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Notes from Nanjing

NR Times’ writer Andrew Mernin attended the largest neuro-rehab event in the Asia Oceania region recently and made a few notes along the way

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In a packed auditorium not far from the Yangtze River, hundreds of delegates are on their feet clapping vigorously. They have just discovered that one of their national heroes has been sitting among them undetected all evening.

Xia Boya is China’s rehabilitation poster boy (or man, since he’s now 70). In his twenties during an attempt to scale Everest, his team hit bad weather just 250 metres from the summit. Xia gave his sleeping bag to a teammate who was struggling to survive. But his kindness came with a heavy cost – frostbite and the subsequent amputation of both his legs. Yet 43 years after that failed mission, he finally achieved his dream of climbing the world’s most unforgiving peak.

The televised feat from last year was replayed on big screens at the 2019 Asia-Oceania Congress for Neurorehabilitation in Nanjing – China’s ancient capital. The sight of Xia dragging himself up the final few metres made for an emotional opening to the conference. Applause broke out when an unassuming pensioner in a tracksuit stood up in the crowd and waved.

Xia Boya himself was here for this confluence of neuro-rehab. Not a single chair is empty in this grand hall. Scores of people standing up are lining the outskirts of the room. Most striking, however, is the fact that the vast majority of local delegates are in their late teens or twenties. This is perhaps indicative of China’s accelerated interest in rehabilitation.

A surge of students and young professionals shooting for careers related to severe injury and neurological conditions is emerging. Partly this is driven by soaring demand. A landmark paper on rehabilitative medicine in 2009 reported that China had a personnel gap of 15,000 rehabilitative specialists and 28,000 therapists. While no update on this is available,  trends suggest that the need for more rehab specialists is intensifying.

By 2050 it is expected that the proportion of  China’s population which is 60+ will have risen from 15.2 per cent in 2015 to 36.5 per cent, putting pressure on many areas of healthcare. Around 2.5 million people in China suffer strokes every year, with 70 to 80 per cent losing the ability to perform routine activities and requiring care. A 2017 paper reports that only 11.5 per cent of patients undergo some form of rehabilitation within the first week of their stroke; 42.4 per cent do not receive any rehabilitation.

Meanwhile, the Chinese Journal of Traumatology reports an estimated 3m to 4m incidences of traumatic brain injury every year. The sheer number of neurological disease cases in a population of 1.3bn also creates massive demand for newly qualified rehabilitation workers. The number of Parkinson’s cases, for example, is expected to hit 5m in China by 2030, according to the World Federation of Neurorehabilitation.

Also driving heightened interest in neuro-rehab careers is the rapid reform of China’s healthcare system generally. Over the last decade, the Chinese government has been in the process of expanding social health insurance, reforming public hospitals and strengthening primary care. In 2016 it announced the ‘Healthy China 2030 blueprint’ – a plan to provide universal health security to every citizen by 2030.

China’s is an insurance based system whereby almost a third of citizen health costs are paid for by the individual. The aim is to reduce this to 25 per cent by 2030. Investment which helps to improve, and better connect, services, is being ramped up, while key goals such as earlier detection of diseases and increasing life expectancy have been put in place. All of which may aid the development of rehabilitation services.

The private sector – including technology developers – may have a lead role to play in this. The exhibition floor at the congress is themed around ‘high tech integrated with neurorehabilitation’. Exoskeletons, virtual reality systems and robotics are all represented. The dominant tech forces, by some distance, however, are functional electronic stimulation (FES) and transcranial magnetic stimulation (TMS) therapy machines.

Almost every firm’s products are made in China and marketed entirely to the Chinese market. None I meet are targeting the European market, with enough demand in their homeland to fuel steep growth curves. The private sector’s role is also evident in hospital development. During the week-long conference, eight of the world’s most eminent neuro-rehab practitioners are shown around a new children’s rehab hospital in Nanjing.

They arrive to a heroes’ welcome from a small army of hospital staff, photographers and management flanking the lobby. Despite my repeated protestations that I’m merely a lowly hack there to make up the numbers, I too am lauded as a globally pioneering doctor in neuro-rehab. I autograph a huge sign in reception, then I’m presented with a doctor’s coat and ushered into numerous photo opportunities.

The chief clinician at one of India’s largest rehabilitation hospitals leans into me and whispers: “I spent 16 years at medical school, and you’ve become a doctor in 10 minutes”. My fraud continues as we move from ward to ward, with awaiting staff clapping us from one room to the next. I adopt the classic ‘doctor-walking-with-intentwith-arms-behind-the-back’ approach gleaned from Casualty and ER.

We are then taken into a large boardroom. Hospital staff file in and stand around the perimeter, while we experts take up seats at the table. After a presentation about the hospital, from its enigmatic founder who was inspired to set it up by his disabled brother, the spotlight turns to us. “How would you recommend that we make a success of this new hospital?”

I frantically scribble ideas on a notepad, while my fellow luminaries from the US, Switzerland and Indonesia thankfully step forward to speak up. The microphone edges agonisingly closer to me but my sage advice is ultimately left unsaid.

“Good luck for the future,” I write, while my peers feverishly pen relative essays in hospital management on a questionnaire we’ve all  been handed.

Back at the conference, I meet a German rehabilitation medicine physician currently involved in setting up a hospital in Shanghai. He explains an interesting distinction between European and Chinese rehab. “We’re building a rehab centre in the German tradition, mainly focusing on stroke,” he says.

“What’s amazing is that we’ll do the western approach to rehab each day, and then they’ll go off and do traditional Chinese medicine activities.”

He’s not convinced that all of it works towards recovery, but is open minded and admits that some herbal treatments do show promise. “Of course herbs work, its chemistry, but the rest depends on the frontal lobe. I call it the Hollywood machine. It can give you anything.”

I also meet Benny, leading a Mongolian delegation of rehab professionals. There, wrestling and horse-riding accidents are among the biggest causes of brain injury, he tells me.

A gaping shortfall in the number of rehabilitation doctors makes brain injury care a huge challenge – especially in the vast country’s rural areas with sparse hospital coverage. But interest in neuro-rehab is growing. It will soon host its third annual congress on the field and its development is gathering pace. The wider Asia-Oceania region, like most of the rest of the world, is typified by falling mortality rates but increasing morbidity and disability levels.

Dealing with this requires new approaches utilising improved technology, knowledge, research-based evidence and services. All of these topics are covered in-depth in the conference programme in well attended talks. The appetite among Chinese delegates to learn from rehab professionals in other parts of the world is evident in every session. Momentum certainly seems to be building in China and that can only be a good thing for neuro-rehab’s global progress.

 

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Insight

Taking time to look back – so the way ahead is clearer

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Reflective practice within healthcare settings is widely talked about, but not always so easy to implement in the workplace. NR Times speaks to one neurological centre about how it benefits patients and staff there.

Reflective practice and discussion in healthcare settings is a professional requirement for nurses, as laid out by the Royal College of Nursing revalidation requirements as part of their continuous professional development.

It allows professionals to take time to pause and reflect, communicate and plan, which undoubtedly leads to better outcomes for patients and staff.

But in reality, reflective practice can often be left to the bottom of the pile, underneath many of the competing responsibilities facing staff who are often pressed for time.

It could be argued that this is also why reflective practice is so important – healthcare staff are facing so many pressures that it actually makes less sense to neglect the important work of individual and team reflection.

The Royal College of Nursing defines reflective practice as: A conscious effort to think about an activity or incident that allows us to consider what was positive or challenging and if appropriate
plan how it might be enhanced, improved or done differently in the future.

Staff at Elysium St Neots Neurological Centre in Cambridgeshire started doing regular, weekly reflective practices when its new hospital director, Fiona Box, came into the role a few months ago.

The nurses and healthcare assistants from a ward are invited into the meetings and in their absence the therapy staff monitor patients and provide activities.

“We thought it would be helpful for team members to give them the opportunity to think, learn, and to hear their opinions,” says charge nurse Jemima Vincent.

“If we have an incident with a patient, we discuss it in the session” she says.

Sessions are led by the management team, with added input from psychology teams on each ward.

They will talk through any strengths, weaknesses and opportunities, and work through an analysis to learn from the incident and create an action plan.

They talk about the worst-case scenario in relation to an individual situation and discuss how staff would manage that, so they’re better prepared in the event of it happening.

While they focus on one patient at a time, issues arise during conversations that bring in their wider experiences.

In an article* published in the Nursing Times in 2019, Andrea Sutcliffe, chief executive of the Nursing and Midwifery Council said: “In these challenging times for health and social care, it’s so important that collectively we do all we can to support our health and care professionals, and their employers, in devoting time to individual, reflective, personal and honest thinking.”

Fiona has received encouraging feedback from staff, who say the meetings help the staff feel much more involved in a patient’s care and allow the team to increase their knowledge and understanding resulting in a more consistent way of working.

“Healthcare workers often don’t fully understand patients’ diagnoses or why they’re reacting in a certain way, for example,” Jemima says.

“They know a patient presents with certain behaviours and may be taking medicine to help them cope but they’re not aware why the patient is showing signs of aggression and the best response to deescalate the situation,” she says.

“It’s a learning opportunity for staff, because reflective practice means that they can understand a patient’s diagnosis and why they behave how they do,” Jemima says.

“Reflective practice answers their ‘why’ questions, and gives them a more open mind.”

Jemima also benefits from the meetings; it’s a way for her to get to know staff better, especially when it comes to learning opportunities.

“I’m able to understand what level of support each member of the team requires, including training needs and if they need more knowledge on a specific topic.”

In her final year as a mental health nurse student on extended clinical placement at Elysium St. Neots, Jo took part in a reflective practice session.

She had just finished her dissertation, in which she looked at how settings can increase the opportunities and variety of reflective practices within hospital settings.

The aim of Jo’s session was to reflect on the recent deterioration in a patient’s mental state and the resulting impact on their well-being to ensure staff had a consistent approach to support the patient.

The hospital’s director Fiona asked the team about the patient’s care plan, diagnoses and needs and wishes.

Where staff were unsure of the answers to questions, Jo says Fiona gave them answers and encouraged the team to share their knowledge of the patient, problem solve and come up with an agreed plan to move forward with.

Jo found the session helpful and was impressed with how the healthcare assistants were so involved in the discussions about all aspects of the patient’s care, including the more clinical elements.

Healthcare assistants told her they found the session helpful too and that it made them feel like they had a better understanding of the patient’s changing mental state, behaviours and needs.

Jo says having the opportunity to reflect on practice is a crucial skill for all healthcare workers to help them learn from their experiences and increase self-awareness, which, in turn, can improve individual professional standards, strengthen teams and enhance patient-centred care and clinical outcomes.

For referrals to Elysium St Neots Neurological Centre or other Elysium centres visit: www.elysiumhealthcare.co.uk/neurological

Reference source: https://www.nursingtimes.net/news/ professional-regulation/nmc-highlights-importance-of-nurses- reflection-on-practice-18-06-2019/

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Robots and resilience at Askham Rehab

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NR Times reports on a new rehabilitation approach taking place in Cambridgeshire.

Despite a year of relentless change and upheaval for all involved in neuro-rehab, one provider in Cambridgeshire has been able to keep its ongoing development on track.

Askham Rehab, part of the Askham Village Community, is a recently-launched specialist rehabilitation service incorporating the latest in rehab robotics and sensor assisted technology.

While the firm has invested in state-of-the-art technology to do the heavy lifting, however, its rehab services remain person-centred, as director Aliyyah-Begum Nasser explains.

“We’re a specialist rehab centre in essence, and so, although the robotic technology helps us to get the most out of our patients and staff, we are very much family-focused.

The equipment is obviously fantastic but we know from experience that a person’s mindset, and their ability to sustain whatever improvements they make, comes down to the people who are supporting them – their family members.

“We’ve been on some real journeys with many of our family members who just didn’t understand the impact of a brain injury in terms of how it can impact behaviour or what it can do for cognition.

“Once they understand that, suddenly they become a lot more compassionate, and a lot more supportive; they become part of the recovery process, rather than being a frustrated observer.”

With recognition of the family’s paramount importance to recovery, Askham Rehab does everything within its power to harness this force – including by enabling families to stay together in specially-designed apartments on site.

Aliyyah-Begum says: “The flats are fully adapted, with cantilever cupboards, height-adjustable sinks in the bathroom and full wet room with turning spaces.

“We have the patients themselves participating in rehab, specifically to their programme, but relatives are also there from the beginning, seeing the improvement and being part of our process from the outset.

“We think of the centre as more of a rehab environment; it’s not a just care home with therapy as an added extra.

“So from the minute our patients wake up to the minute they go to bed, everything is based around their recovery goals, and everyone is working together towards achieving them.”

And robotics are an important tool in pursuing these goals through patient exercise. They help therapists to achieve the repetitions and intensity needed to progress their clients, as Aliyyah-Begum explains.

“The point of the robotics is that they respond to the patient. For example, if you set the machine on a left lower limb, but it senses that there is more pressure being exerted through the right limb than the left, it will automatically respond to make sure the patient is moving the correct part of their body.”

The centre’s head of rehab and nursing, Priscilla Masvipurwa, says: “This is a real a game changer in our approach to rehabilitation.

“Robotics help to bridge the gap, increasing the frequency and repetitiveness of treatment, something that’s an essential part of the process.

“We anticipate that this will enable us to support our patients in reaching their goals in a more efficient and sustainable way.

“The centre has so far invested in four items from robotic rehabilitation firm Tyromotion, but is looking to add more over time, as the benefit to both staff and patients becomes ever more evident.

Aliyyah-Begum says: “It’s really important to the team at the centre that the robotics aren’t just seen as an add on.

“There is a lot of nervousness about robots replacing therapists, but our service is still very much therapy-led.

“What this means in practice is that, where a resident would previously have had maybe an hour of therapy time in an afternoon, now you have an hour of therapy time, and then you can carry on exercising if you want to, or carry on playing games with other residents.

“For example, one of our machines, the Myro, enables patients to play games like bat and ball, or perform virtual tasks like sweeping leaves.

“However, because it is all sensor-assisted, if it senses that the patient needs to work a certain hand, it will alter what it is asking them to do accordingly, while they won’t even necessarily feel they’re having therapy – it’s all part of the game, and part of their socialising with other residents.”

Askham Rehab forms part of the Askham Village Community, on the edge of Doddington village, in Cambridgeshire.

It provides specialist care for people of all ages, offering day visits, respite care and continuing long-term support, both on-site or at home.

The site consists of five homes, three of which are specialist neurological facilities. In total, the neuro-rehab team can look after up to 52 patients at any one time, with 120 staff made up of rehab professionals and specialists.

The team comprises carers nurses, physiotherapists, occupational therapists, speech and language therapists and psychologists.

Aliyyah- Begum believes that the introduction of the robotic rehab services, combined with the patient-led therapy the group has been offering for 30 years, can only enhance the centre’s outcomes.

She adds: “We know that there is an increasing number of care homes that offer specialist therapy, but the difference with Askham Rehab is that we have embedded it into the whole culture of our setting – and the outcomes really speak for themselves.

“We often discharge people earlier than planned, and that’s a testament to the fact that the patients are really working hard with the team throughout their stay with us to achieve their goals – and that is the key.”

For more information about Askham Rehab, visit www.askhamrehab.com

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Astrocytes identified as master ‘conductors’ of the brain

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In the orchestra of the brain, the firing of each neuron is controlled by two notes – excitatory and inhibitory – that come from two distinct forms of a cellular structure called synapses.

Synapses are essentially the connections between neurons, transmitting information from one cell to the other. The synaptic harmonies come together to create the most exquisite music–at least most of the time.

When the music becomes discordant and a person is diagnosed with a brain disease, scientists typically look to the synapses between neurons to determine what went wrong. But a new study from Duke University neuroscientists suggests that it would be more useful to look at the white-gloved conductor of the orchestra – the astrocyte.

Astrocytes are star-shaped cells that form the glue-like framework of the brain. They are one kind of cell called glia, which is Greek for “glue.” Previously found to be involved in controlling excitatory synapses, a team of Duke scientists also found that astrocytes are involved in regulating inhibitory synapses by binding to neurons through an adhesion molecule called NrCAM. The astrocytes reach out thin, fine tentacles to the inhibitory synapse, and when they touch, the adhesion is formed by NrCAM. Their findings were published in Nature on November 11.

“We really discovered that the astrocytes are the conductors that orchestrate the notes that make up the music of the brain,” said Scott Soderling, PhD, chair of the Department of Cell Biology in the School of Medicine and senior author on the paper.

Excitatory synapses — the brain’s accelerator — and inhibitory synapses — the brain’s brakes — were previously thought to be the most important instruments in the brain. Too much excitation can lead to epilepsy, too much inhibition can lead to schizophrenia, and an imbalance either way can lead to autism.

However, this study shows that astrocytes are running the show in overall brain function, and could be important targets for brain therapies, said co-senior author Cagla Eroglu, PhD, associate professor of cell biology and neurobiology in the School of Medicine. Eroglu is a world expert in astrocytes and her lab discovered how astrocytes send their tentacles and connect to synapses in 2017.

“A lot of the time, studies that investigate molecular aspects of brain development and disease study gene function or molecular function in neurons, or they only consider neurons to be the primary cells that are affected,” said Eroglu. “However, here we were able to show that by simply changing the interaction between astrocytes and neurons — specifically by manipulating the astrocytes — we were able to dramatically alter the wiring of the neurons as well.”

Soderling and Eroglu collaborate often scientifically, and they hashed out the plan for the project over coffee and pastries. The plan was to apply a proteomic method developed in Soderling’s lab that was further developed by his postdoctoral associate Tetsuya Takano, who is the paper’s lead author.

Takano designed a new method that allowed scientists to use a virus to insert an enzyme into the brain of a mouse that labeled the proteins connecting astrocytes and neurons. Once tagged with this label, the scientists could pluck the tagged proteins from the brain tissue and use Duke’s mass spectrometry facility to identify the adhesion molecule NrCAM.

Then, Takano teamed up with Katie Baldwin, a postdoctoral associate in Eroglu’s lab, to run assays to determine how the adhesion molecule NrCAM plays a role in the connection between astrocyte and inhibitory synapses. Together the labs discovered NrCAM was a missing link that controlled how astrocytes influence inhibitory synapses, demonstrating they influence all of the ‘notes’ of the brain.

“We were very lucky that we had really cooperative team members,” said Eroglu. “They worked very hard and they were open to crazy ideas. I would call this a crazy idea.”

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