NR Times Issue 21 by aspectpublishing

NR TIMES NEURO REHAB TIMES

/21

THE RISE AND RISE OF THE EXOSKELETON H ow t h e key p l aye r s a re i n s p i r i n g next-gen rehab

All eyes are on us now HOPE FOR P A R A LY S E D P AT I E N T S The impossible made

Zen Koh discusses how Fourier Intelligence is poised to lead the growth of the burgeoning rehab tech sector globally

p o s s i b l e t h r o u g h O N WA R D ’s pioneering technology

DOMESTIC VIOLENCE AND B R A I N I N J U RY Wo r l d - f i r s t r e s e a r c h p r o j e c t to better support survivors

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A DV E R T I S E M E N T

NRT-2022

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Looking to the future As we rapidly progress through 2022 - where is the time going? - it’s always nice to reflect on what’s happening in the world of neuro-rehab around us. When you do that, and take stock of what is going on, the great progress we are making becomes apparent. This issue of NR Times is reflective of that, as we take the opportunity to highlight some of the hugely positive developments happening to benefit the lives of people living with neurological injuries and conditions. The development of an ABI Strategy is a major step forward in delivering much-needed brain support to people living with brain injury. With the launch of the Call for Evidence, those whose lives it will affect are able to help shape the future. This is a very welcome move and our congratulations and thanks go again to all those who have pushed to get things this far. However, as Paul Brown quite rightly raises in this issue, the Government must get behind the strategy with the resources and funding to truly make the change that is needed - this is absolutely critical. We also feature the amazing news about ONWARD’s work in enabling people living with paralysis to regain the ability to walk, and even to run and swim. International headlines were made recently with this truly phenomenal development, which has given so much hope to those with spinal cord injury around the world. Robotics is another fast-developing area within neuro-rehab, and the options available to patients are growing almost by the day. We feature some of the key players in the manufacture and use of exoskeletons - including our cover story, which looks at the unrelenting progress of Fourier Intelligence - and discover more about their life-changing role in the recovery of seriously injured people. Equally life-changing is the pioneering project from The Disabilities Trust to increase support for domestic violence survivors living with brain injury - by empowering services to deliver better and more bespoke support, building on the fantastic efforts from the United States, they are helping to change futures. And at NR Times, we too are looking to the future with our new design - we are delighted with our new image and hope you are too. Special thanks go to our designer Sophie who has done an outstanding job. I hope you enjoy this issue - and, as ever, please get in touch with any feedback, ideas or comments. Deborah Johnson deborah@aspectpublishing.co.uk

company/nrtimes @editorNRTimes

CONTENTS

COVER STORY How Fourier Intelligence is ready to lead global rehab tech

13 ‘LEVEL NEURO-REHAB P R OV I S I O N ’ The need for the ABI Strategy to address disparity

1 4 S AV E T H E O L I V E R ZANGWILL CENTRE Campaign against its proposed closure gains traction

1 6 A B I S T R AT E G Y Call for evidence launched

18 PIONEERING PROJECT LAUNCHES Social workers’ ABI knowledge targeted

Contents 21 ’TRAIN THERAPISTS T O D E L I V E R D I G I TA L’ The need for on-the-ground upskilling

28 NEURO-REHAB AND DOGS Human techniques can gain effective results

22 MAKING THE IMPOSSIBLE POSSIBLE How ONWARD is giving hope for paralysed patients

30 THE POWER OF REMOTE REHAB How the rise of digital spawned an international business

2 6 TA R G E T I N G C O G N I T I V E DECLINE THROUGH VR: How a shopping task can help detect early-stage issues

3 2 A P P R E VO L U T I O N I S E S ABI SUPPORT One family’s experience leads to new levels of support for others

CONTENTS

37 HORSES AS HEALERS Calvert Reconnections introduces new therapies

40 SIX THINGS N O - O N E T E L L S YO U When your child has a neurological condition

RISE AND RISE OF THE EXOSKELETON A look at the key players and leaders in the rehab robotics scene

6 4 B R A I N I N J U RY A N D DOMESTIC VIOLENCE: World-first project to increase support for survivors

8 2 F A M I LY L AW A N D B R A I N I N J U RY : What to do when your family dynamics change post-brain injury

7 0 F A M I LY VA L U E S D R I V I N G A GLOBAL BUSINESS: THERA-Trainer discusses staying true to its roots

8 6 W H AT A D V I C E D O YO U W I S H You’d given your friends and family after your stroke?

76 A CARING LEGACY How Richardson Care has care at its core

96 THE PERFECT STORM Impacting the future of case management

C O V E R S T O RY

Zen Koh, co-founder, deputy group CEO and CEO of Global HQ at Fourier Intelligence

C O V E R S T O RY

sponsored feature

To d a y ’s investment creates t o m o r r o w ’s talent As a business on a path of strong global growth, while being acutely aware of its responsibility as a leader, one area in which Fourier is keen to make a difference is in creating tomorrow’s talent. Opportunities are being created around the world for aspiring young engineers and developers, and partnerships have been formed with a growing number of leading academic institutions. “Existing knowledge can never be enough in this industry. We are always advancing and with that, we need the talent to enable this development,” says Zen. “We are working with some of the leading researchers to create joint labs, we offer scholarships for PhD students with the Shirley Ryan AbilityLab and University of Melbourne. We want to continue to partner with universities to offer the highest standards in continuing education. “The MotusAcademy (founded to enable ongoing professional development in advanced robotics rehab tech) will offer a research platform and will help to lead this further, with the highest standards and results. “We can never think what we are doing is good enough, as we can always do more. The world is advancing, and through knowledge, we can continue to advance.”

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N R news

A cognitive rehabilitation business is expanding and creating over 30 new jobs on the back of increasing demand for its specialist services

BIS Services is recruiting new rehabilitation assistants to add to its growing team, which delivers support to people living with brain injury and neurological illness to recover cognitive function through bespoke therapy. The business, based in Kent, is increasing its geographical reach on the strength of demand and supports clients across the South of England. Through its expansion, BIS Services is building on its longstanding reputation for community work through the opening of The Link, an independent living property which offers 12-week residential placements, and the creation of its ‘holiday home from home’ BIS Lodge. And to help meet increasing demand and continue its award-winning cognitive rehabilitation service, BIS Services is looking for more than 30 new rehabilitation assistants to join its team. Natalie Mackenzie, director of BIS Services, said demand for its services has “gone through the roof”.

“Since we came out of lockdown, there are so many more people who need our support. We cover a really huge area geographically and to ensure we deliver the quality of service we are known for, we need more excellent people,” she said. “We have a wonderful team and are looking for new people to join us. It’s hard to find the right ones, but we know they are out there. “Cognitive rehabilitation is very specialist and can make such a positive difference to clients’ lives and we’re really proud of the reputation we have built for our work. “We now want to grow our team as we continue to expand as a business, so we can deliver the highest quality service to even more clients who need our support.”

To learn more about joining the business, email office@thebiss.co.uk

N R news ‘Too often we see the haves and have nots in neuro-rehab - and that’s not fair’ Action must be seen by the Government in backing the creation of an ABI strategy if the pledge to better support people living with brain injury is to truly be delivered upon, according to one of the sector’s leading figures. Paul Brown, secretary of UKABIF, said it is vital that proper funding is assigned to support the strategy - the development of which is being led by Gillian Keegan, minister for care and mental health, alongside Chris Bryant, chair of the APPG on ABI - and to implement the support and resources which are so badly-needed. Hailing the go-ahead from the Government over the creation of the strategy as “great news”, Paul added: “It’s important to remember we have been here before many times we’ve had documents produced by Government and we get to a certain stage but then don’t get any further. “This time, we need to see it through, and once the strategy is put in place, we need to see the money following it - there’s no point in pursuing it if the funding isn’t there. “We also need consultation with the right people, their involvement is crucial in this process. Rehabilitation consultants in particular have a role to play.” Estimates have been made that there is a £15billion cost to the public purse through not having a proper strategy to deliver adequate support for people living with ABI in the community. Campaigners have pointed to the role effective neuro-rehabilitation could play in reducing that vast sum. “We see how, with proper focused rehabilitation, people can make a good recovery from their injury in a lot of cases, but too often we see that the rehabilitation they receive in hospital is not carried through into the community,” says Paul, partner at Burnetts Solicitors in Newcastle and chair of Headway Wearside.

I hope that the creation of the strategy will effect change

“Through the role I have with my clients who have legal claims, I fully appreciate the benefit the additional rehab and treatment can have, but sadly that is not available to everyone. “In terms of provision, too often we have two levels - we see the ‘haves’ and ‘have nots’ and that is not fair. There is very much a postcode lottery when it comes to community services. “In the North East region, where I’m based, there is a great disparity in provision. We have the Northumberland Head Injuries Service and then the Sunderland and Gateshead Community ABI Service, which cover Northumberland, Gateshead and Sunderland, but then in County Durham there is nothing. “These are very real issues which must be addressed and I hope will be in the creation of the strategy. Chris Bryant and the APPG continue to highlight such issues in Parliament, and we continue to stress this through UKABIF, and I hope that the creation of the strategy will effect change.”

Adults living with spinal cord injury (SCI) have an almost 80 per cent increased risk of developing psychological conditions, such as depression and anxiety, compared to people without the traumatic injury, a new study shows. The research revealed that people living with a spinal cord injury were diagnosed with a mental health condition more often than those without the injury – 59.1 per cent as compared to 30.9 per cent. The Michigan Medicine-led team also found that chronic pain among adults living with SCI can have an equally significant negative effect, and is closely associated with post-traumatic stress disorder (PTSD), substance use disorders and other mental health conditions. In most cases, said the research team, chronic pain was an even greater influence on these conditions than exposure to living with the injury itself. The findings come from analysis of private insurance claims of more than 9,000 adults with a traumatic SCU and more than a million adults without. They accounted for a range of psychological conditions, from anxiety and mood disorders to insomnia and dementia. Researchers say the findings should prompt healthcare professionals to identify mental health conditions when seeing patients with SCI and refer them to mental health providers for treatment. “Improved clinical efforts are needed to facilitate screening of, and early treatment for, both chronic pain and psychological health in this higher-risk population,” said Dr Mark Peterson, lead author of the paper and associate professor of physical medicine and rehabilitation at Michigan Medicine.

N R news

Families and charities have united behind the campaign against the planned closure of a specialist neurological rehabilitation centre, which would be a “backward step” in delivering the bespoke support so badly needed by brain injury survivors. A consultation has been launched by Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) to consider the closure of the Oliver Zangwill Centre, which provides neuropsychological assessment and rehabilitation for adults with an acquired brain injury. The centre – which supports people aged 16 to 64 who have non-progressive brain injury and require cognitive rehabilitation – has been hailed by countless families as being a lifeline, enabling their loved ones to make a recovery beyond expectations. Each year, in the Cambridgeshire and Peterborough area alone, around 4,000 people are admitted to hospital with an acquired brain injury diagnosis, with thousands more in surrounding areas. However, the CCG claims that referrals to the neuro-rehab centre have fallen in recent years. But charities have opposed the closure proposals, arguing that neuro-rehab and brain injury support provision should be made a priority in light of the Government’s announcement that it will create an ABI strategy, in response to a campaign for it to do so. Chloe Hayward, executive director of UKABIF, told NR Times: “On the one hand, we have the acquired brain injury strategy being developed by the Government, which we hope will take steps to ensure people have the access they need to support and neuro-rehabilitation,

but then on the other we have this amazing internationally-renowned service facing closure. “The Oliver Zangwill Centre has produced some fantastic professionals who work in this field, as well as helping people and their families to access amazing care, but now we are told this will have to be picked up by charities and the independent sector. This is not something that can happen; charities just cannot provide this level of specialist rehabilitation and the independent sector, although providing great services, may not have sufficient availability in this area. “We have seen it before with the closure of other services, where overnight they disappear and there is nothing to replace them. The Oliver Zangwill Centre is very specialist and takes particularly complex referrals from as far afield as Greater London, which shows the need for its services.

On the one hand, we have the acquired brain injury strategy being developed… b u t o n t h e o t h e r, we have this amazing internationallyrenowned service facing closure

We fear its closure could be a catastrophe for neuro-rehab provision for so many families.” Peter McCabe, chief executive of brain injury charity Headway, said: “We are appalled that this highly-regarded NHS service may be closed. “Neurorehabilitation remains one of the most costeffective forms of treatment available to the NHS. “It can increase a brain injury survivor’s independence, reduce the need for costly ongoing state support for either the survivor or their carers, and even enable a return to employment for some. “And yet access to neurological rehabilitation on the NHS remains patchy, inconsistent and in short supply across the UK. “The loss of this specialist NHS centre may signal a move towards privatisation, with brain injury survivors and their families paying the greatest price. “Patients would be sent to specialist units further from home, making it hard for their loved ones to play a supportive role in their rehabilitation, while those not able to claim personal injury compensation payments made find it harder to obtain referrals and therefore denied access to crucial rehabilitation.” Amanda Hymus’ son Haydn was helped by the Oliver Zangwill Centre after he sustained a traumatic brain injury in a cycling accident in 2018. Haydn had part of his skull removed to relieve pressure on his brain caused by swelling. He was in a coma for two weeks before beginning the gruelling process of relearning some of life’s most basic skills. “The support provided by the Oliver Zangwill Centre has been exceptional,” said Amanda. “They provided speech therapy to help with Haydn’s aphasia and they’re helping him relearn how to read and write. “They delivered training sessions to staff at Haydn’s college to help them better understand the effects of brain injury and how to support him with the challenges he faces. “They even help him to become more independent by assisting him to travel by bus to the centre for his rehabilitation sessions. “The support they have also provided to me as the mother of a brain injury survivor has been invaluable and enabled me to keep going. “It would be an absolute travesty for people not to have access to the services this specialist centre provides as there is really nothing quite like it. “We would have been totally lost without them and Haydn would still be trying to get to grips with life and how in fact to even live. “His mental health has improved leaps and bounds and he feels that he can again contribute to life and live as a whole person.”

We’re here to helphere We’re We’re here families to help to help living with families families dementia living with living with dementia dementia

Support at your fi ngertips Support Support at your at your fingertips fingertips

Visit our Virtual Carers Centre for a wide range of support and information. Visit our Virtual Carers Centre for Visit our Virtual Carers Centre for dementiacarers.org.uk/vcc a wide range of support and information. a wide range7895 of support and information. 020 3096

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Neuro Rehab Times-260x205mm_19Nov.indd 1

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Neuro Rehab Times-260x205mm_19Nov.indd 1

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N R news

UKABIF joined other brain injury charities and organisations at the House Of Commons for the launch of the Call for Evidence in the Government’s recently-agreed Acquired Brain Injury (ABI) national strategy The minister of state for care and mental health Gillian Keegan and Chris Bryant MP announced the launch of the Call for Evidence. Chris Bryant, chair of the All-Party Parliamentary Group on Acquired Brain Injury, secured the ABI strategy at the end of 2021 and he and Gillian Keegan co-chair the ABI strategy programme board which first met earlier this year. Chloe Hayward, executive director of UK Acquired Brain Injury Forum (UKABIF), said: “We are very pleased the Government is giving acquired brain injury the attention it deserves with the ABI strategy. “The call for evidence will help the panel to focus and prioritise their efforts, so we need people with lived experience of brain injury – whether, survivors, carers or professionals to participate. “This will ensure the panel has the best available information to develop their strategy.” Minister of state for care and mental health,

Gillian Keegan, said: “It is absolutely essential people living with acquired brain injury get the best possible care and treatment and that we take steps to prevent these injuries wherever possible. “Together the cross-government programme board and the call for evidence will allow us to deliver a strategy to address issues that matter most to those with acquired brain injuries and other neurological conditions.

We n e e d p e o p l e t o c o m e for ward with ideas and suggestions based on t h e i r e x p e r i e n c e o f b ra i n i n j u r y a s p ra c t i t i o n e r s , p a t i e n t s o r fa m i l y members so we can get t h i s s t ra t e g y r i g h t

Chris Bryant MP said: “I’m delighted that the Government is starting to pull together a crossgovernment strategy on acquired brain injury. “We need people to come forward with ideas and suggestions based on their experience of brain injury as practitioners, patients or family members so we can get this strategy right. “I urge everyone to take part if they think they have an insight to offer.” The Call for Evidence survey will provide an opportunity for the Strategy Programme Board to hear first-hand from the people most affected to help find out what services are needed, where there may be gaps, and how the government can support services to help fill these. To have your say in the Call for Evidence go to www.gov.uk/government/consultations/ acquired-brain-injury-call-for-evidence If you require further information, contact ABIcallforevidence@dhsc.gov.uk

N R news Leading rehabilitation clinicians have come together to write a new book on the interdisciplinary team (IDT) approach to complex physical rehab ‘A Practical Approach to Interdisciplinary Complex Rehabilitation’ is a practical and evidence-based guide to complex rehabilitation from an IDT perspective, exploring the diverse roles and challenges of the team. The 15 chapters are written by clinicians who are highly experienced across a range of disciplines and settings, from early acute rehabilitation to community rehabilitation. The book has been developed by Drs Cara Pelser, Helen Banks and Ganesh Bavikatte from The Walton Centre NHS Foundation Trust and Cheshire and Merseyside Rehabilitation Network (CMRN). Together with a wide range of medical, nursing, AHP and psychology colleagues from the CMRN they have captured each discipline in a user-friendly format, covering topics which

are under-represented in current literature such as vocational rehabilitation and socioeconomic factors. The CMRN is hosted by The Walton Centre NHS Foundation Trust and is the UK’s only specialist rehabilitation clinical network commissioned from hyper acute to community services and NHS Foundation Trusts. Dr Ganesh Bavikatte, consultant at The Walton Centre in Liverpool and clinical lead for the CMRN, and one of the editors of the book, said the text will be an invaluable resource for all healthcare staff working in rehabilitation. “Whether you work in medicine, nursing, dietetics, neuropsychiatry, occupational therapy, physiotherapy, psychology, rehabilitation coordination, speech and language therapy, or vocational rehabilitation therapy, there is something to learn and take from this book,” he said. “Most importantly, the book looks at the team approach, which is critical for the benefit of the rehabilitation patient and their personalised goals.

“I am delighted to see it in print and be able to share the work of the staff from the Cheshire and Merseyside Rehabilitation Network with our colleagues across the country and the world.” Clinical psychologist Dr Cara Pelser said: “The book demonstrates the hard work and sheer dedication of NHS staff who, during a pandemic, have continued to successfully collaborate to develop and produce a piece of work everyone should be proud of.” The Cheshire and Merseyside Rehabilitation Network is a clinically-led network responsible for 103 inpatient beds and community services across the region. It provides high quality specialist rehabilitation across a coordinated pathway from hyper-acute to community services based on a patient’s needs not diagnosis. It operates on a hub and spoke model, with the hub at The Walton Centre, where there are 10 inpatient beds in the hyper acute specialist rehabilitation unit, providing early specialist assessment and supportive rehabilitation for patients who have typically stepped down from critical care, high dependency units or major trauma centres and 20 inpatient beds in the complex rehabilitation unit to provide supportive rehabilitation for patients with complex medical, nursing and therapy needs. Active rehabilitation is provided in the spoke units at Liverpool University Hospitals NHS Foundation Trust, St Helens and Knowsley Hospitals NHS Trust and Wirral University Teaching Hospital NHS Foundation Trust, and extended rehabilitation at Oak Vale Gardens, Priory Care.

N R news

Pioneering project to improve social workers’ ABI knowledge Social workers and their knowledge of acquired brain injury (ABI) is the subject of a new research programme, which aims to enable them to deliver better support to survivors and their families. People with a brain injury often have to deal with complex problems affecting their relationships and personality, often without the right safeguarding support they need. To help address that, a new two-year research project, led by the University of Essex, is looking to improve social workers’ knowledge of ABI, to give them a better understanding of the needs of those they are supporting. Project lead Professor Andrew Bateman, from Essex’s School of Health and Social Care, said: “The consequences of brain injury can be devastating for an individual and their family and friends. "People have to struggle with changes in their emotions, thinking skills and behaviours that are sometimes not easy to understand.

“In worst case scenarios we have seen suicides and other serious bad outcomes such as drug addiction, crime or homelessness. The aim of this important project is to help professionals support all brain injury survivors more effectively.” The Heads Together programme has received £253,000 funding from the National Institute for Health Research (NIHR) to address the skills and knowledge gap in social work education around brain injury. Professor Bateman, who is also chair of the UK Acquired Brain Injury Forum (UKABIF), will join forces with a team of experts to support the Brain Injury Social Work Group, International Network for Social Workers in Acquired Brain Injury and UKABIF throughout the project, to improve understanding and practice around brain injuries. It is hoped this will ultimately lead to better social care. The project will involve developing educational

resources for social workers, service users and their families to better address the needs of people with brain injuries, include materials for families and service users to support advocacy when working with social workers and help support the potential role of social workers within an interdisciplinary team. Brain injury specialist Professor Bateman added: “The NIHR support for work in this sector will mean that we can make a great difference to the lives of people affected by brain injury, through improving awareness and training of social workers. “The timing of this research is especially important after some recent tragic serious case reviews that have pointed at the need for this research and training.” The funding will enable the project research team at Essex – which includes lecturers Caroline Bald and Akudo Amadiegwu – to meet with brain injury survivors, social workers and their managers to get a detailed understanding of the changes needed. Chloe Hayward, executive director at UKABIF, said: “We know that some difficulties following ABI can be invisible. “To meet the needs of people with ABI, social workers need specific knowledge and skills to recognise and understand these underlying difficulties. “With this knowledge, social workers can ensure appropriate social care is provided, and they can use skills to identify and work around their clients’ ABI challenges. “We need a better understanding of social workers’ current ABI knowledge. “This research opportunity will address this along with looking at what are the barriers to acting on this knowledge, how can organisations and managers better support social workers and what kind of training is needed.” Earlier this year, a Safeguarding Adult Review into the death of a 42-year-old Brighton man, who had an acquired brain injury, found the current safeguarding system to be insufficient and a lack of expert knowledge in brain injury among the agencies working to protect him. Following that Review, UKABIF wrote to Social Work England and the Secretary of State for Health, gathering more than 100 signatures from experts across health, social work and law in support of their call for improved training for social workers. “We believe social workers play a vital role in supporting individuals and families affected by ABI but cannot do so effectively without the knowledge they need to practice to the best of their abilities,” added Chloe.

N R news

Schools and teachers who have not received adequate training are buckling under the strain of providing mental health support for children, a new report has revealed A group of education and health experts, writing in the Journal of the Royal Society of Medicine, say investment in schools and teachers is urgently required to support them to promote good mental health and respond to problems. Rates of mental illness amongst children have increased by 50 per cent in just three years, with only a quarter of children with a mental disorder receiving support from mental health professionals. Data from the Office of National Statistics shows that teachers are the most common source of support for such children.

E-scooter head injury risks laid bare through new research The head injury risks to e-scooter riders as a result of falls have been revealed through new research. Through simulations, early-stage evidence has been collected that could help sharpen safety regulations regarding speed limits, helmet and wheel design, and pothole management. Lead author of the study, Dr Mazdak Ghajari, from Imperial College London’s Dyson School of Design Engineering, said: “Our findings could add to the evidence governments need to make astute decisions on e-scooter safety, which we hope will reduce the likelihood of head, brain, and facial injuries.” E-scooters are the fastest growing mode of micro-mobility and come with environmental benefits. However, there are serious concerns about injuries caused by e-scooter accidents, and countries around the world have differing views on appropriate speed limits and levels of head protection. Only around four per cent of e-scooter riders wear helmets, compared with 50 per cent of cyclists – and the relationship between e-scooter falls and their speed and design, road surface conditions like potholes, and wearing helmets, is poorly understood, yet the consequences can be severe. To highlight safety concerns for riders, Imperial researchers simulated 185 falls on three digital

Like overstretched professionals on the frontline of healthcare, disproportionate numbers of teachers also experience poor mental health themselves. Teachers, together with GPs and social workers, constitute ‘tier 1’ of the Child and Adolescent Mental Health Service (CAMHS) and are considered able to offer general advice and treatment for less severe problems, as well as referring to more specialist services. In practice, say the authors, teachers end up providing crucial support for children across the spectrum of need, because

human body models that represented three different sizes: a 50kg weight, 1.5m tall female; a 76kg, 1.7m male; and a 101kg, 1.9m male. These represent the fifth percentile of adult women and 50th and 95th percentile of adult men respectively. The researchers simulated the unhelmeted models riding an e-scooter with 10in wheels at five different speeds over 12 differently sized potholes. They found that even at lower speeds, the speed of impact between riders’ heads and the ground was comparable to the speed used to test bicycle helmets. Reducing e-scooter speeds from 30 km/h to 20 km/h led to a 14 per cent reduction in this impact speed and a 12 per cent reduction in the impact force, but falls at all speeds reached the threshold for skull fracture. Although impact speeds echoed those from bicycle falls, the angles of heads at impact differed, highlighting the need for e-scooter specific helmet testing methods. Fifty-six per cent of the impacts were to the forehead and rest of the skull, and 44 per cent were to the face, indicating that open-face helmets like bicycle helmets could help prevent a slight majority of head and brain injuries but would not protect against facial ones. While bicycle and motorcycle helmets are heavily researched and regulated – although the effectiveness varies greatly – research for developing e-scooter helmet standards has yet to catch up. Dr Ghajari said: “Unlike bicycle and motorbike

it is difficult to access specialist services. The government currently funds mental health awareness training for only one teacher per school. The authors point to government research that found just 40 per cent of classroom teachers in England report feeling equipped to teach children in their class who have mental health needs, and only 32 per cent know how to help pupils access specialist mental health support outside school. The study’s lead author and former teacher, Chloe Lowry, of the Institute of Education at University College London, said: “It is both astonishing and alarming that teachers are not adequately trained for these roles. “Given the essential role schools and teachers play in supporting children’s long-term health and wellbeing, and responding when problems arise, funding support from the health sector to equip this forgotten health workforce could be transformational.”

helmets, we don’t yet have a gold standard for e-scooter helmets. “Our research highlights the need for developing methods that are specifically designed to test helmets under impacts sustained by e-scooter riders, accounting for the angle of the head and likelihood of head and face injuries.”

N R news

Exercise ‘can deliver memory improvements after brain injury’ Aerobic exercise can deliver cognitive improvements in brain injury survivors who live with significant memory loss, a first-of-its-kind study has revealed. The pilot study provides proof of concept data on the potential benefits of exercise through cycling in cognitive function in people living with traumatic brain injury. The Kessler Foundation research has showed that 12 weeks of supervised moderate aerobic cycling may improve memory and processing speed in individuals with disabling cognitive deficits caused by traumatic brain injury. “Our results support the need to explore the relationships between exercise training, cognition, and functional and structural changes in the brain, which may establish the path toward optimal protocols for clinical implementation,” says Dr Brian Sandroff, senior research scientist in the Center for Neuropsychology and Neuroscience

Research at Kessler Foundation. The study, the first of its kind among people living with brain injury, saw participants enrolled in a single-blind randomised control trial, which included five physically inactive individuals with a ten-year history of traumatic brain injury and significant memory impairment. They were randomised to 12-weeks of supervised moderate aerobic cycling exercise (intervention), or 12 weeks of stretching and toning exercise (control). All participants underwent neuropsychological tests of memory and processing speed and structural neuroimaging studies of the brain before and after their 12-weeks of exercise. “Compared with controls, the exercise group demonstrated substantially greater improvements in auditory verbal learning and processing speed, and larger increases in volumes of their left hippocampus, left cerebellar cortex, and right cerebellar

cortex,” reported lead author Dr Carly Wender, postdoctoral fellow in the Center for Traumatic Brain Injury Research at Kessler Foundation. “We also found that large intervention effects favoured the exercise group, which showed gains in processing speed and volume of the right thalamus.” Although this study is small and data are preliminary, it is the first to look at cognitive function and morphological changes in the brain in response to exercise in people with traumatic brain injury related memory impairment. Global cognitive impairments, as seen after traumatic brain injury, present major treatment challenges for clinicians, says Dr Sandroff. “Because of their effects on multiple cognitive domains, exercise interventions, which are low cost, noninvasive, and readily available, are an attractive option to explore in this population,” he added.

N R news

‘Equip therapists with

the skills to implement digital health'

Therapists charged with delivering digitalisation strategies must be given appropriate training for the implementation to be a success, says one of the neuro-rehab sector’s champions of remote rehabilitation. Leanna Luxton, co-founder of Remote Rehab, believes that for healthcare to truly adopt digital and technology-led rehabilitation for patients, securing the support of those on the frontline is crucial. Remote Rehab was created during the pandemic to unite therapists from around the world and share best practice in digitalisation, and the team recently delivered the Virtually Successful conference - a first-of-its-kind event which shared the inspirational stories and experiences of international rehab tech entrepreneurs and innovators. But while digital adoption remains a hot topic, with unprecedented levels of use since March 2020, Leanna believes that unless therapists are given proper training, its impact will not be as effective. “We are seeing more conversations around

this topic, and trusts are now looking at this seriously as we’ve seen the impact and need for digital services - but up-skilling the workforce is crucial to really embedding this,” says neurophysiotherapist Leanna, who has been a prominent voice around the need for digital adoption in healthcare. “We’ve got people using VR, apps, digital platforms, but they often aren’t understood by the therapists on the ground. They don’t know how to use them properly, so how is the impact going to be felt by patients? “You can spend thousands of pounds on VR headsets but if you don’t know how to input that into the pathway, how it can improve the patient experience, then how is it going to work? “Using digital as part of a blended approach to rehabilitation can really enhance or supplement the dose or intensity of rehabilitation, but we know there is resistance to change or adaptation. There is a need for us to be at the forefront of the change or these things will be forced upon us.’’ “But we see this as something that proper training, proper up-skilling, can really help with. If you embed the technology into a service, and therapists can see how it benefits their clients, then that is the way forward. This is where Remote Rehab comes in.”

Through the five-day Virtually Successful online event - which was held in partnership with NR Times - therapists from across the world heard from more than 50 leaders in digital innovation as to how they had overcome the challenges around acceptance to secure successful adoption and roll-out. The conference, which covered all aspects of telehealth and its implementation, is now available to access online and can form part of the digital training and increased awareness of individual therapists, multidisciplinary teams (MDTs) or entire NHS Trusts, Integrated Care Systems (ICS) and Academic Health Science Networks (AHSNs). Pricing structures for each individual or group have been devised accordingly. “We want the conference to be as accessible as possible and give people throughout this community the chance to hear and learn from the speakers,” says Leanna. “The pricing shouldn’t prevent that, which is why we’ve come up with a number of very costeffective options. We want the decision to be a no-brainer, so that staff can hear this insight and learn from it and then act on it. “As well as teams being able to access the conference, we’re also looking at holding workshops where we can help in setting up or implementing a service, which will help to embed the technology. “We are committed to doing all we can to support teams in using digital, so we can all make change together.”

INTERVIEW

Making the impossible possible The concept of three people living with complete paralysis regaining the ability to walk independently is something that, in the ver y recent past, would have been dismissed as being impossible

For years, spinal cord injury has been regarded by many as the ‘graveyard of neuroscience’, where hope was in short supply and the outlook for those daring to dream of the day that may change was bleak. But now, through the efforts of pioneers who have led the research breakthroughs that are now shaping reality, the ability of technology to change lives is being seen by the whole world, with people watching in amazement as paralysed patients rediscover the ability to move. After being implanted with spinal stimulation technology developed by ONWARD - the first time its epidural electrical stimulation (EES) had been trialled in humans - all three participants who were part of the STIMOBRIDGE trial were able to take steps independently within a single day.

After five months of rehabilitation, they were also able to use their legs to stand, walk, swim, and/or cycle. They also regained control of their trunk muscles. Such colossal steps forward in SCI are now giving new hope to people living with paralysis - and are helping to show, rather than being impossible, what could become the new possible for the future. “We were very pleased with the results of STIMO-BRIDGE, although we as a company are not going to be pleased with just impacting subjects in a clinical trial,” Dave Marver, CEO of ONWARD, tells NR Times. “Our job and our unique role is to scale these therapies so they can provide benefit to hundreds of thousands of people with spinal cord injury around the world. “These results show great promise, but we

still have a tremendous amount of work to do to achieve our vision.” And for ONWARD, that vision is to change the lives of people living with SCI globally, to enable them to enjoy and live their lives in the ways that matter most to them. Established in 2014 to focus specifically on SCI, the venture has led truly groundbreaking research into this long-underserved area. Founded by neurosurgeon Dr Jocelyne Bloch and Professor Gregoire Courtine, Swiss-based ONWARD has taken decades of research and translational science to bring to fruition two viable commercial solutions. With its ARC EX and ARC IM devices, ONWARD - backed by many of the leading European life sciences venture capital investors - has led the charge on redefining the outlook for SCI patients.

INTERVIEW

Its ARC IM, recently subject to the STIMO-BRIDGE trial, consists of an implantable pulse generator and lead that is placed near the spinal cord, controlled by wearable components and a smartwatch. A pivotal trial is set to begin within the next 12 to 18 months. The ARC EX is an external, non-invasive wearable stimulator and wireless programmer, which targets the rediscovery of upper body movement. Currently subject to the international Up-LIFT trial - the largest SCI trial of its kind - it completed enrolment of 65 participants ahead of schedule, despite the many challenges presented by the COVID-19 pandemic. Currently being trialled at sites across the world including in the NHS Greater Glasgow and Clyde (NHSGGC), as well as Neurokinex sites in England - the aim, pending necessary approvals, is for a commercial launch in the first half of 2023. But while the excitement at the potential of ONWARD is palpable, with the first introduction of its technology into rehabilitation centres across the United States, UK, France, Germany and the Netherlands potentially barely a year away, Dave is keen to ensure expectations remain realistic. “Certainly this will give hope to people, and I think the fact we enrolled all 65 subjects in UpLIFT ahead of schedule, despite all the challenges of clinics closing and difficulties with quarantines and so forth, speaks to the enthusiasm that the clinical community has for this therapy,” he says. “They have really embraced it, as the participants did in STIMO-BRIDGE. We, and they, are showing what is possible. “But I do think it’s important to not overstate it, I don’t want to create false hope, because these subjects really committed themselves to the therapy and to the rehabilitation process.

INTERVIEW

“I think there is great potential that many people with paralysis will be able to stand again with the benefit of our therapies, maybe take some steps. But then it really depends on their particular circumstances and their overall level of health, their willingness to commit to rehabilitation, whether they can go further than that. “And, of course, not everyone with spinal cord injury, desires necessarily to walk again, they may have other priorities. And that's why ONWARD is also committed to addressing other

challenges that affect the quality of daily life, such as blood pressure and trunk control and use of better use of the upper extremities. “And then in the future, we'll be looking at incontinence and restoration of sexual function, the whole battery of things that people with SCI have to contend with.” Through its longstanding and deep-rooted commitment to the SCI community, ONWARD has secured relationships with of some of the world’s leading organisations in this area, including the International Spinal Research

Trust and the Christopher & Dana Reeve Foundation. The latter has even become ONWARD shareholders, to help further its pioneering work. For Dave, while the word ‘pioneering’ is wellused, for ONWARD, it is also well-earned. “I think we are seen as pioneers in this area because we've chosen to focus on serving the spinal cord injury community,” he says. “It's a smaller population than other populations with movement-related challenges, like stroke and Parkinson's, for example.

INTERVIEW

l-r Prof Gregoire Courtine, Dr Jocelyne Bloch, Dave Marver

Most businesses orientate toward the largest potential markets, whereas our founders really had a passion for helping people with spinal cord injury. “And that remains the core vision, that was their raison d’être, and it’s with that commitment and determination that we have achieved such progress. “We haven’t partnered with existing spinal cord stimulation companies, we've developed our own technology platform that is built for the specific purpose of not stimulating the spinal cord for pain management, but stimulating the spinal cord to restore strength and function. “But I think the progress we have made also reflects the close collaboration that we enjoy and value with our scientific partners. We have a group of people so committed and driven by our mission, which I think is why we make the progress we have done. “We develop that lead together in a very rigorous way, with our vision at the heart of that.” Constantly looking to the next innovation and how its technologies can be even more beneficial to those who need them, ONWARD is also considering how, post-commercial launch, its ARC EX could be used remotely.

“Later, we’ll be seeking approval for it to be used in people's homes, so they can conduct periodic sessions maybe once or twice a week in their homes to continue gains that they have observed in the clinic, and build on those gains,” says Dave. “We’ll be looking at a successor study to Up-LIFT which would look at safety and performance when used in the home.

Our job and our unique role is to scale these therapies so they can provide benefit to hundreds of thousands of people with spinal cord injury around the world “Without question, it’s important with spinal cord injury to be able to operate this technology, which is why we were keen to incorporate voice activation into the system. Both of our platforms can be programmed by the clinician, but in the future may be operated by and used by the injured with their voices. “But very importantly, we do our best to

connect as frequently as possible with people with injury to inform the design of our product platforms, and inform our future direction as a company. “We consider ourselves part of the community, so that feedback to ensure the design of our technologies is really usable and accessible, in my view, is vitally important.” And with such huge advances and new-found hope for the future, many conversations have turned to whether SCI may be curable. “I wouldn’t rule anything out, with human ingenuity and so forth, but what I would say is more realistic at this point is to have optimism - quite a bit of optimism - that movement and strength and function can improve, and in some cases, be restored with the benefit of therapies like ours,” says Dave. “Perhaps other therapies and technologies will emerge, if you look at how far we have come. But for us, our vision is to support the SCI community around the world through our therapies, and we’ll continue to do that. “We’re making steady progress across all areas of our plan, and while what we’re doing is difficult and complex, I’m confident we will come through.”

TECH

Using the basic, everyday task of a shopping trip, a new virtual reality (VR) experience can help to detect and measure early signs of cognitive decline

Revolutionising the traditional pen-and-paper approach to testing cognition, VStore offers an immersive alternative which can detect cognitive issues with accuracy, having been proven through trials. The simulation of a real-life environment, which tests the thinking and processing skills needed to accomplish complex daily tasks, is proving a compelling combination. The ability to detect early-stage mild cognitive decline could not only help in the early diagnosis of dementia or mental health issues, but enable better outcomes for patients and their families through the provision of more sensitive care pathways. Moreover, statistics predict that advancing the diagnosis of dementia by as little as two years could save the NHS up to £10billion per annum over the next decade. And with the potential of VStore understandably proving attractive to healthcare, pharma and insurance sectors alike - with diversification into concussion monitoring in sport also in the planning - the commercial launch of the product could be as little as two years away. “This can be a gold standard in cognitive testing and we've got the research to back that up. We can also be pretty convinced that it can be used across the board,” says Gemma Timms, chief operating officer of its creator, Vitae VR. With excitement building about its potential, the project’s impending launch comes as a result of years of work. VStore began life in 2015, born from the thinking of Professor Sukhi Shergill, of King’s College London and Kent and Medway Medical School, who saw the need to find a more effective way of establishing cognitive decline than the paperbased method which is still widely used today. Working alongside visual effects business

Vitae VR

Outpost VFX, Prof Shergill’s concept became a reality which has since been continually developed. “Sukhi had the brilliant line that if he could change anything about the way we do our jobs, it's understanding cognition much better,” recalls Gemma, co-founder of Vitae VR, which spun out of Outpost VFX to pioneer VStore. “He said he'd like to take every patient to a supermarket and have them walk around, give them a shopping list. That's how you get around. That's how you live your daily life. And that's a much better test for medical teams than anything you can do with pen and paper or on an iPad. “And that’s how it all started. By using VR, we can replicate that experience in a safe environment, which is really very life-like.” The system has become proven in its efficacy, with a trial involving 142 healthy individuals aged between 20 and 79 years showing its power to demonstrate cognitive ability through the shopping task.

The principle of VStore is that each participant - who wears a VR headset to become part of the immersive environment - is given a list of 12 items, which are then selected from a walk around the supermarket, put in a basket, and are paid for at the checkout with the correct money. The person then goes to the coffee bar to order a drink. While such a task probably seems second nature to most people, VStore is collecting crucial information on their cognitive ability and finding signs of any decline. “We measure a number of critical actions during the process and these measurements are taking place every millisecond,” says Mike Rundle, acting CEO of Vitae VR. “And through that the data collected so far, we can point to VStore as being a very, very accurate predictor of mild cognitive impairment. We can say this is what a normal brain at say 50 years old should be doing, but your functionality is actually coming up shorter than that, so there could be a problem there.

TECH

“While we’d hesitate to call ourselves a diagnostic tool at this point, we can show signs of cognitive impairment with a finer degree of accuracy, which we believe will ultimately advance the diagnosis of dementia.” And as well as being able to spot signs of cognitive decline at an early stage, crucially, VStore has the potential to help redefine a number of areas of practice in other industries, beyond the healthcare market where it could play such a prominent role in primary, secondary and residential care. “Beyond the medical side of things, the ability for governments, for insurance companies, for healthcare providers, to be able to assess what

a person’s future needs are going to be with a population that's in decline due to age or due to whatever condition they've got, is incredibly important,” says Mike. “To be able to predict this kind of information is gold dust for a lot of people. “Also, there are the sporting aspects of being able to test people for head injuries and concussion in sport. We’re looking into, for example, how you can adapt this to wearable technology inside headgear - for example NFL football helmets, or for when you get a measurable impact through a through a tackle in rugby, then you can use this sort of thing to keep monitoring the progress of your players.

“So the applications are endless, really.” As for pharmaceutical companies, Vitae VR believes Vstore’s value lies in its usability and accuracy of measurement during testing and evaluating their products, providing fixed benchmarks of cognition for those taking part in clinical trials of drugs, such as for Alzheimer’s disease. “While treatments are desperately needed, as the FDA has repeatedly stated, there's no real test for cognitive function in the trials as a baseline,” says Mike. “So whilst you may have data which indicates that ‘drug X’, for example, has a positive effect on degeneration, and the speed at which your brain is deteriorating, you've got no baseline test for it. And for that reason, you can't actually say what is definitely happening. “We're basically saying that what we have shows promising results as an accurate measuring tool and perhaps a diagnostic tool further down the line, subject to further tests, it's certainly a more accurate way of recording what is happening to patients during drug trials, or in any form of therapy that they're going through.” With one such trial with a large pharmaceutical company now underway at King’s College London, discussions are already being held about its potential wider adoption - which could be within the new few years. “We're now at the point where we’re ready to say that this is a product we think we have confidence in, it works, and it can be brought to the market,” says Gemma. “And there are a number of other routes we are interested in exploring. “It’s something we are talking to the primary and secondary care markets about, and that's not just in the UK, that is definitely in the US too. “I hope it is something we will see in the marketplace certainly within the new few years.”

INSIGHT

Neuro-rehab and my dachshund Hans Simone Budding, an Until the age of 15, if someone asked me if I was a cat or dog person, the answer was always cats - we had two Burmese cats who were incredibly clingy. But one night my dad brought home a dachshund whose owners were emigrating, followed by a second dachshund looking for a loving family and then a third who needed a new home. I was truly a dog lover by this point and so when the inevitable happened and we welcomed a dachshund puppy to our family I named him Hans and he became ‘my’ dog. One morning my parents woke up to Mollie (Hans’ mother) seemingly paralysed in her back legs. After a consultation with the vet, it was deemed that she had injured her spine and required spinal surgery. The surgery would require a lengthy recovery period where she would have to be kept relatively still and movements of her back to a minimum. Mollie of course had other ideas! In fact, it was so lovely when she came home and realised that her feet were working again, she leapt jovially like a grass dolphin over our lawn. Other than a few staples in her back and overly cautious parents, her recovery went smoothly. Less than two years later, Hans woke up in pain and paralysis halfway down his spine. Another trip to the vet confirmed that he too had broken his back and had a spinal cord injury requiring surgical intervention. Given our previous experience, we did not hesitate to go ahead with the surgery. Sadly, it did not take us long to realise that his recovery was going to be very different. After surgery he had not regained the wag of his tail or the movement of his hind legs, his back half of his body remained flaccid and he had severely atrophied muscles where a once plush bottom was. He was incontinent of both his bladder and bowel but could empty both sufficiently for the vet to discharge him from the hospital. At home he would drag himself around

occupational therapist with Renovo Care Group, shares how human care practices i n s p i r e d h e r d o g ’s recovery from spinal cord injury

with the strength of his front half of the body, fatiguing easily as he did not have the strength or endurance to cope with these new extra demands for mobility. It was sad to see how his personality was changing, from being the first in line to inspect the kitchen for snacks to just laying in his bed and hope that his humans would bring him a takeaway snack. My colleague working in neuro-rehabilitation at the time mentioned to me that her dog also had spinal surgery a few years prior and how she undertook rehabilitation with him in the swimming pool and even made it functional for him by providing him with a tennis ball to chase. The inner drive of the occupational therapist to even make doggy rehab functional made me giggle, but equally made me think and wonder about how transferable human adult rehabilitation techniques would be for my Hans. As I was working away from home, I asked my parents to send me videos of his current mobility and I could then provide them with tips and suggestions of what exercises to do with him. The first video showed a doggy with a flaccid posterior half of his body, unable to move his hind legs or tail. Now, for the tail, I have no knowledge base to draw from, but for the flaccid lower half I instructed my parents to use some sort of suspension therapy (lifting the back half of the body with their

strength and allowing him the opportunity to ‘run’ around as before) and the use of proprioceptive feedback techniques in the hind legs. The second video showed Hans using bunny hopping movements of the hind legs, due to no dissociation of his legs established yet. My recommendations were to continue with the use of proprioceptive techniques but to include doing cycling movements with his legs to help him dissociate them. At this point I had moved back home as I had changed jobs. Because Hans could only mobilise by dragging himself around in the home and outside on the grass and tarmac (and at this point he did not believe he was disabled anymore) he would often have big bleeding scraped wounds on his tail, paws and penis. His decreased sensation meant that he did not realise how painful it was on the tarmac and grass. This was where my knowledge of hand therapy and different taping techniques came in handy. I dressed his little wounds and then covered it up with Coban (which in turn provided sensory feedback) and added Hyperfix to ensure he

INSIGHT

Many months later Hans is now able to walk independently again, he is mostly continent, and he is living his best life could not bite it off. To my surprise the Coban provided enough sensory feedback to Hans that he started to try and stand up on his hind legs independently, it also provided him with a non-slip grip to aid him with his many attempts. At this point I investigated assistive devices for dogs and came across rubber paw socks and a ‘drag bag,’ but Hans did not know what we were doing to him when we placed him in the drag bag and unfortunately the rubber socks were so tight it cut off circulation so neither were an option for him. His physiotherapist started coming regularly to give him therapy. He started to use even more therapeutic modalities such as hydrotherapy (which he hated), using the TENS machine and using kinesio tape. Over time he became stronger and stronger and started to bear weight over both his legs and mobilising independently without the use of the suspension harness. As he gained more control

his back became more hunched. My parents were concerned that this was indicating that he was in pain, but the therapist in me knew that he was hunched at the level of his spinal injury and was using compensatory muscles to help him mobilise. The natural reaction my human spinal injury patients have is ‘’please give me a back brace’’ and so my parents were requesting the same from Hans’s physiotherapist. It brought a smile to my face when she responded the same way I do to my patients ‘’the brace will decondition his body and would be a barrier in making the muscles he requires to mobilise independently weaker.’’ Just an important side note here, for some spinal surgeries the use of a back brace is vital, always follow the guidance from your specific therapy and recovery team. Similarly, a pooch wheelchair would take away the opportunity from him to weight bear and weight shift over his affected limbs and

therefore inhibit his recovery. Many months later Hans is now able to walk independently again, he is mostly continent, and he is living his best life. From both his and Mollie’s recovery, I learnt that many parallels exist between the recovery of animals and humans. Many modalities are just as useful in both species and the neuro plasticity principles I apply in my services to human patients could also be applied to my dog’s recovery. The importance of adjusting our practise to individuals, their personalities and circumstances and knowing that people recover, progress and adjust at different paces was borne out in the stories of Mollie and Hans. In my work at Renovo Care I often think back to these experiences to help remind me that my patients all have goals which are important to them, and that perseverance is a key component of this.

INTERVIEW

Harnessing the power of remote rehab Out of the necessity to pivot to digital during the early days of the pandemic, an international online business has been created to support people living with the impact of concussion and brain injury around the world The Cognitive Rehab Coach was born from seeing how effective remote support could be for clients who are eager and able to embrace it, with people from the United States to New Zealand now benefitting from therapy delivered from the UK. Founder Natalie Mackenzie, a highly-esteemed cognitive rehab therapist and also director of BIS Services, runs both individual and group sessions across the globe - something she admits she embarked on from the greater acceptance of the quality and impact of virtual therapy which has come from COVID-19. “I still do client work and love doing client work, but the challenges of running a business often mean you can’t do as much as you’d like. You can get very lost in the running of a business, when you're a clinician. So this has been very interesting and led by the changes in digital offering we’ve seen from COVID,” she says. “Through delivering therapy this way, I can do a large amount of client work with much less travel time and greater reach. With the BIS, we can spend anywhere between two and eight hours with a client. I've got clients who are two hours away, so I can spend six hours of my day only seeing a client for two hours. “But with the Cognitive Rehab Coach, I can spend six hours online with six different different groups or six different clients. It’s kind of brought back the reason why I love the work that I do. “Clients can be a bit more autonomous and self-led with the learning and assignments I give them, so they can be shorter packages, but with the same level of information they're being given. “That also led on to me doing group programmes. That kind of one-to-many offering through small groups, in addition to the one-to-one sessions, are proving to be really effective.

INTERVIEW

“But it was through what we did with BIS that showed me what was and wasn’t possible. The virtual timetable was a huge learning curve for me in terms of what clients will tolerate right in a group online setting - which at BIS is not a lot - whereas the concussion and post-concussion syndrome demographic find that slightly easier. There have been a lot of lessons.” And the lessons in what was possible also extended into what was essentially a ‘needs must’. For many clients at BIS Services - which delivers in-person cognitive rehabilitation to clients living with brain injury and neurological problems across the country - the experience of digital adoption into therapy was rather more challenging. “We did take our virtual timetable online for a period of time, we did pivot to adapt to the challenges of staffing and keeping clients and staff safe,” she says. “But now, the only time we go digitally is if someone is in isolation and we can flip back into the online support. We do face the same challenges with engagement and being able to functionally practice things with clients, but at least we know it will be for a short period of time. And the transition is much easier now, too. “But for BIS and our team of RAs (rehab assistants), all of whom have been specifically matched to each client, wherever possible, we’ll do face to face. But although that’s from a therapy point of view, that’s not to say digital hasn’t been really important in many other ways.” But while Kent-based BIS has not adopted digital as a core part of its therapy offering to clients, digital has proven to be effective in other ways. Through the creation of online events and opportunities, clients continued to be challenged and stimulated. “Our weekly quiz night became a therapeutic activity, as well as a bit of fun,” says Natalie. “We had a group of people who really got on well, but you’d probably never have put those people in a room together. It was the one it was the one activity that we kept going for the longest because clients were so engaged in it. “We rotated themes and gave clients the opportunity to write a quiz themselves, and we know hours of work went into that 45-minute quiz. It was a lovely thing to see. “We also did a couple of comedy nights where the clients did comedy for us, and we would record it for them. I thought that was really brave to do that in front of your peers. Then the following week, the client would then review it as part of their learning to see what they wanted to improve on. “These were ways in which Zoom did really deliver some great benefits to us.”

And in terms of its impact on how BIS operates, technology has also delivered benefits in terms of staff training and supervision. With 45 rehab assistants across the South of England, and extending as far north as Manchester, the opportunity to unite the team online rather than in person has been a very welcome opportunity. “They’re all so busy with clients that to even find one day a quarter where we bring everyone in for training can be really prohibitive,” says Natalie. “But now, I’ll deliver it live for any staff who can’t be here in person, and then it’s made available on our virtual library. For supervisions too, you don’t want to have people coming down from Manchester, spending all those hours travelling, when you can do it online now.” Online training and learning has been a key area of development and acceptance, within BIS and for countless other organisations around the world. For Natalie too, she has embarked on her own digital learning experience, securing qualification as an ADHD coach. “I have a lot of brain injured clients with ADHD, but there isn’t an ADHD coaching course in the UK. I ended up doing a year-long course in America and the ability to train digitally has been amazing,” she says. “While the opportunity would have been available before COVID, I guess it wasn’t as accepted, my preference would probably have been face to face. But now, there is much greater awareness and acceptance, because it works and we’re all seeing that.” Going forward, digital will continue to be a key part in the administration role of BIS, and of course will be fundamental to the continued growth of the Cognitive Rehab Coach although the early experiences of COVID showed Natalie and her team the need to avoid becoming over-reliant on its use for some very human reasons. “In clinical work, we’re not used to being on computers for six or seven hours a day, let alone the challenges of talking pretty continuously for that long,” says Natalie. “We had really bad headaches and were just so tired, we even started having problems with our vision. I remember losing my voice for a couple of days too. But now, we have got into what I think is a good working pattern, where we can flip to digital for our clients if we need, but we’ve learnt what works and what doesn’t. We are now using that to our advantage and making it work best for everyone.”

With the Cognitive Rehab Coach, I can spend six hours online with six different different groups or six different clients. It’s kind of brought back the reason why I love the work that I do 31

B R A I N I N J U RY

The app set to revolutionise ABI support From the devastation of Luke Parry’s brain injury has come a solution which is set to support countless families across the world in living and coping with neurological illnesses and injuries

Neumind has been created to improve access to bespoke solutions for individuals and their loved ones faced with acquired brain injury, using technology to widen access to specialist neurorehabilitation and to support people with ABI in the practicalities of their everyday lives. Through Alfred - a mobile app which takes its name from Batman’s assistant - a host of therapies and resources can be accessed to support the recovery and independence of the person living with brain injury, and gives their care givers a crucial role in them achieving this. And while now in its final development stages and heading for trial amongst survivors and

families in the UK, the creation of revolutionary Alfred has been enabled by its chief product tester - Luke. It was in 2012 when Luke, then a student at Oxford University, was seriously injured after a fall from height. Sustaining a serious brain injury, the initial prognosis was that he was unlikely to ever walk or talk again. Happily, Luke has defied all expectations - and is even in the development squad for the 2024 Paralympics, which gives an indication to the extent he has overcome the initial outlook - but his recovery has not been without significant trauma for both him and his family in adapting to their new lives, compounded by a realisation of the lack of access to specialist resources.

B R A I N I N J U RY

“Soon after someone you love has experienced this kind of injury, as a family you realise everything has been turned upside down. It takes a while to understand the new dynamics and how you can contribute as a care giver,” says Dr Ellis Parry, Luke’s identical twin brother and CEO of Neumind. “But while you’re adapting to that, you realise what support exists for both your loved one and for you as a family. Statistics indicate that 70 per cent of people with ABI don’t get adequate inpatient rehab, and actually, inpatient is the best rehab that we provide. “So following that, you have to follow the community pathway, which now because of COVID, can have a waiting list of up to a year. The average we’re seeing is eight months, which is just crazy. And that’s really where someone needs input, but it tends to be one session a month, and there’s no way anything is going to land in that one hour session. “And with the caregivers, who are so critical to achieving the long-term outcomes, they don't really receive a lot of guidance, training or support. “So we wanted to explore how we could combine cognitive assistive technology with long-term, low touch support from specialists.” It was while Luke was an inpatient in the internationally-renowned Oliver Zangwill Centre that Dr Parry began to fully realise the benefits top-class specialist neurorehabilitation could have. “We had to campaign hard to get Luke in there, because there are only a few NHS spots, but it really opened my eyes to what was possible in rehabilitation and what was missing from the standard pathway. If he didn’t have that, I think we would all be in a very different place to where we are now,” says Dr Parry. “While he was there, Luke was using a device called Neuropage, which was basically a paging device from the 1990s. It would send practical reminders, while reinforcing certain things that Luke was doing. “We realised that was super important for someone with a brain injury, to have constant practice and taking the therapies and concepts into their daily lives.” From there came the desire to create ‘Neuropage 2.0’ which could build on the principle of the outdated technology and harness the power of modern day machine learning to create a tool to help survivors get the support they need to adapt to their new lives. Dr Parry, an Oxford engineering graduate who achieved his PhD last year, assembled an equally expert team to help create the memorably-named Alfred.

“Alfred was a code name between Luke and I at first, but it stuck,” he says. “But I think anyone who has survived a TBI goes on a bit of a superhero journey in many ways. You go through that dark period and then find yourself rising from the ashes.” The multi-faceted app offers a range of resources primarily to the survivor, but also delivers benefits to families and care givers, alongside healthcare professionals. Taking the concept of Neuropage to the next level, Alfred uses ‘smart prompts’ personalised multi-media messages which can be either practical or therapeutic, to support survivors in stimulating neural pathways associated with memory. Tackling the issue of access to specialist rehabilitation directly, Alfred also has a growing library of verified exercises and strategies, which resemble real life activities and enable re-adjustment to daily life. Through advanced analytics, Alfred is also able to determine what creates optimum responses for each person, helping to guide the best possible outcomes. The app enables a person to connect with others, such as care givers or therapists, who can support them in their progress. While still a work in progress, Neumind is looking at ways to introduce access to specialists as part of Alfred’s offering, something which is often prevented by cost. “It can be up to £120 an hour to see a senior psychologist or a senior occupational therapist,

I think anyone who has survived a TBI goes on a bit of a superhero journey in many ways. You go through that dark period and then find yourself rising from the ashes

and outside of the medico-legal world, most people just can't pay that much money,” says Dr Parry. “And in order to get any benefit, you need to do a lot of sessions. And those sessions, if you're not properly supported cognitively, can go in one ear and out the other. “So we've been exploring different models of how we can provide a more cost effective, longer-term kind of support, and that is something we are developing and is still ongoing.” And the fact its development continues is something the Neumind team are keen to work on collaboratively with those who need it. With a growing core of regular users - with Luke as “chief tester and biggest critic” - feedback from those with lived experience is crucial to Alfred being the solution Dr Parry hopes it will ultimately become. “We want to understand the kind of problems people face much more,” he says. “Brain injury unfortunately doesn't get the recognition and doesn't get the investment. In order to innovate in this area, there are no clear funding streams. It's really difficult. “And the diversity of people's problems also means that the solution isn’t simple. We've worked with some other startups who work in, for example, tinnitus, conditions with single symptoms, single intervention applications which are much smaller, much simpler to develop. “Brain injury needs and deserves its own set of tools - but if you take the NHS recommended apps, there's 15 different categories of apps for someone with brain injury. And inside each category has maybe five or six different apps. There's nothing for brain injury, they’re all generic apps which tackle fatigue, or memory, things in isolation. “For most people with brain injury, they'll probably have several issues in these areas, which might mean they have to download 20 apps, and somehow figure out how to use them. “So for us, for Alfred to be exactly what people want and need, we are learning from the experiences of others.”

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A Silent Epidemic:

Tr a u m a t i c B r a i n I n j u r y S u r v i v o r s i n t h e c o m m u n i t y In the UK there are an estimated 1.3 million individuals enduring the long-term effects of traumatic brain injury (TBI) living within the community. Often symptoms of neurobehavioural disability, a legacy of TBI, can go undiagnosed and unsupported, inhibiting how successfully they can live within the community and putting a huge strain on their relationships and family life

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Professor Nick Alderman is clinical director, Neurobehavioural Rehabilitation Services & head of psychology at Elysium Neurological Services. He is acknowledged internationally as one of the foremost experts in neurobehavioural rehabilitation, having more than three decades experience in this field. In June 2021, Professor Alderman, and his research colleagues at Swansea University, published a study which looked at the prevalence and predictors of neurobehavioural disability amongst survivors with TBI in the community. In this EveryExpert article, we talk with Professor Alderman about how the Swansea Neurobehavioural Outcome Scale (SASNOS) can be used in a community setting and the necessity to raise awareness about the silent epidemic of TBI survivors across the UK.

Hi Nick, thanks for talking with us today. Could you start by explaining more about how the lives of individuals, who are enduring the long-term effects of TBI, are impacted in a community setting? Nick: “Neurobehavioural disabilities can be very complex. There is a large range of symptoms that are due to a variety of factors that people can inherit as a result of a traumatic brain injury. For example, there’s the organic damage to the brain itself. When the damage is to the frontal part of the brain this can have a significant impact on a person’s life within the community, because this is the part of the brain that's responsible for controlling behaviour and picking up feedback. A function of the frontal lobe is also to enable us to adapt our behaviour to new and novel situations. “So, when people have frontal lobe damage as a result of a TBI, not only are they more likely to have challenging behaviour, they can often have real difficulties in coping with novel situations. This produces a sort of dilemma as in situations, like a formal conversation or structured exchange, where people are well rehearsed in the behaviour, because before injury the behaviour was just habitual, there are no obvious problems. The person can seem to be functioning ok. This is why individuals can perform well in formal assessments but outside of the assessment they actually struggle in many aspects of life. “As soon as you put someone into a new or novel situation where they’ve got to think on their feet, you see problems with planning and organisation. This can easily result in frustration, and because they may also have difficulties inhibiting behaviour as another legacy of TBI, they may express this by shouting or being aggressive, which can be frightening and intimidating to other people. “So that’s the organic damage, but of course there’s damage to function as well, particularly to cognitive function, memory, attention and planning skills.”

So neurobehavioural disabilities arew about a lot more than just challenging behaviour or aggression?

And these are considered quite basic social interactions – conversations, exchanges etc. So if an individual can’t manage this it can be quite limiting on Nick: “Yes, exactly. It’s about all different sorts what they’re able to do in everyday life. of impact on people that have a very subtle, but in many cases, a very catastrophic effect on their day-to-day lives. One common example is that individuals can often have difficulties with the ability to attend to multiple events. For instance, let’s take myself as I'm speaking here now. I'm having to think about what I’m saying, what I’m about to say, I’m looking at you to see if you’re paying attention to gather some feedback. So I’m having to process lots of things at the same time and that has an impact on my behaviour. “For individuals with brain injury, often their ability to monitor, in that sense, is much more restricted. So in social situations where an individual with TBI is engaging in conversation with another person, and somebody else joins that conversation, perhaps the conversation changes direction, the individual with TBI can struggle to respond appropriately. “Somebody with these sorts of difficulties can't pick up on the fact that the conversation has changed, because they're so intent on monitoring their own output in terms of their verbal behaviour. As a consequence, their behaviour therefore becomes socially inappropriate because they're not adjusting it to the new set of circumstances. It can often be labelled as rude or ignorant, when they’re not deliberately being so. The behaviour is a product of the cognitive problems they have.”

Nick: “Absolutely, and this issue is often missed in formal assessments – because of the reasons explained earlier. People will think of things like aggression because that’s easy to conceptualise and much easier to measure. But when it comes to the social niceties it's much more difficult to establish their impact. “For clinicians working face to face with individuals with brain injuries, we have long been cognisant of these issues but there weren’t really any good instruments out there to measure neurobehavioural disability in the round. That’s why we developed the SASNOS and why it’s important from a rehabilitation point of view. We need global measures to give us this all round assessment, otherwise they’re biased. If clinicians are only measuring aggression, for example, they’re not measuring these other very subtle symptoms that are often the bigger problem. “The other thing is, which led to the development of the SASNOS, was the fact that nearly all of the measures that were being used had been modified from psychiatry so they hadn't been specifically developed for brain injury. There's obviously an assumption on the part of people who think that the psychiatry of aggression is going to be the same as the psychiatry of brain injury, and they’re not. The drivers are completely different.”

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So let’s talk about your recent paper, looking at the use of the SASNOS in the community. What was the reasoning behind the study? Nick: “The main motivation was to try and illustrate the prevalence of neurobehavioural disability holistically, not just with aggression, but with the whole range of symptoms that individuals experience. The SASNOS has been used extensively in patient settings. We’ve successfully been able to compare the prevalence and severity of neurobehavioural disability for people in specialist neurobehavioural units such as the Avalon Centre. “But, we know from the research, that most people who have these sorts of difficulties are out in the community and they don’t get access to the appropriate support. There are 1.3 million people, it is estimated, that are living in the community with the long-term effects of an acquired brain injury, including traumatic brain injury. The research shows that these difficulties are chronic, they don't go away and they don't tend to get better. They are more disabling in terms of community reintegration than physical disabilities. They are the reasons why marriages and families break up, why people have hit out at home and ended up in prison or on the streets, or in long term psychiatric care.

“So the motivation to look at the community group is very much from that point of view. In the paper we show that the difficulties weren’t as severe as you would find in patients who’d been admitted to specialist neurobehavioural programmes, because they’re a particular sample. But the difficulties were still quite severe, even for violence and aggression. Particularly with interpersonal relationship problems and problems with cognitive function.”

Was there anything particular about the community sample in your study? Nick: “Well the main point to stress here is that these individuals looked for all intents and purposes like they are fully recovered. However TBI is a silent epidemic, individuals seem to be functioning normally and, if you look at someone, there doesn't seem to be anything wrong with them. But actually the reality is very different. “It’s only when people are put in situations where their ability to direct frustration gets tested, or they are put into a very unique situation and they don't have the capacity to cope. They’ve lost the ability to plan and change behaviours. If they’re in novel or new situations their difficulties really come to the fore.”

Could we talk a little more about contextualising and self-awareness i.e. the individual has an awareness that they have this disability or that they’ve been impacted in this way. Does this self-awareness help them to manage behaviour and responses?

version that the person themselves can complete. So clinicians and researchers can look at that paradox.”

If the individual who has TBI doesn’t have that insight into their situation, they’re not going to come forward for help, so do you have to rely on the families to come forward? Nick: “Yes often we do, the families are usually the torch bearers or flag bearers for trying to get their relatives into a rehabilitation programme. Or it’s because their behaviour is such that they’ve got into trouble with the law, and may need residential neurobehavioural support. “An individual can suffer a TBI and make a good physical recovery whilst they are in hospital, because they’re in an environment that’s structured and supported. They get to know the environment and can make progress. However when they get discharged, often without a follow up, they're just left to get on with it and that’s where the difficulties begin to show. “That’s why it’s quite unusual for us to see patients within months of injury, it’s usually years before the full social impact of the injury is felt. So this is why the SASNOS is important, it makes these hidden disabilities, that have such a catastrophic impact on daily life, apparent and visible which gives them substance. And it can be done much more quickly, hopefully reducing the negative impact on the individual and their family.”

Thanks for your time today Nick, as we conclude our conversation is there anything else you’d like to add?

Nick: “You’d think it would, but it doesn't always. Some people are very insightful about what has happened but this can lead to an increase in depression because they are very aware that their situation has changed. Others have less awareness and insight. For example, if you ask relatives or someone that knows the individual well, and talk to them about their difficulties, there's often a disconnect. Relatives can describe numerous difficulties and then we talk to the person with TBI and they might say “I don't have any problems and I don't know why I'm here today”. It can be a barrier for rehab because if people don't recognise that they are experiencing difficulties, they won’t necessarily want to seek out rehabilitation. “An advantage of the SASNOS is that it has two versions. One version that people that know the person with TBI can complete, and another

Nick: “Well I’d just like to reiterate the importance of continuing to try and educate people and raise awareness of the issues for individuals with TBI who are living within the community. I often refer to the startling statistic that there are 1.3 million people living with TBI in the UK, many of whom are living without adequate support. As a silent epidemic, they are hidden from sight, until their difficulties become so great they need help from residential services. “The figure of 1.3 million people just refers to TBI but if you add to that the number of people with other forms of acquired brain injury, that's a sizable portion of the population. And if this article can contribute to that growing movement of raising awareness and education, that would be a very positive contribution.”

Get the latest insights, blogs and news from Elysium Neurological over on their EveryExpert thought leadership hub: www.elysiumhealthcare.co.uk/neurological/every-expert

THERAPIES

Using horses as healers at Calvert Reconnections Peter Cunningham

Brain injury rehabilitation centre Calvert Reconnections has highlighted how equine activities are delivering positive life-changing outcomes for participants Calvert Reconnections is the UK’s first acquired brain injury (ABI) rehabilitation centre combining traditional clinical therapies with physical activity in the outdoors. Amongst the range of facilities available is the Lake District Calvert Trust Riding Centre, a British Horse Society approved riding school which offers riding and carriage driving for people of all abilities. The stables are purpose-built with indoor and outdoor arenas, viewing gallery, state of the art lifts and electronic hoists. For those unable to ride, there are adapted wheelchair accessible traps. The benefits of equine activities in brain injury rehabilitation are well recognised through independent research. A study by the University of Basel found that animal assisted activities, including the use of horses, can significantly improve the social behaviour and communication skills of patients with brain injuries.

The research found that that the benefits of equine activities are attributed to several factors, one of which is how highly motivated patients are to care for the horse. The effect is seen particularly strongly in people who are hard to reach through standard therapies, either because of issues with social interaction or problems with cognitive function and verbal communication. Further research from the US supports the positive outcomes of equine activities. Researchers found that the movement of the horse as a person is riding at a simple walk gives them balance, coordination and self-confidence. Furthermore, when a person is riding a horse, the rhythm and motion is therapeutic; the body gains strength through its adjustment to the horse’s gait. Calvert Reconnections’ equine activities are tailored to the participant’s individual rehabilitation programme and delivered by qualified instructors working closely with the centre’s clinicians. Stables Manager Henri Carew, a qualified British Horse Society instructor and Riding for the Disabled Coach, has over 20 years’ experience working with children and adults of varying disabilities through the Calvert Trust. “The vocational opportunities for participants are having a hugely positive impact on their life,” said Henri.

“It motivates them to get out of bed in the morning to look after the horses and creates a structure to their day. They become part of our team and some go on to support other riders which is so empowering. “This all takes the focus off the participant’s own challenges and on to the care of the horses and other riders.” Claire Appleton, head of service at Calvert Reconnections, echoed Henri’s thoughts. “Equine activities are an important part of our service and the outcomes to date have been outstanding,” she said. “Most participants enjoy this type of activity so much they don’t even consider it as a part of their rehabilitation programme.” Calvert Reconnections actively seeks to incorporate a wide range of outdoor activities into each participant’s rehabilitation programme, as a means of securing the best possible. This may range from reflective activities such as fishing, bird watching or a nature walk to higher adventure activities such as horse riding, canoeing, rock-climbing and abseiling – all closely assessed and graded to a person’s interests and functional abilities. Importantly, participants are involved in every aspect of the activities they undertake. They complete meaningful tasks, from concept to completion, in a real-world setting.

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Through its Relatives’ Support Group, St Andrew’s Healthcare has played a key role in helping families deal with the aftermath of brain injury since 2005. NR Times learns how it is extending that commitment to supporting relatives at every stage of their post-brain injury experience

Alone Yo u a r e n o t

Brain injury can be an utterly devastating, life-changing event, not just for the survivor, but for their family too. But having been thrown into such an unknown and dealing with the trauma of what has happened to their loved one, accessing the support and information to help rebuild their family can be hard to find. Where do I go? Who can I trust? Where can I ask the tricky questions? Who will really understand? It was these very issues which underpinned the creation of the Relatives’ Support Group at St Andrew’s back in 2005. Led by Dr Keith Jenkins, a consultant clinical neuropsychologist who had previously established such groups whilst with the Priory Group, and the then-lead social worker Mary Lees, they recognised the possibility for families to be able to come together to share experiences, while also learning vital information. “When this absolutely life-changing injury happens, it can be a great struggle, not just for the injured person, but for their family,” says Dr Jenkins. “It’s easy to feel you’re the only one in this situation, that no-one else can understand what a struggle it is, that no-one else can be struggling to cope this badly. And that’s

a really hard situation to be in, it can lead to isolation and make a very difficult situation so much worse. “But through family support, you can realise you aren’t alone. There are others in your situation. And whether it’s to find someone else who can understand, or to share the benefit of what they’ve learned along the way, the opportunity to do that can be hugely valuable.” The monthly groups, hosted by the brain injury service at Kemsley, St Andrew’s Hospital, comprise a speaker focused meeting alternating with a peer support meeting speakers have included a local MP, lawyers, therapists, social workers and benefits advisors - who tackle the issues families commonly face, empowering them with the information they need to know their rights and make informed choices. Family members of people living with brain injury from across Northamptonshire and beyond attend the meetings in significant numbers, whatever the stage of recovery of their loved one, with some people having attended for many of the groups’ 17 years in existence. Indeed, Mary Lees attended the group to co-facilitate for 15 years after retiring. However, St Andrew’s recognised that, in addition to the support it delivers for families of those living with brain injury across the

Northamptonshire community, relatives of those currently in its specialist ABI service perhaps needed something more specific to their needs. “For some people this is very new, but for others they are a lot further down the road, and for those in the early stages, you’re not always ready to start thinking that far into the future,” says Dr Jenkins. “At first it can be especially challenging, so by meeting relatives in a similar position, whose loved ones may even be on the same ward, and sharing experiences, that can be very important.” That has led to the creation of a second group, which welcomes relatives of those currently with St Andrew’s. While a very recent creation - it launched in November 2021 - it has been welcomed and continues to attract new people to each session. Both groups are overseen by Dr Jenkins and social worker Jodie Keeley, and are currently run virtually - having been paused for the first time in their history due to the Pandemic in April 2020, and resuming online in November 2020. Remote access enables relatives from around the UK to access the support of the group wherever they may be geographically. Whatever stage a family has reached in their experience of adapting and living with the

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effects of a loved one’s brain injury, both groups are dedicated to providing a much-needed forum for relevant support and information. “In a recent group, a family member said that it can actually be the relative who suffers more than the patient - patients sometimes don’t realise they’re in hospital, or that they have been in hospital for so long, and they have the benefit of activities to take part in and people around them to help,” says Jodie. “But for the relatives, they’re having to get on with their daily lives, going back to work, living at home on their own, worrying all the time about their loved one and what the future might hold. “It’s absolutely vital for these families to have access to support, as it can be a very, very difficult situation for them.” “We hear all the time from relatives that it’s a battle, it’s very rare that we’ll hear someone say that things have gone smoothly or easily, or that they have not had to fight for what they’ve got for their family member,” says Dr Jenkins. “In this respect, it can be especially good to know that you’re not alone, that it’s not just you that has this battle. That can actually be supportive and reassuring in its own way, a kind of universalisation of the experience. “People often find it useful to sound off about the system and how rubbish they think it is, how frustrated they are, or to find out how other relatives have gone about it. And that’s why the interaction is so valuable, particularly among people who can otherwise be, and feel, very isolated.” And aside from the experience-sharing and social opportunity, the access to practical information is equally important, says Dr Jenkins. “Through our speakers, we’ve always tried to choose people and areas that relatives are going to get a lot of benefit from, to answer the questions they have posed and to help inform them on some really important topics they may otherwise not know how to tackle,” he says. “Family members might not know who to speak to in social services to get things done, or what a Carer’s Assessment entails, all kinds of things they might not know how to get answers to. Through our groups, we can help to address the unknowns and get them their answers. “But sometimes, the information that we might have available as professionals or organisations isn't necessarily always the information families feel that they want, or they need. “A case in point was at a recent meeting in our new group, when we were having a conversation about where could a couple of family members go with their loved one, when

they come here to visit. “For them, the very practical concerns were what is available in Northampton? Where can we go with our loved one to get something to eat? Where is there a nice park? Where are the disabled loos? What’s the parking like? “It’s those kinds of things that can make a visit into the community a positive experience or not. “Jodie and I have taken a lot from that, and we now have an ambition to put together a pamphlet to give to our relatives, to give them a guide to places they might want to take their loved one locally, and to include the answer to key questions, like parking and loos!” And while the groups are clearly of great value to relatives, they are of great value to the professionals, too. “When you're at work, and it's your job to be professional and in control of your emotions, you're focused on doing your job,” says Dr Jenkins, who proudly keeps a cake topper made by one of the relatives for the third anniversary of the group by his desk. “You have to be managing your emotions in what are tragic situations that you're working with the end product of. “But over the years, there have been many times through being able to listen to the relatives in the group, when you can just feel how awful it is. "And to me, that's always been really powerful.

“In some sense, you can put yourself into their shoes, because they’re a mother, a sister, a brother, a husband, just like everyone else, and you can kind of relate to that by hearing what they're going through. “And for me, that’s a kind of motivator. There are often times I’ve done one of the groups and feel much more focused and re-energised afterwards about the job I’m trying to do. So I think it gives back to us as well.” Going forward, future logistics of the group are still being decided, and whether to run both in-person and online groups, or to go with one or the other. “We have relatives at present from as far away as Scotland, and we generally do get people from right across England, so the online groups for them work really well, as they don’t need to time their visit so they can attend a group in person, it’s much more flexible for them,” says Jodie. “But equally, there is a lot of value in doing this kind of thing in person, so we’re looking at maybe doing some of both - but the main thing is that we’ll continue to do all we can to support our families, and in every way that we can too.” * Dr Jenkins is happy to speak with anyone looking to establish a similar support group for relatives of people living with brain injury. To contact him, email kjenkins@standrew.co.uk

SIX

THINGS No-one tells you w h e n yo u r c h i l d has a neurological condition

INSIGHT

Receiving a lifechanging diagnosis of a neurological condition can be devastating and overwhelming – particularly when it’s for your child – and can leave you uncertain where to find support and who to turn to

Here, Michelle – whose daughter had a postnatal stroke 12 hours after she was born, which resulted in her developing epilepsy – shares the benefit of her experience in what you need to know in such a situation.

G o o g l e i s n’ t always your friend Of course it is important to do your research when it comes to looking into your child’s condition. Google is certainly the easiest way to find information, but it isn’t always the most reliable. There are some people out there trying to sell products that they’ll convince you are necessary for your child’s health. This is where it is important to have a community around you who can help you filter out those with a less t han helpful motive for ‘support’.

Be honest with yourself about your emotions As a parent, it’s natural to have hopes and dreams for your child and often we don’t even realise what they are until we are faced with the possibility that all might not all be possible. You want your child to have as smooth as path as possible through life, so when you learn your child might not be able to do everything other children might be able to do, grief is only natural. Every time you get a new piece of information the process feels the same, you grieve for what could have been then remind yourself of the delight of what is right in front of you. Be excited for the future but at the same time be honest with yourself about your emotions. It’s okay not to be okay.

I t i s n’ t a l l a b o u t w h a t t h e y c a n’ t d o Society has a habit of looking at the world through a ‘deficit-based process’, where we judge people and things by what they can’t do. Instead, we should look at what they can do and at all the incredible abilities your child has available to them. This will help you paint a mental picture of what they might be able to do, rather than what they might have trouble with doing. In addition to this, it helps to assume your child either can or will be able to do something and then give them all the support they may need to do it. This helps to cultivate a mindset in both yourself and your child that ‘practice makes permanent’. Learning to express themselves through art and music, instruments and even dance will help build new neural pathways. These new neural pathways will help the child with their development in the long term. Just one minute a day can be enough to help in spectacular ways so remember, little and often is key.

Support groups can be useful Support groups can be vital for emotional support and practical help. Some of those at support groups will have already faced the same barriers you are facing and will have great advice or be able to share their experience with you. However, bear in mind that while the people there are going through a similar situation to you, none of you are going through the exact same thing – what works for them may not work for you, and vice versa.

Wo r k o n a c t i v i t i e s Talk with your child’s paediatrician or physiotherapist to develop an activity plan of activities to suit your child’s abilities and how often your child can do them per day. For babies, you may be able to start working on tummy time activities and midline crossing activities as soon as possible. Repeat tasks little and often – less is more (remember neural pathways). These activities are essential for the development for any child, by setting some time aside to really focus on doing them regularly the long term results you will see from your child will be nothing short of amazing. Make them fun, quick, varied and engaging. Stick with them and the results will speak for themselves.

See the person in front of you Finally, it’s easy to feel a bit hopeless when you read your child’s report. The way these reports are written may inadvertently encourage you to think your child will grow to be capable of very little. Your child is capable of incredible things. These reports are important diagnostic tools that help us care for our children and to access funding they may need, but they can’t capture everything about your child; their creativity, their adaptability.

Some extra mini tips: Read Babytalk by Sally Ward. This is especially helpful if you feel guilty for being strapped for time with your child because of work or other responsibilities. It reminds us that just twenty minutes of good connection with your child can make all the difference. Find a song to listen to that motivates you and reminds to have hope. Play it on repeat when you need to. Mine is I Hope You’ll Dance by Lee Ann Womack. Research the term ‘neuroplasticity’. Learn about the plasticity of the brain and teach your child about it when they are old enough to understand. It’s not common knowledge that the brain has an immense adaptability, nor is it common knowledge that there are things you can do to improve this ability.

REPORT

A S P E C I A L R E P O R T O N T H E L AT E S T DEVELOPMENTS IN EXOSKELETONS

E XO S K E L E T O N U P DAT E

E xo s ke l eto n s a n d r e h a b r o b o t i c s a r e g r ow i n g exponentially within neuro-rehab, with the level of progress set to increase significantly i n t h e ye a r s a h e a d . H e re , N R T i m e s l o o ks a t s o m e o f t h e key p l aye r s a n d i n n ova t i o n s helping to drive this thriving sector forward

REPORT

How HAL forged a new path in rehab tech NR Times speaks to Yoshiyuki Sankai, founder and CEO of global exoskeleton leader CYBERDYNE. CYBERDYNE is the Japanese health tech pioneer behind HAL – the world’s first “wearable cyborg”. Medical HAL (hybrid assistive limb) bridges brain-nerve systems and muscles through unique technology which converts faint signals on the skin’s surface into movement. Since its emergence in 2008, its influence has spread to almost 20 global territories and into the lives of people with a growing range of conditions. As well as being effective for patients with neuromuscular disease, spinal cord injury and stroke, early outcome data suggests HAL could also help people with Parkinson’s, cerebral palsy and MS. We spoke to founder and CEO Yoshiyuki Sankai to find about more about the technology’s rehab possibilities.

NRT: What does Medical HAL have that other rehab robotics or exoskeletons are not able to deliver? YS: It is used to treat various diseases, including eight types of slowly progressive neuromuscular diseases, where no other effective treatment method is established yet. They are spinal muscular atrophy, spinal and bulbar muscular atrophy, amyotrophic lateral sclerosis, CharcotMarie-Tooth disease, distal muscular dystrophy, inclusion body myositis, congenital myopathy and muscular dystrophy. These diseases are intractable, and once they strike the person, they will gradually lose control over their body. However, during five years’ worth of postmarketing surveillance conducted towards these patient groups, we found out that Medical HAL can maintain the user’s physical function above the baseline for at least 37 months, and even improve it by 30 per cent at the point of 37 months. We also observed a reduction of creatine kinase level in the blood of patients who went through HAL treatment. This suggests that HAL enabled the patient to move their bodies without causing excessive stress that will progress muscle destruction.

What is the technological breakthrough that has enabled these outcomes? While HAL looks like a robotic device, the controlling system differs dramatically from other similar-looking devices; a robot will move autonomously according to how it was programmed to move once it receives the command. However, HAL is controlled by a bio-electrical signal that leaks from the wearer’s skin surface. When a person moves their body, the brain transmits signals to command the movement from the brain through the nerves to the targeted muscles. Once the muscle receives the signal, it will move accordingly to the commanding signals. However, for a person with diseases or injuries, these transmissions and reception of signals may not function properly. The role of HAL is to act as a bridge, or perhaps a translator, between the brain-nerve systems and the muscles.

So the patient is able to feel more in control of the movement rather than being moved robotically via external controls? Yes. Because the bio-electrical signals include information on how the brain wants the body to move, the assistance provided by HAL based on this signal will feel very natural, almost as if it is part of their own body. Once the movement is realised, the sensory information of that movement is synched with the intention transmitted from the brain and fed back to the brain. This forms a loop of information

What’s next for HAL in terms of its ongoing development?

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improvement of sensory of bladder and urinary issues. We believe HAL is an exciting technology with unlimited potential.

We want to make the technology lighter and make it into something that could be worn easily like cloth to contribute to the good health of people around the world. At September 2021, HAL was being used in 19 countries and regions. We started in the medical field, but now the technology is expanding to other areas such as supporting workers when lifting heavy things and supporting disaster sites. In recent months, we also started a new service that utilises HAL for exercise at home and services to improve the performance of athletes.

Please tell us about HAL’s work with Paralympians

transmission between the brain-nerve and musculoskeletal systems. This unique loop of signals improves and regenerates the wearer’s physical function. Again, this loop of signals can only be formed by synchronising with the intended signals at the perfect timing. This isn’t easy to achieve with conventional treatment methods with physiotherapists or most robotic systems that use completed body movements to trigger its assistance. HAL can accomplish this at the perfect timing and repeat this hundreds and thousands of times without causing excessive stress, even for patients who have difficulty moving their arms or legs. Its efficacy is proved after long years of clinical trials and research.

What evidence is there for HAL as an intervention for neuromuscular disease? We conducted surveillance of Medical HAL in 20 facilities, involving 218 patients, with 72 treatment sessions over 3.5 years. Patients’ physical function remained above the baseline. HAL will not cure the disease, but it will increase the function temporarily. Our study suggests that nine treatment sessions per month (one to two sessions per week) should maintain the physical function well above the baseline. Also, in terms of the safety of Medical HAL, we saw the level of creatine kinase in the blood was reduced after using HAL for both the short and long term. Creatine kinase is an indicator for the

progress of muscle destruction, and the reduction of it suggests that the technology does not destroy the muscle at all.

How effective is it for spinal cord injury patients? The first large-scale trial towards spinal cord injury using HAL was conducted in Germany, and since then, there have been several pieces of research conducted towards this patient group . We have conducted a test towards 55 chronic patients (average 6.85 years after injury). By then, it isn’t easy to imagine spontaneous recovery. However, after 60 sessions of HAL over three months, we were able to double these patients’ walking speed. And even if the patients stopped using the technology at high frequency, we observed that the improvement remained in the patient group.

And what about stroke and other neurological conditions?

If we can share a story that our British readers could find it interesting, for the Tokyo 2020 Olympics, the British Paralympics swimming team trained near one of our satellite facilities. We did a trial session with HAL so they could experience how it works. We will plan to offer the technology to Britain on a full scale, and so, once we do so, we would like to work with those athletes and many more others to improve their physical functions and athletic performance.

And your partnership with a UK-based local authority We’re currently working with Hampshire County Council to help the caregivers in their community. After about two years of trials, they acknowledged its benefits and decided to implement it on a large scale. We believe Britain is a nation that is very eager to adopt good technology once they observe outcomes through scientific research. We will do our very best to disseminate this innovative technology in Britain and many others worldwide.

We completed a clinical trial towards 49 acute stage stroke patients who had reached ‘plateau’. From there, we separated them into two groups – one undergoing an hour of traditional rehab and 20 min of HAL, and the other, 80 minutes of traditional rehab. On the ‘six-minute walking’ test, the group with access to HAL improved by 34.1m versus the other group’s average of 17.34m. There is also positive early outcome towards Parkinson’s, cerebral palsy, and MS. There are also reports on the

REPORT

The future Three leaders from the world of rehab robotics shared their insights on the industry’s future at the inaugural MotusAcademy webinar series launch

of rehab The debate featured Fourier Intelligence founder and incoming IISART president, Zen Koh; Gery Colombo, founder and former CEO of Hocoma; and Alex Kollreider, CTO and founder of Tyromotion

robotics

Gery: We showed the first Lokomat prototype at a rehab fair in Dusseldorf in 1999. I would say 95 per cent of the therapists and clinicians that that came to our booth said we were crazy for ‘trying to replace the therapist with a machine’. We had a similar experience in Toronto. The clinicians just weren’t interested. The only person who saw its potential was rehab pioneer, Neville Hogan. To cross that barrier to even get people to try the new robots was a huge challenge at the beginning. We’re now in a completely different time. Clinics know and understand different robots. The young generation is very open to new technology.

Do you envisage that there will be a reduction in the cost of rehabilitation robotics in the coming decade? Alex: Yes, definitely. It’s economics of scale. The challenge for us is increase the numbers to bring the cost down. But this is a growing industry. I’m pretty sure that in the next couple of years, the costs will go down dramatically for all kinds of robots. MotusAcademy president, Professor Robert Riener: I believe the cost efficiency is getting better. There’s hope that we can treat more patients in a more effective way so that the same expenditure goes further.

Gery: As long as we have hundreds exoskeleton providers, each selling 100 machines, the cost will still be high because economics of scale cannot be reached. But if one company was to sell exoskeletons in their thousands, the price would really start to drop. The question will be whether we reach that within the next five years, or whether it’s going to be another 20 years. Zen: Over the past few years, we have successfully consolidated some smaller players in Asia. Now we are also looking at a partnering with companies in North America and Europe, so that we can deliver more optimised solutions to actually prevent confusions in the market, because some of us have similar solutions. We want to make it as easy as possible for clinicians. They are very busy and don’t have time to go through loads of documentation before making a decision. And hopefully, in the near future, we will see some meaningful consolidations that create economies of scale so we can pass the savings on to clinicians and patients. What would your words of wisdom be for people starting out in this industry today? Gery: It’s really important not to try to reinvent the wheel. Maybe it’s much more important to improve what is already out there. The other thing is related to collaboration. Robotics is an interdisciplinary field and we’re bringing our complex technology into healthcare, which itself is very complex.

Look for great partners because, if you find these, you can achieve success much more quickly. Alex: One thing we need to ask ourselves is, why do we really want to do this personally? Because it’s hard work. You need to be tough to stick it out. I’m not saying don’t do it, but ask yourself why. Gery: It’s very rewarding when you walk to a clinic and a patient thanks you for inventing the Lokomat. If you’re in this for fast money, you’re in the wrong market. But it can be rewarding. Zen: I’m also hoping the young people will realise that the industry is growing. The numbers are showing that. We are now able to attract young, passionate and inspiring engineers to work with us to support us, maybe even lead us to make this industry even more meaningful.

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Gery, what would you say has been your biggest challenge in this industry?

Who do you feel is the next rising star in this field? Perhaps an individual working in a lab somewhere, or the next piece of tech or big start-up? Alex: Everybody dreams of being able to slip into an exoskeleton and go about your daily life. We all know that we are miles away from that. But if someone was to develop these ‘electronic trousers’ in the next few years, they would be a hero. But it’s not only the technicians who evolve this industry, it’s also the user. We are completely depending on users to drive innovation and also the clinicians and the therapists who are using our devices in great ways. Gery: The next breakthrough will happen with combination. The best rehab exoskeleton in the future might be added with feedback with neurostimulation. That’s the big story right now, right from Lausanne, where you add a spinal cord stimulation with the exoskeleton. Zen: I think moving forward, there should be a group of people willing to collaborate, work as a team, use their strength to positively change the industry, create products that can have positive clinical outcomes and functional recovery. We need to have a team of people who can sense future trends and create solutions for the future. There’s a lot out there now. AI, VR Meta. How do we use these technologies to create commercially successful creations for the future that can drive our industry forward?

REPORT

What’s the next big thing that you’re looking forward to incorporating into the existing technology that perhaps you have amongst your portfolios? Do you consider new medical certification regulations, such as the MDR in Europe, to be obstacles for new innovations? Does time to market become unrealistic? Gery: That’s one of the things that should really bother us. And it’s also one of the things that should bring us to work strongly together. Medical device regulations here in Europe are getting too restrictive. We should not punish the whole industry because of one or two unscrupulous companies. If there’s too much regulation, a lot of small companies will not even be able to afford to get onto the market. You could argue that’s good for the existing companies, because they will not have as much competition but again, for innovation, it’s bad. Rehab robotics is too small an industry to change the whole European rules and regulations, but at least we should do our part in changing this development in the right direction. Zen: We need to involve multiple stakeholders, policymakers and decision makers. The doctors, neurosurgeons, therapies, OTs, PTs. Also, the hospital CEOs. If they don’t understand what we are doing, they won’t find the budget to buy our technologies that will make a difference to the rehab team. Let’s not forget the patients. Sometimes they do so much research that they become experts as well. We need these people to join us in speaking with a unified voice. Last but not least, I think the researchers like Robert, the engineers, the scientists should also make their voice heard so the industry can move forward in a more positive way.

Alex: I think that, as we already discussed, there will not be a single next big thing but the integration of the existing technology. But I think it’s also worth thinking about the differentiation between countries and health care systems. Up until now, we’ve been trying to sell the same device everywhere, with no particular strategy for existing systems in Europe, the US or China. We have to ask ourselves, how can we adapt to better fit these systems? It’s much easier to adapt the tech than to change the system itself. This is how we get reimbursement. Gery: The ‘sexy’ time of when you could invent some new, groundbreaking device is over. We now have to take the next step. It’s about indication – when, where and how can we optimally use the device. We have hundreds for lower and upper extremity, only a few for the hand, which is maybe still an unsolved problem.

T h e ‘s e x y ’ t i m e of when you could invent s o m e n e w, groundbreaking d e v i c e i s o v e r. We n o w h a v e to t a ke t h e next step

I also think that combination of different technologies still has a potential. If whether it’s deep brain or intra spinal stimulation, or whether it’s just some hip or vagus nerve stimulation, or any other kind of nerve stimulation combined with the optimal feedback. Robert: We can also optimise things using machine learning and artificial intelligence to improve the continuum of care and to better develop novel technologies. We’re only at the beginning of digitalisation and I think that the pandemic pushed this a bit further. Gery: I also think that if the industry would stand together and collect data together, we would be much stronger. Collaborating in this field would make a lot of sense. We have big potential now that AI can help us analyse this data. And we have easy ways to bring this data together. Zen: Innovation is so important. But companies like Fourier, even though we receive some funding, it can be costly to fund that innovation. This is why we partnered with the likes of the University of Melbourne to drive that research. We have decided to invest more into the labs, to apply our research and potentially commercialise it. We want to work as a bridge to bring good ideas to market. Our aim is to encourage more young people and new companies to create opportunities and technologies for the future.

CONTENTS

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REPORT

Pushing the boundaries of what’s possible for patients Through the dedication of the team at The Royal Buckinghamshire Hospital in pursuing every possible rehabilitation option for their clients came a European first – the use of an exoskeleton for a patient with a spinal cord injury and an amputation

In what was only the second time in the world, an exoskeleton helped a person with a spinal cord injury and an above-knee amputation to regain the ability to walk. The Royal Bucks team overcame additional challenges in this case too a catalogue of further injuries to their client, plus the limitations of the COVID-19 pandemic – but nonetheless still achieved a truly remarkable outcome. “There were many challenges, and this had never been done before - the only other time in the world was with a petite female, but this was with a man at the top of the height limit for exoskeleton use, in addition to everything else,” says Eva Sobonova, head of therapy at The Royal Bucks. “But we will always try, and this shows what can be achieved.” Having been left with life-changing injuries after a road traffic collision in September 2019, Noel - a 45-year-old with a background in high performance sport - faced a significant uphill battle, initially for survival, but particularly to fulfil his ambition to move again. With complete spinal cord injury, Noel was also forced to undergo an above-knee amputation to his left leg due to the extent of tissue damage. Additionally, his right knee was badly injured, he had fractures throughout his body and needed surgery for totally torn cuff rotators in his left shoulder. To make matters worse, he also developed a grade three pressure sore in his heel during his stay in ICU. But true to the characteristic of displaying huge determination that high performance athletes possess, Noel arrived at The Royal Bucks in November 2019 with the ambition not just to use an exoskeleton, but to achieve four specific goals through its use: > to be able to be upright when going out with his son > to be upright and use dynamic standing (walking) when going to the park or attending social gatherings > to improve his trunk mobility and trunk balance > to reduce pain in the lower back associated with immobility when using a wheelchair. He was very driven, I think this is the difference you get from someone with a sports background like his, he was very up for the challenge,” recalls Marcelo Rohde, senior physiotherapist at The Royal Bucks. “He saw it as ‘OK, I’m in this situation, I need to get on with it and need to achieve all I can in rehab.’ And that is where the conversation started about the exoskeleton.”

alone to then use with an exoskeleton. “His consultant was seeking a second opinion with the spinal prosthetic consultant, and he said that with the spinal cord injury, we shouldn’t go for prosthetics to stand statically - not even considering the walking because of the loss of feeling together with the pressure being applied to the stump through the movement,” recalls Eva. “But Noel was so driven, he took this into account and said ‘I'm taking the risk.’ He was aware of the risks but wanted to go ahead. His consultant was happy with that, so we said let’s do it. And we started the journey.” And with the intensive rehabilitation programme The Royal Bucks devised for Noel, in only a matter of weeks he was walking. Despite the fact that COVID-19 lockdown came just as he was beginning his trial on the REX - at that time supported by straps rather than a prosthesis – and the move toward the exoskeleton had to be put on hold; the inpatient rehab that continued during lockdown enabled him to be discharged in June 2020. During that time, Noel had been assessed for his prosthetic leg via Zoom consultation with Dorset Orthopaedics - proving that lockdown truly was no barrier to progress - which had to be made to the exact requirements of its use with the exoskeleton. Differing from a standard prosthesis, Noel required a free knee joint to follow the step trajectory from the exoskeleton and an hydraulic ankle joint to reduce resistance. The socket was modelled to distribute the forces around the stump and prevent any points of pressure but also

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Determined to get up from his wheelchair and achieve the many wellbeing benefits associated with regaining the ability to stand and be at eye level with others, Noel was keen to explore the potential for using an exoskeleton. The challenge was welcomed by The Royal Bucks team, even though it was totally new for them. Also, given the array of additional challenges that Noel faced – it seemed that in fact the task was a world-first in its own right : as opposed to the patient who had a different presentation in the United States, but who nonetheless first accomplished the feat with her team. “We didn’t have any experience of this, it was unheard of in Europe, but when he made the suggestion it was something we were keen to explore. As clinicians, we are always looking at new ways to do things and this was a really good challenge for us,” says Eva. “It may be difficult, but we are always going to look into every single option and look at how we can achieve it.” But the challenges were many, and added together would probably have dissuaded many clinicians from even considering the use of an exoskeleton. Marcelo says: “To have an amputation was a challenge. His height was another challenge, he was at the limit of the size. And then he had a big pressure sore, as well as problems with his knee. Then we had the fact that the whole prosthetic needed to be custom made, completely custom fitted to him to use that type of device. And the fitting had many challenges in itself.” Indeed, one consultant expressed doubt as to whether he should be fitted with a prosthetic at all let

needed to be shallow to fit within the ReWalk and not impede the mechanism of the exoskeleton. The usual programme of ten two-hour sessions was extended to 14 sessions, to accommodate adjustments to both the device and prosthesis, and to allow for training for Noel’s wife and his brother. This was completed within a two-month period, and following the trial, Noel decided to invest in the ReWalk device for his permanent use. More than a year on, Noel now walks in ReWalk two or three times each week, for up to an hour each session, covering an equivalent of one mile in an outdoor setting. He notes the significant benefit to his wellbeing through being able to walk outdoors and stimulate his trunk muscles and internal organs, as well as in people seeing him out of his wheelchair. “The movement in the trunk, which decreased his pain in the back, has been very important for him, because he was always uncomfortable sitting in the wheelchair and a little bit afraid of a bigger movement in the wheelchair,” says Marcelo. “It has been fantastic to see the results of this. There were many challenges we had to go through together to get there. We had to get all the companies, everyone involved, in the same room because we needed to work together throughout, to access capital, to get the prosthetics right, to get the exoskeleton right.” Eva adds: “We will always look at every option in rehab, and using an exoskeleton is one of them. But in doing so, we will always make all the justifications and answer every single question. This is hugely important in supporting the finances that support our decision. We go through all of the clinical reasoning and establish this is something we can try. “In this case, there were so many challenges, but it shows what can be achieved through collaboration and determination.”

REPORT

Achieving life-changing outcomes through rehab tech For almost 30 years, Anatomical Concepts (ACUK) has been supporting the recovery of people following life-changing accident or illness by making robotics accessible to survivors throughout the UK Their drive is to enable clients to achieve goals they may have thought were never again possible - covering a whole spectrum of potential, from living a healthier life through to rediscovering the ability to walk. The suite of technology offered by the business is being used by therapy centres, physiotherapists and individuals across the UK to life-changing effect. A portfolio of products ranging from the Indego and Tek RMD to FES Cycling & iCone is available for use across the UK, both in therapy environments and in people’s homes. ACUK whose team travel across Britain from its base in Scotland - is maximising the rehab potential of countless survivors who otherwise may not have access to such technology.

“It feels very grandiose to say what we do is life-changing, but we hear that from people all the time. Through the use of our technology, we are helping people to achieve such special moments, the kind they maybe thought they’d never achieve again,” says Carolyn Jones, director of Anatomical Concepts. “Too often, clients - whether they’ve just left hospital, or are a couple of years into their rehab journey - are told to have modest expectations, not to get their hopes up. But we see every day that our clients want to challenge that, and that through the use of this technology, their expectations for their life and health are so much bigger than they were at the start.”

In therapy environments, significant gains are routinely made in the ongoing recovery of people living with the effects of spinal cord injury, stroke and MS, and ACUK are keen to share this knowledge with clinical partners. With Indego therapy centres in The Royal Buckinghamshire Hospital, The Wellington Hospital and More Rehab, and long standing relationships with Prime Physio, Neural Pathways and others nationally with FES, upper limb rehab and more, Anatomical Concepts is providing an accessible means for people to engage with high-tech neurorehab devices. “We work with therapy centres, physios and OTs across the UK, and we’re seeing great skill and equipment sharing – particularly More

Through the use of our technology, we are helping people to achieve such special moments, the kind they maybe thought they’d never achieve again The trial is subject to a rigorous assessment process after referral - usually from a case manager or a clinical partner, although selfreferral is possible - with an initial four-hour consultation for suitability. If that is found to be successful, a 40-hour training programme, usually across a week, is then undertaken in a therapy environment, to ensure users are fully equipped with the knowledge they need to take the device home. “It’s important that people are safe and confident and can get their step count up, we’ll also look at them getting in and out of a car and other practical activities - it’s critical it’s exactly right for them and their lives,” says Carolyn. “The trial at home allows them to see how this can fit with their lifestyle and requirements.

Sometimes it doesn’t! One client used to wrap cars before his accident, and for him the goal was that he wanted to reach the roof of the car so he could vinyl wrap it like he used to. “For him, the exoskeleton wasn’t suitable for that, but the range of technology is wonderful and we were able to look at what else we could offer. Ultimately, he found the Tek RMD gave him the stability to do that job. “We don’t want people to adapt their lives around a piece of equipment, we want to find the solution that fits them. It’s whatever adds value to their recovery. But whether in a home or therapy environment, the outcomes remain the most important result of using the technology, says Carolyn. “People have a range of ambitions. It could be that they want to be able to throw and catch a ball with the kids. It may be that they want to be as strong and healthy as they can be. And whatever their personal goal, our kit can help them achieve that,” she says. “By using the right combination of rehab technology there can be so many other benefits, like reducing risk of osteoporosis, improved circulation, wounds heal quicker, improvements to the core. Incremental progress over time can have a big impact. “Our aim is to help people regain their health and independence, whether that’s through walking, or finding the right combination of equipment, therapy and knowledge.- we can support people in that, and every day hear of the difference that is being made to their lives. And that’s what it’s all about.”

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Rehab and Neural Pathways with the Indego. Through collaboration, we can achieve better results much faster, and robotics can help achieve some fantastic outcomes,” says Carolyn. “By working together sharing ideas and equipment, they are achieving some really special things for their clients. By using technology, they are being inventive and really setting the bar in what can be possible. “For incomplete SCI, Stroke and MS we’re thrilled with what therapy walking in the Indego can achieve. It has great adjustability so we can progress the individual to a freer gait pattern, supporting them just where they need it. With pre-gait training exercises we add challenge and incredible progress. “As just one example, there was a client at More Rehab who couldn’t walk and depended on full-time assisted care. But through the use of a range of therapies by the team, they progressed through to using the Indego for gait training - but now they no longer need the Indego as their walking has progressed so much. “And that’s exactly what we are working with these centres and therapists to achieve - we don’t want people to be using this kit forever if they don’t have to, we want them to break free of it and live their lives.” For individuals considering personal use, they have the opportunity to trial an exoskeleton for three months prior to potential purchase, to ensure the technology enables them to achieve their goal.

REPORT

KEEOGO -

helping users to keep on going beyond their rehab goals

Rehab tech pioneer B-Temia recently launched a new and improved version of its flagship product KEEOGO. The smart orthosis is a lightweight, user-friendly device which is proving an effective intervention across a range of neurological conditions, in clinics and community settings. Here chief market officer Andy Hayes explains more What sets KEEOGO apart from other neuro-rehab technologies? KEEOGO is a SMART powered knee orthosis. Essentially it is a low profile, lightweight device, which the user can put on in minutes and which utilises motors at the knee joint. It can help people who have experienced a neurological incident or condition, like stroke, incomplete spinal cord injury or multiple sclerosis, to regain their independence; by replacing lost function at the knees and enabling them to walk more easily, for longer.

Who can most benefit from using the device? It’s important to note that this is not for everyone, and the wearer needs to be able to stand and have some strength in their hips. After some training together with a clinical specialist, however, it is possible to return to activities the wearer enjoyed previously, such as playing with grandchildren, going for a walk or, in some cases, even jogging or dancing.

Is it used in rehab clinics too? Yes, as a gait training tool. It improves gait and helps users to become stronger. All the parameters of gait are tuned by the clinician to make sure the wearer is getting the best use out of the device. How exactly does the user benefit from KEEOGO? The name KEEOGO comes from the phrase “Keep on Going” which tends to be what happens when people wear it. KEEOGO helps people to walk more easily, with less effort, and aims to improve their autonomy. Think of it as a SMART wearable robot, where the user is always in control. It is constantly thinking and reacting to the wearer’s movements. It knows when you are going up or down stairs, or bending down, and provides the assistance at the knee to give you enough power to complete the movement.

How can people try KEEOGO Before someone can walk in KEEOGO, they need to be assessed for their suitability by a KEEOGO certified practitioner. The first step is to click the “is KEEOGO right for me” link on our website, upload a few short videos and we will let you know if we think KEEOGO can help. We can then put you in touch with the most convenient certified provider. They will invite you for an evaluation and if appropriate, try KEEOGO. For most people the benefit will be instantly noticeable, improved walking speed and using less energy, people just “keep on going”. Further gait training may be required to get the best out of the device and gain the most benefit. You can also speak directly to your neuro practitioner directly and we will be happy to work with them to find the most suitable way

for you try KEEOGO. Depending on which country you are located in, there are different options to acquiring KEEOGO for personal mobility, please contact us for more information.

Some call KEEOGO a dance partner - it follows your lead and supports and assists when you need it

How can neuro-rehab professionals incorporate the device into their work towards client goals? The neuro-rehab professional has access to the various parameters within the SMART software and can modify KEEOGO's assistance in number of ways to challenge the user towards their goals. This includes, but is not limited to: varying levels of assistance between the left and right side, targeted assistance with specific phases of walking and/or weight bearing, allowing the user to work in difficult range of motions otherwise not possible and increasing quality and quantity of repetitions. Combined with an intuitive user interface and the possibility to complement KEEOGO use with other tools such as parallel bars, AFOs, harness systems, etc., the device is quite versatile and can be used to great effect for various exercises and goals within a user's rehabilitation goals.

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Innovation-wise how does KEEOGO differ from other devices? KEEOGO has the ability to “motorise” the user’s knee movements; but it is the SMART software combined with the human machine interface, or the way the device behaves when you wear it, that makes it unique. Some people refer to it as a dance partner, in the sense that it follows your lead and supports and assists when you need it. It is not a robot that does the same thing over and over, it is constantly thinking how it can best assist you on every step, and even knows when you are going upstairs or bending down. Also, the device fits the wearer in a comfortable easy-to-use way, which complements the biomechanical principles of the body.

Is user-friendliness also a crucial element of KEEOGO? Yes. Every user is different, but most people can put KEEOGO on in a couple of minutes, and it can be worn all day. Some people drive while wearing it (switched off), but people can just put it on in the morning and go about their day. It is possible to go to the bathroom while wearing it. Two batteries will provide enough power for the majority of people, but it takes less than an hour to charge each one, should you need more. As the wearer improves, their trained clinician can adjust their parameters to ensure KEEOGO is tuned exactly to their needs. In terms of research and development, how might KEEOGO evolve in the coming years? The wearable robot platform we have developed at B-Temia can be used in many applications. KEEOGO is the medical version, but the platform can be used as an industrial exoskeleton, preventing injuries, or improving stamina. This gives many options for the future of KEEOGO. We are working on adding features making it even more useful as a clinical rehabilitation tool, and also looking at ways to expand the inclusion criteria making it possible for more people to benefit from it. Some of the claims presented in this article don’t reflect the current indication cleared by the Food and Drug Administration in the US. Please contact B-Temia to inquire about the indications for use.

REPORT

EXOMOTUS M4 -

upping the ante on rehab robotics As one of the leading names globally in rehab tech, Fourier Intelligence is helping to pave the way towards a brighter future for patients in their rehabilitation journey

With an array of sector-leading technology solutions, comprising products to support upper limbs, lower limbs and balance and movement, Fourier is keen to drive forward its progress even further. Now, with the launch of its latest exoskeleton the ExoMotus™ M4 - the potential for patients globally has been increased even further. The creation of this product - as well as the numerous currently in development by Fourier has been enabled through its partnerships with key names in neuro-rehab around the world, with collaboration playing a central role in Fourier’s approach to achieving the best patient outcomes. Joint laboratories and clinical partners are now established throughout the world, with more being developed all the time, ranging from the Shirley Ryan AbilityLab in Chicago to the University of Melbourne.

exoskeleton, and the frame has a vertical degree of freedom at the exoskeleton support module, to ensure a natural walking pattern. ExoMotus™ M4 also supports adjustable speed, stride length and stride height to meet different user’s needs, allowing it to be as bespoke as possible in its support. The exoskeleton also forms part of Fourier’s pioneering RehabHub™ concept, which was launched in 2020 and is now widely used in neuro-rehabilitation, elderly care and community-based rehabilitation settings. The comprehensive rehabilitation solution is equipped with highly efficient, interconnected, and cost-effective robots that deliver functional training, assisting clinicians in providing treatments and enabling effective and consistent rehab to patients. Its biggest site to date is in Yongchi

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Since being established in 2015, Fourier has become a recognised and respected name in the world of rehab tech through its commitment to devising practical solutions to the issues patients face. In only seven years, it has established presence in 54 countries around the world, with more than 10 million usage hours for its portfolio of over 20 AI-powered rehabilitation robots. It has grown exponentially to become the first rehab tech business in the world to attract major investors on board, with Saudi Aramco and Softbank both committing significant support. Staying true to its commitment to change people’s lives for the better, the innovation is only increasing, with significant investment going into developing its team and the next generation of talent. And through its capability and expertise, the ability to develop life-changing rehab technology is only increasing, with the ExoMotus™ M4 being the latest example of what is possible. The product, the latest in Fourier’s Motus suite, can provide robot-assisted rhythmic gait pattern to minimise gait abnormalities during the crucial early stages of rehabilitation. Through walking on the ground, plantar sensory feedback is given during training. It enables people with lower limb impairments to perform routine movement functions - such as standing, walking on level surface and mild slopes - to increase their activity level. Gait parameters can be individualised to suit the user’s needs. Importantly with the ExoMotus™ M4, it has an integrated balance support frame to prevent the person falling. This minimises the labourintensive work of a therapist with a normal

Rehabilitation Hospital in China, one of the most advanced rehab centres in the country, and is successfully enabling positive rehabilitation outcomes for growing numbers of patients. Zen Koh, co-founder and group deputy chief executive of Fourier, believes the RehabHub™ model, against a backdrop of its proven success in Yongchi, can be replicated around the world, to help bring its technology to more people who need it. “Robotics are helping humans to do rehab better, but for many it is something they can’t afford. But through the creation of this state-of-the-art RehabHub™, this is enabling robotics for all, not just the rich people,” says Zen, who is incoming president of the International Industry Society in Advanced Rehabilitation Technology (IISART). “We had a launch and patients were so excited they flocked to the clinic, it was a phenomenal success. This could be a very successful model which could be replicated and shared with the world. “Of course people are sceptical about what they outcome will be when they have invested so much money, but when the financial model is right, it can work very well. Yongchi is not in one of the bigger cities in China, but they have adopted this model where they don’t charge high fees and have made it accessible. “We are working to fine tune the clinical and financial model so that robotics can make a difference to people’s lives without burning a hole in their pocket, and we hope this will be used around the world.”

The exoskeleton also forms part of Fourier’s pioneering RehabHub™ concept, which was launched in 2020 and is now widely used in neuro-rehabilitation, elderly care and community-based rehabilitation settings

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REWALK 6.0

Personal Exoskeleton The ReWalk Personal 6.0 Exoskeleton is designed for all day use at home and in the community. It is the most customizable exoskeleton and is configured specifically for you. This precise fit optimises safety, function and joint alignment. Distributed and supported here in the UK by Rebotics Technology Ltd www.rebotics.co.uk for training, tech support, servicing and maintenance

The ReWalk 6.0 is the sixth generation of the ReWalk system and is seen as the market leading Personal device for home use. The ReWalk can provide independent walking for individuals with Spinal Cord Injury. The ReWalk 6.0 controls movement using subtle changes in the candidate’s centre of gravity. A forward tilt of the upper body is sensed by the system, which initiates the first step. Repeated body shifting generates a sequence of steps which mimics a functional natural gait of the legs. In partnership with our network of training centres in the UK and Ireland, ReWalkers can train to use the ReWalk independently at home and in the community. It has the ability to climb and descend steps and curbs, allowing it to be used in the urban environment giving ReWalkers more independence and choice. As well as gaining new independence, there are many medical benefits to regularly standing and walking for individuals with a spinal cord injury – ReWalk is truly More than Walking! The ReWalk is customizable for a precise fit which optimises safety, function and joint alignment and the newest generation ReWalk 6.0. Over 20 locations are available in the UK where candidates may test and train in the device.

The ReWalk is a wearable robotic exoskeleton that provides hip and knee motion to enable individuals with spinal cord injury to stand upright, walk, turn, climb and descend stairs. The system allows independent, controlled walking while mimicking the natural gait pattern of the legs.

Who can benefit from it? ReWalk is intended for use by individuals with Spinal Cord injuries, both Complete and incomplete, whose hands and shoulders can support crutches. Height between 160cm 190cm (5'3" to 6'2") and weight requirement up to 100kg (220lbs). Other factors such as bone density and range of motion need to be considered and will be evaluated during your assessment.

It has shown good results in the following: > Reduction in fatigue and improved sleep patterns > Reduction in pain > Improvements in bowel and bladder function > Reductions in swelling > Maintenance of bone mass > Improved seated balance

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What is the ReWalk Exoskeleton?

Is it for clinical use only? No. The ReWalk is designed and intended for personal use and after your assessment at our training centres, you will have the option to buy your own.

Am I able to buy one? Yes. The ReWalk is available to buy and even rent for training purposes

What do our R eWa l k e r s s a y ? "Being up on my feet again is just incredible. Aside from the physical benefits, the feeling of being eye-to-eye with my friends and family is just so good." “No words can describe how amazing it is to stand & walk again after sustaining a T3 complete spinal break, the ReWalk has taken me from being in a wheelchair at 4’2 and put me back to being 6’2. There’s a lot of talk about physical advantages of this great equipment which I am sure are brilliant but, for me it’s the psychological part, as I get the most amazing buzz every time I am up and walking, even if it’s just for an hour.”

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Rebotics Technology Tw o o f t h e b e s t - k n o w n n a m e s i n t h e U K m o b i l i t y s e c t o r h a v e combined their expertise to create a first-of-its-kind business which brings together robotics and technology from around the world Stephen Ruffle and Richard Holland-Oakes have created Rebotics Technology, to bring advanced technology to the NHS, private rehabilitation centres and individual patients living with neurological injuries and conditions. Rebotics Technology builds on the significant expertise and reputations of Stephen - who has helped to shape the current UK exoskeleton market through the introduction of ReWalk & ReStore from Germany - and Richard, whose family-owned business Recare is a leading name in mobility and rehabilitation internationally. Richard’s son James, who himself 42 years in the industry, is also part of the business. The business, which focuses on a ‘rehab without wheels’ approach, is bringing innovations which were previously only available overseas to the UK for the first time - such as the KEEOGO, which has been brought from Canada - making world-leading technology more available than ever before. And already, only months after its launch in

August 2021, Rebotics Technology is winning work around the country, including with leading neuro-rehabilitation providers including Hobbs Rehabilitation and STEPS Rehabilitation. Now, through their unrivalled combination of insight into the sector and esteem they have built for their work individually, Rebotics Technology marks a significant step forward in the continuing development of the UK’s rehabtech market and its range of products. For Stephen, the business marks a diversification from his work solely with ReWalk, whose Personal Exoskeleton product suit focuses on spinal cord injury but now also supports stroke through the introduction of the new soft exoskeleton, ReStore. “I was interested in broadening the range of products we can offer to the UK. The model of a mobility dealer was something that appealed, working with different manufacturers to give people the solution they needed,” says Stephen, who has worked collaboratively with Richard on projects over the past two decades, and most recently when Recare was appointed to oversee

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the service and maintenance work at ReWalk. “Previously, if I was working with a rehab centre or a patient and they had a brain injury or MS, for example, I wouldn’t have the products necessarily to help. “But now, our focus goes much wider, we work with many different manufacturers from around the world. We’re broadening what we can service with assistive technology. So through this business, we can be a solution provider for whatever people need.” As the founder and owner of Recare, which has built a stellar reputation since its inception from the Holland-Oakes family’s kitchen table in 2008, Richard is determined the same focus on quality and accountability should be a staple of Rebotics Technology. “For me, it’s not - and will never be - about selling things because we make the most money. The first questions we will ask any manufacturer that comes to us will be: ‘Do you have a spares manual? Do you have training?’ Because there’s no point selling these products if we then can’t look after them,” says Richard, who began his career in prosthetic manufacture and went on to become sales and marketing director at Ottobock. “We are not just the sales force, we have the clinical side to it and the technical and warranty support to repair things, as well as the absolute focus on quality and service. “We make sure we can look after our products and give the customer the support that’s needed. The MHRA has recently issued some new regulations around this, but we’ve been doing it for years.

product portfolio, and it has been a task to bring all of these products together, but technology and exoskeletons are a huge, huge market now.” The launch of Rebotics Technology comes at an exciting time for rehab tech and robotics globally, which had been growing for several years but experienced exponential development during the COVID-19 pandemic as technology came to the fore in neurorehabilitation like never before. “We’ve gone through the pandemic period where you couldn’t work with people like you’ve always done, in gyms and with a lot of people in there, so people have had to look at other things. And that’s where we’ve really seen technology become so much more accepted,” says Stephen. “I think people now see solutions when perhaps they didn’t necessarily see there was a problem before, but the evidence is there for everyone to see. You can achieve much more intensity,

This is a fast-growing market and through Rebotics Technology, we’re helping providers - both NHS and private - in the UK to stay at the forefront of that “And actually, a lot of the rehab centres and individuals we work with are so pleased that they can now source this equipment, and not just buy it, but there is somebody there that can actually give them advice. They like the fact they can go to one single place, one person, for all of this. “And for us, if you've got more tools in your bag, then we can be helping more people. We can go to a rehab centre or individual and be able to say, ‘You’ve had a stroke or you have Parkinson’s, we have a product that will be able to help you. We are a problem solver within the

more repetitions, and even use technology in conjunction with traditional physiotherapy. “Previously, you could have three physios working on someone, manipulating somebody on a treadmill, for example. But if you look at assistive technology, you can have one therapist and a robot doing exactly the same job. “And in fact, during that session, they can get three, four, possibly five times the amount of repetitions done so that you get more intensive training, there’s obviously a saving of resource too.

“That’s where we see Rebotics Technology coming in - we can look at what is needed and find a solution.” And through its global reach, Rebotics Technology is able to bring products to the UK which previously would only have been available overseas. Richard says: “This is an exciting time for us as a business, but particularly for the industry. If you look at how our approach to disability has changed in the last 20 or 30 years, from conventional approaches to high-tech, digital approaches, it’s moving so quickly. I’ve been on that ride, and in the last couple of years, it has gone forward massively. “We are now in a situation where people search for things on the internet, they find the information they want, they know what’s out there. We’ve had quite a few comments from people saying they’re so pleased there are now things in the UK that they can come and see and try, whereas before they’d have had to think of jumping on a plane to Canada or Berlin. But now, they don’t need to.” “It has been interesting to speak with manufacturers around the world, I think the UK and Germany are seen as the countries in Europe who are really pushing assistive technologies,” says Stephen. “And because the UK has that reputation, and we’ve come so far in these past couple of years, there are so many opportunities to work with manufacturers and bring the very latest technology and equipment here - and that’s what we are doing. “This is a fast-growing market and through Rebotics Technology, we’re helping providers both NHS and private - in the UK to stay at the forefront of that and bring in the exact products and technology they need.” www.rebotics.co.uk 03303-202497 Stephen@rebotics.co.uk

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Hobbs Rehabilitation helps develop new exoskeleton for stroke recovery AI, cloud computing and robotic technologies are being h a r n e s s e d to p r ov i d e a b et te r p r o g n o s i s f o r s t r o ke p a t i e n t s with upper limb impairments

AiBle is a three-year cross-border project between the UK and France aiming to improve the recovery experience of stroke patients, with a focus on developing an EMG driven upper-limb exoskeleton based on AI and cloud computing with virtual reality gamification. The project lead is Portsmouth University, under the guidance of Professor Zhaojie Ju, professor in machine learning and robotics. The UK Clinical Partner is Hobbs Rehabilitation, an independent provider of neurological rehabilitation for adults and children across the south of England. Hobbs has the largest independent therapy team in the UK with over 100 specialist clinicians and their specialist clinical expertise brings real-time clinical relevance to the AiBle project. Hobbs’ robust relationships with a range of academic bodies and commercial companies has led to participation in several clinical trials and research projects. The company is often approached by tech development companies and engineers looking for a clinical partner to work with on their neurotechnology device development. Hobbs is the mastermind behind MiNT (Masterclass in Neurotechnology), an innovative clinical educational platform as well as a resource for engineers,

Here (above) the team are working on functional measures and parameters of movement to help. EMG data collection and VR games design. / EMG data collection with 2 of the 30 selected patients.

The significance of including clinical knowledge and patient feedback within product design has become more apparent as the project has evolved

This online clinical education platform bridges the gap between the device, the patient and the clinician. AiBle is an EU Interreg project, which provides a framework for the implementation of joint actions and policy exchanges across member states.

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SMEs and tech companies to access clinical expertise. Hobbs' role, in collaboration with the French clinical team at the Brest University Hospital Centre, is to shape product design, and to design and perform clinical trials to ensure that end-user engagement is considered throughout product development. Helen Hobbs, co-founder and Director at Hobbs Rehabilitation comments: “The significance of including clinical knowledge and patient feedback within product design has become more apparent as the project has evolved”. Hobbs are providing clinically relevant data to ensure that the robot is a meaningful rehabilitation tool. Therapists are also working with the engineers to advise on patient specificity; positioning, stability, weight of a typical arm affected by stroke etc. Helen Hobbs adds: “We are able to add value to the project with our specialist interdisciplinary teams’ combined knowledge working with patients using VR games as part of their rehabilitation. We inform the project with real examples and feedback from clinicians and patients which helps in the design of the games themselves, bringing functional relevance." Ali Gomes Da Silva, specialist neurological physiotherapist and clinical lead at Hobbs’ Intensive Neurotherapy Centre at Bristol adds: "It takes 400 to 600 repetitions of one movement to try and retrain the brain. The level of intensity has been clinically proven to play a critical role in successfully maximising the impact on neuroplasticity in the shortest space of time." “With therapy alone, you may only achieve 30 repetitions in a one-hour session but using neurotechnology in a targeted way to influence the right type of change to the central nervous system, therapists can see results in as little as two weeks of intensive therapy”. “We are keen to help stroke patients access evidence-based and cutting edge resources. Therefore, it is exciting to help create a therapy tool which has wide reaching potential for the stroke population. Improving patient outcomes and experience is the driver behind all of our research collaborations”. Hobbs’ credentials in the neurotechnology market are further strengthened as MiNT appears as a guest society at RehabWeek 2022 in Rotterdam.

The project overall has a budget of €4,875,139.99, of which €3,333,849.26 has been co-financed by the European Regional Development Funds. More information available at www.euaible.com.

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Reimagining Rehabilitation – making strides with exoskeletons S T E P S R e h a b i l i t a t i o n s h a r e s S h a m a s ’ s t o r y, a n d h o w t h e u s e o f a n exo s ke l eto n h a s h e l p e d to t ra n s f o r m h i s l i f e

STEPS Rehabilitation is the only place in the UK that gives clients access to an array of world leading robotic and VR technology within a residential rehabilitation setting. In this feature article they share the story of Shamas, who is able to live more independently after using the ReWalk Exoskeleton as part of his intensive rehabilitation programme.

CASE STUDY / Shamas Background: Shamas was born in 1992, and as a young child he was diagnosed with a rare form of dementia and Cobalamin C deficiency which resulted in him developing significant physical difficulties and cognitive delay. His condition meant he was wheelchair bound from the age of 11, and despite undergoing an intensive 8-month period of rehabilitation as a child, he was still only able to perform very short bursts of crawling. As Shamas progressed though his adolescent years he became increasingly frustrated with his levels of physical dysfunction which left him low in confidence and extremely introverted. By the age of 27, Shamas wanted to explore ways of improving his condition and was admitted as a residential client to STEPS for a year of intensive interdisciplinary rehabilitation. A life-long Liverpool FC Fan, Shamas was invited to walk the length of Anfield football pitch in his exoskeleton.

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Rehabilitation Goals: Shamas became a residential client at STEPS in July 2020. His overarching goals were to reduce his neuropathic pain, increase leg strength, improve his posture, extend his overall range of movement and mobility with a view to facilitating a more independent way of living. Rehabilitation Programme: After observing a demonstration of the ReWalk exoskeleton, Shamas expressed an interest in trying the technology for himself. The team recognised the benefits that an exoskeleton would have in helping Shamas achieve his goal.

However, the contractures in his hamstrings, coupled with his weight initially made him ineligible to access the suit. Shamas therefore worked with STEPS' interdisciplinary team to refocus his target of using the ReWalk device. His intensive rehabilitation regime included extensive daily physiotherapy, aquatic therapy and therapy assistant led sessions. The focus of sessions was on global strengthening, stretching, splinting programs, standing frame, functional electrical stimulation, and cardio-respiratory focused sessions. Working with STEPS’ chefs, Shamas

successfully shed over 15 kgs to reach the 100 kg exoskeleton weight limit. Following an initial and secondary assessment for the ReWalk, Shamas loaned the exoskeleton and used it for a 3-month period before purchasing his own device. Jamie Storey, a Specialist Rehabilitation Physiotherapist at STEPS undertook exoskeleton Companion Training to support Shamas in using the suit. This facilitated Shamas in accessing the exoskeleton 4 times a week as part of his residential rehabilitation programme. “Shamas was a very introverted character, who rarely showed his emotions," explains Jamie. "However, after using the ReWalk his entire demeanour changed.He became more confident, positive, and sociable. Seeing him walk for the first time in 17 years was an extremely emotional and uplifting moment for all involved.” As a lifelong fan of Liverpool FC, Shamas was invited to go for a tour of Anfield and walked the length of the football pitch in his exoskeleton, something that he had previously only ever dreamed about. In July 2021 Shamas left STEPS and returned home, taking his exoskeleton with him. He continues to use the suit regularly with his care and community therapy team and has recently progressed to walking independently in the suit under close supervision only.

FIND THIS EXOSKELETON SPECIAL REPORT ONLINE at nrtimes.co.uk for videos and more on some of the devices featured.

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T h r o u g h a g r o u n d b r e a k i n g n e w s t u d y, d o m e s t i c violence survivors will be supported in identifying a n d c o p i n g w i t h b ra i n i n j u r y l i ke n eve r b e f o r e . N R T i m e s l e a r n s h o w t h e n e w D i s a b i l i t i e s Tr u s t initiative builds further on pioneering efforts from Ohio in the United States

Making brain injury a priority in domestic violence support A world-first project to advance understanding of the impact of domestic violence and brain injury, to empower support services to better assist survivors, is being launched in the UK. The Disabilities Trust is working with five domestic abuse services across the country to establish the an estimate of prevalence of brain injury and how that impacts the day-to-day lives of those affected. The partnership is believed to be unique globally in terms of its breadth and level of engagement, and aims to increase the understanding of brain injury in domestic violence services, enabling them to identify the signs of brain injury and deliver the bespoke support that each survivor needs. Statistics show that two thirds of domestic abuse practitioners in the UK feel mostly unprepared to support someone with a brain injury, highlighting the urgent need for change. Now, The Disabilities Trust - which has helped to lead vital research in this area for many

years, including securing standardised questions for all prisoners on ABI sustained through domestic violence - is spearheading the charge to make positive change to the lives of those living with brain injuries caused by intimate partner violence (IPV). “We are working hand in hand with the domestic abuse sector on what is truly a groundbreaking project,” says Jocelyn Gaynor, head of Foundation at The Disabilities Trust. “We know from research that there is a gap in detailed knowledge from both the brain injury and domestic violence sectors in how best to support survivors, and that there is an absence of specialist training. “To help address this, we want to understand the impact of brain injury on everyday functioning and the practical implications of this on people’s lives. “We want to ensure people working in this sector have the skills and tools they need to support survivors, and we’re delighted this

project has been embraced as it has been.” The project builds on groundbreaking research from the United States, where Ohio Domestic Violence Network worked alongside public health scientist Dr Julianna Nemeth from Ohio State University - supported by Katherine Snedaker, founder of Pink Concussions - to highlight the scale of brain injury in domestic violence survivors, but the huge lack of awareness from those in positions of support. By bringing together agencies across the state to consider the impact and prevalence of brain injury in domestic violence survivors - in what was often the first time many had made the link - positive change continues to be made for people living across the state. The group has become a beacon in the US for its work, which began in 2016, with the National Coalition - which works with statewide domestic violence coalitions across the country - reaching out to Ohio for guidance on addressing brain injury.

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They are now working collaboratively with the The Disabilities Trust to take forward the significant progress and awareness they gained during their work in the US. “In this organisation, that has provided support to domestic violence victims for 30 years in the United States, we have never really considered brain injury as a framework for understanding things,” says Rachel Ramirez, founder and director of the Center on Partner-Inflicted Brain Injury at the Ohio Domestic Violence Network, which was established as a result of the research. “We were holding groups with people who had spent their entire careers in domestic violence, and they really were thinking about this for the first time. “And even though when talking directly with survivors who were very open about the repetitive head trauma that they had experienced, none of them had put a context of brain injury on that. “So if they’d said ‘I’ve been hit on the head more times than I even know’, and we’d have asked ‘Well do you have a brain injury?’, no-one would have made that connection. “I had worked at a statewide organisation for a decade working on domestic violence and did a major capacity building project on traumainformed care across the state for years.

Reflecting over the years, there are many cases I can recall where things would make much more sense if we had been aware of brain injury

And I never once mentioned brain injury at all. “It’s one of those things where it's very quickly obvious once you stop and think about it, but just no-one ever had.” The research, which Dr Nemeth recalls was done on “a shoestring” budget due to lack of funding, they were able to bring together all of the 75 organisations which form part of the state-wide Domestic Violence Network and find out the true situation and implement action from there. “We basically applied a public health planning process,” says Dr Nemeth, who has a background in domestic violence advocacy. “To better help survivors with mental health and brain injury, we needed to learn more so the programmes of support can better accommodate their needs. “We did a needs assessment, where we talked to domestic violence service organisation staff members about what they knew about brain injury, and what they would need in order to provide more effective services for survivors. “Then we talked to survivors about their experiences, and what they would need to be able to access services better. And what we found was there was a huge discrepancy between survivors experiences coming into services, and the training and the preparation that advocates had."

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“So as a result of this, we’ve created a new intervention called Care. It's really an advocacy framework that takes into account brain injury, it puts brain injury on the table along with trauma and all the other issues that domestic violence survivors are dealing with, but really recognises that brain injury is one of those things that's really affecting the way survivors are coming to services and are able to move through services effectively. “We’ve created a whole host of tools that advocates then can use directly with survivors, to directly speak about it head injury. They didn't want medical terms, so this is all lay, very simple and accessible language. “This isn't about diagnosis, it’s about truly just trying to communicate injuries that have happened to you, because of violence that been inflicted on you. It’s not their fault, they’re not crazy, it’s not what their partner is saying to them - there is an explanation for what is happening to them.” With training being implemented across Ohio Domestic Violence Network, the Care intervention is delivering results to survivors state-wide, with outcomes charted through a new evaluation measure. “We wanted to understand how the member organisations were using the Care intervention, as well as understanding the impact that that intervention was having on advocacy practice, both from the perspective of the practitioners as well as the survivors,” says Dr Nemeth. “We have documented that the Care intervention is effective and raising the trauma-informed practices of advocates in general, so they're more flexible and more accommodating to meet the needs of survivors in general, because they're now putting brain injury on the table. “And they're also around a wide variety of issues, including substance use and mental health and suicide and other concerns that survivors brings to the table, which we can do because we’re addressing brain injury directly, recognising this is what brain injury survivors are dealing with.” The project also saw the creation of the US’s first Center on Partner-Inflicted Brain Injury, which is helping to influence approach nationally. “We provide lots of training and technical assistance and talk to people across the country around this area,” says Rachel. “I think we've also recognised that there are so many unique characteristics of a domestic violence survivor’s situation - safety concerns, the inter-personal nature of the violence, this is a really very different beast

than head injury from sports, or the military, or car accidents or falls. “We can't take existing brain injury protocols and make a couple of little changes - we recognised the need for something entirely different and separate. “In domestic violence and the dynamics behind that and the gaslighting, survivors often think they’re crazy, they’re stupid, this is may fault, all the things that are told to them throughout their abusive relationships. “But by having a context and to be more selfaware of how they’ve been impacted by their brain injury, and to have a reason for that, is so important. “I think that we've come very much to believe that early identification, and even

just knowledge that survivors can have themselves, can really help prevent additional, worse health outcomes in a multitude of areas.” Through the pioneering work of Ohio, which continues to help change thinking across the United States, the outlook for survivors in accessing domestic violence services is improving all the time, but with much left to do. The fact the UK is now building on this work further is something very much welcomed by both Rachel and Dr Nemeth. “For us, it was kind of like we got to the end of the project, and then you realise we're just at the base of the mountain,” says Dr Nemeth. “And there's this huge mountain to climb, but that’s one of the reasons why we were so excited about connecting with the UK.”

S o u t h a m p t o n i s o n e o f t h e f i ve l o c a t i o n s a c r o s s the UK to be part of the new study with The D i s a b i l i t i e s Tr u s t . H e r e , K a r e n M a r s h , I DVA s e r v i c e m a n a g e r, d i s c u s s e s i t s h u g e i m p o r t a n c e . “We’re a high volume, high risk service, working with around 700 women each year, and we’ve always been keen to do whatever we can to better support them. It’s a privilege to walk into their lives and to say ‘We can help you, we care about your safety, we don’t have any other agenda’. We want to make a difference to their lives and we’re really passionate about doing so. “But while we do offer a raft of support, our knowledge of brain injury in domestic abuse is very limited. As a team, sometimes we talk about something being wrong, we know there’s something, but we just don’t know what it is. “And that’s why it’s so important for us to be part of this project with The Disabilities Trust - everyone working in a service like this needs to know more so they can do more to help women living with brain injuries. “Thinking about it and reflecting over the years, there are many cases I can recall where things would make much more sense if we had been aware of brain injury. Through this project, it will help us massively to be able to work better with clients who have experienced traumatic brain injury. “And importantly, I think it will make a huge difference to them as well. I’ve been doing

this job for 15 years but I cannot ever recall a client saying to me ‘I think I’ve got a brain injury’. But if they were to have that knowledge, they could think ‘Oh right, this is why’. “I think sometimes things can get too much for women anyway, it can be overwhelming. There are some really complicated processes around the court system, the criminal justice system, the referrals to children’s services, health services and housing, and the list can go on. “There are some clients with complicated child protection plans, I’ve seen some mothers who have three different courses over four days each week. If you add that to everything else she has to contend with - the shopping, the children, the school run, the abusive partner - and then add in an acquired brain injury too, then it becomes very, very difficult. “The majority of our clients have been strangled, many have experienced years of repeated head trauma, but brain injury is something that hasn’t really been thought about as it should have. “Through this project, it now will be, and we are so excited to be part of it and implement what we learn into our service.”

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PUTTING PEOPLE FIRST: Exemplar Health Care’s Service User Ambassador scheme

Service User Engagement Manager – Exemplar Health Care At Exemplar Health Care, we know that our care services are more likely to be effective if they’re developed and delivered with the direct involvement of people who use them. One of the ways that we do this is through our Service User Ambassador scheme. Each of our care homes has a Service User Ambassador who works with colleagues and managers to make important decisions and get involved in projects that impact their lives. The role gives people the chance to represent their views and the views of their peers during monthly Service User Council meetings, and gives them a direct say in what happens in their home and the wider company. Valuing lived experience makes our services a better fit for the people who use them. We see personal experience as a strength!

Our ambassadors also benefit from the role a lot. It builds their confidence, it helps them to practice new skills and it really gives them a purpose around their home. Service User Ambassadors are looked up to and recognised in their home by other residents and staff. We've tried to make them feel part and parcel of the fabric of what we do - they have an ID badge and their photos up on the wall. In recent years, Service User Ambassadors have helped run company-wide events such as the Exemplar Elite Games and Exemplar’s Got Talent. The initiative also offers people the chance to get involved in a range of roles around their home. This can include things like blog writing for the company’s website, volunteering for duties in homes or organising activities for the other residents.

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Co-delivering induction sessions Some of our Service User Ambassadors get involved in the recruitment process, such as Chris who lives at our Thames House care home in Rochdale. Chris is a long-time Parkinson’s patient having been diagnosed with the condition aged 30, and helped set up the scheme as the founding Service User Ambassador.

Sense of purpose

One of his favourite roles is co-delivering induction sessions for new colleagues. The induction is an important part of our new colleagues’ career journey with us. They learn more about the company and our values, as well as complete training relevant to their role. Chris and I run one of the induction sessions which covers all aspects of service user engagement including meaningful activity, dignity, respect, co-production and involvement. Having one of our service users co-deliver a session, provides new colleagues with a personal insight, and gives them the opportunity to ask questions before they start working in their home. It beings the personal touch to their induction and an insight that cannot be gained purely from listening to presentations. Chris has a natural sense of humour, which makes him brilliant at this role. His input makes the sessions fun, relaxing and very personal for everyone involved. Co-delivering the session also brings lots of benefits for Chris. Being an ambassador gives him a sense of purpose and he loves meeting new people. Chris shares: “I’m the ambassador of Thames

House and I’m responsible for doing the will of the people. “In the past, I’ve always been in charge of my own company or a director of a company. I like to keep busy so I took on the ambassador role here. “As an ambassador I help the manager interview new people to work here. I generally tend to be the light hearted one, whereas she asks the serious questions – and we generally get some good people. “I also talk to people when they start working with us. I talk to them about life in my home and my role as an ambassador. I end the session with a summary of key messages and tips for staff as they start their new role. “They ask me questions which I answer. I prefer this style as it allows me to inject my own personality, and means that I don’t need to learn a script or prepare a speech!” Our new colleagues love hearing from Chris during their induction. This session is often rated the highest in colleague feedback. It facilitates education through personal expertise and experience, and brings a personal perspective to people’s learning.

People come to our homes with a history, they've had a life, they’ve done a lot out in the community, so why not continue to do that while they're living here?

help plan our four weekly activity plans and I have done some interviewing for new colleagues. “Helping me to plan things gives my life meaning and the staff come to me to show people around. “I have also made friends with another service user and I am a befriender and peer buddy. I love doing these things as it makes me feel good and I understand how they feel having been in the same position myself.” These opportunities are changing people's perceptions of what it’s like to live in a care home. You often hear about when people come into care homes they think that it's the end, they don't know what to think, but they're not expecting any of these types of opportunities to be available to them. It's important that they don't feel like that, as it's about maximising the quality of life for them and giving them a purpose.

The feedback from our service users has been overwhelmingly positive – for many, being an ambassador empowers them and gives them a sense of purpose. Some of the Ambassadors have said to me it helps them rediscover qualities and skills that they perhaps may have forgotten that they have. It also helps them to build new skills and continue to act as an integral part of our society. Sarah is the ambassador at our Ribble View care home in Preston. Following a number of failed placements, Sarah has really settled into life at Ribble View, partly thanks to her role as an ambassador. She shares: “I wanted to become a Service User Ambassador as this role gives me a purpose. I

INTERVIEW

Otto Höbel (CTO), Jonathan Kopf (2nd generation CEO) and Peter Kopf (1st generation CEO and founder)

INTERVIEW

Family values AT THE HEART of global rehab robotics As one of the early pioneers in the field of rehab tech, THERA-Trainer continues to expand internationally on the strength of the expertise and reputation it has built over the past 32 years. NR Times meets CEO Dr Jonathan Kopf, who discusses his pride at being at the helm of one of the last family-owned companies in the fast-growing sector

INTERVIEW

“I don’t think my father ever really thought of the scale we’d be working on as a business, more than 30 years later. His aim was to do rehabilitation better using technology and to help people live their lives.” And from the creation of the first device in 1990 to enable wider access to tech-led rehab - then in its infancy as an industry - Peter Kopf lay the foundations of THERA-Trainer, now a globally-successful business and pioneer in rehabilitation robotics. With an array of products for lower limb rehabilitation - all of which are designed and manufactured in-house at its base in Southern Germany - now in use in 70 countries internationally, THERA-Trainer is also making waves around the world with its Complete Solution, a specially-devised and evidence-based treatment programme which is consistently delivering positive outcomes in gait improvement. Regarded as one of the leaders in the fastdeveloping rehab tech sector, THERA-Trainer remains distinct from its competitors as one of the last family-owned companies, now being run by the second generation of the Kopf family, with Peter’s son, Dr Jonathan Kopf, taking the reins as CEO and overseeing its ongoing expansion. And it is both its product suite - which is set to see new additions in the near future - and its family business ethos, which is at the heart of the trusting relationships it builds with clients worldwide, which Dr Kopf believes are crucial to THERA-Trainer’s growth. The latest step in that journey saw it establish a UK base through the acquisition of Medicotech. “Since my father made the first prototype in 1990, we have had the values of ‘safe, easy, effective and affordable’. I think particularly easy and affordable stand out in the industry today,” says Dr Kopf, who joined the family business after almost a decade at McKinsey.

Being a family-owned company means our family name is tied to the brand, which means the quality we provide is extremely important to us

“We’re proud to have the easiest to use robotic devices in the market. We believe that technology should make a therapist’s life easier, not more complicated. So designing our devices to be as easy to use and quick to setup as possible is one of our core goals and achievements. “And while we produce very high quality, premium robotic solutions, we try to sell them to hospitals at an affordable price that allows many of them to acquire our technology. For the cost of a single exoskeleton, you can buy our Complete Solution, covering the entire continuum of care. “My father was motivated by bringing better equipment to the industry and to the people who need it, and that remains central to what we do. “For us, the proudest moments are when patients are able to celebrate a milestone. We have people who are training in our THERA-Trainer lyra who haven’t walked for so long, and then they discover how it feels to walk again. Seeing their joy and knowing what that means to them is what it’s about.” Having been one of the early major players in the rehab tech market, THERA-Trainer is uniquely placed to see how the industry has developed around it. “I think looking at the industry, there are a few companies who shaped the industry landscape that we see today,” says Dr Kopf. “We are innovators coming from sensor-based cycling and balancing technology with a much broader robotics portfolio than we did at the start, but it’s not us alone – other companies have, for example, successfully pioneered exoskeletons. “Back then, it was very different being a pioneer, it was the whole concept of being a self-made businessman rather than a situation where you get millions of dollars from investors which you can then invest in research and development as well as marketing. Instead, you had to have a sustainable business model, everything comes from your own pocket. “Nowadays, it does feel quite unique to be a family company, where the family is hands-on and has been for over 30 years. We have built up the business ourselves, but now the field is much more crowded. “It’s to the benefit of every patient if there are more solutions out there for them. And the further we push robotics in rehabilitation as an industry combined, the more we can achieve for the patients.” In delivering that, the ongoing expansion of THERA-Trainer continues at pace, but for the past few years has focused particularly on key markets like the US, UK, France and its native Germany, where it is proud to be headquartered and call home to its 130-strong team. Its presence in the UK was bolstered recently

INTERVIEW

with the creation of a dedicated UK division through the acquisition of Medicotech, a longstanding partner of THERA-Trainer. “We have realised that for some markets, it's very important to be there directly, instead of only going through partners,” says Dr Kopf. “We have countries around the world that we're selling to with partners, and generally that works really well. But there are some markets where you simply feel like the potential is much higher, if you can actually go there yourself and offer the entire portfolio to the market directly, then that serves both us and the customers in these markets. “I think that is important in building a brand in a significant market, that the relevant people get to know you and the business and probably see for themselves the big difference between you and other competitors who exist. “We have worked in the UK for many years and been very successful, but that is why we took that step (in acquiring Medicotech). That got us to the point to actually say this is a really important core market that we want to dedicate our attention to. “I believe that our growth will accelerate in the years ahead as a result.” By building subsidiaries, and creating the accompanying brand recognition and trust, the increasingly international THERA-Trainer business remains proudly based in Germany. “Being a family-owned company means our family name is tied to the brand, which means the quality we provide is extremely important

to us. Everything is made in Germany, and will continue to be so,” says Dr Kopf. “This makes it more challenging to compete with companies producing in low cost countries. But we believe customers value the quality of ‘Made in Germany’ and we’re ensuring through efficient production processes to make this quality level ‘affordable’ to clinicians and patients. “We collaborate with universities and researchers across the world and, for example, also have a think tank with brilliant researchers in Slovenia for early stage research and prototyping – but our core is in Southern Germany and will continue to stay here in the future.” While the world has changed significantly since the inception of THERA-Trainer - not least in terms of the rise of rehab robotics and the sizeable investment that can attract - Dr Kopf is committed to ensuring the business stays true to its independent roots. “We have some exciting product launches this year and next, and we will be building upon our THERA-Soft software solution to improve that and bring even more into it,” says Dr Kopf. “Amongst others, we’re researching into artificial intelligence, virtual reality and augmented reality, and I think there are a lot of very, very interesting directions to come in the

next few years, some very positive changes. “But one thing that won't change is that we will stay a family-owned business. It's always sad to see competitors who have really good products get sold, and then resold, and you see how things often decline. “We want to stay as a long-term reliable partner, which means we need to continue with our sustainable business model. “So I don't think we'll join the race for acquiring lots of investment - we want to stay independent. That, I firmly believe, is the best way not only for us, but for our partners and all of those who need it most.”

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Early stage head injury care: Filling the Gap Having seen how consequences of minor head injuries can go undetected Reach established its pioneering Headlight service. This is now helping to save countless people across the country from serious cognitive consequences further down the line. NR Times learns more about the programme’s growing recognition and impact among insurers, lawyers, case managers and clients alike

After sustaining a head injury when he was hit by a car while cycling, Andy spent two nights in hospital. With medical teams confident of no serious injury or lasting consequences, he was discharged home to resume his life and return to work as a teacher. However, three weeks later, the resumption of his normal life became a huge challenge for Andy, with ongoing difficulties with cognitive function, sleep, anxiety and emotional issues making both work and leisure a daily struggle. Andy’s situation is not uncommon. Individuals may sustain a minor head trauma which doesn’t require immediate medical intervention but they do have some seemingly minor symptoms. If left untreated these symptoms can have serious consequences further down the line. It was in response to situations like this that rehabilitation specialists Reach developed the groundbreaking Headlight service. It is a firstof-its-kind triage system for minor head trauma at an early stage. Headlight can pick up issues which previously may have been left untreated. The therapies and intervention needed to support the person can then be delivered.

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In Andy’s case, Headlight’s screening process established the extent of the cognitive and emotional issues he faced, and a full Post Concussion Syndrome (PCS) assessment recommended a course of therapy sessions. Happily, as a result, Andy was able to return to work and resume his life pre-head injury. While the service can have potentially lifechanging positive consequences for clients, it is proving equally compelling for insurers and lawyers. Developed in partnership with Aviva, and following an “overwhelming positive” pilot, Headlight was formally launched last year and is now being used by other major insurance names. It enables more minor consequences of head injury to be detected and treated at a very early stage, saving the value of the claim from amplifying further down the line as more serious consequences manifest. For law firms too, the creation of Headlight has brought new provision to stop clients falling through the gaps between symptoms undetected through initial medical treatment and the more serious Immediate Needs Assessment (INA), giving them the certainty that they can secure the right interventions for their client to secure the best possible outcome. Case managers are also turning to Headlight for support for their clients, together with Reach’s team of 65 specialist neuro occupational therapists being who are on-hand to deliver the much-needed assessment and recommendations for intervention for previously unrecognised issues. “There was a real need for early indication of red flags for people who suffer milder head trauma, and that just wasn’t there,” says Heather Batey, managing director of Reach. “Previously, the level of injury might not have been picked up, so the client may have ongoing problems that the insurer maybe never knew about, and it has settled because it's a low value claim. “Or if a case manager is involved, the claimant lawyer might be looking to get an INA, but that’s quite robust, and probably over the top for that level of injury. For the insurer, that sets alarm bells ringing, as it’s almost like hitting a nut with a sledgehammer. “So before Headlight, it was either too much or nothing at all. But now, this is a really

good option for them, because it gives early notification of any signs and symptoms, and actually gives a steer on what needs to be done about it. “Highlight is a tool to identify, at a very early stage, if the client has a problem which should be of concern. This is filling a gap in treatment which is much needed for everyone involved”. After referral, Headlight - which is delivered virtually, making use of widely-used video conferencing technologies from Microsoft Teams to WhatsApp video - completes an initial screening process with each client, which focuses on their day-to-day life and activities, and will then recommend one of three courses of action.

advice on how to function better in different situations, whether that is at home or work. “We often find that if somebody has got a cognitive blunting as a result of a head trauma, and then they're back at home but not back at work, they can be functioning quite well; but then the physical and cognitive demand on them is lower. Once they are put back into the situation they were in preaccident, they may struggle. “So it’s identifying what they’re doing on a day-to-day functional basis and seeing how we can support that. “Not only does it help practically, but it also gives them a voice, like someone is listening to them. For a lot of people who have had a head trauma, because they weren’t knocked out or sustained a concussion, it isn’t taken as seriously as it should be. This is giving them a helping hand.” While Reach operates nationally from its base in North Yorkshire, the development of Headlight as a virtual service means it can deliver rapid intervention to clients, wherever they are in the UK. “It is working brilliantly. We can have one of our team in Glasgow providing an assessment to somebody in London, so geography is no obstacle to this,” says Heather. “And also, quite a few of these clients have gone back to work, so we can do these assessments in the evenings as well. "So we've got total flexibility across the board and it makes it a very swift process.” While the service has primarily worked with referrals from workplace and road traffic accidents, Heather sees significant scope for the future, with Headlight’s ability to establish early-stage consequences of head injury being highly transferable. “One area we will be looking at into the future is around concussion and head injury in sport. There is great scope for the service there, so that’s something that is definitely in the plans,” reveals Heather. “This is a key area where diagnosis is robust but no clinical pathway is provided, and this leaves the players with ongoing symptoms and options. “We are in discussion with major sporting bodies regarding the future clinical picture for these players.”

Highlight is a tool to i d e n t i f y, a t a v e r y e a r l y stage, if the client has a problem which should be of concern. This is filling a gap in treatment which is much needed for ever yone involved For some, no further action will be needed; for others, the ‘light touch’, which includes signposting the client to resources or referring them to their GP; or for those with the more concerning symptoms, a full PCS assessment will be carried out. Therapeutic interventions are then devised around each person’s bespoke needs. While Heather and the team expected the vast majority of referrals to require no further action - “we probably expected 80 per cent to be fine, and for us to be no more than safety check for the majority,” more people than expected have required further assistance demonstrating in itself the value and need for the service. “We find that clients are having problems, but they don't have this toolbox and strategies to help them,” says neuro OT Heather, who founded Reach over 30 years ago. “They could say to us that their memory is unchanged but then we test that out and find that there are issues. We can give them some

I N P AT I E N T

Building on

a caring legacy

Laura and Greg Richardson-Cheater

Having begun life as a care operator when Brian and Jackie Richardson opened up their own home to support people with learning disabilities, it’s fair to say the ethos of care and compassion has been at the heart of Richardson Care from the very outset And from that decision in 1989, when ten people moved into the Richardson family home to get the kind of residential care not available elsewhere in the Northampton area, has spawned an esteemed care provider and now secondgeneration family business. Run by Laura - who was ten years old when her parents turned to caring for those who needed them - and Greg Richardson-Cheater, the business now has six homes in Northampton; three for learning disabilities and three specialist brain injury homes. And the family connection is ever-present, with Laura and Greg showing the confidence in the quality and standards they operate with one of their residents being Laura’s uncle, who has schizophrenia. “We opened our home as dad was a teacher who supported adolescents who had learning difficulties,” recalls Laura. “It really sparked an interest for him, because there wasn’t much provision back then. And through my uncle, who has severe schizophrenia, we saw it from the family side as well.

The challenges that exist, the care and support people need. My dad always looked after him. “But from there, from dad wanting to help, we realised there was scope for a family business. A business which is all about caring for people, because we do care.” Greg, who began his career with Richardson Care on a volunteer placement in 1992, before becoming a senior support worker going on to marry Laura and together building the business further - says: “I suppose you could say we’re putting our money where our mouth is with the fact that Laura’s uncle is here. People say residential care homes should be somewhere you’d be pleased to put your own family, and we’re showing that we are. “When we offer a placement to somebody, we know that this person has parents, siblings, sons and daughters, and we take that responsibility to all of them seriously. We will look after them as best we can because at the core of everything is that we care about these people. “Some of the guys in our learning disability homes have been with us for nearly 30 years, so it becomes an enormous family tie.”

I N P AT I E N T

Having grown from Brian and Jackie to now employing around 180 people across the six Northampton homes - the most recent of which, brain injury specialist centre The Coach House, opened in 2019 - the onus remains on retaining the ethos of care and commitment in the business. With family involvement running throughout the business, in addition to the care provision - from Laura overseeing the interior design of the homes to Greg’s brother being involved as architect - the expansion of the Richardson Care is something Greg and Laura, working alongside operational and clinical director Jane Payne, are committed to getting right. “We have got a lot bigger and we can’t be everywhere at once, but we’re still small enough to be around when we’re needed. If a family member wants to speak to me, they can do that,” says Greg. “We’re involved whenever it’s appropriate, but you don’t want to micro manage people, you want people to have the autonomy to do their job. You have to trust and respect them enough to do that, and they have to trust us too. “Quite often they know better than us anyway. We have some great people here, and many of our MDT have been with us for a long time, they are a brilliant team who we have been lucky to work with for a number of years.” Laura continues: “For us, it’s really important that everyone is involved in care and in the ethos, whatever they do in the business. “So, for example, when we deliver our crisis intervention training, that’s to all of our staff, whether you’re in admin, a cleaner, a maintenance worker. So if a crisis does happen, then everyone has a level of understanding so they can respond in a way that is appropriate. “We’re really committed to developing our people, so that they feel they’re really part of the business they play a vital role in.” With the ongoing growth of Richardson Care, and accompanying expansion of its workforce, recruitment continues at pace. Amidst the well-documented challenges of recruitment and retention within healthcare, the business recently carried out an evaluation of how to be the best possible place to work for its staff.

“We don’t have a big staff turnover, but haven’t been immune from the challenges of Brexit and COVID, and sadly have lost people because of both of those factors,” says Greg. “We do have a lot of really long-serving people who have been with us for many years. Recently, we had two retirements, one was ten years and the other 25 years. But by addressing the need to bring in new people, we have taken the opportunity to look at what more we can be doing. “As well a salary increase, we have looked at other ways we can be competitive. As a result, we have become more user friendly for people who have kids or family commitments by looking at the rota and seeing what we can do. “For example, we have one member of staff who said she found it really difficult with the before- and after-school clubs, she was having to put her kids in at both ends of the day, which is a big cost. So by making adjustments, we hope that will really help.” And as well as investing in its staff and the development of homes, Richardson Care also continues to invest in rehab provision for its clients. One recent introduction is the RehaCom cognitive therapy software platform, which is already delivering positive breakthroughs. “As well as the care, we are really developing the rehab side of things,” says Greg. “RehaCom is really helping with the psychology, in terms of the emotional support and cognitive rehab we can deliver. “We’ve got a couple of cases where there are some specific memories that have been brought to the fore that people have brought up. And with one man, his sense of well being and worth has come from that because he can measure his progress specifically. “You can see the incremental progress and that’s so valuable, to see and to know you’re getting there.” While many operators look at geographical expansion once they establish a successful model of care, for Richardson Care, the decision to be base in Northampton is a very conscious one. “We look at other companies that have been going along similar sort of time, they've expanded much, much more than what we have,” says Laura. “But it's just not what we're looking for. We're looking for manageable, we're looking for quality, we want to be able to feel proud about what we're doing.” “We’ve been offered the opportunity for expansion more than once, on numerous occasions in fact,” continues Greg. “But we find this is an ideal place to be based. It’s well situated, not too far from London, and people know us here, they know who we are. We were in Waitrose recently and we were talking to a lady who works there, she was asking about one of our service users who comes in but she hasn’t seen them for a while, so she was just checking they were OK. “We never want to lose that role we have in the community by going elsewhere, it’s something we want to continue to build.”

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Empowering people to live

their best lives with pain

Through the launch of the Holistic Education for Living with Pain (HELP) programme, Think Therapy 1st is helping to give new hope to people living with pain. NR Times learns more about the first-of-its-kind initiative which is set to change the lives of countless people who too often suffer in silence While pain is something that is all too often dismissed, leaving people struggling to manage their daily lives with few places to turn for practical support, for Think Therapy 1st (TT1st) comes the opportunity to use their expertise to make a life-changing difference. As pioneers of a pain management programme which saw 100 per cent of participants report improved functioning as a result, and vast decreases in the level of pain in daily activities such as socialising - where the pain rating reduced from an average of 7.6/10 preprogramme to 2.6/10 afterwards - the team wanted to create an even more compelling offering for those in need of bespoke support. While the initial pain programme was an occupational therapy (OT) only project, now, with the launch of the Holistic Education for Living with Pain (HELP) programme, TT1st have extended their MDT to include psychologists and physiotherapists. A unique programme in the field of pain, HELP is delivered on a one-to-one basis over a four-tosix month period, and importantly is delivered in a person’s own everyday environments. Participants are empowered to live their lives through the power of education, with the onus on the activities and tasks they can do, rather than what their pain has restricted them from, re-opening the possibility of returning to leisure, work or the employment market.

And while TT1st does not make any claims to reduce levels of pain through HELP, the vast majority of participants do experience a reduction in pain as a result of their involvement. For Helen Merfield, managing director of TT1st, the expansion of the initial pain programme is a welcome opportunity to tackle the issue of pain in new and impactful ways. “We got awesome results from the programme, but we could only help a small cohort. We felt we needed to reach out to more people with a wider spectrum of conditions, pain is something I feel very passionately about and people need support,” she says. “I've always felt that people with pain get a bad rap, they’re often just told it’s all in their mind. And while the mind might play a part, no one consciously chooses to be in pain, they don’t get up in the morning and decide ‘I’m going to have pain today’. “We want people to be living their best lives in spite of - or as I like to say ‘to spite’ - their pain. We HELP them to recover a life that has meaning and purpose. “We wanted to help a wider population but wanted to test it on a smaller scale first. And because the results were so great, we have invested in making it even better - and hopefully the results will be even better too.” Leading the HELP programme, which launched

earlier this month, is Steph Fleet, a pain specialist OT who joined TT1st in 2020 and who Helen credits with “taking the bull by the horns” in breathing new life into the company’s pain offering. Through adding in psychology, with TT1st working alongside neuropsychology specialists at Sphere Rehab, HELP is bringing together experts in their field to deliver the best possible results to clients. Dr Katherine Dawson, director at Sphere, said: “Partnering together in the development of a stepped care functional model to inform when therapy is indicated (as well as identifying different levels of intensity) is a great opportunity to deliver positive client experiences and outcomes. “We are also really looking forward to exploring how technology can help with early interventions in the functional management of pain.” Steph Fleet

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TT1st clients in action, doing their therapy with purpose and great outcomes! Under Steph’s guidance, HELP has been created to be tailored to the needs of each client. If psychology input is required, their needs are determined through the use of a newly-developed algorithm by Sphere. Clients will be screened at the assessment to determine which mix of disciplines they require, OT only, OT and physiotherapy, OT and psychology or all three. With a fixed fee pricing structure, HELP can be completed in a timescale to suit the needs of each individual client, with a speciallydesigned workbook and a raft of resources – including podcasts and video – to support them through the process. “Pain is something that doesn’t get talked about like it should, I feel really strongly for anyone experiencing any level of pain that unless you talk about it and develop some strategies, then it’s just going to keep continuing and holding you back,” says Steph. “They’re going to learn how to manage their pain, so that they’re able to do the things that they need to do, but also the things that they want to do, despite their pain experience. They will learn lots of techniques and develop tools to do that. “We wanted to create a programme that was flexible and exactly what people want and need, and already, although HELP is new, we are seeing some brilliant results. “I’ve got a client who’d been standing in an almost brace-like position, her knees and back have been bent, as if she’s about to run. “The physical reason for this position had resolved, so we talked about it in terms of her brain being hyper-alert to danger, therefore she was defaulting into this position essentially being ready to run. “I helped her see she no longer needed to be ready to run and the danger had passed and it was safe to straighten up. “She has done that for a week and her pain experience has dropped massively, because

she’s standing in the right position again and recognising that she’s not in imminent danger. “So that conversation, and the strategies we came up with, have enabled her to see positive change.” The client, Juliet from Dorset, said: “The key thing I've been taking away to help me when Steph's not with me is becoming aware of my standing position. “I'm telling myself that I can stand up straight and I recognise that I've been locked in my traumatic experience. I'm now much more aware which has helped me to progress. “Improvements are being made and my perception of pain has reduced a lot." Helen continues: “It's all about tailor-making it for everyone. “Although there are fixed components, there are more components than required because not everyone will need everything. Some people will need more of one type of support than another. “But what we see is that because it’s tailored, they start seeing improvement almost from day one, there's so much education involved that we are teaching them to be their own therapist, putting them back in charge of their pain experience rather than it running their life.” One big difference to other pain management programmes is the delivery in a participant’s own environment, be that their home or places they spend time or need to access. “The majority of current programmes on offer are great, but they’re not delivered in an environment where people are actually living their lives, they’re often in a a completely different environment,” says Helen. “While people may get a solid two or three weeks to focus solely on education and therapy, they leave and have to come back to real life. The programme finishes and they just go home. They’ve learnt all of this information, but how do you actually apply that when you’ve got a

family, kids, a dog running around? “What you thought could transfer quite easily because it all made total sense when you were on the course now goes out of the window, and you find that within three or four months they’re back to where they were before. “That’s why delivering it in a person’s own environment, with all of their daily routines and tasks around them, is so important. So that even after we leave them, when they have a new environment, whether it's a new job, they've moved house or they’re just going to a different cafe, they’ve got the tools they need in their toolkit to keep them safe in that environment.” Steph adds: “HELP is also unique when compared to others which are in a group setting. There’s nothing wrong with a group session, but this makes it so individualised and so accessible for the person.” “And then we take the education and learning we have delivered and we put it into practice, with support from an OT, physio or psychologist, depending on what they need. We're going to do it with them, in their environments with the world happening around them and model it with them, which is why we get such great results.” And with such a pioneering programme to work with, Steph, who has a Masters in rehabilitation, is delighted to have the opportunity through TT1st to make a difference. “All the clients I’ve worked with over the years have experienced pain to some degree, whether that’s psychological pain or physical pain,” says Steph. “And I've always found it really interesting how it can really limit people's abilities and last longer than many of the physical challenges they manage to overcome. “Rehabilitation is my absolute passion but pain kept on coming back as something that affected so many people and doesn’t get talked about. The individual often feels that it’s their fault - and then I came to TT1st and had the opportunity to really jump into helping them.”

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Dr Anita Rose, consultant clinical neuropsychologist, Renovo Care A transition is defined as a passage from one life phase, condition, or status to another (Schlossberg, 1984) I have been recently reflecting together with my patients about the transitions they experience during their time of neurorehabilitation. Transitions are challenging and we all face transitions in life. They can be simultaneously exciting, challenging and at times extremely frightening. I liken this to being on a very large roller coaster. You have no idea what you will face next, a huge dip, a very high climb, a dark tunnel, or a steep curve. The ride for some will be exhilarating and they will go back again and again but for others it is extremely frightening, and they cannot wait to get off. For those who sustain an Acquired Brain Injury, or are diagnosed with a long-term neurological condition, they experience a very rapid change and transition that impacts on all aspects of their life. Their identity, physical wellbeing, employment, and relationships can all be affected, challenging them to face a traumatic transition from the “before” to the “after”. Neurorehabilitation represents an opportunity to start the process of recovering their life, but this brings with it more transitions. Research has indicated three key transitions occur during neurorehabilitation: 1) From hospital to inpatient rehabilitation, 2) From inpatient rehabilitation to home and 3) Return to productivity. However, there are clearly many other transitions that occur during the process of neurorehabilitation. Many of our patients talk about transitions such as moving from well to disabled, from having a tracheostomy to not having one, from not being able to transfer to self-transfer, changes in mobility, speech, psychological wellbeing and cognition. Whilst many of these are positive and exciting changes patients can still express distress, “is this as good as it gets?”, “how do I act now?” etc. We can all recognise that transition brings with it a change, but it also brings with it increased stress. Whilst some stress is motivating and

pushes you to feeling motivated to move forward, to take on the challenge, for many this stress can produce a negative reaction making the transition more difficult to navigate. This is particularly true of unexpected transitions such as sustaining an ABI. So how can we support our patients? Firstly, we need to understand the link between mental health problems and life transitions. There is a clear need for those of us working in neurorehabilitation to ensure that we pay more attention to the psychological and psychosocial aspects of life transitions. We need to ensure we are focussing on, as Prigatano (1991) recommended, the disordered mind and the wounded soul. He is highlighting the need to recognise the residual cognitive and personality problems caused by the ABI which in then in turn causes psychosocial deterioration. By providing psychological rehabilitation, including psychotherapy, we can

The most important intervention needs to focus on the transition to ‘ t h e n e w m e ’, a n d ‘a d a p t i n g to life in the real world'

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“Change is situational. Transition, on the other hand, is psychological. It is not those events, but rather the inner reorientation and self-redefinition that you have to go through in order to incorporate any of those changes into your life. Without a transition, a change is just a rearrangement of the furniture. Unless transition happens, the change won’t work, because it doesn’t “take.” W i l l i a m B r i d g e s , Tr a n s i t i o n s : Making Sense of Life's Changes

help our patients cope during transitions. The most important intervention needs to focus on the transition to ‘the new me’, and ‘adapting to life in the real world’. We spend time as an Interdisciplinary Team (IDT) supporting our patients in preparing for transitions through their journey through activities such as regular reviews, goal planning and psychotherapeutic interventions. Such activities enable us to support our patients to set reasonable expectations. It is important to recognise that unmet expectations often create frustration, sense of being overwhelmed, increased distress and as result can reduce motivation. By setting small achievable goals we can support the “crossing of the bridge” from one state to another. The bridge may wobble but the goal is in sight. Our patients are given routine because it is

recognised that establishing a routine creates a sense of consistency and can help in the adjustment process of transitions. Regular sleep and wake times, ensuring good nutrition and access to nature are some of the things that support the building of a bridge that connects the “me before” to the “me now”, a significant transition which can be the most challenging one to navigate. Psychotherapeutic interventions based on Compassion Focussed Therapy support our patients to practice self-compassion. Change is difficult and the navigation of transition is not easy. There is no right and perfect way to deal with transition. It can be painful, scary and push someone to retreat rather than move forward. Helping patients to become kind and compassionate toward themselves during these times, asking them what would they say to their best friend, their partner if they were in the same position and then to offer that same

opportunity to themselves, teaching them to use self-talk and using compassionate mindfulness exercises all aiming to facilitate a smoother transition. To face and deal with the disordered mind and the wounded soul. I recognise in my own life that life’s transitions are not straight forward and that often as a Neuropsychologist I hold a belief that “I should be ok” or “I am always fine”. However, my patients teach me so much and as I reflect at the journeys I am privileged and humbled to walk with them, at the bridges of all shapes and sizes we face, the roller coasters we ride and the mountains we climb to reach the open space, that they are brave to open their wounded souls to healing. My reflection leads to be determined to ensure that those of us working in neurorehabilitation continue to be mindful of the need to pay more attention to the psychological and psychosocial aspects of life transitions of those we work with.

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Family Law and Brain Injury

Relationship difficulties due to brain injury

The impact on family life of a brain injury A brain injury can have a devastating and life-long impact for an injured person and their family. Depending upon the type and severity of the injury, an injured person may have a reduced life expectancy, be reliant on others for care and may often have other symptoms such as fatigue, depression, irritability, memory loss, behavioural

changes and changes in personality. Indeed, personality changes and emotional disturbances are common following a traumatic brain injury. Such personality changes can include disinhibition, impulsiveness, obsessive behaviour, anger and aggression, mood swings, apathy and loss of initiative and egocentricity. These effects can cause immense difficulty in family relationships and in severe cases can even lead to a complete relationship breakdown. This article explores the legal ramifications when that happens.

Families of brain injury survivors often report that they are living with “a new person” following their injury. The emotional, behavioural, physical and cognitive effects of a brain injury will often have an impact on existing and future relationships and family dynamics. For example, the spouse or partner of a brain injury survivor will often take on the role of carer, and this can lead to the boundaries in their relationship changing, a power imbalance being created which can result in friction, unhappiness and eventually relationship breakdown. It is not only adult relationships that can be affected by a brain injury. The reaction of a child to a parent sustaining a brain injury will depend on a number of factors such as the child's age, their temperament, the quality of the relationship prior to the brain injury and the impact the injury has had on the individual. Changes in a parent’s personality after a brain injury will commonly result in the child or children involved feeling distant or confused about the relationship. The uninjured parent may also be concerned from a welfare perspective about the time that their brain injured partner spends with the children, for example, if they have developed anger issues, memory loss or disinhibition.

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T h e n e e d f o r e a r l y Fa m i l y L a w a d v i c e If an injured individual is pursuing a personal injury claim and they have received, or expect to receive in the future, a significant sum of money intended as damages, to meet their needs, then, for the reasons set out in this article, it is imperative that they seek expert Family Law advice. This applies whether the injured person is married or not. An individual who has already received their compensation, and is later intending to get married, should always consider entering into a prenuptial agreement. This will protect the sum of money they received as damages and which was intended to compensate them for their injury, to meet their future care and rehabilitation needs and to provide an income. If the individual who received the compensation is already married, they should consider entering into a post nuptial agreement which will have the same impact as a pre nuptial agreement entered into prior to marriage. In every case, a detailed breakdown of the damages should be obtained, which specifies what percentage of the damages were awarded for each element of the compensation, such as re-housing and adapting a home, care needs or loss of earnings. This breakdown should be made clear in any pre- or post- nuptial agreement so that each party is clear on what assets should be ring-fenced outside the matrimonial pot for division in the event of a breakdown of the marriage. Both married and unmarried individuals need to consider carefully the mechanism by which their compensation monies are managed. If the funds are to be held in trust and managed for the individual, then careful consideration must be given to the way in which the trust is set up, who the beneficiaries are and in what way the funds are invested for the benefit of the injured individual. If an element of the fund is chosen to be invested in some form of investment portfolio, and the individual is married or in a relationship, consideration must be given to whether such

investment is made in the individual’s name or in joint names with his or her partner. It is important to be aware that Investing funds or purchasing property in the joint names of both parties will “intermingle” the money, meaning that should the relation breakdown in the future it is more difficult if not impossible for the injured individual to recover those funds fully from the investment made in joint names. Personal injury lawyers dealing with serious injury cases should therefore work closely with family law experts to consider these issues from the outset of the case and not only after the damages have been received. Early intervention and advice on potential family law issues throughout the length of the claim will potentially benefit the injured individual in the future, should they experience a relationship breakdown. Personal injury lawyers who deal with such cases develop a relationship with their clients which often means they will open up to them about difficulties they may be experiencing in their home life. This can often be a cue to introduce the client to an expert family lawyer to assist and give advice.

Legal Services If the injured individual has sustained a brain injury through no fault of their own, it may well be that they are pursuing a personal injury compensation claim for damages. This may well include a claim for loss of earnings both current and future and a claim for compensation which may be used in order to purchase a new more suitable home for the injured person or indeed for a sum to pay for lifetime care. It is important to be aware that, during the lifetime of a personal injury case, Family Law issues can frequently arise, whether the injured individual is married, considering marriage or unmarried.

The emotional, behavioural, physical and cognitive effects of a brain injury will often have an impact on existing and future relationships and family dynamics 83

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Personal Injury Compensation and Divorce Proceedings

Cases that involve personal injury and divorce are complex. The Family Courts will balance the competing interests of the respective needs of the parties to the marriage, including any needs resulting from life changing brain injuries, and the needs of any children of the family. In England and Wales, the Court's objective in resolving financial matters in a divorce is to achieve a fair outcome for the parties. The Court, when making a financial order in divorce proceedings, will apply the criteria set out in Section 25 of the Matrimonial Causes Act 1973.

The Court will automatically give priority to the needs and welfare of any minor child of the family. The remaining considerations include, the income and earning capacity of both parties, their needs, obligations and responsibilities, the standard of living during the marriage, the parties’ ages, and any physical or mental disabilities and their contribution to the family. As Baronness Hale stated in the leading case of Miller:McFarlane, the ultimate objective of any matrimonial settlement “is to give each party an equal start on the road to independent living”.

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If an injured individual is pursuing a personal injury claim and they have received, or expect to receive in the future, a significant sum of money intended as damages, it is imperative they seek family law advice The guidance provided by the Court as to the treatment of personal injury awards in divorce cases is as follows: 1. The starting point for a division of the assets of the marriage will be equality. The issue of “need” will be one of particular importance in a case which involves a serious brain injury and will frequently justify a departure from equality. 2. Personal injury compensation awards will not automatically be excluded from the asset pot which is up for division upon divorce. Although the compensation award may sit outside the traditional matrimonial pot for division, it remains a source of further funds should the Court deem that the needs of the other party and any minor child of the family cannot be met by the other assets of the marriage. 3. The nature and the complexity of the injuries sustained by an individual will be a relevant consideration. For example, if the individual who has sustained a serious brain injury is unable to work in the future and an element of their compensation has been calculated in order to meet their future income needs, this will be an important factor for the Court to consider. Further, if part of their compensation has been calculated in order to meet their additional care needs, this too would support the individual's claim that that particular aspect of the compensation needs to be ring-fenced outside of the matrimonial pot for division. 4. The Court will consider the circumstances in which any personal injury damages were received together with the size of the award as this will affect how the damages award may be shared with the other spouse. Specific considerations in relation to this would be whether the compensation award was received pre-or post-marriage and whether or not the compensation funds were placed in trust for the seriously injured individual.

5. The needs of any children of the family will usually be treated as paramount, although this must be weighed against the needs of the brain injured party. This area of law is extremely fact specific, so it is extremely important to seek expert legal advice from an early stage as steps can be taken to try and protect personal injury compensation funds in the event of relationship breakdown. Such measures include the drafting of a cohabitation agreement for married couples, the drafting of a pre-or post-nuptial agreement, placing the compensation funds in a trust and access to approved financial advisers with experience of dealing with personal injury compensation funds. In the leading Court of Appeal case of Wagstaff v Wagstaff [1992] 1 FLR 33, the husband in this case sustained a serious spinal cord injury following a road traffic accident. He was paraplegic. He pursued a successful claim for personal injury damages. The Court in this case was asked to consider whether the husband’s damages award should be considered part of the matrimonial pot for

division. The parties had been married for 8 years and there were no children, although the wife had two children from a previous marriage. The husband’s accident occurred six years into the marriage. The husband used his damages award purchase a specially adapted home and to start up a business. The balance of his award was invested in order to provide him with an income. The only other major asset in the case was the former matrimonial home. On the facts of this case, the Court of Appeal held that needs of the husband, both immediate and long term, had priority and no order should be made for the wife that would interfere with providing, within reason, for those needs. The Court of Appeal did however confirm that personal injury damages were an asset available for the court's consideration when dividing matrimonial assets after a divorce; ''the capital sum awarded (as damages) is not sacrosanct nor any part of it secured against the application of the other spouse…the reality of course is that the compensation is a financial asset which…. has to be taken into account when the court comes to exercise its powers in accordance with section 25 of the Matrimonial Causes Act 1973'.

S l a t e r a n d G o r d o n Fa m i l y Law Offering Slater and Gordon has a national family law offering. The team comprises of family law experts who between them have over 100 years of family law experience. The team can offer expert legal advice on pre-nuptial and post-nuptial agreements, divorce proceedings, matrimonial finances, issues arising for unmarried couples such as cohabitation agreements and disputes in relation to property and issues involving children such as child arrangements and all of their private law applications. For specialist advice, contact us at www.slatergordon.co.uk

K AT E A L L AT T

What advice do you wish you’d given friends and family after your stroke? Life after stroke can be a daunting prospect and the support and understanding of family and friends is often crucial. But it can be a challenge to communicate to how you feel to others, and to know what the future will look like. To support with this, stroke survivor and GripAble ambassador Kate Allatt shares some of the key pieces of advice fellow stroke survivors wish they’d given their friends and relatives following their stroke A life changing event such as a stroke can seem like something that happens to ‘other people’, but not to you. It can be hard to come to terms with, but by seeing the rehab process as a journey to rebuilding yourself, you can truly become a better, stronger person, one day at a time. Post-stroke recovery looks different to everyone. The effects of stroke can vary considerably, and can include memory loss, cognitive impairment, emotional difficulties, balance problems, sight loss, weakness, and much more. Whilst wrestling with concerns about the future, work, and finances, survivors are often having to remember how to carry out basic movements such as breathing in and out, as well as everyday tasks like going to the toilet or showering.

Rehab can feel like a daily challenge and something that requires a great deal of determination and motivation. But with the right support and understanding of loved ones, steady progress is possible. After all, you can’t eat an elephant in one go – it’s bite sized chunks. Setting small, achievable goals that matter to you is the key to seeing incremental changes and progress. Advice for family and friends of a stroke survivor At a recent GripAble peer-support Zoom discussion for stroke survivors, we discussed what we wish we could have told our family and friends in those first few days, weeks, and months after our stroke, knowing what we know now.

Here’s what fellow stroke survivors wish they’d told their family and friends after their stroke: > Be patient and give me time – recovery is a marathon, not a sprint > Focus on hope what that I canthe do,advice not what I can’t do prove It is my points raised > Just because I look it does not mean a useful source of ok, information and guidance for I am better stroke survivors and their families in the future. > My journey won’t be on a continuum – I will make small gains over a long stretch of time > Don’t look back or forward, focus on the present and take each day as it comes > I won’t ever be my former self again, and that’s ok – for those of us that have experienced strokes brought on by stress, carrying on as we were would not be possible nor helpful > Don’t underestimate my abilities – stand up for my right to continue working if I want to, or support me in finding a new role that suits my needs > There is more to me now than there ever was > There will be good days and bad days – never give up hope > Everyone’s experience of stroke recovery is different – stroke survivors are all on the same journey, but in different vehicles, and on different roads

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Remaining True to Core Values Delivers Positive Outcomes ‘Person-centred’ is one of today’s buzzwords, but back in 1989 when Richardson Care was founded, it wasn’t quite so common. The provider of specialist residential care has placed individuals at the centre of their care for more than 30 years, and its core values remain as relevant today as ever. “Ensuring that someone feels welcome, safe and part of their local community goes a long way to support their rehabilitation” says Director, Laura Richardson-Cheater. “Treating someone with dignity and respecting their individuality, while supporting them to develop daily living skills, helps them to increase their independence.” Although the therapies have become more advanced, the principles upon which they are based remain the same: Community presence, Choice, Dignity & respect, Community participation and Competence/skills development.

“In the complex world of brain injury, sticking to our principles and always asking ‘what is best for the individual?’ ensures that we continue to deliver positive outcomes for our service users”, adds Laura. “It also means that we continue to innovate, and we are supported by an amazing clinical team and dedicated care staff.” Richardson Care has six care homes for adults with brain injury or learning disabilities in Northampton, which provide long and short term rehabilitation and a home for life. For more information call 01604 791071 or visit www.richardsoncares.co.uk www.richardsoncares.co.uk

Respect & Restore Specialist residential care and rehabilitation for adults with acquired brain injuries. • Portfolio of services to meet a variety of needs • Innovative person-centred care • Unique ‘family’ environment • Focus on social integration • 30-year proven track record Proud to be an independent family business.

Call us on 01604 791071 to find out more or email admissions@richardsoncares.co.uk

www.richardsoncares.co.uk The Richardson Mews, Kingsland Gardens, Northampton NN2 7PW

RC NR Times H/P Advert MAR22.indd 1

25/02/2022 10:03

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New faces covering new spaces as Breakthrough Case Management expands geographical coverage A lot has happened in Breakthrough Case Management’s relatively short history. “We’ve been able to rapidly scale Breakthrough without compromising the values behind its foundation,” says Annabelle Lofthouse, who co-founded and directs the company along with Catrin May, both of whom are Registered Nurses each with over 30 years’ clinical experience and significant case management expertise Establishing the company in 2018 and launching the following year, Breakthrough’s innovative aim to significantly reduce the outsourcing so often associated with complex personal injury cases, has been well received. “We’ve always had a resolute focus on the client and a determination to provide referrers with a first class, responsive and pro-active service” says Annabelle, “at the same time as seeking to develop, innovate and push the boundaries of rehab provision.”

The company’s growth over the last year is testament to such an approach. Recent referral rates demonstrate a growing awareness of the company’s reputation and instructions are now regularly received from both claimant and defendant solicitors. Case Management with Care Serving as a single point of access to a network of highly experienced professionals, Breakthrough’s inhouse care and rehabilitation

service ensures quality care provision alongside continuing functional rehabilitation with evidenced measurable outcomes. Its use of Cloud hosted care recording apps ensures that real-time, meaningful reports are monitored and ready to view on demand at any point in the lifecycle of a case. The development of two senior roles within the company, Head of Case Management Operations and Clinical Services Lead, have bolstered an already robust support structure. “The creation of these new roles” says Annabelle, “- has created an environment which naturally drives up quality”. Catrin agrees, adding, “It’s also enhanced responsiveness and instilled a real confidence in the team that is just great to see and exactly what we were aiming for”. In response to increasing demand, the company has focussed on the recruitment of additional case managers to the team, attracting the very best talent in the field and facilitating an expansion of geographical coverage to include the Northeast and South of England, including wider representation in London and Hampshire. Annabelle has written previously about people being at the heart of Breakthrough. A firm advocate for shared values as a requisite for getting recruitment right, she says “we’re delighted to welcome some outstanding new case managers to our high performing team”. “Our standards are high, and we make no apologies for that! Breakthrough case managers all have a minimum of 10 years clinical expertise, they bring a wealth of experience to the table and a shared commitment to achieving results”. Catrin observes, “We actively look to recruit from a variety of clinical disciplines, and this brings a diversity of opinion and input that benefits the entire team”. Annabelle adds “it’s a truly collaborative approach which leads to an innovative environment and ‘out of the box’ thinking for our clients and their rehabilitation. The company’s growth is, however, about more than impressive statistics. Director Annabelle Lofthouse notes, “This wasn’t a company born of hard-nosed ambition. It was about a desire to make a difference – to provide an exemplary case management service that never compromised on its person-centred ethos. The fact that those values have remained steadfast throughout the significant growth of the company, is what we, as directors, and our ever-expanding, similarly motivated team, are most proud of”.

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We t a k e a l o o k a t s o m e o f t h e c o m p a n y ’s n e w e s t r e c r u i t s .

Beata Roberts is based in Dorset and covers the South and Southwest of England. Beata graduated as a Physiotherapist in 2005 and has since worked in a variety of community settings. With a wealth of expertise in assessing, identifying and managing care and therapeutic needs; she is highly experienced in coordinating multidisciplinary teams, setting goals and ensuring that rehabilitation potential is maximised. Beata champions person-centred rehabilitation and ensures that clients receive tailored support to achieve objectives and goals. Beata is particularly skilled in managing teams of carers for her clients, including 24-hour complex support provision.

Jill Ferrie is based in the Northeast of England Jill qualified as an occupational therapist in 1998 and has spent much of her career specialising in the area of brain injury and neurological rehabilitation, both clinically and managerially. Her extensive career in case management began in 2006 and she has since supported both children and adults with a range of injuries. Jill uses her extensive rehabilitation experience to coordinate goal-directed programmes of care, treatment and therapy. She understands the importance of working collaboratively with individuals, their families and professionals to achieve functioning potential. Alongside case management, Jill prepares expert witness reports and leads a team of expert nurses and occupational therapists.

Kate Golding covers London, Hampshire & the Isle of Wight Kate is a highly experienced case manager with a special interest in head injury, complex trauma and mental health. Kate qualified as a general nurse in 1998 and spent the next six years working in Accident and Emergency and prison nursing. In 2000, Kate completed a BSc Psychology and went on to study for a MSc in Advanced Clinical Practice at The University of Southampton. Kate has a special interest in working with children and adults who have experienced emotional/psychological trauma. Making a difference individually and at an organisational level is what drives Kate and inspires her to influence change wherever she can.

Sheileen Berry is based in the South and Southwest of England Sheileen qualified in 2005 with a MSc in Health Through Occupation, and a Post Graduate Diploma in Occupational Therapy (OT). She has worked in a variety of settings including acute hospitals, community rehabilitation, clinical commissioning, and adult social care. She has over 16 years’ experience of assessing, planning, and treating clients with complex needs. including trauma and orthopaedics, amputation, brain injury, neurological conditions, stroke and spinal cord injury Sheileen is motivated to provide the best rehabilitation outcomes and believes that a personcentred collaborative approach is the best way to achieve this. She has excellent listening skills and is able to swiftly build rapport, trust and understanding with clients, families and other agencies.

To find out more visit: www.breakthroughcasemanagement.com/find-a-case-manager

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Wa n t t o k n o w t h e s e c r e t t o d e l i v e r i n g a strong rehab service?

HAPPY, SUPPORTED STAFF.

Meet Bonnie, Lisa, Shainy and Stacey from Askham Rehab as they share their journeys to now working for one of the leading neuro-rehab providers in East Anglia One thing they share is that when they first started working with Askham they did not think they would be working in rehab. However, over time and with the support of a management team committed to personcentered empowerment for staff as well as residents, they have flourished. Each of them now contribute directly to quality of life improvements of the rehab patients at Askham. Every member of the Askham team has a story to tell – one that involves self-development, professional ambition, and personal drive to be the best they can be, and in so doing bring this out in their rehab patients too. Askham is always looking for motivated individuals to join their team – if you could see yourself working alongside Bonnie, Lisa, Shainy, Stacey or their colleagues, please get in touch.

‘ I m ove d f r o m t h e k i t c h e n i n t o s p e e c h t h e ra py ’ For Bonnie Nelson, her 14-year career at Askham has been varied, and through her initial role as a kitchen assistant, she saw first-hand the impact speech therapy had. “I saw the speech therapists at work and thought that’s something I’d really like to do,” she says. “I loved working in the kitchen but wanted to be more involved with the residents and their rehab, so wondered whether I could be a speech therapy assistant. I started helping out at first, but it was too much to do alongside my job. “Askham were really supportive and gave me the option to choose - I jumped at the chance to work in speech therapy.”

Now, having made the move in 2013, Bonnie is loving her role as a speech therapy assistant. “It’s such a valuable and rewarding role, and of course it’s not just about speech, it’s about swallowing, eating and drinking, really vital parts of their lives,” she says. “There are some very special moments, such as when you work with someone and they regain the ability to say their children’s names, or someone is able to follow a normal diet after having to have pureed food. It’s lovely to share that with them. “It is lovely to feel like you’ve made a difference to people’s lives and to see their progress.” She remains grateful to Askham for the opportunity to re-train and move to a rehab role. “Askham were great and supported me with training on the job, and giving me the opportunity to complete some courses in speech therapy, which I did in my own time,” says Bonnie. “I’m so pleased it’s a move I’ve made, and Askham is a lovely place to work.”

‘I became a carer during t h e C OV I D p a n d e m i c ’ Having resumed her career at Askham after taking a break to raise her family, Lisa Keel took on a role as a weekend kitchen assistant in 2018. After realising the work/life balance worked for her, with Askham accommodating her need for childcare-friendly hours, she took on a role working Monday to Friday. But having already progressed at Askham through her kitchen role, Lisa realised she would love to move again during the COVID-19 pandemic. “I’d spent my time at Askham watching the carers at work and wishing I could do more to help,” she says. “I couldn’t mix two jobs, so I decided I wanted to challenge myself and move into care.

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“Although it was during a very difficult time, I was already working within a care home setting and just felt I wanted to support the care team, and especially the residents. I knew I wanted to put all I’ve got into it.” So in September 2020, Lisa, with support and training from Askham - including specialist brain injury training - moved to become a carer. She recalls how difficult yet rewarding that challenging time was. “This was at a time when residents couldn’t see their families, which was heartbreaking, but we as the care team effectively became their families during that period,” says Lisa. “Just being there for them was so important, to support them with their physical and emotional needs. When a resident had COVID, I was put in the isolation team, which meant that one resident needed even more support during what was a particularly difficult time. “You were so conscious of that fact that you were the only people our residents were seeing and you wanted to do all you could. It’s your job to make sure they’re safe and happy, and that was never more important than during that time.” Through the dedication of Lisa and her colleagues during the pandemic, Askham’s care and rehab regime was able to continue, and residents progressed despite the challenges. “We do get a lot of appreciation and ‘thank yous’ from residents, and their families too, many of whom we were able to keep in touch with their loved ones through using tablets and screens during isolation,” says Lisa. “It’s very hard to say goodbye, as much as you also want them to leave and move on in their lives, but you do establish a strong bond. It does make you feel very proud to be a carer and to know the contribution you have made.”

‘I was supported in relocating from India’ Shainy Mathew was living in India in 2011 when an opportunity to relocate to England and work in nursing came up. Initially working to complete her adaptation programme having moved from overseas, Shainy became a registered nurse around eight months later.

Initially moving to Cambridgeshire alone, leaving her husband and baby in India, they joined her shortly afterwards, at which point Askham offered their assistance in supporting the family. “My husband had to work too, so I was able to do my hours around his, which worked well for our childcare. My flexible shifts meant we could organise this,” says Shainy. “If my son was ill or I had problems with childcare, I would call the lead nurse and was told not to worry, they would support me. Although we were here on our own with no family support, Askham felt like our extended family. “The transition process in moving to a new country for the first time was often challenging, but I have been supported in every way. I have never felt pressured or unsupported because of childcare and I’m so grateful for the help I have been given over the years. “The management and my colleagues were fantastic and so supportive. It made moving to a new country and being able to work a really good experience.” Through Shainy’s dedication to her role in nursing, on the retirement of the long-serving lead nurse, she was offered the position. “I was delighted to be offered the role as lead nurse, it was the service I knew and loved working in, but just with more responsibility. It was a great opportunity for me,” she says. “Askham gave me the time to spend with the lead nurse before he retired, to work with him and learn more about the position I was about to take over. I was also given extra shifts to ensure I was fully prepared. That meant it was a very smooth transition for everyone. “I got the chance to speak with one of Askham’s directors, Aliyyah-Begum Nasser, and the management team about the promotion and they were all confident that I could do it - and I am really loving it. “As lead nurse, you have two days where you work on the admin, which is very different, but is very responsible in reviewing care plans, medication records and funding matters. It is a vital role and one I really do enjoy - and I still get plenty of opportunity to be with the patients.” And it is the interaction with the patients that continues to inspire Shainy as a nurse. “You see what they go through and the progress they make, and it is lovely to feel you play some role in that,” she says. “You feel very much valued, there is a lot of happiness and job satisfaction in what we do. This is a great environment and a very positive working environment, and I love my work with the patients. “I’m very grateful for the support I’ve had since I came here, and the opportunity for promotion. Askham is a great place to be.”

‘A s e c o n d m e n t m a d e m e w a n t to pursue a rehab career’ Having joined Askham in November 2018, initially in a part-time care assistance role, Stacey Hawkins was keen to progress particularly after seeing the power of rehab through a secondment opportunity. “I was offered a four-month secondment, where I worked with all four disciplines physiotherapy, psychology, speech and language and occupational therapy,” she says. “I learned a lot from this and really enjoyed it. I got so much insight into the sessions. A position came up for a rehab assistant, and having seen how much I loved working in rehab, I decided that’s what I wanted to do.” Stacey was successful in her rehab assistant application, which she took up in September 2021, being given full training on-site to equip her for her new role. “I read all the assignments for each Individual and look at what their goals are, we then work on these and build exercise plans and explain the treatment we feel is right for them,” she says. “This is different for everyone, as everyone will have different needs and outcomes, so we work on finding the best and safest equipment and ways to do it. We often have to demonstrate to patients what we would like them to try, and we have to be calm, understanding and always listen.” And the role is giving Stacey new levels of job satisfaction. “I love being able to make a difference to people’s lives and seeing them achieve all they can in their rehab goals,” she says. “Seeing the gratitude on the people’s faces, and their family members too, is priceless. The feeling is unreal to see people progress in their own ways and give someone their independence back. “But while I absolutely love this role, I feel just as valued on the rehab team as I did when I was working on the care floor. Askham is one big family, and I’d say thank you to everyone here who has helped me on this journey.” Askham is always welcoming new staff into its growing community. For further information, please contact 01354 740269.

About Askham Rehab Askham Rehab is part of Askham Village Community, a family-run operation with more than 30 years’ experience of working in the sector, including a decade within the field of neurological rehabilitation. Askham Rehab recognises excellence as something that goes beyond the norms of accepted practice and towards its pride in achieving a ‘best-in-class’ service.

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" It was my goal to be able to stand up and to get out of the wheelchair…

but being able to walk again is really amazing."

For Chris, who had been reliant on his wheelchair for eight years after a cycling accident, his life changed when he came to QEF's Care and Rehabilitation Centre From losing hope of ever being able to walk again, through the intensive rehabilitation regime and dedication of the team at QEFs Care and Rehabilitation Centre, Chris was able to walk again with the support of a walking aid. “I never believed I would be able to do this,” he says, having lived with paralysis since his accident, which has resulted in multiple major operations over the years. But for the QEF team, the restoration of belief and hope is central to all they do. From its new 48 bed unit in Leatherhead, which has significantly expanded QEF's capacity over their previous 17 bed unit in Banstead, it is able to support people with a wide range of neurological injuries and conditions. The team work with people even before they are admitted to understand their ambitions and help people achieve them. QEF has a full therapy, nursing, care and neuropsychology team on site, whose expertise combine to deliver bespoke rehabilitation through one of its four approaches - intensive neuro-rehab, slow stream neuro-rehab, care for long-term conditions, or short-term respite care - which can see clients stay for anything from a few weeks to over a year. And through its move into the purpose-built Care and Rehabilitation Centre in 2020, QEF is able to continue building its service offering to clients, who come from across the country and as far afield as Jersey.

While traditionally known for its work in longterm rehabilitation for acquired brain injury, QEF’s Care and Rehabilitation Centre is now also delivering life-changing outcomes for people living with spinal cord injury - such as Chris - as well as stroke, MS, Parkinson’s and Guillain-Barre syndrome. “We have grown so much, but we’ll always be just as passionate and dedicated to our clients and to supporting them as much as we possibly can,” says Emma Berkshire, lead physiotherapist at the Care and Rehabilitation Centre, who has been with QEF for 16 years. “In 2006, we had two physios and we now have ten in the inpatient team. That has grown hugely and it’s the same with the OT team, the SLT team and the clinical psychology team. We didn’t have on-site nurses when I first started, but now we have 24-hour nursing care. “We’ve seen a lot of progress in quite a short time, but what we continue to pride ourselves on is the way we work together as a team. And I feel we’ve managed to maintain that strong team unit, even though we’ve grown in such a significant way.

“We often get client feedback about what a strong team we are across therapy, nursing and care, and that is hugely important to us.” The fact QEF has its whole neuro rehabilitation team on one site is very significant in the quality of care they are able to deliver, says Emma, and is key to their delivery of client-focused rehab and results. “It gives us a unique opportunity to work together and give that really holistic approach to our clients. We all work collaboratively, the physios, OTs, SLTs, along with the clinical psychologists, nurses and care staff and really support each other,” says Emma. “I also think it’s quite unique that we have such a strong clinical psychology team, there are a lot of services out there who don’t have the level of psychology support that we do. “But we all combine to do everything we can to enable each client to meet their full potential, and we’ll tailor our treatment programmes to achieve that. Even before they arrive here, we’ll do the assessment - sometimes a virtual assessment - because we know how much can be achieved by chatting to the client and treating therapy team at that stage. “Then, within the first 24 hours of the client arriving here, the therapists meet the new client and do their assessments, and then build on that as they go, working with clients and their families to put a personalised plan together around what they want to achieve. “It’s really important to us to understand what they want to achieve - whether that’s going back to work, getting back to gardening, playing golf - and we work from there as a team to help achieve their full potential. “And as we’re all on one site we can meet regularly to discuss these ongoing goals and progress and tailor our support accordingly that kind of close-working is so important in delivering the best possible support and care.” And from the delivery of such standards of care is coming growing relationships with the NHS. Having worked with East Surrey Hospital for

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" We’ve seen a lot of progress in quite a short time, but what we continue to pride ourselves on is the way we work together as a team."

QEF's Care and Rehabilitation Centre

several years, initially to deliver acute stroke rehab but now also supporting more widely with neuro-rehab, QEF is now working far beyond its local area. “We started working with East Surrey Hospital about four years ago, which was a big change for us at the time, but the kind of challenge we really relished,” says Emma. “But in moving to Leatherhead, we are now able to work with other NHS Trusts and explore other kinds of contracts. We now work with NHS Trusts across SW London, Surrey, Sussex and Hampshire, who come to us for the intensity of our rehab for their clients, and we

are expanding to work with other NHS Trusts too. “I think this is a really important role that we play, and it enables us to support these Trusts and help relieve the pressures that the NHS is under at the moment.” Going forward, QEF is continuing to expand its geographical reach, working with clients from across the UK in delivering the support it has become known for, but with the more recent added advantage of its Care and Rehabilitation Centre, which has won international CEDIA awards for its use of accessible technology in every client bedroom. “Our building is fantastic and is enabling us

to look to the future and the continued development of the service,” says Emma. “We have amazing facilities, ensuite bedrooms with accessible technology, and such a brilliant therapy gym where all of the therapists can work. It’s a very calming environment set in countryside surroundings, with lots of communal areas inside. It has been a great move for us. “But while we’ve grown in terms of the size of the team and the number of clients we have here, we’re always going to have the clients at the heart of everything we do. That will never change, and we’re really proud to have that at our core.”

Wa t c h a v i r t u a l t o u r. . . of QEF's Care and Rehabilitation Centre and meet the therapy and nursing teams at www.qef.org.uk/CRC_virtualtour

Modern and spacious therapy gym

Emma Berkshire, Lead Physiotherapist

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Chroma’s new and improved website now offers an inclusive online experience Chroma, the UK's leading provider of arts therapies, now provides an inclusive online experience to enable website visitors to access their online content and services, barrier-free Implementing the assistive toolbar from Recite Me, visitors to Chroma’s new and improved website are now able to access a wide range of accessibility and language support tools to customise their digital experience. The Recite Me assistive toolbar includes screen reading functionality, multiple reading aids, customisable styling options, an on-demand live translation feature that boasts over 100 languages including 35 texts to speech, and styling options. These features help to support the 20% of the population who may encounter barriers when navigating the website due to having a disability, learning difficulty, visual impairment or if English is not their first language.

Daniel Thomas, managing director at Chroma said, “We are really pleased to be able to offer this assistive toolbar from Recite Me on our website as our whole ethos encompasses inclusion – the arts therapies we provide are inclusive for all and our website should reflect that too. “We receive many visitors to our website who are living with a disability of some kind and now Recite Me’s assistive toolbar allows us to provide an inclusive online experience to all. Barriers to understanding and accessing important information online remains a problem. “But our work is concerned with the mental health and wellbeing of our clients, families and prospective clients and we want to

provide them with an inclusive experience right from the start. Ross Linnett, founder and CEO of Recite Me said, “We are delighted to have been able to work with Chroma and provide them with the software to help support their diversity and inclusion strategy. Recite Me accessibility software provides users the opportunity to customise their experience in a way that suits their individual access needs which seems especially fitting for Chroma’s clients. We hope their online visitors are able to get the very best experience out of the site.” To experience the new toolbar, its features and the website visit www.wearechroma.com

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The power of Music Therapy in helping people with psychological issues post-trauma Music Therapy has once again proven itself effective in helping to support people with cognitive issues Sarah Morgan, a qualified music therapist at Chroma, uses song writing as a means to help those living with a brain injury, overcome cognitive issues such as trouble remembering, planning tasks, learning new information, sustaining attention, or dealing with emotions. Loss of identity is a common emotion following a traumatic or acquired brain injury. Song writing lends itself to emotional expression when the victim has a decline in speech and language skills or has trouble discussing difficult memories. For brain injury survivors, the process of song writing enables them to explore, question, and connect with their new sense of self and challenge the perception of how they see themselves versus how the world sees them. A loss of identity following a brain injury ultimately negatively affects wellbeing. The transition from loss to acceptance takes time. Song writing offers a creative, identity-based exploration, which effectively helps to reveal issues in order to explore and make sense of them. Sarah is currently supporting a young rapper who sustained a brain injury due to a road traffic accident (RTA), through song writing, improvisation and the use of music recording software. Her aim, and his own personal goal, is to help him begin to identify as himself once again. Cognitively, song writing helps develop attention, concentration and task-planning and prioritisation skills. It also utilises working

Song writing offers a creative, identity-based exploration, which helps to reveal issues to explore a n d m a ke s e n s e of them

memory by allowing the client to repeat and manipulate phrases. Engaging in making music focuses attention on a positive creative expression, and stimulates and induces the release of brain chemicals such as dopamine and serotonin. Music plays an important role in providing a creative and emotional outlet and provides the client a positive focus. Song writing provides the client with a vessel to process trauma - by writing about the traumatic event or feelings surrounding it. In this particular case, creating new music enabled the client to re-connect with an integral part of himself – the rapper, which was a significant goal of his rehabilitation.

C A S E M A N AG E M E N T

The scale of the ‘perfect storm’ of increasing difficulty recruiting and retaining skilled support workers has been laid bare through new research from BABICM. The survey of the organisation’s membership attracted over 200 responses in only six days, and highlighted the breadth of challenges case managers face in the current climate

Reasons given for the Among the headline findings were:

recruitment problems included:

Over

90% 72%

had experienced increased difficulty in recruiting

believed case managers should be vaccinated

Low pay

> Increased rates of pay in other sectors > Poor working conditions

skilled task and those skills are not seen as present in some/many candidates that do apply > Support Work agencies not being able to access staff > Loss of candidates and loss of some existing staff due to Brexit > The task is a

Unsociable hours

undervaluing of the role of support worker/rehabilitation assistant. > A sense that the career was not an attractive one. > Impact of the pandemic on the role > Introduction of mandatory vaccinations > Pre-existing crisis in recruitment (pre-Brexit and pre-pandemic) > Low status of employment, an

82% 96

anticipated recruitment and retention of staff would be impacted by the implementation of a mandatory vaccination policy

C A S E M A N AG E M E N T

BABICM launched its research in early 2022 in response to concerns being raised from its membership about the mounting challenges in recruitment, and the specific effects of this on clients’ direct health, welfare and safety concerns, financial impacts on the cost of care and the potential for clients to run out of funds to meet their needs. Also, said BABICM, those involved in personal injury litigation were asking for information to inform their calculations relating to the future costs of care for cases yet to be settled. In summary, BABICM said: “The survey link was only open for 6 days and received over 200 responses. This may be considered highly indicative that the issue of recruitment is a very taxing one presently for case managers. “The uniformity of responses with regards the impact upon recruitment and retention of low rates of pay, Brexit, employment conditions, the impact of the pandemic and

the status of support work was significant. “The impact of recruitment difficulties is felt in terms of decreased quality of life and choice for service users, increased costs to service users/funders, increased reliance upon family support, increased case management time and costs, increased reliance upon more expensive services, increased risks, safeguarding issues, and loss of community placement. “These were not expressed solely as concerns but as actually manifesting presently. “The nature of compulsory vaccinations to maintain employment/achieve new employment was seen by some as an ethical question, with views expressed across the spectrum from those who believed that this was a matter of personal choice to others who believed that mandating vaccinations was the correct course of action to reduce risks. “The impact of the proposed mandating of vaccinations was viewed by most as worsening

an already difficult situation with regards recruitment and, as was often noted, the retention of good, trained and skilled staff already in post. “The possible loss of skilled and experienced staff anticipated by the mandating of vaccinations was considered to increase risks by some, particularly if this led to the loss of employment of skilled and experienced staff. “The reliance solely upon vaccination to manage risk of infection was highlighted by some as being unlikely to achieve the desired outcome. “The crisis of recruitment was considered ongoing with no end in sight and to have predated the law regarding mandatory vaccination. “Increasing wages and improving conditions of work are suggested as necessary. Balanced against this is a recognition that funding is simply not available for some, in particular those with settled litigation claims or those reliant upon the state for funding/partial funding.”

VICKI GILMAN

It’s been a busy start to the year for BABICM Mirroring the rest of society, the welcome return to relative normality after two years of COVID-related change seems to have increased our activities beyond pre-pandemic levels! As the year began the crisis in care and the difficulties case managers are experiencing in recruitment and retention of support workers became a hot topic. The factors driving these problems seemed to be mounting with their combined effect escalating the difficulties on the ground and impacting clients, families and support workers. It is of course the way of supply and demand economics in a competitive market that high demand for scarce supply will lead to price inflation. Accordingly we became aware that some clients were having to pay inflated rates, sometimes at exceptional levels, to secure care. Following a lively discussion at a Council meeting and some Twitter activity with members of the personal injury litigation world, the BABICM Research Group were able to quickly put together a survey – The Perfect Storm Survey. Whilst the survey findings themselves are concerning, it was very positive the way members shared their experiences allowed findings to be gathered and compared and then rapidly shared publicly. I feel proud that the voice of case management is being heard and is adding to the body of information on these most challenging issues. It has been delightful to feel that face-to-face events can again be confidently planned and we have a wide range of relevant and interesting events coming up in locations across the UK as well as our now well-polished webinars. Our annual conference returns to its summer position in the calendar on June 15th and 16th. Last year we had a waiting list for delegate places, so this year we have changed venue to the East Midlands Conference Centre where we can safely accommodate more people.

I am really looking forward to seeing everyone gathered together – I think this must be the largest gathering each year of case managers specialising in complex and catastrophic injuries and other professionals who work closely with them. In the past couple of years our Advanced BABICM peer review process has gone fully online (this will not come as a surprise!), whether for this reason or a combination of factors we have seen a growing number of applications for Advanced Assessment and we have recently appointed another advanced membership assessor. I am delighted to see this growing body of case managers who have demonstrated their level 3 standard of practice (as per the BABICM standards and competency framework) and as a graduate of this process I heartily encourage eligible case managers to put themselves forward for this formal peer review; a process which takes some time and effort but which requires a level of reflection which in itself I found to be professionally positive and helpful to my case management practice. A theme for 2022 across case management

could easily be quality and standards – with the continuing development toward a register of case managers, the recent IRCM consultation on the draft standards for case management, BABICM’s new series ‘What is good case management practice’ published in our newsletters and online, the numbers of case management registrations with the CQC and the increasing interest from the legal profession in implementing more specific due diligence practices. In addition to protecting clients it is my view that these quality measures can only strengthen the sector and those who work in it. At times it may feel like an additional burden in terms of administrative processes but when I stop to consider the question ‘What would I want for a member of my family?’ Greater regulation, accountability and standards to be measured against would certainly be important to me and I suspect this would be so for the majority. So as I contemplate the start to the year and the road ahead I am full of optimism and hope for increasing freedom for all from covid concerns and a year of strength and development for case management in the UK.

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