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The shifting plates of disaster zone rehab

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Rehab units on wheels could revolutionise the way spinal injuries acquired in natural disasters are handled, savings thousands of lives each year, clinicians have been told.

They might also be the catalyst to creating vital neuro-rehab care networks needed in many parts of the developing world, a leading expert believes.

Over 6,000 natural disasters between 2000 and 2017 killed two million people and injured a further three to five million.

Around 90 per cent of natural disaster deaths and 98 per cent of injuries affect people in developing countries.

Severe spinal injuries are a major cause of death at the time of the disaster – and also in the days and weeks that follow; often due to a total lack of rehab infrastructure within reach of the disaster zone.

In the Haiti 2010 earthquake, for example, more than 220,000 people were killed and 300,000 were injured.

A report published six months afterwards suggests there were only 150 people remaining in Haiti with earthquake-related spinal cord injuries – still an unprecedented amount in a nation not set up to offer adequate spinal injury care.

As one research paper on Haiti (Burns, O’Connell, Landry 2010) noted: “Some facilities decided not to treat
catastrophic injuries, such as spinal cord injuries (SCI), because of the resource-intensive needs of these patients, perceived low survival rates, and ‘minimal chance of ultimate rehabilitation’.”

Severe injury rehab understandably sits
far below the provision of shelter, food and basic medical care on government and NGO agendas immediately following disasters.

Its value in saving lives, and rescuing survivors from a lifetime of serious limitation, however, has not been overlooked by those shaping disaster relief development.

Among them is Jianan Li, a professor and chief doctor in rehabilitation medicine and president of the Chinese Society of Physical Medicine and Rehabilitation.

He recently shared China’s progress in disaster recovery at the World Congress for NeuroRehabilitation in Mumbai.

He said: “China has built up an emergency management system from a national network to all parts of the country. With natural disasters, the location and severity of injuries is unpredictable but certain rescue actions and disaster relief – including rehab relief – can be prepared.

“It’s very important to realise that rehab 
in natural disasters is very different from
the normal rehab need.

“When any disaster happens, local medical personnel may be involved in the relief effort but may also be victims and local medical facilities may be damaged or destroyed. The most important task for the local government is not rehab 
but to provide settlement for survivors.”

“Institutional rehab is limited to acute and sub-acute stages, not the long-term.”

The magnitude eight earthquake which hit southwestern China in 2008 saw 11,028 hospitals and clinics destroyed, amid 87,150 fatalities and missing persons and 374,000 injuries.

An SCI was sustained by around 15 per cent of all patients admitted to their nearest tertiary care hospital.

A post-event study shows the possibilities of the type of long-term rehab many disaster victims in the developing world are not afforded (Y. Li et al, 2012).

It also highlights the importance of a speedy response to potentially catastrophic injuries in disaster zones.

It concludes that institutional-based physical rehab programmes for disaster-related SCIs may significantly improve functional outcomes.
In the aftermath of that disaster, a national rehab team formed, made up of rehab professionals from institutions in other provinces.

The team provided rehab
services to SCI patients and others in newly established rehab departments of three hospitals in the worst affected areas from two months to up to two years after the quake.

The study, which followed 51 severe SCI cases, shows 90 per cent resumed walking – most through KAFO (knee ankle foot orthosis).

Nearly everyone who needed a wheelchair was able to operate it independently following a rehab programme, while over 
90 per cent regained some self-care ability prior to discharge.

Most victims (70.6 per cent) were rescued within 30 minutes of
the disaster but only one patient began rehab therapy within a month – with most beginning two to four months afterwards.

“Rehabilitation effectiveness was found to be inversely related to time to rescue and time to rehabilitation,” researchers stated.

“Significant improvement in MBI scores [a measure of independence in daily tasks] with rehabilitation was achieved by groups that were rescued from the rubble within 30 mins and/or received rehab no later than three months after the injury; the group that was rescued and began rehabilitation relatively later showed the smallest improvement.

“These findings are consistent with common assumptions about neural plasticity and optimal windows of opportunities for rehabilitation.”

In other words, getting disaster victims on an adequate rehab programme quickly can have a dramatic impact on their outcome.

In China this is made more challenging due to the mountainous and remote nature of some areas – and the sheer vastness of the country; as highlighted in the SCI study’s findings.

Most of the SCI patients were discharged to mountainous, rural areas with poor roads, inaccessible public transport and non- inclusive homes, it reports.

In less developed countries, building the foundations for a post-disaster rehab programme is even harder – with facilities destroyed, poor infrastructure and a dearth of on-the-ground rehab skills.

Li’s proposed solution is the mobile rehab truck – a rehab unit on wheels which could be despatched to any disaster zone in the developing world.

He said: “It needs two very important
things – manpower and equipment. It would need rehab equipment, but also medical equipment such as x-rays, ultrasound and so on. We would also need sleeping bags, tents and cooking facilities.

“It could be moved into the poorest and most remote areas which have no rehab facilities and help to build up their first rehab infrastructure. We would set up a hospital in the disaster zone and provide services for 13 months or longer.

“For example, if there was an earthquake
in Nepal, we could go there and work on a rolling basis until it was needed somewhere else in the world. The mobile hospital could take another vital resource there – training. Professionals could train people working in the disaster zone and employees in the area.

“My dream would be to support it through an NGO comprised of industries, charity organisations, academic bodies and even some hospitals.”

Li is hopeful that there will be enough 
global interest in the idea to gain the support needed to get it motoring in the not-too-distant future.

Another useful addition to post-disaster rehab will be further advancements in telemedicine, believes Raju Dhakal, who also spoke at the World Congress in Mumbai.

Dhakal is medical director of the Spinal Injury Rehabilitation Center (SIRC) Nepal and a leading authority on spinal injury rehab in disaster zones.

He was part of the team that helped to treat spinal injuries in the aftermath of the Nepal 2015 earthquake, which killed 9,000 and injured at least 22,000 people.

Working out of SIRC – supported by spinal injury experts via telemedicine – 81 SCI patients were admitted for comprehensive care by a multidisciplinary medical rehabilitation team within four weeks of 
the disaster.

Special cases, including a
 third trimester pregnancy with incomplete unstable spine fracture, undiagnosed SCIs in children, misdiagnosed spine fracture,
SCI with stroke and SCI complications linked to associated injuries, were all well managed through tele-consultation.

A study into SIRC’s work found that: “Tele-consultation through various means such as telephone, e-mail, and video conferencing can improve the quality 
of healthcare by aiding in diagnosis and management of patients, and to train healthcare professionals.

“The accessibility of specialty and subspecialty expert care can reach a larger population base thereby reducing the morbidity and mortality after SCI and eventually increasing quality of life. Information technology and modern portable communication devices should be incorporated in disaster preparedness and post-disaster SCI rehabilitation.”

Dhakal said: “At the time of the earthquake our centre had no standard telemedicine systems. Often the internet and phone lines weren’t working and sometimes we had to work very slowly, with lots of disconnections.

“Despite these problems, telemedicine really helped with patient care and rehabilitation.

“The advantages of telemedicine are that there are no visas required for experts – and no travel problems or risky trips for professionals to earthquake zones. It also increases international links between healthcare experts.”

Also speaking at the World Congress was Angela Tulaar, a disaster rehab expert working in Indonesia – where there is a near-constant threat of volcanic eruptions, earthquakes, floods and tsunamis due to its position on the Pacific Ring.

She provided detailed context of the challenges facing rehab staff in disaster zones. After particularly devastating earthquakes she had seen spinal injury patients having to lie on floors or in hospital car parks awaiting treatment, such is the burden disasters can put on local infrastructure.

She concluded: “To plan for disasters you first must gather enough information and send the advanced team in as early as possible – then set up short and long-term goals, recruit staff and list the equipment needed.

“And, you must implement community-based rehab through which education and training is very important.”

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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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