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Neurophysios blending in-person and telerehab

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Neurophysiotherapists are adopting a ‘blended approach’ in delivering rehab to their patients, incorporating both in-person therapy and telerehab, as they plan for the future of the profession post-pandemic.

Telerehab has grown hugely in its use since March, with therapy and consultations being delivered remotely due to the restrictions around social distancing and the shielding of many vulnerable people.

However, while physio practices and clinics have now re-opened and have resumed seeing patients in-person, many have realised the benefits of combining face-to-face contact with telerehab and plan to continue to use both into the future.

Having been an early adopter of telerehab, with its introduction being made years before the pandemic hit, PhysioFunction plans to continue its use alongside clinic-based appointments.

The business has built on its existing telerehab provision to add online therapy groups and classes to its offering, as well as expanding the remote technology service, all of which can be combined with in-person therapy to increase a patient’s rehabilitation opportunities.

“The blended approach works really well for many clients, but particularly those who are more vulnerable,” says Claire Everett, clinical operations manager at PhysioFunction and a senior neurological physiotherapist.

“Even prior to the pandemic our use of video consultations was working well, but I think everyone has got a bit more tech savvy over the past few months, so it’s definitely a key part of what we do now and will be into the future.

“For those who find it difficult to get out to appointments, or people who don’t want to leave their home at the minute, or for those who are having to isolate, we can see them by video instead of cancelling their appointment. It’s very important in having continuity.”

But while telerehab has grown in importance for PhysioFunction, which works with patients from a 100-mile radius from its specialist outpatient rehabilitation unit in Northampton, seeing people face-to-face can and will never be replaced.

“There will always be a need to see clients in person, that face-to-face contact is so important,” says Claire.

“For some things we offer, like FES assessments and fitting, that has to be done in the clinic. So in some scenarios, there is no alternative.

“But if people do want to come into the clinic, they can do so, in accordance with all the safety and hygiene measures we have introduced. Our waiting room is closed so we escort them in and out of the building, and their appointment will take place in their own room or ‘zone’, which allows for social distancing.

“We have had to change the layout of the building a bit to accommodate this, but we are trying to keep things as ‘normal’ as we can with regard to treatment and chatting to our team.”

While there was some initial reluctance from some clients, the combination of telerehab with in-person treatment is now widely accepted, says Claire.

“For some people, I think they had to see for themselves that the use of video worked, they needed that reassurance,” she says.

“But once they have realised it is effective, it can be a great addition to what they do with us in the clinic. There has been an increase in uptake for our classes, our neurofit class is helping clients to exercise while staying at home and following the guidance of the second lockdown.”

And as well as clients, the use of technology is benefitting the PhysioFunction team too, adds Claire.

“For the PhysioFunction team too, we’re finding the blended approach works. We had a CPD in-house event recently, which was done via Zoom, and that takes away the need to come in on a day off, or for people to stay at work late, as it’s done remotely,” she says.

“The blended approach works well for us and our clients alike, and it’s something we will absolutely be continuing to offer here.”

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More Delicious Innovations from Wiltshire Farm Foods

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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.

Wiltshire Farm Foods Minced Cod in a Parsley Sauce

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

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Forget brain regions, it’s all about networks in neuroscience

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Dr Ginny Smith - Neuroscience communicator and author of Overloaded

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.

Overloaded by Dr Ginny Smith

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.”

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How the C-Brace is opening up a new world of possibilities

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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.

Indications:

  • 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
  • Polio
  • 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.

For more information about the C-Brace contact Ottobock or Dorset Orthopaedic through their website enquiry pages: www.ottobock.co.uk or www.dorset-ortho.com.

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