Laura Nicholls, lead speech and language therapist at The Bridge Neurological Care Centre in Middlesbrough, reflects on the rehabilitative journey of her patient Angela on regaining some normality following a lengthy admission in intensive care.
Firstly there’s a couple of things you need to know about Angela before I can tell you about her journey. She isn’t usually one to let another person speak for her but I have been given full permission to share with you all the ups and downs of her rehabilitative journey.
Angela has acquired the very fitting nickname ‘The Duchess’. This comes from her previous occupation as a community matron, her fine eye for detail, her drive for perfection and her tendency towards bossiness.
In April 2019 Angela was admitted to hospital with Myasthenia Gravis that resulted in Myasthenic crisis (respiratory failure).
Myasthenia Gravis is
a rare long-term neurological condition that causes muscle weakness.
In Angela’s case she experienced severe difficulty swallowing, loss of voice (aphonia) and severe breathing problems.
This resulted in the insertion of a tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe/ trachea to help you breathe) with 24/7 ventilation to assist with breathing.
This emergency procedure can often cause weakness and structural damage that further complicates an individual’s recovery of function. This means that often the long-lasting impact of having difficulty speaking, eating and drinking on someone’s quality of life is not fully realised until the months after initial survival has been achieved.
It is the role of a speech and language therapist to provide assessment, treatment and support for individuals who have difficulties with communication, or with eating drinking and swallowing.
Angela’s swallow and voice were severely affected second to muscle weakness and poor breath support. This resulted in poor airway protection when she was eating and drinking meaning food and fluids entered the trachea and lungs rather than the oesophagus leading to the stomach. This can cause serious health concerns as it can result in airway obstruction (choking), chest infections, pneumonia and death.
I worked closely with Angela to identify what was most important to her and what would make a difference to her quality of life and wellbeing. Angela identified that she would love to be able to have a gin and tonic and FaceTime her family and friends without them having difficulty hearing her.
This was a huge target for a lady who was nil by mouth with an unsafe swallow having all her nutrition and hydration needs met via a tube into her stomach (percutaneous tube) and who had a very weak voice; Angela’s friends and family would often ring her but could only have a one-sided conversation as Angela’s voice was too weak to be heard over the phone.
From thorough assessment, I created an intensive swallow and voice rehabilitation programme when Angela was discharged to us in August 2019 which utilised specific muscle building/strengthening exercises to target the areas of breakdown in her voice and swallow.
This programme focused on improving oral control and coordination, improving laryngeal elevation and hyoid excursion (good range of movement is required to swallow safely), improve airway protection, increase strength of cough and strengthen her vocal cords to increase strength of voice. Angela completed this programme multiple times per day.
Her exercises were recorded onto her iPad for her to work through daily and support her in the completion of these.
Angela’s recovery and ability to wean from ventilation was lengthy and unpredictable at times. She suffered a number of setbacks and respiratory complications during her recovery that impacted her ability to complete therapy. However she remained determined and focused on what she wanted to achieve.
By December 2019, she made significant progress. Through her dedication and perseverance with her rehabilitation programme she achieved her goals. After months of being unable to eat and drink Angela’s swallow was now safe – she was able to eat and drink without difficulty or fear of choking.
Angela’s voice was also a lot stronger, she went from being inaudible on the telephone to being intelligible 100 per cent of the time and being understood in all communication environments with no incidents of communication breakdown with familiar or unfamiliar listeners.
Angela continued with her rehabilitation programme and in February 2020 she attended her local flower club meeting where she addressed all 70 attendees, delivering a 10 minute speech without difficulty.
This was a major achievement given that she was struggling to make herself heard to one individual in a quiet room six months prior.
It was a moment of great pride when she introduced me to the audience saying: “This is Laura, my speech therapist, without whom I would not be able to speak to you all today and without whom I would not be able to enjoy this gorgeous spread you have put on for us all.”
In March 2020 the tube into Angela’s stomach was removed as she no longer needed it to meet her nutrition and hydration needs – she could do this by eating and drinking herself.
The therapy outcome measures graphs clearly show the positive outcomes she has been able to achieve through therapy, but the true outcome is written all over her face – smiling ear to ear.
Through therapy Angela did not just regain the ability to speak and swallow, she gained confidence in recovering functions that she thought she had lost forever and a new appreciation for the things in life that people often take for granted.
Angela has been a complete joy to work with and one of the greatest honours of my career has been to work alongside her.
Now enjoy your G&T Duchess – you deserve it.
Laura Nicholls is a speech and language therapist at The Bridge Neurological Care Centre in Middlesbrough, which provides specialist inpatient neurological rehabilitation and complex care for people with neurological illnesses, acquired brain and spinal cord injuries. For more info visit www.elysiumhealthcare.co.uk.
Osteoarthritis: breaking the cycle
Medical technology company Ottobock shares its expertise on approaches to the condition.
Why is Cartilage Important?
Bones that come in contact with other bones are covered by cartilage at their contact points. Cartilage does not have blood vessels – it is supplied with nutrients through movement of the joint. That’s why regular exercise is so important!
Cartilage ensures that the joint surfaces move against each other in the most efficient way and with little friction. It absorbs shock, cushioning the joint, and distributes the forces acting on the joint.
If cartilage is damaged and its gliding properties are affected, it can no longer serve its purpose and the joints range of movement can become limited.
Typical Progression of Osteoarthritis
When osteoarthritis of the knee develops due to joint malalignment, an accident, advancing age, obesity or excessive strain, the damaged cartilage is no longer able to properly fulfil its function.
This results in pain and reduced mobility. The affected patient instinctively assumes a relieving posture to reduce strain on the knee.
However, this often leads to new problems in other places, such as the hip, and reduces the supply of nutrients to the cartilage, for which movement is required – sparking a vicious circle.
The cartilage develops cracks and begins to break down. At the same time, the bone thickens at the site of the damage.
When the cartilage layer is completely worn away, the affected bones come into direct contact and rub against each other causing joint pain and inflammation.
The thickest joint cartilage is located behind the kneecap (patella). This is an area of high stress. Osteoarthritis occurring in this area is known as patellafemoral osteoarthritis
Signs and Symptoms
There are several common symptoms that signal knee osteoarthritis. They can occur individually or together. However, with the initial onset, you may not notice any of these symptoms
When symptoms appear they usually occur in the following order:
- Cracking in the joint
- Pain during load bearing activities, such as carrying a heavy object
- Pain during every day activities, such as climbing the stairs
- Reduced mobility
- Swelling and inflammation
Joint specific exercises: with regular exercise mobility can be maintained and muscle strengthened, ensuring the cartilage is supplied with the nutrients it needs.
Temperature: with acute inflammation, cold relieves pain and reduces swelling. Heat relaxes the muscles and tendons and increases the flow of nutrients. Heat may only be applied when the joint is not inflamed.
Creams: various over the counter products are available at your local pharmacy including gels and creams that can help relieve pain.
Orthopaedic devices (braces and supports): these are applied externally to the knee, reducing pain and improving mobility.
Lifestyle: living a healthy lifestyle can help to combat osteoarthritis. A healthy diet and an active lifestyle reduces the chance of obesity, putting less stress and strain through the knee joints.
An orthotic fitting is a key component in the treatment of osteoarthritis. It can provide the following:
- Pain relief
- Support daily activities
- Support during activities that affect the joint, whether at work or during sports
Did you know?
An osteoarthritis patient takes an average of around 1,200 tablets a year to manage pain. But this can lead to damage to the stomach, bowel and liver.
An orthosis from the Agilium line is therefore a good alternative. It’s worth-while for anyone with knee osteoarthritis to test the effectiveness of the orthoses themselves.
The Agilium Line
The braces in our Agilium line are designed specifically to target the symptoms of osteoarthritis of the knee.
Each works in a different way to address the various characteristics of osteoarthritis of the knee. At the same time, we placed great emphasis on their comfort and suitability for daily use.
The Agilium Freestep, the Agilium Reactive and the Agilium Softfit are used to treat unicompartmental osteoarthritis of the knee.
The Agilium Patella is used for patients with patellofemoral arthritis.
The Agilium Freestep is used to treat OA, although it is not applied directly to the knee. Instead is worn on the foot, right inside the shoe! For targeted relieve, it alters the load-line of the knee – the point where the body weight impacts the cartilage.
The Agilium Softfit is a pull on knee brace with a textile base and single upright that stabilises and relieves the knee using a three point force system to offload the affected compartment (side) of the knee.
The Agilium Reactive also uses a three point force system to offload the affected compartment (side) of the knee. However, the innovative closure system in the upper calf provides comfort while sitting without compromising the stable position when standing.
The Agilium Patella combines a textile structure and stabilising component with a dynamic re-alignment mechanism enabling it to maintain the central alignment of the knee cap, reducing pressure behind the knee cap.
Find the appropriate brace with Agilium Select.
Visit our website or go to ottobock.com/agilium-select
Masturbation linked to stroke in medical case study
Doctors in Japan have reported how masturbation sparked a bleed on the brain of a 51-year-old man; as published in the Journal of Stroke and Cerebrovascular Diseases.
Doctors at the Nagoya City University Graduate School of Medical Sciences in Japan explained that the man attended hospital after orgasming, with the sudden onset of a searing headache that lasted for around a minute. This was followed by an intense bout of vomiting.
A CT scan showed an acute subarachnoid hemorrhage in the left hemisphere.
The researchers note that masturbation causes an increase in heart rate, blood pressure, and noradrenaline plasma levels – which are likely to contribute to the risk of splitting a blood vessel in the brain and result in a hemorrhagic stroke.
The man was treated with stents and coiling, two techniques used to bolster the blood vessel and maintain blood flow to the brain, and he went on to make a full recovery.
The study authors say that they found just two other cases of masturbation-linked strokes in other scientific literature.
The Japanese man survived and was discharged after nearly two weeks in hospital in an “excellent” condition.
Engineers develop ultrasound patch to monitor blood flow
Breakthrough could help to better predict stroke and other cardiovascular conditions earlier.
Engineers at the University of California San Diego have developed an ultrasound patch that can be worn on the skin. It monitors the blood flow through major arteries and veins deep within the body.
It is hoped that it could help clinicians diagnose cardiovascular conditions faster. It could also help to diagnose blockages in the arteries which could lead to strokes or heart attacks.
The ultrasound patch continuously monitors blood flow as well as blood pressure and heart function in real-time. Assessing how much blood flows through a patient’s blood vessels could help diagnose blood clots, heart valve problems and poor circulation in the limbs.
For many patients, blood flow is not measured during a regular visit to their doctors. It is usually assessed after a patient shows signs of cardiovascular problems.
The patch can be worn on the neck or chest and can measure cardiovascular signals up to 14 centimetres inside the body non invasively with high accuracy.
How the patch works
The patch is made of a thin, flexible polymer that sticks to the skin.
There is an array of millimetre-sized ultrasound transducers on the patch known as an ultrasound phased array.
These are individually controlled by a computer. Another feature is that the ultrasound beam can be tilted at different angles to areas in the body that are not directly below the patch.
It can operate in two modes. In one, all of the transducers can be synched together to transmit ultrasound waves which produce a high-intensity beam that focuses on one spot.
This can be up to 14cm deep in the body.
The other mode allows the transducers to be programmed to transmit out of sync producing beams at different angles.
In being able to manipulate the beams, it gives the device multiple capacities for monitoring central organs as well as blood flow with high resolution.
When the electricity flows through the transducers, they vibrate while emitting ultrasound waves that travel through the skin into the body.
When they penetrate a blood vessel, they encounter the movement of red blood cells flowing inside. The cell movement changes how the waves are transmitted back to the patch.
This change is recorded by the patch and creates a visual recording of the blood flow. It can also be used to create moving images of the heart’s walls.
Sheng Xu, professor of nanoengineering at the UC San Diego Jacobs School of Engineering said:
“This type of wearable device can give you a more comprehensive, more accurate picture of what’s going on in deep tissues and critical organs like the heart and the brain, all from the surface of the skin.”
Xu added: “This is a first in the field of wearables because existing wearable sensors typically only monitor areas right below them.
“If you want to sense signals at a different position, you have to move the sensor to that location. With this patch, we can probe areas that are wider than the device’s footprint. This can open up a lot of opportunities.”
The researchers say that the easy to use patch could allow patients to wear the patch and monitor the results themselves. It doesn’t depend on a technician to read the results
The next stage
The patch is not yet ready for clinical use. The researchers are currently working on a way to make the electronics wireless as it currently needs a power source and benchtop machine.
Image credit: Nature Biomedical Engineering
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