating.
People working on developing their speech sounds or breath support had automatic feedback as they could see themselves on screen and could work to imitate lip patterns and breathing techniques as modelled by the speech and language therapist.
Our aim was to safely maintain and progress rehab goals while encouraging routine, structure and preventing development of new issues. Some have surpassed expectations and are continuing to make significant gains and progress. This in part is due to the adaptability that online delivery presents.
During a face to face session, we often have a fixed time period. However, through virtual sessions, we can be more adaptable to personal wants/needs, breaking sessions up into ‘bitesize’ chunks. This can assist people with limited attention or difficulty processing and is helpful in fatigue management.
Nevertheless, online therapy does not work for everyone, and many people and their families miss face to face input and support. Some people find multi-tasking prohibitive, some can find technology intimidating. Others find it difficult to follow the conversation, particularly where they are more dependent on non-verbal cues, or are challenged attentionally when people speak over each other.
We need to consider how we can embed online therapy in our routine practice; for who online therapy presents opportunity and for who it may create challenges.
Assessment of new clients was restricted. Many of our clients pose non-obvious difficulties. Assessing how a person interacts with their environment can be difficult, and it can be difficult to form that initial relationship which is key to good neurorehab.
Bridging a gap
During the pandemic, many people reached out to connect with us remotely. For others, the services they needed altered. We have seen an increase in dietetic referrals, perhaps due to reduced gym, and community healthcare provision.
The use of eHealth and virtual therapy has meant we were able to bridge the gap, ensuring minimal disruption to rehab through remote transfer of therapy skills, including educating and training other household members and support staff.
This training is a key part of our roles and online support, and voiceover Power Points and videos of ourselves disseminating information have been important. Attending a session virtually can empower both the person, the family, and their support teams. It can provide a positive forum to educate staff and monitor learning across the whole team.
Some support staff and families reported feeling more empowered during lockdown as they had clear connections between the therapy input and the person. We were able to bridge a gap for those who were able and willing to engage and found a new tool to add to our repertoire.
Forward-thinking and planning
As we move out of lockdown, our teams have reflected that remote therapy via video link is possible, but isn’t always preferable. The challenge will be to develop a hybrid system that puts the patient at the centre of their rehab.
Remote therapy via video link happened in a unique bubble and in response to a crisis and it is unclear at this stage how these external factors impacted on the success or otherwise of virtual rehab.
Used well, the barriers of geography and travel could enable specialist therapists to support local therapists to provide effective rehab for those with complex conditions. There is also more opportunity for therapists to benefit from ease of access to international perspectives and training resources that are rapidly developing online.
As we are returning to increasing direct engagement, we are facing the new challenge of working in and communicating in PPE, which introduces challenges in establishing and sustaining a therapeutic relationship.
This period has been challenges for therapists. However, we have learnt together, along with the people we support and their families, and want to make sure these learnings aren’t lost.
Virtual therapy spaces present an opportunity for us to provide services across longer distances and in diverse and flexible ways, that, for some, may enhance progress toward their goals. For the foreseeable future, while therapy services are resuming face to face intervention, there will likely be a continuation of some remote methods.
Physical distancing and personal protective equipment will likely present new learning for us, and requires ongoing reflexive practice as we continue to grapple with the shift from ‘hands on’ to ‘hands off’ service delivery.
We have seen that people are increasingly deteriorating; both physically and mentally, and the novelty of remote therapy becomes less effective as it becomes increasingly obvious that we are hands-on for a reason. As humans we need the subtle combination of touch, communication, concern, community, movement and freedom to keep us well.
This article was collectively written by:
- Jackie Dean, case manager at n-able Services Ltd
- Ann Pimm, physiotherapist at Summerseat Physiotherapy
- Hayley Power, speech and language therapist at A.T Therapy
- Sian Riley, dietitian at Red Pepper Nutrition
- Susan Pattison, physiotherapist at SP Therapy Services
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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