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The neuropsychologist teaching tai chi

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When lockdown began, many people with a traumatic brain injury (TBI) were faced with their treatment and support being paused, or having their face-to-face services moved online.

Giles Yeates, consultant clinical neuropsychologist and tai chi instructor, spoke to NR Times about how he’s wasted no time in moving his classes online.

Yeates hosts online tai chi classes, which are streamed live on the charity Different Strokes’ Facebook page and YouTube channel. The classes are moderated by Alison Smith, who had a stroke last year.

Tai chi involves physical routines to strengthen the body and improve flexibility, achieve regulated breathing and focus on the body to improve inner energy, which in turn, is believed to improve circulation. It’s based on attaining a flow state of mind, which is said to be achieved when people become fully immersed in what they’re doing.

“When you speak to monks in China, they describe it as a very esoteric language. It transforms different types of energies in the body, where something unique happens in the mind,” Yeates says. “The idea of flow comes close to it, where you forget who you are and you’re in the rhythm of that act. This state of mind has a lot of physical benefits.”

When it comes to adapting classes for people with brain injuries, Yeates says this can require a lot of cognitive adjustments, for example, doing movements that mitigate memory problems, such as teaching backwards, or structuring the class for attention difficulties.

“Tai chi comes in many different forms,” Yeates says. “It can contain some complex movements, or be quite simple. It’s about finding which movements help people relax their body, slow their mind and get into flow. It involves moving from your core, rather than thinking about moving your limbs.

“In any given group of long-term survivors of brain injury, each person has a unique constellation of needs,” he says.

Yeates didn’t know the needs of those who would watch his classes, so he decided to cast his net wide.

“We start the class seated and do one side of movement using peoples’ preferred arm,” he says. “Then, they’re given the option of bilateral movement. Even when they’re doing both arms, I’m focusing on telling people to move from their body, not their arms.”

“Then there’s the option to stand and walk, to coordinating arms and legs, and doing positions in different ways to get into a flow state of mind. The idea is to do it the way that’s right for the individual.”

Yeates has done eight classes so far and has found it to be very different from the face-to-face classes he taught before lockdown.

“It’s difficult because doing stuff on screen can be more tiring and draining. It can be more demanding than face-to-face, so I’m trying to keep the movement simple and give a range of options for people. It’s about the state of mind when they’re doing it, rather than doing the actions properly,” he says.

Yeates’ main goal is getting people out of their heads and into their bodies. In the classes he’s taught in the general population in Oxford, he’s found this to be a particular issue.

“Oxford is an intellectual place, and people here are in their heads all the time and neglecting their bodies. When we teach them, they want to understand it intellectually, but they need to switch off their minds and let the body lead.”

Yeates hopes to continue doing the online classes long-term and plans to evaluate it for one year. Participants are encouraged to fill out a survey before they start the group and afterwards, so Yeates can track any improvements as they continue attending classes. He’ll be looking at people’s mobility, balance, anxiety, fatigue and mood, using scales of smiley and sad faces.

He then intends to compare his online group to his face-to-face group, looking at the benefits versus the limitations of online classes, which have more limitations of delivery but are generally more accessible.

“It seems to be reaching a lot of isolated people, which is one of the main aims,” Yeates says.

Yeates trained in martial arts with monks and nuns in the mountains in China and then trained to teach tai chi and kung fu in the general population. Naturally, given his 17 years’ experience of being a neuropsychologist, Yeates has been tracking the scientific evidence of tai chi on the brain.

But while he found some studies on the psychological benefits for people with neurological conditions who practice Tai Chi, there were gaps in the research, which tended to be focused on physical intervention.

“Tai chi can get you into a particular state of mind, where anxiety and depression go down, but these studies were focused on physical interventions,” he says.

This prompted Yeates to deliver tai chi himself among people with neurological conditions, and carry out his own research.

“The elephant in the room in the literature is that no one is talking about it in this way, so we wanted to say that this is what needs to happen to make it valuable for people.”

He is collaborating with the Centre for Rehabilitation/Department of Movement Science at Oxford Brookes University to develop a pilot tai chi for people with TBI, and will evaluate the effects it has on participants’ physical and mental wellbeing.

However, when the pandemic came, Yeates had to hold off incorporating tai chi as part of his one-to-one clinical work.

“Covid-19 arrived so now more people will be acquiring brain injuries through the virus, but can’t get to places to help manage their fatigue or anxiety,” he says.

Yeates found that, during the pilot, some people struggled to get to a fixed location.

While research on the impacts of tai chi on the brain is limited, some studies have shown that tai chi can help alleviate fatigue; a common symptom following a TBI.

“Fatigue hasn’t been studied as a direct outcome, but when it’s measured you can see that tai chi, along with mindfulness meditation and yoga, has benefits for sleep quality, improves energy and reduces fatigue,” Yeates says.

“In Chinese practice, they say doing tai chi improves vitality and energy, whereas in the west, our approach is that if you have a depleted supply of energy you need to manage it wisely.

“Another option is increasing your energy in a holistic way without side effects. Evidence suggests these practices might be deemed to be doing that,” he says.

Benefits for fatigue come from approaches that involve regulated breathing, stretching and attentional focus, Yeates says, which tai chi, yoga and mindfulness all encourage.

“It’s the idea that the circulation of vital energy for many people is less than optimal, it doesn’t get circulated around the body and used to its best advantage. In China, there’s a concept of stagnant energy, the idea of a blocked pool where water doesn’t flow through it.

“Brain injury survivors are fatigued and irritable, they have a lot of movement and agitation and fatigue at the same time, the energy isn’t going where it needs to be.

“It’s early days, but there’s something about breathing, focusing attention and using body through relaxing and stretching that seems to have an impact on whatever energy is available to the person.”

Yeates eventually wants to train rehab processionals to incorporate tai chi movements, and train yoga and tai chi instructors on how to adapt their classes, learning how to use cognitive strategies to make practices more accessible

Interviews

‘I lived in pain for so long – finally I’ve found a way to manage it’ 

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Despite a cycling accident, Ian has managed to get his life back

Having been left with serious injuries in a cycling accident, Ian recovered from the physical impact but continued to suffer chronic pain. Here, he discusses how he has learnt to deal with it and get his life back on track.

“About two years ago, I was involved in quite a serious accident while I was out on my bike. I flew over handlebars and hit my head on the ground, leaving me unconscious.

I was left with an array of injuries, including decompression of two of the disks in my spine, which needed an operation to resolve. But from being in the ambulance after my accident – the earliest point I can remember after coming off my bike – I was in enormous pain.

While over time I have managed to recover my body functions, having struggled in the aftermath of the accident, I continued to experience pain. Most days were pretty tough. I was on a lot of medication, which contributed to my fatigue.

I was sleeping a lot, spending a lot of time in bed, I was very tired all of the time and in a lot of discomfort.

I’d always been very, very active, and enjoyed cycling, motorcycling, tennis, walks with friends and family, I was a very outdoors person – but that all came to a halt. The most I could manage was a short walk, and even then I was very fatigued.

I didn’t understand what was happening to me or why, it was just continuous, unrelenting pain.

By this point I had returned to work and the demands of my job. I was just about managing to keep on top of my commitments, but only just.

With a wife and two young daughters, my life had typically been very busy and very active, but now I was unable to do as much together, or spend as much time as I’d like with them.

This went on for over a year, and was, without doubt, the toughest time of my life.

My case manager helped me to find a solution which has enabled me to rediscover my life, through a programme called RESTORE, pioneered by RTW Plus. 

Through RESTORE, an online learning programme which supports you to understand and manage pain, and take back control of your body and life – which enables access to a consultant and support from health coaches 24/7 – I have been educated in what I can do to help myself.

All of a sudden, from not knowing what had happened to me and feeling helpless, I was supported in understanding what was going on.

Prior to that, what had happened wasn’t described to me that well, and I had so much medication that everything was often quite blurry. The concept of chronic pain wasn’t something that was addressed once my physical injuries had healed.

Through this programme, I was educated as to what had happened to me. As a keen cyclist, I’d had many accidents in the past, but all were short-term tissue damage, which were very painful at the time, but that pain went away. I now was able to understand why this time was different, and to be realistic in my expectations.

I’ve never been good at pacing myself, but now I was able to stop and think what it was I was trying to do, what I wanted to do, and how to manage and achieve that.

Crucially, by understanding my pain, I became less frustrated and less dependent on medication, meaning my life would not always have to be a cloudy blur. I became more confident as a result.

From believing this was how my life was going to be, not very pleasant and full of pain, now I had hope and confidence it was going to get better. There was light at the end of the tunnel.

Understanding more about pain got me really engaged, and I started reading about it and looking for examples. After work, I’d be picking up books and learning more. Having the knowledge about what is happening to you, and how to help yourself, is so powerful.

Having been able to come to terms with my pain during the 16-week course – it’s usually eight weeks, but was tailored around my busy work schedule – I could then get my life back on track, backed by the confidence I had rediscovered.

I’m now cycling every other day, which I haven’t done since my accident, and am getting my life back to what it used to be. I’m doing things that matter and spending time with my family, which is what it’s all about.

I realise I am on an ongoing journey with my pain, and that hasn’t finished and will continue for some time to come, but I’m in a good place now – a place I could never have imagined being a few months ago.”

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Interviews

‘I lost my sense of smell through brain injury – I’m grateful COVID has shone a light on its impact’

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Smell loss if one of the long-lasting symptoms of COVID-19

Having been in a near-fatal car accident, Sally Smith has recovered physically, but a brain injury resulted in the permanent loss of smell. Here, she discusses how the once-tricky subject has now become much more accessible through its association with COVID-19.

I used to love the smell of Christmas. I honestly think that was my favourite part. The mulled wine, the spicy fragrances, the turkey dinner cooking – that really made Christmas for me.

However, for the past five years, I’ve had to live without this, after losing my sense of smell as a result of my brain injury. As 80 per cent of the flavour of food comes from its smell, my sense of taste has also been seriously impacted.

It has been a pretty life-changing experience, one which I could never have appreciated the impact of. Christmas certainly isn’t the same, but neither is any other day.

The smells of summer – the cut grass, the flowers, the barbecues – all lost. The overpowering sensation of walking through the perfume departments of stores is something I can only remember. Even the smell of burning to alert me to the fact I’ve left the dinner in the oven too long is gone forever. And the taste of my favourite foods and wine is also tainted, with a flavour so faint often I wonder what is the point.

While people are sympathetic, they don’t understand. But how could they? I’m not sure I could have prior to my own experience.

Often, their sympathies extend to something like ‘Well at least you’ve still got your hearing/sight’ as if it’s some competition between the senses. Or ‘At least you’re still alive,’ which is quite dramatic, but nevertheless true.

I did come close to losing my life in a car accident five years ago. As a back seat passenger, I bore the brunt of a lorry crashing into the back of the vehicle I was in, and suffered a range of injuries, my brain injury being the one which still affects me now and always will.

I was undoubtedly lucky, apparently it was miraculous I survived, and I do feel so fortunate to have few other lasting affects apart from my loss of smell.

The topic was one that there were few opportunities to talk about, as devastating as it was personally for me, given the fact that so few people had experienced it for themselves.

Until a few months ago, that is, and the fact that loss of smell become a symptom of COVID-19. Suddenly, it stopped being a subject that was just plain weird, and one that everyone was talking about. People began to understand.

My next door neighbour had COVID-19 and lost her sense of smell for a short period. ‘It was only at that point I realised how horrendous it is,’ she said to me after her recovery. ‘Who knew I’d actually miss the smell of my daughter’s dirty nappy?’

And while that’s perhaps not something you’d ever think you’d miss, when you find yourself in the situation of not being able to smell anything at all, however divine or revolting, you do feel a great sense of loss. Of wishing to smell anything at all.

Thankfully, for most people with COVID-19, this is a temporary state, but I have heard there could be more than 100,000 of those recovering from this terrible virus whose loss of smell has extended beyond four weeks. I can only hope this is not a permanent state for them, although undoubtedly there is much more about COVID-19 and its lasting impact we have yet to discover.

For me, my situation is permanent, and living in a world with no fragrance is the reality. Yes, things could be much worse, and I realise that, but for me, it has been life-changing.

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Interviews

Inspiring a brighter future for residents

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A neuro-rehab provider which opened its first facility in Worcester shortly before the first lockdown has succeeded against the odds – and now has plans to expand in 2021, as NR Times reports.

Inspire Neurocare provides support for people with a variety of neurological conditions, offering rehabilitation, respite and palliative care.

The firm opened its first specialist care centre in Worcester in February 2020, and this will be followed by further facilities in Basingstoke and Southampton in 2021/22. Inspire prides itself on a novel model of care that has “no limitations on the possibility of recovery,” all led by director of clinical excellence Michelle Kudhail.

A key element of the centre’s approach is the team’s commitment to understanding that every patient, and the circumstances that led them there, is different.

Whether this means enabling people to leave high dependency hospital units and develop their independence in a modern, home-from-home environment, or providing long-term support or end-of-life care, the service is designed to work around the needs of each patient.

Michelle’s background means she is the ideal person to head up the Inspire team, having worked as a neuro physiotherapist in the NHS until 2010, before moving into the private sector.

Michelle Kudhail, director of clinical excellence at Inspire Neurocare.

She takes an holistic approach to patient care, which has led to the creation of a team of life skills
facilitators and therapists at the provider, who develop their care around the needs of everyone.

“The life skills facilitators support and assist the residents to do as much as they can for themselves,” she explains.

“As the name suggests, their role is more than a carer; it is to facilitate the residents in all aspects of their care, whether that’s helping them get their breakfast, choosing what they are going to wear, or taking their medication.

“Their skills are broad because we want them to be involved in all aspects of the residents’ care; and because we want to provide what they need at the time that they need it.

“Roles such as this also enable us to evaluate the outcome of any action. If a resident has been given pain medication, a facilitator can assess whether it’s been effective, rather than a nurse giving the medication and then not seeing them until the next round.

“We also know from a therapy perspective that some patients don’t respond well to having therapy at a fixed time on a particular day; they simply might not feel like doing it. Our facilitators mean we can best provide interventions for the resident when they want them.”

Alongside this role, the facility also employs a wellbeing and lifestyle coach, focussing on the health and emotional needs of both residents and their relatives, particularly during a time when COVID has caused a lot of uncertainty.

Michelle says: “We wanted somebody that had relevant experience in working with residents, particularly with neurological conditions but also with a well-rounded experience so that they would not just focus on one aspect.

“The idea is to have somebody who can offer support in all areas, whether it be psychological, emotional or physical.”

Staff are overseen by experienced rehabilitation consultant Dr Damon Hoad, who shares his clinical oversight with the interdisciplinary team and supports patients on their journeys.

The rest of the clinical team have a wealth of experience within neuro services in and around the region.

The design of the Worcester facility draws on Michelle’s years of experience, and she had the opportunity to use her skills to help develop the purpose-built home.

She says: “We’ve had a lot of involvement all the way through from knocking down the pub that was there, to seeing it grow. Having the opportunity to be involved from the ground up was fantastic.

“Within the build itself we try to consider the needs of younger people, and so the inside of the home is very much a contemporary design and a lot of research has gone into its development to ensure it has the correct, up to date, equipment.”

Adding to the sense of autonomy staff are keen to foster, is the independent living flat, which staff are able to support via environmental controls.

With soundproofed rooms, residents can enjoy listening to music or watching films without disturbing others.

In common with all care facilities, the impact of COVID means that a lot of thought has had to go into the long-term plans for the property. The recently-built visitation suite – known as the ‘family and friends lounge’ – allows visitors to meet their loved ones in a safe and COVID-compliant way.

The suite includes separate access for visitors from outside, and features a large transparent Perspex screen separating each side of the suite, while an intercom enables contact-free communication.

As well as creating an infection barrier, the screen also assists when it comes to residents who may struggle to understand that they are unable to hug their relatives, while still allowing them to communicate and see each other up close.

After each visit, the room is cleaned and decontaminated in preparation for the next visit.

As Michelle explains, human contact is essential for emotional wellbeing, adding: “We’ve tried to create an environment that is as safe as possible, because we know how important visits are to the residents but, more particularly, to their relatives.

“Supporting the residents through this time is vital. We have residents that are used to going out and doing things in the community and we have had to adjust by being creative in the ways in which they can still access things that they enjoy and still communicate with their families.”

And while the pandemic has certainly delivered some challenges, Michelle and the Inspire team have been able to look at some positive outcomes.

She explains: “One of the positives for us is that it gave the team and the residents the opportunity to really get to know each other.

“We could also develop the life skills facilitator role to its truest form, because everybody was very much working together dealing with the crisis, supporting each other and supporting the residents.

“It was a testing time but it actually it brought the team together, bearing in mind the facility opened literally as everything was going into lockdown.”

The creation of the COVID-secure visitation suite is just one example of the creativity with which all at Inspire approach care, Michelle says.

By looking to build collaborations with other organisations, Michelle also hopes to share her hard-won knowledge, potentially becoming involved in research and training in the future.

Despite the upheaval of its first few months, the Inspire team has already achieved some successful patient outcomes.

One such success story is the case of Adrian, who came to the centre for specialist neuro-rehab following a car accident in which he suffered a severe brain injury. In the months that followed, Adrian’s journey enabled him to walk out of the service and return home to his wife and children.

(See Adrian’s story below – and read more here).

While the coming months may bring more challenges, as COVID lingers and vaccinations are rolled out, the Inspire team seemingly has the skills, approach and dedication to rise to whatever the future holds.

www.inspireneurocare.co.uk

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