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Update:concussion in sport

A run through the latest developments in concussion in sport research and protocols.

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A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.

Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.

“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.

“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”

Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.

Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.

Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.

Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.

“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”

The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.

The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.

Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.

These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.

The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.

Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.

“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”

A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.

There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.

A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.

EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.

This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.

This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.

SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.

“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”

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Insight

A week in the life of a rehabilitation assistant

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Katie Pinn, Senior Cognitive Rehab Assistant at BIS Services.

My week really starts on a Sunday as this is when I plan my upcoming week, I check to see if any clients have appointments during the week, what goals we are working on, where we are in each and make sure there’s lots of variety within sessions.

My first client on a Monday I must check in on their well being, ascertain level of productivity over the weekend and schedule the new week. This particular client I’ve had to provide with much support due to shielding during both the 1st and the second lockdown.

During the first lockdown many clients’ support went virtual, however due to vulnerability support had to be given face to face. One major barrier to delivering virtual support was teaching the client how to use new technology, this can be difficult for anyone, however the extra challenges caused by brain injury exacerbated the difficulties. When teaching someone with a brain injury something new repetition is key, I model how to use WhatsApp video and Zoom practice with the client regularly and created simple and clear visual instructions.

This particular week I am meeting a new client in preparation so spend a long time reading the referral form and speaking to management. During meet and greets it’s really important to try and build rapport with client and family ascertain the client’s interests, consider how these could be linked into support and try to open their mind to the idea of working with you. It’s quite a skill and I think I’ve become quite adept at building rapport quickly. It really is key to future engagement and can make or break starting a new package.

Tuesdays I’m working with a different client and again it’s important to plan and structure our week, with this particular client I also support budgeting skills. After a brain injury many clients can also be financially vulnerable and are patients of the Court of Protection and under Deputyship and are provided with a weekly budget. It is important to make sure this is spent sensibly. Enough money has to be left for food, for themselves and any pets, transport fees and bills if this is something the client is able to manage.

It’s important to encourage clients to save, and this allows exploration of executive functioning skills. One of these client’s goals focus is around decorating their home. We want to encourage clients to maintain goals independently if possible in order for clients to engage and have a sense of autonomy and also achievement. Practical support is needed in this case as my client had impaired sight as well as coordination difficulties, which makes tasks like painting very difficult. However, I didn’t want to complete this task for them so I focus my help with small fiddly bits encourage them to paint the large areas.

Our work is not about completing tasks for them, far from it; it involves teaching, encouraging, motivating and so on. If we need to actually get our hands dirty and pull our sleeves up to do that, that’s what we do! After sessions it’s important to complete our sessional reports ASAP and update multidisciplinary team on any important information.

This is particularly important with clients struggling with their mental health, which has been pertinent this last year more than ever. Communication has always been of upmost importance, and now more than ever. At BIS Services our supervisors and managers are available for us to contact all the time if we need some advice or are concerned.

Wednesday I’m back in Ramsgate. In the early stages of rehab, clients often lack insight into their brain injury and consequences, which creates hurdles for support. It is challenging to teach clients strategies to compensate for brain injuries if there’s a lack of understanding why it’s needed. I do a lot of work around insight, particularly with one of my clients where I provide education and as difficulties arise I highlight and then help problem solve in the moment.

Immediate feedback is really important and it must be approached in a sensitive and cautious manner. Insight changes can also trigger a shift in mood,  which is inevitable after any injury and emotional support and empathy is required. I liaise frequently with Neuro Psychologists as most clients also receive psychological support, but not all the time. In those cases our input is even more challenging as we can often be the only person clients have to talk to, and this again has increased through the pandemic.

My second client has better awareness of his brain injury and is able to engage in cognitive and audio visual exercises. This is great for stimulating neural pathways strengthening connections and ultimately improving function. We practice functional transfer and tasks to practice new skills and cement more familiar ones.

Late afternoon I plan activities for my last few clients for the week. With another client we focus on functional skills and their hobbies. These sessions are always fairly fun, often involving baking, crafts, or photography.

in the evening I may I have an MDT meeting online. Again, this is a chance to speak to the professionals in the team, incorporate any advice and get feedback.

Thursday mornings I’m doing a few shops with the client. Lots of planning is involved before going out. Meal planning, simple recipes, cupboard checking when ingredients are needed and so on.  Plans and lists are written down for the client and support is given around journey planning as well as problem solving in the shops, if an item is out of stock and substitute needs to be found, which is often difficult for my client.

Many clients can also find the hustle and bustle of the supermarket stressful or anxiety inducing, so it is important to help clients, especially those who have difficulty emotionally. I assist with encouraging and regulating breathing techniques and calming in the moment.

In the afternoon I had a supervision with the educational psychologist for a new client, to teach me about assistive technology and how to incorporative in sessions and manage fatigue. My Fridays are quite hard and they’re not the ideal end to the week but i try to incorporate fun activities and manageable tasks as clients could be quite fatigued by the end of the week.

My first client I actually do their food shop on their behalf as they’re not able to access the communities themselves due to lockdown. I still have to pre-plan their shop and cash handling needs to be looked at. My next client we actually do quite a lot of work around relaxation.

In the first lockdown BIS Services set up a virtual timetable and we’ve kept a library of resources so I sometimes accesses the hypnotherapy recorded sessions and use this so that my client is in the right frame of mind for their psychology session in the afternoon. This is their opportunity to talk through the week. I prompt them to think about any stressors and we set mindset for the weekend. A lot of work is done around building resilience and perspective with this client.

My final client then sees me in another county (we get around a lot!) The first thing we focus on is  community access for this younger client. What may be as simple as buying a coffee for you and I becomes a challenge someone with brain injury. I motivated and supported the client to order and pay for their own items. Functional practice of independent living tasks, activities of daily living and hobbies and interests are all considered. On Friday I get home about 7:30 just in time to travel to  my stable, feed the animals and hope the Gin and Tonic fairy has left me something for when I return home!

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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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