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The way ahead for rehab tech

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NR Times invited three experts for a virtual discussion on the changing role of technology in rehab after brain injury.

Neuro-rehab specialists Anna Wilkinson and Rebecca Bancroft, of physiotherapy provider More Rehab, are joined by Louise Jenkins, partner and serious injury specialist at Irwin Mitchell.

Anna Wilkinson (AW): Using tech gives us a different way of rehabilitating someone; it keeps patients attentive, keeps them concentrated and keeps them motivated to reach their goals.
The key to neuroplasticity is the amount of repetition. This is where the technology plays a vital role.

As therapists, it is extremely hard and laborious to achieve the amount of repetition you can achieve with technology. Technology and hands on work should go together –
for example, therapists may work on alignment in a therapy session to help the patient achieve a normal movement pattern.

Once they have established that, we can put them on the tech to repeat and practice.

Rebecca Bancroft (RB): What’s also very important with the technology is the quality of repetition and the feedback we receive. We could give somebody an exercise sheet and tell them to go home and do one hundred repetitions of lifting their arm in the air, but this can be mind-numbing, especially when they get to day three or four.

What’s more, we don’t know if they’re doing the movements correctly. Technology gives us the control of feedback; it alerts both the patient and the therapist if they’re getting the movement wrong so we can intervene and keep them on track.

AW: Our clients tend to be very excited about using the tech because it means they are getting more practice within a week than they would with traditional therapy. This additional practice and repetition results in quicker and better recovery which is the ultimate aim.

I think a big component of it is related to their interest and their engagement; technology really helps make it fun for them. Some of the equipment has games installed, some of it has a feedback function.

These features make it possible for them to track their progress and makes the therapy much more interactive.

RB: Some people get a little nervous around tech, but for other people it really makes them tick. It all depends on the kind of exposure they’ve had to technology before.
A client that’s very in tune with using an iPad or an iPhone tends to love the technology we use.

There are other clients that potentially aren’t as familiar with technology so tend to be more hesitant.

The tech may or may not be for them, but we always try it out and see whether they like it.

AW: Deciding which tech we use is about gathering knowledge of what’s out there, as well as getting to know the clients and what they want and what motivates them.

Clients are motivated by very different things. For example, people have very different attitudes towards technology; some love it whereas others find it quite frightening.

Louise Jenkins (LJ): At Irwin Mitchell, we’re committed to understanding the latest options available and the full range of technology that is out there, whatever the cost might be.

This is why we make sure we’re connecting with companies like More Rehab very closely so we can find the right solutions for our clients and give them rehab choices including access to

the best available technology and equipment to facilitate their recovery.

Some of the new equipment coming onto the market can be incredibly expensive, but within the legal process, we are entitled to claim what is reasonably required to restore someone’s quality of life to how it was prior to their injury.

We aim to build these innovative items of equipment into our legal claims in order to keep pushing the legal process to keep pace with developments in therapy developments.

AW: Louise is right that the technology can be very expensive, and it takes a good lawyer to justify it and demonstrate the fact that it will improve the patient’s life. The justification process is very much interwoven.

As professional therapists we can explain how the technology is going to make the patient more independent, give them better movement, which will then give them better function, improve quality of life and ultimately may reduce other costs.

It’s not just about giving them the best treatment that they can get, it’s about achieving the best outcome. From there, legal experts can explain why we’re using the technology and how we balance up the costs.

LJ: For people who have legal claims, we can receive interim payments to trial new technology.

This gives us the evidence that shows the benefits it has brought to the client, which helps to justify the cost.

Gone are the days where you simply put in a claim for 10 to 20 sessions of physio. This does have its place in many cases but we also look more broadly and holistically at a client’s needs. We think about what we can do to really give them the best chance of recovery, to restore the best function possible and the highest levels of independence.

AW: If you take the Indego, our ‘walking robot’, as an example, we can achieve more walking in 10 sessions with the walking robot than 20 to 30 sessions with a physio in a lot of cases.

This is because if you’re trying to walk somebody with two pairs of hands, it’s heavy, so you might only get two metres in one session.

With the robot, they can be doing hundreds or thousands of steps. So, although technology might look more expensive as an upfront cost, in the long term it could end up less expensive.

RB: The Indego Exoskeleton is a fantastic piece of kit. It makes it possible to walk somebody who is completely paralysed or has an incomplete spinal injury or a mild to severe brain injury.

We can use it as part of a therapy session to improve gait patterning.

You can adjust the settings to give the patient what they need and allow them to use the function they have. This is called ‘variable assist’, which is the real beauty of the technology. You can tweak it little-by-little as the patient progresses.

AW: We also have the AlterG, which is a really interesting concept; it’s an anti-gravity treadmill. Essentially, the patient’s lower body is zipped into a pressurised chamber which surrounds the treadmill and eliminates gravity.

This allows us to get people walking and running much sooner than if they were holding their own weight.

Particularly if pain is a factor. Both the Indego and the AlterG allow us to make adaptations to people so that they can achieve better gait for a longer period of time than they would do on ‘dry land’.

BR: The anti-gravity treadmill is great for managing neuropathic pain and it’s also very good for improving balance because the patient is de-weighted and completely safe.

Our latest piece of kit is called ICone. It’s a totally interactive computer game-orientated arm robot for upper limb rehab.

The client sits with their forearm supported and holds onto a cone. They can then interact with games that can either be passive, active, assisted or resisted. This incorporates the trunk and the whole shoulder complex.

We also have the GripAble device which is a smart mobile device for assessment and training of hand functions.

AW: We’re inspired by the approach to neuro-rehab in other countries. In the UK, the evidence shows many acute centres barely look at arm rehabilitation in the hospital; it’s all about getting people functional so they can be at home.

Whereas in countries like Italy, they send their neuro clients home with these technologies and the outcomes that come from that are much better.

A lot of our clients don’t have the tech at home and come to clinic to use it more regularly, currently due to the associated costs, but it is something that we’d like to look forward to doing in the future which we’re very excited about.

Louise Jenkins is a partner and heads up the specialist serious injury team at Irwin Mitchell’s Sheffield office. Anna Wilkinson is managing director of More Rehab, while Rebecca Bancroft is clinical manager of More Rehab.

Legal

Neuropsychological testing in the COVID-19 age

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NR Times reports from the side-lines of an Irwin Mitchell event which explores the case for tele-neuropsychology.

COVID-19 has presented major challenges to those delivering neuropsychological assessments.

Perhaps in the early days of the pandemic, deferring assessments may have been an initial consideration. But as it became clear that the crisis would be around for months, rather than weeks, other solutions were quickly sought.

Such assessments are crucial in ensuring the seriously injured are given a level playing field in their journey to secure compensation and support for care.

Speaking at the virtual event, Matt Brown, partner in the serious injury team at Irwin Mitchell’s Manchester office, introduces the topic, asking delegates: “Just how important is it that the neuropsychological expert meets the client in person to conduct the testing? Does it matter that the expert is not in the room?”

Also, he continues, “how will clients take to the new method of testing?”

Neuropsychological opinions can be pivotal to the outcome of cases, with huge implications in terms of claims for loss of earnings, requirement for care and support; and the question over whether an individual has the ability to manage their own finances.

In a criminal case, the results may help determine the connection between a brain injury and a criminal act, and the potential need for rehabilitation.

At the beginning of the first COVID-19 lockdown, three options in relation to assessing and reporting psychoneurological impact in legal cases were set out in an article by Dr Freedman:

1. Delay all reports and testing until the situation changed
2. Complete reports based on interviews and medical records (with no testing)
3. Report based on video interviews with remote psychological tests, and review medical records

Dr Nick Priestley, consultant neuropsychologist, advocates option three – but should this continue post-pandemic?

Speaking at the Irwin Mitchell event, he says: “It’s not a question of whether I think it should continue. It will continue as it is a modality of assessment which is valid and revealing with many advantages and very few disadvantages.

“This has been around for almost two decades in some shape or form, and when looking at the evidence there are two very good international peer-reviewed journals that deal with tele assessments in medicine and other clinical fields (The Journal of telemedicine and telecare, the Journal of Cyberpsychology, Behaviour and Social Networking).

“These have been publishing important articles for quite a long time, but in terms of the research – while this has been going on for 10 to 15 years previously, it has accelerated and it has certainly started to come together.”

In the webinar, Dr Nick Priestley answers questions posed by Brian Cummins, barrister from Old Square Chambers in London.

Brian Cummins (BC): When it comes to the devices used to carry out these assessments, what is the best methodology?

Dr Nick Priestley (NP): “There are a number of markers that should be observed and both Pearson’s assessment and that of other authorities – not least the division of British Neuropsychology. [It] has set out certain criteria that must be observed, for example mobile phones are not acceptable to use. There has to be a check on the image size of the respondent’s equipment, there has to be 25cm screen measured diagonally in order that test materials don’t become distorted or fall below a certain proportion.

“This screen size restriction relates to testing as some of the visually presented materials cannot validly be used if they are presented below a certain size or proportion. There has been a great deal of research on the validity of verbal tests, however less objective research on visually presented measures and so, for instance, the Wechsler Memory Scale Four, the sub tests have not been fully validated for tele-neuropsychological use, although they are supported in certain circumstances.

“In terms of software, clinicians need to give very careful thought to the platform they sign up for, but it’s important that the platform used is a professional subscription. When it comes to encryption, in some circumstances, it is an important feature. However when visual materials are presented and copies are made, it’s extremely important that those are destroyed in camera view by the client.

“The recording of an assessment is set out in the consent form and pre-examination interview, but it is unacceptable to record an interview or take copies of the standardised tests.”

BC: While easily managed through physical assessments, are there any rules or restrictions on who can be in the room while a tele-assessment is being conducted?

NP: “In the pre-assessment, it is often the case that a third party is present to help set things up and get things working. However, when the main assessment is in progress, it’s very important there is no one else in the room, which is explained and made clear during the preparation stages. Having a third party in the room during the assessment itself invalidates and complicates the examination.”

BC: Is the ability of a claimant to receive the email and dealt with those instructions, set up the equipment and participate in that pre-assessment, part of the assessment itself?

NP: “It certainly provides valuable information. There are also instances where an individual who may respond in a disorganised or frontal way. Even at that stage, you are gaining pointers, even minor fragments of clinical information, before you get onto the pre-assessment. These are things I would investigate in the assessment and examination in particular detail.

“Neuropsychologists are behavioural scientists, experts in brain behaviour relationships, and a medico-legal report that relies entirely on neuropsychological testing is a weak report as no single test score should ever be used to make a clinical decision.

“Even under the best possible testing circumstances, it contributes to a decision, but the tests used are more proxies to describe underlying abilities, states and functions, and there is no test in any discipline that is capable of explaining with 100 per cent accuracy any underlying trait or peculiarity.

“The emphasis must be on the basis of all evidence and assessment, not just neuropsychological testing but also behavioural analysis.”

BC: Is this virtual method of assessment suitable for all of your clients and if not, when would it not be suitable?

NP: “No, it isn’t suitable for all. For example, those that have complex mental health problems, have language or communication difficulties, or have complex neuro developmental conditions are not suitable for tele-neuropsychological assessment.”

BC: Is it your view that, in the cases for which this is suitable, video is just as effective as face to face or is it still limited? In other words, can you still build up that rapport – what do you do if a client starts crying, for example?

NP: “This is a particularly interesting area, and I think it has been an urban myth that has been developed that somehow tele or remote assessments cannot generate empathy. When you look at the evidence, there is virtually none to suggest that remote assessments are in some way cold or heartless, or that you cannot generate empathy.

“The authorities for this go back a long time. A paper by Kirkwood in 2000 found no significant difference at all when objective measurement was made between face to face and virtual assessment of ‘customer satisfaction’.

“In another paper in 2010, even the clients that initially said they were ‘not keen’ and would prefer face to face, showed an equivalent outcome and did not complain about the modality of the service delivery. In fact, it was just the opposite and they were quite surprised, given their initial scepticism, that it worked just as well.”

BC: How is visual stimuli to be presented in the context of a tele-assessment?

NP: “The logistics of sending things through the post raises so many complications and is something I personally don’t do at all.

“Holding things up to a camera in order that the client can see it, screen sharing techniques and screen mirroring are all approved of by Pearson. and all observe any copyright issues as they are not being reproduced.”

BC: Due to the pandemic and people being stuck at home, could the subjects be displaying signs such as apathy or disinhibition as a matter of the pandemic rather than a result of any illness or injury?

NP: “I think certainly as far as issues of mood are concerned that is likely to be the case. However I don’t think there is any evidence to suggest that lockdown, or more repressive social circumstances, provoke disinhibition or perseveration. Issues to do with empathy and social judgement are still going to be evident within a family setting.”

BC: Are there any disadvantages to doing the assessment within the family setting of the home?

NP: “Yes, and I have found that there’s a very obvious one in that all individuals who have sustained a brain injury all suffer from fatigue problems of some kind or another, so fatigue ability is a ubiquitous problem.

“If you are seeing someone in their own home, the burden of travel to a city centre or unknown location has been removed, and in their own home, behaviours often become less guarded with the number of signs and signals both during the interview phase of the assessment and also during the testing phase become more apparent if you are observant enough.

“It is important to remember that behaviour is environment-specific. When an individual is in your consulting room and everything is ordered, secure and disciplined, it doesn’t easily lead itself as an environment to allowing the individual to show themselves in their least favourable form. There is a degree of constraint on their behaviour in a consulting room that is not going to be there when you are a guest in their home.”

Watch the event in full, including a Q&A session with Dr Nick Priestley, below:

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Legal

‘Wind of change’ revolutionising traditional claims process

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Exchange Chambers and Calvert Reconnections have lead the new research

A “wind of change” in personal injury litigation is enabling the traditional way specialist claims into brain injuries and other major cases are handled to be revolutionised, new research has revealed.

The COVID-19 pandemic has forced major change in the way claims are handled, with much of it being done remotely out of necessity amidst ongoing restrictions on travel and meetings.

However, new research has revealed that as a result of this, litigation has become more efficient, with remote case management conferences, joint settlement meetings and low value trials all set to become the ‘new normal’ post pandemic.

The findings, from barristers Exchange Chambers and brain injury rehabilitation centre Calvert Reconnections, have been welcomed by neuro-specialist legal professionals, who believe the move towards technology brings new efficiencies and collaboration within the claim process.

“A wind of change is blowing through the personal injury sector. Personally, I hope it gets a lot stronger,” says Bill Braithwaite QC, Head of Exchange Chambers and Trustee at the Lake District Calvert Trust.

More than half of personal injury lawyers nationally said that video technology and best practice guidelines for mutual co-operation have made the process more efficient in recent months. Only 19 per cent believed the opposite.

In further findings from the research, 85 per cent of lawyers believe case management conferences should take place remotely as standard.

The majority – 58 per cent – also believe that joint settlement meetings should take place remotely as industry standard going forward, alongside low value trials, which 60 per cent of lawyers believe should be handled remotely.

However, while the consensus was that a technology-led approach was one that should be adopted in many cases, equally there was agreement to the contrary in others.

In high value trials, 97 per cent of personal injury lawyers believe these must continue to take place in person, with 62 per cent also stating that mediations must not take place remotely in general.

Bill Braithwaite QC continues: “Traditionally, we have approached too many areas of our work in an old-fashioned, inefficient way.

“Joint Settlement Meetings are just one example. Over the last few months, we have undertaken hundreds of settlement meetings within Chambers by video.

“They work. Yes, they are different from meetings in person but for negotiation it is usually enough simply to talk.

“I’m also encouraged by the move towards remote case management conferences. They are quicker, simpler, cheaper and at least as efficient.”

However, the leading legal expert believes the industry does need to go further in its willingness to adopt change.

“I’m less encouraged by the reluctance to embrace remote mediations,” he adds.

“In my view, it shows the entrenched views of the profession.  Mediation on video is straightforward and effective and can be managed in just the same way as it can in person.”

Specialist neurotrauma lawyer Kate Nicklin, from Sintons, echoes the positive impact the use of technology has had on the process.

“Personal injury lawyers have truly and readily adapted to the changes brought by the pandemic,” says Kate, who handles complex claims from across the UK.

“My personal experience is that remote working has created more time for collaborative working between the parties delivering mutually beneficial outcomes, including earlier payment of interim payments and the provision of information at an earlier stage.

“Furthermore, there has been an increase in regular client contact; rather than spending time travelling, time is spent with clients and the professionals who work with them.”

However, Kate believes that there must always be a place for face-to-face interaction.

“Some changes will be long lasting, I hope. However, I have missed meeting clients face-to-face and having a cup of tea with them,” she adds.

“Building trusting relationships so that we can seek to understand an individual’s life-changing circumstances, cannot be achieved fully through technology.”

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Legal

A conversation on brain injury

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An acquired brain injury (ABI) can happen to anyone. It doesn’t discriminate and can occur following a traumatic event such as a stroke, illness or accident.

Here personal injury expert Louise Jenkins, of Irwin Mitchell, talks to occupational therapist, Suzanna Anthony, about how she’s supporting people with memory issues through the pandemic; and what methods and tools there are to assist with memory problems that affect daily life.

Louise: So how exactly can a brain injury affect memory?

Suzanna: In many cases, memory loss is first seen in the period of post traumatic amnesia (PTA) which occurs straight after the brain injury when the person starts to regain a level of consciousness. There’s often a lot of disorientation during this period with the person being confused about where they are and who they are. Memory loss around the period leading up to accident can be a problem and it’s widely understood that the longer the loss of memory around the time of the injury, the more severe the damage often is in the longer term. Milder brain injuries can however be equally as devastating on memory, as these are often unseen and take longer to diagnose due to the changes being more subtle. These types of injuries are also often not visible on scans.

Memory problems more often than not come hand in hand with other cognitive problems including difficulties with information processing and attention and concentration. This can sometimes mean that information is not registered in the first place, so then cannot be retrieved as a memory later on.

Louise: What can this mean for everyday life and how far reaching can the effects be – for example in relationships and our ability to work after a brain injury?

Suzanna: I once had a client who summed up their memory loss in a very simple way by saying “my memory affects every verb.” In other words, every single action is affected by memory; it could be hobbies, work, relationships or just simple, everyday tasks such as remembering how to make a cup of tea.

Relationships with others can change due to a memory problem. It may be perceived that someone’s personality has changed when in fact it could be a memory difficulty that is causing them to be forgetful. For example, they may be seen as not as thoughtful as before if they had forgotten a close friend’s birthday or hadn’t checked in with their partner if they knew they had something important going on. It may not be that their feelings had changed at all, but they may need help in remembering the simple actions they would have done automatically before their injury.

Topographical orientation can also become a barrier to someone’s life, so whereas before they used to take the same daily route to work or the shops, they can no longer remember road layouts and landmarks which used to help them make that journey.

Difficulties around topographical orientation can also become a barrier to someone’s life after a brain injury. Whereas before they used to take the same daily route to work or the shops, they can no longer remember road layouts and landmarks which used to help them make that journey.

Ultimately, your memory is who you are and forms the basis of your sense of identity. To lose that can be terrifying and result in a number of psychological difficulties such as depression and anxiety. These all impact on activity levels and often interfere with sleep, which in turn can cause excessive fatigue. Unfortunately it then becomes a vicious circle as severe fatigue impacts cognitive functioning, worsening the situation further.

There are many ways to help overcome a number of the difficulties memory impairments can bring. The key is to find out what is problematic for that particular individual and what their priorities are before you can help them overcome or better manage their memory issues.

Louise: So, could these problems get better over time?

Suzanna: There are a lot of factors to consider. It all depends on the severity of the injury, the part of the brain that was damaged, the person’s ability to engage in rehabilitation, previous lifestyle and the support systems they have access to.

The quality of the rehabilitation they receive is very important but sadly differs quite significantly across the country. One client might only get offered a few sessions of therapy whilst another might be given months of rehab and a tailored, ongoing support plan.

Support systems can have a huge impact upon recovery. If the injured person lives with someone who understands their memory difficulties and will support the use of strategies, it’s very helpful. Having a support worker in place to help with practical, day-to-day tasks can also help significantly, especially if they’re skilled in using rehabilitation strategies so that they can help to promote independence instead of doing things ‘for’ the injured person.

There are studies on neuroplasticity that indicate that improvements can be made for many months and even several years after brain injury. We are finding out more each year about how the brain can regenerate. The initial stages of recovery are paramount as this is where the biggest improvements are seen therefore it’s essential that good strategies, structures and routines are in place that set out a good recovery plan, as soon as possible after injury.

Louise: In a complex world and with guidance and information around the current pandemic changing all the time, what challenges can this present for someone with memory loss?

Suzanna: The COVID-19 pandemic has had a devastating impact on many of my clients who have cognitive impairments, including memory loss. It can be challenging for the general public to keep up with the amount of information being given and the speed at which it is communicated, but this is far harder for anyone with cognitive problems.

COVID-19 restrictions have meant that the support structures and networks that people with memory loss rely on suddenly stopped, or had to take a back seat due to social distancing.

Understanding and following the rules have been a massive challenge and it has been important for people to develop strategies around this to aid remembering of the ever-changing guidelines. One client of mine has a good technique that they have used throughout lockdown: to write down the key points they needed to remember, such as wearing face masks to go into a shop, and they would stick it on their fridge and next to the front door, so they always knew the Government rules.

Many people who experience memory problems after a brain injury can be anxious about getting back out into the community in normal circumstances but this has been further complicated by the current restrictions. For example the two metre and mask rules, which can be forgotten and subsequently bring about feelings of embarrassment. There is a danger that this can cause many to avoid leaving the safety of their familiar environments and ultimately delays their recovery.

It’s vital to speak to your support network if you’re struggling during this difficult time. There are lots of ways cognitive (including memory) problems can be addressed to help you get through this.

Louise: What are the key tools, resources and strategies that are likely to be most effective in supporting someone to be as independent as possible when living with memory loss?

Suzanna: There are all sorts of tools and resources out there these days to support someone who’s experiencing memory difficulties after a brain injury and some that have been particularly useful during lockdown.

Video calling has been a lifeline for many people during COVID-19 to keep people connected and keep some sort of routine in place, whether that’s working from home, weekly quizzes with friends or receiving therapy virtually.

Routine, structure and setting up the environment well is key to making sure you can function as independently as possible within your home and your everyday activities. Put items in obvious places, use checklists and reminder systems, get into routines that help you stay on track with the things you need, and want, to do.

Making your own wellbeing a priority is extremely important. This might sound obvious but stress and fatigue affect everything. Try to plan out your time so that it incorporates rest periods if you need them, mix up ‘thinking’ and ‘doing’ tasks and take time to try and recognise how you are feeling.

There are some great apps and technology that can assist with memory problems. Consider what is out there and think about using devices that will provide reminders, store information and help you to plan. If you rely heavily on technology to compensate for your memory problems, be careful to always have a backup plan. Consider what you might do if your system failed, for example you lost your phone or had a power cut. Sometimes a back up to a cloud based system or a mixture of paper based and tech solutions can be a good thing.

Ask those around you to help support your memory problems and ensure they have a good understanding of what is helpful or unhelpful for you. Ask them not to do things ‘for’ you, but to help you get there yourself. Simple techniques can help, for example by giving you a clue if you forget rather than giving you the full answer. Ask them to help you work on finding solutions to the things you notice you are finding difficult.

Louise: Where can anyone affected by the issues in this article go to find out more about the support available?

Suzanna: Headway’s website is a brilliant resource to assist with all areas of cognitive function. They have reading material available that you can print out or share with friends and family so they can better support you on your journey. Take a look to see if there is a local support group in your area, as speaking to people who truly understand what you’re experiencing can be a big help.

On the The Royal College of Occupational Therapists website there is a directory of independent OTs that can support you further with your recovery. And lastly, check what is in your local area and find local resources that can help. There may be outreach teams which can help you or a local support group.

Suzanna Anthony is a treating specialist brain injury occupational therapist working with people who have experienced an acquired brain injury. She has over 20 years’ experience in neurology and works closely with her clients to overcome physical problems, as well as less obvious but equally debilitating cognitive, emotional and behavioural difficulties that a brain injury can bring.

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