Connect with us
  • Newham House
  • Elysium

Insight

Making the case for cannabis in rehab

Published

on

NRT: What are the headline findings from the report for people working with brain and spinal injury clients?

MB: There is now good evidence to show 
that cannabis, including the non-psychoactive component CBD, can help to treat chronic pain – such as that experienced post spinal
or brain injury – spasticity, nausea and vomiting and anxiety.
We also found moderate evidence that it helps to stimulate appetite, which may also be relevant to neuro-rehab units.
There was limited evidence to support cannabis’s role in alleviating depression
and in brain protection in the context of traumatic brain injury.

What about the risk of schizophrenia associated with cannabis use?

Most literature supports a causal 
hypothesis between cannabis use and psychosis, particularly if usage starts at an early age and 
if the individual has a genetic predisposition to psychosis. It is unlikely that any one environmental factor (such as cannabis use) or any one gene can cause schizophrenia on its own. It appears that cannabis is a component cause in the development of symptoms of schizophrenia and the onset of this mental illness depends upon many interacting factors. However, it is also important to remember that most people who use cannabis do not develop schizophrenia, and most people with schizophrenia have never used cannabis.

It is likely that THC is the main cannabinoid which triggers schizophrenia and psychosis. CBD on the other hand is known to be anti-psychotic and may have a therapeutic role as an anti-psychotic agent although further studies are required.

What impact does cannabis have on chronic pain?

Current treatment for severe chronic pain is often effective but can be associated with serious side effects. Opioids, for example, carry very serious risks, including mortality. Chronic pain is one of the leading reasons for medical use of cannabis in the UK. It is known that the endocannabinoid system is one of the key bodily systems that regulate pain sensation with actions at all stages of the pain processing pathway. Neural signalling through both CB1 and CB2 receptors has a key
role in normal pain processing and considerable animal model and pre-clinical data on both patients and healthy volunteers confirm that modulation of the endocannabinoid system can reduce pain. Cannabis products nabilone, dronabinol, nabiximols and smoked marijuana have all been shown to be efficacious to varying extents in a variety of pain settings in good quality studies. We concluded that there is good evidence for efficacy of cannabis for pain relief in various formulations and in a number of settings.

Could cannabis play a greater role in the management of spasticity after spinal and brain injuries?

There is good evidence for the efficacy of the cannabis extract nabiximols for reducing patient-reported spasticity symptoms, although there is not firm evidence for improvement in objective measures. We consider there is good evidence of safety in the long-term and for continued efficacy. We also consider there is moderate evidence for the efficacy of oral cannabis extract for reducing patient-reported spasticity scores. There is insufficient evidence to make any recommendations with regard to other forms of cannabis. 
One study we considered assessed the effect of nabilone on spasticity after spinal cord injury (Pooyania et al 2010). The research involved 11 subjects who either received nabilone or a placebo during a four-week period and after a two-week washout, subjects were crossed to the opposite arm of the study. There was a significant decrease on active treatment for the Ashworth score in the most involved muscle as well as the total Ashworth score. There were no significant differences in secondary measures which included the spasm frequency scale and the clinician’s and subject’s global impression of change. Side effects were mild and tolerable.

Anxiety is particularly prevalent with people coming to terms with severe injuries. Could they benefit from cannabis?

Cannabis can both increase and decrease anxiety in humans. CBD has been shown to reduce anxiety whereas THC, the psychoactive part of the drug, usually has the converse effect. Overall, we consider there is good evidence for CBD use in anxiety. This evidence base includes a double-blind, randomised, placebo-controlled clinical study led by Bergamaschi in 2011. It showed
that orally-administered CBD was associated with a significant can’t reduction in anxiety, cognitive impairment, and discomfort in patients suffering from generalised social anxiety disorder subjected to a simulated public-speaking test. A further study carried out by Crippa and colleagues (2011) looked at the effect of CBD on anxiety and the brain mechanisms involved. This double-blind, randomised, placebo-controlled study found that CBD significantly decreased anxiety and that this was related to its effects on the limbic and paralimbic brain areas. Improved anxiety levels have also been reported in patients suffering from chronic neuropathic pain (Ware et al 2010b).

What conclusions did you draw about cannabis and epilepsy?

There is certainly a theoretical basis to suggest that cannabis could have implications for epilepsy. While animal model and early human studies are promising, however, at the moment robust trials are lacking but further results are awaited. So there is only limited evidence currently.

In which other areas related to neuro-rehab would you like to see more studies carried out in future?

There is a theoretical basis to suggest cannabinoids could provide neuroprotection in the context of traumatic brain injury, but as yet, evidence is limited and unconvincing. There is no evidence to support neuroprotection in stroke and, in fact, limited evidence shows that heavy recreational users have a slightly increased risk of stroke. So further clarity in these two areas could be hugely beneficial to neuro-rehab professionals. It was also surprising to discover that, despite 
a long history of cannabis use in headache and migraine, there are no good quality randomised clinical trials. I would like to see more studies into neuropathic headaches in particular.

What regulatory hurdles are stopping people benefitting from the medicinal properties of cannabis?

We currently have a shambolic situation in which the very recognition of cannabis as a medicine has potentially delayed its obtainability by people who really need it by several years. Until October this year, CBD was legal to purchase in the UK. Then the MHRA [Medicines and Health Care Products Regulatory Agency], which is sponsored by the Department of Health, said it now recognises that CBD could potentially have medicinal value and should be considered a medicine. This is dependent, however, on manufacturers providing proof of its efficacy. Therefore, individuals, including young children with resistant epilepsy, may not be able to legally obtain CBD in the near future. They won’t be able to until the producers can satisfy the regulations for medicinal products, which will take some years.

Is this situation likely to be resolved anytime soon?

It’s only a matter of time before the UK government legalises cannabis for medical purposes as we are so far behind the rest of the world now. Several more American states have just voted to legalise it there, while it is also now legal in at least 10 European countries. 
We are way behind on this and conflicted because of this nonsense with the rescheduling of CBD.

Continue Reading
Click to comment

Leave a Reply

Your email address will not be published. Required fields are marked *

Insight

Now is the time to embrace better ways of working

Published

on

By Merryn Dowson, assistant psychologist and part of the team behind rehab goal-setting platform Goal Manager

A stitch in time saves nine. Rome wasn’t built in a day. The best things take time.

We are all too aware that some of the most important parts of our lives have been crafted, carved and developed over months and years. Consider your education, for example: you may well have been to primary school, secondary school and then sixth form college. Perhaps you went on to do an undergraduate degree.

You may even have taken another leap and completed a Master’s degree or a Doctorate. This took years. You learned, revised, sat exams, sat resits, applied for places, got results, got rejected, got accepted, and made it here.

One thing is certain: compared to all of this expertise, someone who completed a two-hour online course on the same topic does not come close. We know that putting time and effort into something gives us better results than if we tried a quick approach.

We do not always lead by this example though. Despite the knowledge that great results are only achieved through hard work and perseverance, sometimes we decide just not to bother. Often, a room in our home might look cluttered, worn down and unloved and it could be made to look incredible.

The walls could be painted, clutter cleared, carpet cleaned, furniture patched up, curtains updated, but it is so much effort. We see the effort it would take and keep living with it. It does the job. It’s fine.

We heard this a lot when we began to develop our software. Goal Manager was designed from within a clinical neuropsychology service with young people with acquired brain injury, and we recognised how goal setting was becoming an intimidating concept within our service and our colleagues across the field.

To combat this, we developed an online goal-setting platform which streamlines the key processes of goal setting into one system and allows members of multi- disciplinary teams (MDTs) to collaborate on goal data remotely.

Crucially, it was designed to fill a hole. The more daunting goal setting became, the more it was shied away from, and the guidelines for goal setting that had emerged from the literature were falling to the wayside.

While we designed our platform to save time on completing all of the gold-standard processes of goal setting compared to doing them manually, we found that people had often not been completing them at all. It was all too complicated.

As a result, we recognise that adopting a software solution like Goal Manager can come with its own problems to solve. It requires relearning a lot of
what we know about a concept like goal setting, understanding properly how these key processes work and how they can be applied clinically to benefit clients.

It is only then that you can start to think of ways to make it more efficient. To help with this, our users are offered bespoke demonstrations, guided MDTs through meetings to help with the clinical application of the data, and training on assessments and goal attainment.

This takes time. Our users are often throwing out their previous guide and writing a new one. When surveyed, however, every single one who responded said that it was worth it.

This brings us back to where we started: the best things take time; Rome was not built in a day; a stitch in time saves nine. By taking time to develop an understanding of goal setting and being able to apply it to a software solution, users experience all of the benefits of best-practice goal setting outlined in the literature both for their clients and for their teams.

Clients are motivated, rehabilitation is meaningful, important areas to address are highlighted, MDTs are focussed, clinical practice is evidenced – the list continues. None of this would have been possible without the initial investment of time.

While simple enough to read, this is no doubt overwhelming to apply to your service or practice and, with this in mind, there are some key points to remember. The most significant is that there is no better time than now.

The world is slowly opening its eyes, sitting up in bed and having a good stretch after the darkness of the Covid-19 lockdown. It is not yet certain if we are going back to snooze or if we are leaping out of bed afresh.

What we do know, however, is that we are heading into a brand new day. Even for those of us who continued in practice throughout the pandemic, services have been slightly paused in one way or another, whether that be refraining from home visits or having fewer people in the office.

We are all very aware that we are heading into the “new normal” rather than our old ways. Use this time to bring new and innovative ways of working into your practice. You might completely change your filing system, consider how you approach your waiting lists, or change how you approach MDT meetings.

Whatever you have been wanting to do for you and your service for so long, now is that time.

Perhaps you decide that you are going to welcome change but not all at once. That works too! For users of Goal Manager, we often suggest that starting with one or two clients might feel more manageable than a whole caseload.

This can help get to grips with the new concepts and ways of working without feeling like everything is completely disrupted. This applies elsewhere too. If you are wary of integrating a system into your whole service, start with one corner of it, evaluate, take what you have learned and then look to apply it more widely.

Finally, remember that all time taken to improve and grow impacts more than just what you set out to do. When people lose weight, they rarely conclude
by saying they just lost weight: they often enthuse about how they feel more energised or move easier or feel more positive or experience less anxiety.

This applies to any time you invest in developing your clinical practice or your service.

While time spent learning how to use Goal Manager and establishing it within a caseload is designed to improve goal setting, that investment also leads to improved assessment processes, more effective meetings, improved digital literacy, increased patient involvement and so much more.

The potential is enormous. To motivate you to start the process, look at what you want to achieve and how that might trigger other improvements.

While the world is still trying to drag its head off the pillow to open up the lockdown curtains, look to invest in addressing those needs you have always been aware of but never felt like you could justify the time.

Walk around your “house” and look into each room: is this the best it can be or could I give it a lick of paint?

Is now the time to bring meaningful solutions into my practice? Maybe grab a tester pot and try a new shade on the walls. Sign up for a free trial. Plan to grow and improve. Start building Rome.

To invest in improving your goal setting, visit www.goalmanager.co.uk to register for a live demonstration, sign up for a free trial or request a bespoke tour through the platform and its features.

 

Continue Reading

Insight

Researchers unlock key prognostic tool for brain injured patients

Published

on

In 1974, leading neuroscientist Graham Teasdale co-created the Glasgow Coma Scale (GCS) while at the Institute of Neurological Sciences in Glasgow. This scale has since been used to assess coma and impaired consciousness in patients who have had a brain injury.

The scale is used to describe variations in a patient’s eye, motor, and verbal responses. Each feature is assigned numerical scores depending on the quality of the response, and total scores range from three, which is a deep coma, to 15, which is full consciousness.

The GCS is used in clinics all around the world by physicians, nurses, and emergency medical technicians; and is also applied more widely in other, more complex systems that are used in assessing acute brain damage.

However, all three features of the GCS can’t always be determined in patients. Most commonly, the verbal response can’t be tested, as it’s not possible to determine this response in patients with severe brain injury who are intubated.

When the verbal score cannot be measured, the GCS can still be used in routine assessment and communication about a patient’s condition.

“The GCS should be reported in its component parts, so there is still useful information in the motor and eye components, and the verbal score can simply be reported as not testable,” Paul Brenan, senior clinical lecturer in neurosurgery at the University of Edinburgh says.

“The missing verbal score is problematic, though ,when determining the GCS sum score (eyes + verbal + motor). The sum score is used in clinical prognostic tools, such as the GCS -pupils score, so until now, missing verbal data has prevented clinicians from using these tools.”

But now, Teasdale and Brennan, along with Gordon Murray at the University of Edinburgh, have created a tool to use to assess impaired consciousness when the verbal component of the GCS is missing.

The researchers first examined a database of GCS assessments, and found that the verbal component of GCS was missing in 12,000 patients with traumatic brain injury (TBI), which made up 11 per cent of GCS assessments. These verbal scores were most often missing in patients with low eye and motor scores.

Using GCS data recorded in a database of 54,000 patients, the researchers calculated the distribution of verbal scores for each combination of eye score and motor score. They then combined GCS eye and motor scores into EM scores, and determined the distribution of verbal scores for each EM score. Based on this, they identified a verbal score that clinicians could impute for every EM score.

“Without the verbal component of the GCS, the GCS sum score (eyes + Verbal + motor) cannot be determined, so we developed this imputation tool to enable clinicians to benefit from these prognostic tools for decision making in patients with the most severe brain injuries, where the verbal score is not testable,”  Brennan says.

To test these imputed verbal scores, the researchers substituted imputed verbal scores for actual verbal scores within the framework of prognostic charts, which the authors had previously developed.

These charts take into account the total GCS score, pupil response, age of the patient, and findings of abnormalities. The charts provide predictions about patient outcomes, and are designed to help clinicians make decisions and communicate across teams.

The authors outline in their paper, ‘A practical method for dealing with missing Glasgow Coma Scale verbal component scores,’ published in the Journal of Neurosurgery, that they found that the information gleaned from imputing verbal scores according to each EM score was similar to the variations between precise eye and motor scores, and from full information on verbal, eye, and motor responses.

Imputing verbal scores doesn’t add new information, but allows clinicians to use prediction and prognostic models by filling in verbal data needed for those systems to work.

“We have developed several tools related to the GCS that enhance its ease of use and clinical application, including the GCS Aid, the GCS-pupils score and the GCS pupils Age CT prognostic charts,” Brennan tells NR Times.

“These have been designed to address specific needs. For example, the GCS Aid was developed to support training in assessment of the GCS and to enhance reproducibility of assessment. The GCS pupils score and prognostic charts provide a simple but robust prognostic tool that can be used in the clinic.”

“Prognostic scores are helpful for clinicians to get a reliable prediction of patient outcome, to inform clinical decision-making and to support communication with a patient’s family.

“We know from previous research that clinicians can tend to predict overly pessimistic outcomes for patients, particularly those with severe brain injuries, so these prediction models are designed to prevent that. With our imputation tool, the sum score can be determined and prognostic models used in real-time in the clinic.”

The researchers believe that being able to add verbal scores will help clinicians quickly determine the severity of acute brain injury and estimate patient outcomes.

“We know from the enquires we get and from the number of downloads of materials from our website, that these are very popular and are having a positive impact on clinical care around the world.

“We are confident this missing verbal score imputation tool will be just as positively received,” Brennan says.

 

Continue Reading

Insight

Update:concussion in sport

A run through the latest developments in concussion in sport research and protocols.

Published

on

A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.

Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.

“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.

“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”

Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.

Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.

Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.

Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.

“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”

The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.

The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.

Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.

These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.

The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.

Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.

“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”

A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.

There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.

A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.

EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.

This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.

This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.

SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.

“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”

Continue Reading
Softer Foods

Popular

Trending