Game changing neuro-rehab opportunities are emerging as a result of the coronavirus crisis, argues health and social care investment expert Boda Gallon.
The Impact of the Covid-19 pandemic has been multi layered. Yes, we’re faced with a fragmented health and social care system, continued uncertainty, and a gloomy economic outlook. There are, however, positive opportunities for investment and service redesign within NR and the wider specialist healthcare marketplace.
Increased investment interest for this most resilient of sectors, combined with a clearly identified need for positive change, should drive the creativity needed to embrace opportunities and deliver the much needed integration, improved productivity and efficiency of services across health and social care.
This positive outlook, however, still comes with a need to understand changes in our behaviour, to embrace change, to break down cultural barriers and focus on opportunity planning.
All of which is much easier said than done. A key lesson that has been brought home to us during the Covid-19 pandemic is that heroes are people. Ordinary, but extraordinary, people.
Once we get past fighting fires and lockdown fever most experts agree that things will never be the same. The key reason for this can be found in our primal brain and how we act and continue to live under a state of fear.
The neuroscientific term for this is “a somatic marker,” as coined by Antonio Damasio. I believe that Covid-19 is a negative somatic marker that we’ve
all had installed in our brains over the past several months and is likely to have a powerful, lasting impact on how we behave, but also a positive impact on the aspects of the cultural changes required for the health and social care marketplace to develop.
Change needs to go deeper, and Covid-19, as our generation’s negative somatic marker, is probably the best reason to change we will ever witness.
Covid-19 could also finally be the catalyst for the political will required to drive the full integration and parity between health and social care. It is no real surprise to find the recent disclosure of Camilla Cavendish’s plans that social care could be brought under the control of the NHS to honour Boris Johnson’s pledge to “fix the crisis in social care”.
This will also present opportunities and require new ways of working for people, but this will ultimately drive better and more seamless service experiences for all our patients, clients, residents, customers and consumers.
We are going to find ourselves in an entirely new online environment, with an entire generation of consumers and service commissioners expecting to interact via screens and having the aspiration and confidence of services being delivered in a ‘Covid-19 free’ environment.
This new virtual hybrid world will need to be delivered with empathy to help everyone overcome the negative Covid-19 somatic marker and still meet the basic human needs for relationships, touch and social interaction.
The perceived threat of Covid-19 does not mean that new services cannot be launched or repositioned. The opportunity is to develop more flexible services able to meet all the new behavioural, political, and environmental drivers of the ‘Covid-19 game changer’.
Providers and their people need to respond to this opportunity and reposition from fighting fires and coping around how things have always been, to repositioning ahead of the curve and innovating services towards what will be a new normal.
To date the adoption of digital technology to help improve productivity and efficiency across the system has often faced multiple cultural barriers, with people often sabotaging initiatives as they either feel their role, profession or revenue streams are threatened.
Covid-19 has forced everyone to look at the current barriers in a virtual way and employ different ways of working. Hopefully, this perceived threat now presents a clear opportunity for providers and professionals to deliver complimentary and long-term hybrid solutions for their clients and staff teams that embrace the best of digital and face to face interventions, training and support.
The delivery of community rehab has always faced productivity and efficiency challenges relating to logistics and the supply of and access to suitably skilled professionals, especially in more rural and harder to reach communities.
The proposed long-term somatic marker of Covid-19 now requires services and providers to be nimble to create longer term holistic solutions of their own, coordinating the much- fragmented array of technology options.
There is a need to embrace AR/VR/AI/IOT and to learn from and adopt best practice solutions from the UK and abroad to ensure much-needed efficiency, productivity and value are provided at the same time.
The positive outcome of this burgeoning digital transformation, like Covid-19, is also multi layered.
Offering a renewed focus on flexible working, employee support, management and an array of ‘wellbeing’ opportunities for staff recruitment and retention.
This digital transformation is most keenly required to help support and shape the future of various healthcare settings.
Existing commissioning and strategic planning intentions were already focused on provision away from hospitals and more institutional environments towards community settings with more holistic and social models of care.
The impact of Covid-19 will now hopefully see this process accelerated.
Although the wider roll-out of Covid-19 testing and potential vaccines is critical, providers need to review how the design and operation of care homes can be focused on delivering a ‘Covid-19 free’ moniker.
Enlightened providers need to ensure that cross infection mitigation and the flow of people, process and supplies are given an increased priority. The ability to offer digital triage and re-establish a more effective working relationship with GPs and primary care is essential to plan both avoidable admissions to and discharges from hospital and to provide the level of clinical support that has so often been missing during this pandemic.
Repositioning care homes from what has been perceived as the riskiest place for people to be towards being the safest environment possible has to be a clear goal; as well as a PR opportunity.
A focus on delivering flexible and safe space within residential services is essential to provide for increased independence, community and family integration and improved social inclusion.
New building designs in development need to respond to this now, and existing services will need to take a more strategic review of their estate for the medium and longer terms.
New models of care already seeking to deliver coordinated pathways from hospital to home, need the potential integration of health and social care to truly flourish and develop, but the vision must not stop there.
The extended integration and creative use of housing options is essential along with digital transformation to maximise potential clinical and financial outcomes and deliver the best quality of life for people. There is a lot to be learned from each other.
Previously fragmented sectors need to look vertically up and down patient pathways and supply chains, flex their services, upskill and share staff, embrace elements of isolated good practice and design into their own facilities and services.
Embrace the somatic change
To maximise value together, disruptive innovation driven by Covid-19 needs to be embraced. The independent sector can fully support NHS strategy by complimenting the NHS and building on the many successful collaborative partnerships developed during this pandemic.
Significant public goodwill and the potential political momentum to finally drive health and social care integration can now be leveraged to force past the multiple barriers to change.
Opportunity exists for game changers willing to take advantage of keen investor interest for a market that has proven to be the most resilient in the face of a global pandemic.
This inward investment into our sector can only be a further benefit forcing much needed change, new competition and opportunity to drive service innovation.
Ultimately and most importantly this will deliver better impacts and outcomes for service users, their families, and our colleagues.
We cannot afford to stand still and need to respond to the wider behavioural impacts of Covid-19 to reposition services, partnerships and networks to ensure new models of care and rehabilitation are (re)designed and delivered in more flexible and digital enabled environments.
This will ensure that proactive providers can truly respond to the future needs of customers, service commissioners and an emerging new normal to deliver even stronger, sustainable business models.
Proactive and future proofed business models are what any Investor from owner operators, to specialist private equity and bank funders will be looking to support and develop.
Hopefully, this article will help stimulate some debate and more ideas so we can share best practice and experience together.
More Delicious Innovations from Wiltshire Farm Foods
The latest Softer Foods creation from Wiltshire Farm Foods features an innovation which is entirely unique to the market: the shaping of a Level 5 Minced meal.
The company’s development team decided to incorporate this particular feature to enhance the visual element of its new Minced Cod in Parsley Sauce to further support those with swallowing difficulties in ensuring they receive the nutrition they need.
Committed to creating meals as delicious as they are visually appealing, Wiltshire Farm Foods understands how the aesthetic appeal of a plate of food can impact the appetite. Giving its customers the ability to eat independently with meals that look enticing ensures dignity in dining; something the company is passionate about.
Emily Stuart is the registered dietitian for the company and comments on importance of texture when it comes to those with swallowing difficulties:
“The texture of the main meal component has been designed in line with the requirements for an IDDSI Level 5 meal, in an extremely thick sauce. A Level 5 meal should require little to no chewing, ensuring a safe consistency for those on a Minced and Moist diet.
“All our Minced meals come ready-prepared, delivered directly to customers’ doors, to eliminate the risk that often accompanies home-blending. There are numerous challenges in creating safe, compliant meals via home blending with the process being both time consuming for carers and potentially hazardous for patients.”
Stroke survivor, Kate Allatt, knows first-hand how debilitating living with dysphagia can be, having experienced social isolation and embarrassment around mealtimes when friend and family were eating solid food that she was unable to consume herself:
To view the full Softer Foods range from Wiltshire Farm Foods along with more information on the latest Minced meals visit: specialistnutrition.com
Forget brain regions, it’s all about networks in neuroscience
Having worked for some of the biggest media outlets in the science industry, Dr Ginny Smith has been making brain science accessible for several years. With the release of her first solo book, she sits down with NR Times to discuss the ever-changing world of neuroscience.
The neurotransmitters in our brains and the chemicals that go with them continue to puzzle scientists and academics.
Making sense of it all is Dr Ginny Smith with the release of her new book.
Overloaded: How Every Aspect of Your Life is Influenced by Your Brain Chemicals explores how chemicals control what we do, from basic survival instincts to more complex processes, like forming relationships.
Recognised by New Scientist as one of the top science books in 2021, Overloaded was two years in the making.
One of its central themes is the brain working within networks which are all connected, rather than the traditional notion of individual regions performing specific tasks.
Speaking to NR Times, Dr Smith – who has produced science programmes for the BBC, Cosmic Shambles and the Naked Scientist – explained how changes in technology have brought about different interpretations of how the brain works.
“This idea of regions of the brain that do X or Y is starting to feel a bit outdated,” she said. “Talking to neuroscientists now, it’s all about networks and combinations of regions that talk to each other.”
And this shift in our understanding of the brain could shape new treatments in future.
“The drugs we have at the moment are the best thing that we have, but boosting things everywhere is a bit of a blunt instrument in something so precise as the brain.
“It’s not about if you need something to function, then having more of that is good. No, it’s all about finding that Goldilocks spot.
“One of the things I’m quite excited about for the future is the idea that we might be able to get more granular as to which areas of the brain are actually affected, perhaps on a person-by-person basis.
“It may be that at some point in the future, if you go to your doctor experiencing depression or anxiety, they could scan your brain to find out which area is actually affected and somehow target drugs specifically to that area.”
Overloaded brings together over 30 experts to give a clearer insight into how molecules like adrenaline, dopamine and serotonin work.
These chemicals may sound familiar but they often bring a lot of confusion around what they actually do – something Dr Smith was keen to address.
She explained how the misrepresentation of these substances in the media motivated her to set the record straight with the book.
“I started seeing a lot of mentions of these various brain chemicals. But they were often really oversimplified; like this idea that serotonin is the ‘happiness chemical’.
“It was stuff that takes a kernel of truth from real neuroscience, but simplifies it to the point where it no longer makes any sense at all.
“So I thought that it would be quite interesting to delve into a bit more complexity and find out what is actually going on and how much do we actually know about these chemicals?”
Although now hugely passionate about neuroscience, Dr Smith admitted that she fell into the subject after initially applying to study chemistry at the University of Cambridge.
“The way I’d encountered it before had been much more at the social psychology end of things, but the way it was taught here was like it was it was a real science where you did experiments.
“The complexity of the subject attracted me to it and I like a challenge. But also that the questions around it seemed so important to me. They seem like such vital questions to answer.”
Dr Smith switched her focus to neuropsychology and from here worked part-time in a lab. Due to her self-admitted short attention span, however, she found herself more drawn to the communication aspect of the field.
“I’ve been talking about the brain to anyone who will listen since then,” she said.
Her ability to make neurochemistry coherent was the catalyst for Braintastic! Science, the platform she founded to educate young people about how their brain works.
“Psychology and neuroscience aren’t sciences you necessarily meet at school. But one of the things I like is them explaining that there’s this whole other branch of science that they might not come across.
“It’s important to have a basic understanding of the brain. It can be so useful in so many ways.”
Indeed, a good understanding of the brain is something Dr Smith would liked to have had as a youngster.
“I wish that when I’d been a teenager, I had known a bit more about how a teenager’s brain works. I think it would have made life so much easier.
“Parents also understanding more about how young people’s brains develop would help them understand and relate to them.”
In fact, greater brain knowledge across the board in wider society would be beneficial, she believes.
“I think everyone can benefit from knowing a little bit more about how their brains and how other people’s brains work. I think it would make us a kinder, more tolerant society.”
While covering big neuroscience topics, the book is characterised by personal experiences and stories.
“One of the things I really like when I’m talking to scientists is hearing their passion and their stories for why they got into doing what they do.
“It also shows how science relates back to everyday life. That’s the thing about neuroscience and psychology, it’s all about us.
“I can’t tell you everything about the brain in one book, but I hope it sparks readers’ curiosity, and makes them want to go out and find out more about their brain.”
How the C-Brace is opening up a new world of possibilities
The C-Brace is big news in the progression of Orthotic treatment for neurological conditions. The integration of microprocessor technology into a carbon fibre Knee Ankle Foot Orthosis (KAFO’s) opens up a whole new world of possibilities and mobility for patients dependent on full leg support to stand and walk.
As standard, KAFO users are supplied with locked knee KAFOs. This is where the knee is locked in a straight position throughout their gait cycle, but manually unlocked to allow the user to sit down with their knee flexed. The use of a locked KAFO brings about stability of the knee for users with reduced lower leg muscles strength, when walking on level ground.
However, it also results in the development of multiple gait compensations for the user to progress through the gait cycle with a locked knee. Compensations include; hip hitching on the contralateral side, circumduction during swing phase, and vaulting of the contralateral ankle.
Gait can therefore be slower, require more metabolic energy and increase mechanical stress on the sound leg. Walking on slopes and stairs with a locked knee joint is very difficult and often situations avoided by KAFO users.
An alternative option to the locked KAFO is a Stance Control Orthosis (SCO). In a similar way to the locked KAFO, the knee joint is locked straight during stance phase, but unlocks at terminal stance to allow the knee to flex through swing phase, providing a more natural gait pattern and reduction in compensatory motions to achieve ground clearance.
SCOs require considerable confidence from the user, a consistent step length and are again limited on slopes, stairs and uneven ground. In order to prevent accidental disengagement of the knee lock on challenging surfaces, the user often manually locks the SCO.
Where the C-Brace comes into its own is the significant control available in both stance and swing phase of gait. The system provides stability for the foot and ankle, and stabilises the knee in the sagittal plane with the hydraulic unit replicating the eccentric and isometric muscle contraction of the quadriceps and hamstrings.
It controls both the stance and swing phases of gait with microprocessor sensor technology that can adapt to everyday situations in real time. The technology normalises gait by allowing controlled knee flexion during weight bearing, giving patients the ability to safely navigate quick stops, walk on uneven terrain, and descend slopes, curbs and stairs step over step.
The C-Brace calculates the orientation and movement of the system in space in three dimensions, using this information to control the flexion and extension valves of a hydraulic unit that provide varying levels of resistance to knee flexion. In turn, this allows for physiological knee flexion during loading response, absorbing the shock of weight transfer during heel strike.
In a locked KAFO or SCO, that shock is directly transferred to the pelvis and lumbar spine. Additionally, the C-Brace provides microprocessor swing control that adapts to the varying walking speeds of the patient. It does not require consistent step lengths to function as SCOs do.
Variable step length means a patient can increase or decrease walking speed and length of steps based on the instantaneous activity/mobility needs, making walking safer in unfamiliar or dangerous scenarios like crossing roads.
The C-Brace is also able to provide assistance descending stairs and slopes, allowing step-over-step gait, mimicking the contraction of the quadriceps for lowering the body down a stair or slope. The C-Brace considerably reduces stress to the sound limb in unilateral users, and allows bilateral users to descend stairs and slopes and ambulate on uneven terrain.
Additional features of the C-Brace include:
Stumble recovery: The microprocessor swing control of the C-Brace provides a stumble recovery feature that activates high knee flexion resistance during swing phase extension, in preparation for stance phase, allowing the patient to fully load their orthosis and stabilise the body in case of a stumble.
Intuitive Stance Function: This feature allows the patient to stand in a safe and relaxed manner with a flexed knee without the threat of knee collapse, and automatically switches back in to ambulation mode, turning off the blocked knee flexion when the patient moves. This feature allows the patient to unload the sound leg and rest while securely standing on level or non-level surfaces.
Sitting/Kneeling Function: The C-Brace assists the patient when sitting down and standing up from a chair by providing resistance to flexion or extension.
This adds an extra degree of safety and reduces stress to the upper extremities and the sound limb. The microprocessor automatically detects when the patient begins to sit down, adjusting the hydraulic resistance against bending during the transition to sitting.
Allowing the patient to sit in a controlled manner and at a controlled rate. When standing up from a seated position, the C-Brace blocks knee flexion as soon as the knee reaches a flexion angle of 45° or less, allowing the patient to reposition the foot and load the orthosis, for improved leverage to stand. The kneeling down function allows the patient to kneel down safely with controlled flexion of the knee joint, supported by increased flexion resistance.
Activity specific modes/Freeze mode: The C-Brace is programmable for activity specific needs of the patient in addition to ambulation. For instance, resistance can be reduced to a minimum for cycling, or a flexed knee joint position can be fixed for activities such as Yoga. The user, on their personal C-brace App, can control these modes.
So how can you know if the C-Brace might be right for your patient? The first stage is a thorough assessment, considering both the indications and contraindications of the system.
- Flaccid Paralysis or partial paresis of the lower limb
- Quadriceps deficiency leading to poor knee control during stance phase
The patient may present with regular ‘giving way’ of the knee, reporting stumbles or falls when walking on flat, graduated or uneven surfaces. The C-Brace may be appropriate for a number of neurological conditions, including but not limited to:
- Spinal cord injury between L1 and L5
- Multiple sclerosis
- Neuromuscular disease
- Muscular atrophy or Traumatic paresis
Essential requirements for the use of the C-Brace:
- The user must be able to stabilise their trunk and stand without support.
- The muscles strength of the hip extensors and flexors must allow the controlled swing of the affected leg, or this must be possible through compensatory hip/trunk movement.
Contraindications of the C-Brace:
- Swing phase initiation is not possible
- Insufficient trunk stability
- Severe spasticity
- Knee or hip flexion contracture of more than 10°
- Non correctable genu varus/valgus greater than 10°
- Body weight less than 40Kg or greater than 125Kg
- Height <140cm
- Leg length discrepancy >15cm
- Fluctuating Oedema or severe skin irritation that precludes the use of an orthosis
The C-Brace Dynamic Test Orthosis (DTO) is a trial orthosis, which features the C-Brace joint unit. The DTO can be set up to each individual user and programmed to their individual gait requirements, allowing users to test the function of the orthosis within the clinical setting.
The DTO can also provide valuable evidence to the function and benefits of the C-Brace for payers. The DTO can be trialled with support from the Ottobock Orthotic Academy Clinician or through Ottobock’s clinical partner Dorset Orthopaedic.
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