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Latest neuro-rehab developments
Recovery of over half with mild TBI ‘longer than six months’
More than half of people who experience mild traumatic brain injury (TBI) are not recovering after six months, a new study has warned.
A dedicated Commission by world-leading experts has highlighted the advances and persisting and new challenges in prevention, clinical care and research in TBI.
Among a number of key challenges, the Commission’s report finds that more than 90 per cent of TBIs are categorised as “mild”, but over 50 per cent of such patients do not fully recover by six months after injury.
Improving outcome in these patients would be a huge public health benefit, the study notes. A multidimensional approach to outcome assessment is advocated, including a focus on mental health and post-traumatic stress disorder (PTSD).
Other key issues highlighted in the report include:
> Outcome after TBI is poorer in females compared with males, but reasons for this are not clear
> Major disparities in care, including lower treatment intensity for patients injured by low-energy mechanisms, deficiencies in
access to rehabilitation and insufficient follow-up in patients with “mild” TBI
> Advances in diagnostics and treatment approaches.
“The scale of traumatic brain injury around the world is staggering, with 55 million people affected at an estimated cost of $400billion each year,” says Antonio Belli, Professor of Trauma Neurosurgery at the University of Birmingham and an author of the Commission report.
“As a leading cause of injury-related death, this significant report pulls together both the successes in understanding and treating brain injury as well as the task ahead for policy makers, clinicians and researchers."
The 2022 Commission has been produced by world-leading experts and was presented at the Collaborative European Neurotrauma Effectiveness Research in TBI project (CENTER-TBI) at their meeting last week in Antwerp, Belgium.
This is an update to the first Lancet Neurology Commission on TBI, which was launched at the European Parliament in 2017
The 2017 Commission set out priorities and recommendations to address the challenges in TBI from the perspectives of policymakers, clinicians, and researchers.
Since then, new knowledge has been generated by large observational studies, including CENTER-TBI and other studies conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, designed as a coalition of funding agencies and scientists to advance the care for patients with TBI through collaborative efforts.
ONWARD ARC-EX study reveals remote use potential
The potential of the ARC-EX device from medtech pioneers ONWARD has grown even further with the conclusion of its trial for at-home use endorsing its feasibility and safety.
The ARC-EX device, set to be launched commercially next year, delivers non-invasive stimulation of the spinal cord, targeted to help restore movement and other functions in people with spinal cord injury (SCI) and other movement disabilities.
Recently, the results of its Up-LIFT pivotal study confirmed its efficacy when used in clinics, with a global trial – including two sites in the UK – endorsing its ability to make statistically significant and clinically meaningful improvement in upper extremity strength and function.
And now, through its LIFT Home Study, its potential in the home setting has also been clearly shown, with 97 per cent of therapy sessions successfully completed and 100 per cent of participants completing the study with no serious adverse effects.
“Today’s results from the LIFT Home study support the potential for ARC-EX Therapy to be used safely at home, which would enable people with spinal cord injury to live even more independently,” said Dave Marver, CEO of ONWARD.
“We expect to launch first in clinics, but as the community gains more experience with ARC-EX Therapy, we envision many patients will also want to use this technology at home."
The ARC-EX device is set to launch in the second half of 2023 and will be the first commercial launch by ONWARD, which is using years of research and innovation to create innovative therapies to restore movement, independence and health in people with SCI.
Its other main device, the ARC-IM, delivers stimulation of the spinal cord through implant, and its huge promise was shown through the STIMO-BRIDGE study, which restored the ability of three paralysed patients to walk, run and swim, when combined with intensive rehabilitation.
In its LIFT Home Study, 17 patients were enrolled from five leading spinal cord injury research centres in the United States – Craig Hospital in Denver, Colorado; Shepherd Center in Atlanta, Georgia; Spaulding Research Institute in Boston, Massachusetts; University of Minnesota; and the University of Washington.
Participants performed training on activities of daily living three times per week over a one-month period.
“To maximize recovery after spinal cord injury, it’s critical that we develop treatments that can be safely and effectively delivered in the home environment,” said principal investigator Candy Tefertiller, executive director of research and evaluation at Craig Hospital.
“Integrating home-based therapy not only facilitates opportunities for ongoing recovery, but also allows therapy to focus on more relevant activities for that specific individual.”
ONWARD said it now plans to discuss the findings from the LIFT Home study with regulatory authorities to define the appropriate approval pathway for home use.
Supporting children with special needs through play and sensory stimulation
By Sorina Milhaila
Play is incredibly valuable for all children, but having special needs could create unexpected barriers. We caught up with Alex Ford, founder of PODS – the world’s first interchangeable sensory play spaces – to find out how the pop-up tents could redefine play through technology and innovation.
The needs of little ones vary a lot. When it comes to play, however, pediatricians have crucially highlighted the importance of free play time.
According to a clinical report by the American Academy of Pediatrics, play is essential to development because it contributes to the cognitive, physical, social, and emotional well-being of children.
Not only does it help children gain healthy emotional development but it also promotes healthy brain development, strengthening many neuronal connections that would otherwise disappear or weaken if not used.
Additionally, experts have suggested that play areas with special, calming places can help children with autism and sensory integration disorders find comfort, relax, and re-focus when they need breaks.
“The longer a child can play for the better,” says Alex Ford, founder and creative director of PODS, the pop-up, themed sensory tents for children.
He started to understand the importance of play early in his life when he was partnered with a younger autistic boy at school.
I’ve always seen how restless children can get especially when they don’t have their own space to relax and calm themselves in,” Ford remembers.
“I used to spend quite a bit of time with my autistic friend and I noticed when he had a meltdown, he would go underneath the table to relax and shut himself off. This got me thinking about a ‘calming safe space’ where a child can be themselves, have their own place and feel like being in another world.
“Fast forward a few years I then became a designer and specialised in structured design and my creative curiosity and experience with children with sensory needs led me to design PODS.”
“We, as adults, don’t see how children see things. But for them, PODS is almost real life and
that’s what makes it
so magical."
The themed inflatable play spaces create a 360° immersive environment great for children living with special sensory needs and physical disabilities. Each PODS product can be inflated and deflated within 40 seconds and has a range of interchangeable themes with corresponding audiobooks – think dinosaurs, igloos, astronauts and submarines.
“Imaginative play is huge and it is the reason behind the product,” says Ford. “With our interchangeability, children can be getting off into outer space one minute, and then they can change the theme, the app, the sound effects and walk with dinosaurs the next minute.
“We, as adults, don’t see how children see things. But for them, PODS is almost real life and that’s what makes it so magical. If we can prolong that magical experience, then I think we’re doing a good thing.”
The advanced technology behind the product is what makes it something that complements other toys, enhances play, and focuses the mind for learning.
This is one of the reasons why PODS are also used around the world in specialist schools, hospitals, creches, respite centres and hotels, as well as in the home. Their portability makes them ideal for such places, says the founder.
“You can just pop it up from a backpack or walk it from room to room in seconds. It’s really easy. You can put it in the boot of a car or on a passenger seat and that makes it a key piece of equipment to most child caregivers, but particularly to those with learning and physical disabilities.
“We have quite a few parents with physically disabled children. So, when they’re not in their wheelchair, they use our PODS whilst laying on their back, gazing up and seeing all the colours changing.
“They’re incredibly fun and they are hours and hours of playtime. The immersive experience that you get is quite literally unique and there’s nothing else like it. We say it’s out of this world because we provide themes that children would possibly never get the chance to experience.”
After successful demonstrations with the original PODS, the company has developed the Therapy PODS as safe, relaxation spaces for the elderly or those suffering from dementia
“Because colour therapy is quite a big thing, we came up with the idea of PODS for adults,” says Ford. “Being surrounded by a small environment, immersed in a changing of colours can really affect your state of mind, even as an adult.
“Now, we’re working on something whereby we can create the landscape of a train station or forest that could evoke the senses through providing an immersive experience and help people calm and relax.”
To find out more about PODS,
visit podsplay.com.
Experiences of a Lost Tribe
The Lost Tribe - Stories from Survivors of Cauda Equina Syndrome contains a number of accounts of those with lived experience of the debilitating condition, the symptoms and impact of which remain misunderstood, even by many working within healthcare.
The book, published by Cauda Equina Champions Charity, brings together the personal stories of people whose lives have been changed dramatically by Cauda Equina Syndrome and who now live with permanent disabilities and lifelong consequences as a result.
Among them are former Blue singer Duncan James, a world champion powerlifter, a RADA-trained dancer, and emergency services staff, who discuss their difficulties in accessing the treatment they needed and the impact of the condition - but also how it is possible to rediscover a great quality, and enjoyment, of life despite Cauda Equina.
The Lost Tribe also contains the insight of two leading medical professionals who are committed to raising awareness of Cauda Equina Syndrome - spinal cord injury consultant Munawar Mecci and consultant spinal surgeon Mike Hutton.
All proceeds generated from The Lost Tribe will go to the Cauda Equina Champions Charity, to help finance vital support and access to services for people living with Cauda Equina Syndrome, whose urgent need for medical intervention is often not recognised by healthcare professionals.
No specific care pathway is currently in place for such patients, although work is underway to implement a new strategy next year.
Claire Thornber, founder of the charity and herself a survivor, says: “It was actually Mr Mecci who used the phrase ‘The Lost Tribe’ in the very powerful piece he has written for us, and I think it is right to say that.
“We do feel like we’re a lost group, because there is no care pathway, and while the NHS is now addressing it, it has been a very slow process.
“The idea of the book was that by bringing the very personal stories together of people from all walks of life and professions and show the impact Cauda Equina has had on their lives.
“We want it to be of use to healthcare professionals and patients alike - we want to highlight the red flags that should be there when people experience lower back pain, and to give insight into what that might mean and what they should do.
“Even within healthcare, we find Cauda Equina still isn’t recognised as it should be, so hopefully this will give them insight into how they can better support their patients.”
To buy The Lost Tribe, visit here
Extract:
Jumping from a helicopter and landing on a telegraph pole with a pineapple strapped to the top.
I was thirty-nine when it happened. I turned over in bed one night in September 2010 and suddenly this pain in my back gripped me, so vice-like I could hardly breathe. It was as if I was instantly paralysed, whilst being electrocuted at the same time. I couldn’t move any further. I couldn’t get up. It was terrifying. I never cry, but now I burst into tears. My sobs woke my partner Dan, who was sleeping next to me. I had no idea what was happening to me, and he wasn’t sure what to do for the best. So, he called 111 and they told me to get to the G.P. in the morning.
I didn’t exactly need them to tell me that.
The pain was searing. And then I became aware of pins and needles in my buttocks. It felt as if I had enormous weights strapped to each one, as if all the muscle tone had disappeared.
It was a sensation I had never felt before. I knew something
wasn’t right.
In fact, something was very wrong.
I had been having lower back pain and sharp sciatic pain radiating from my hips down my legs for some time, first one leg then the other. The first time I ever had a back problem was about fifteen years before in the mid ’90s when my boyfriend at the time assaulted me. He was getting increasingly violent to the point where I was quite used to the odd black eye. But on this occasion, he not only punched me in the eye, but grabbed the hairdryer I’d been using and struck me over the head with it too. That must have sent me to the floor because the next thing I knew I felt him boot me so hard in the lower back I went to jelly. I stayed down until he went out and I knew then I had to get out the flat and not be there when he came back, but when I went to stand up, I could barely walk. So, I crawled out of the flat, across the car park to my car on my hands and knees and managed to drive to my friend’s house for safety.
The following day I hobbled to A&E, and they advised bed rest until it got better, which it did after a week or so. From then on, I regularly had a grumbling back, but I thought it was nothing to worry about; it always resolved itself.
In 2003 I started my own cleaning business. Well, I was never very good at being told what to do so it was much better to be my own boss. I employed a few other girls, but did a lot of the cleaning myself, so I could be extra sure the clients got the best service and had nothing to complain about. Shoving a hoover around your own home isn’t great on your back but doing it day in day out around other people’s homes and offices and hauling equipment in and out of vans over the years, turned that grumbling back pain into sciatica. Being the boss meant nobody told me what to do, but it also meant I didn’t feel I could ever take the day off sick, so I told myself to suck it up and get on with it.
However, as time went on, the sciatica became so bad I couldn’t stand for long periods or even sleep at night. Queuing in a shop, for example, was impossible and I had to start relying on the girls to do most of the cleaning, while I just supervised; something I was never happy doing. I even started to get strange sensations in my genitals, so I did a bit of googling of my symptoms and that’s when Cauda Equina Syndrome popped up: Cauda Equina Syndrome Medical Emergency.
NIH recognises CTE caused by repetitive TBI
The leading medical research agency in the United States has publicly acknowledged for the first time that chronic traumatic encephalopathy (CTE) is caused by repetitive traumatic brain injuries (TBI), in what is hailed as a “landmark moment” in the fight to end the brain disease.
The National Institute Neurological Disorders and Stroke (NINDS), part of the US National Institutes of Health (NIH), has agreed to update its official statement on cause after being petitioned by 41 of the world’s eminent experts on CTE and related areas of science.
The letter, spearheaded by the Concussion Legacy Foundation (CLF), urged NINDS to review the current evidence outlined in the 2022 article Applying the Bradford Hill Criteria for Causation to Repetitive Head Impacts and CTE.
Now, Dr Nsini Umoh, program director for TBI, responded that the NINDS official statement on CTE causation has been updated to now say: “CTE is a delayed neurodegenerative disorder that was initially identified in postmortem brains and, research-to-date suggests, is caused in part by repeated traumatic brain injuries.”
“The National Institutes of Neurological Disorders and Stroke new statement on CTE causation is a landmark moment in the fight to end CTE,” said Dr Chris Nowinski, study lead author and CLF founding CEO.
“We thank all the scientists who built the evidence and advocated for this change as well as the families of the brain donors who died with CTE for their important role. The impact of this change will save lives.
The announcement comes just days before the Concussion in Sport Group’s (CISG) sixth International Consensus Conference on Concussion in Sport in Amsterdam, where a meeting of doctors, organised by FIFA, the International Olympic Committee, World Rugby, and others, is expected to debate their own position on CTE causation.
Their most recent statement claimed “a cause and effect relationship between CTE and concussions or exposure to contact sports has not been established.”
“We thank all the scientists who built the evidence and advocated for this change as well as the families
of the brain donors who died
with CTE for their important role. The impact of this change will
save lives.”
NINDS joins the US Centers for Disease Control and Prevention (CDC) in recognising CTE is caused by repeated traumatic brain injuries.” The CDC fact sheet defines repeated traumatic brain injuries as “concussions, and repeated hits to the head, called subconcussive head impacts.”
The NIH and CDC each independently concluding that CTE is caused by repeated traumatic brain injuries, like those suffered by contact sport athletes, military veterans, and victims of abuse, is expected to have significant public policy and medico-legal consequences.
Many international professional sports organisations that are part of the CISG are facing lawsuits from the families of former players diagnosed with CTE and former players exhibiting cognitive and behavioural symptoms that may be caused by CTE. Some sports organisations have defended those lawsuits
by citing the CISG statement on CTE causation.
Dr Robert Cantu, medical director of the CLF, has served as a coauthor of CISG statement to promote improved concussion care but has been on record disagreeing with their CTE statements.
Dr Cantu served as senior author on the paper that helped inspire NIH to change their statement on CTE causation. After Dr Paul McCrory resigned as chair of the CISG in March due to allegations, now proven, of serial plagiarism, Dr Cantu was invited to co-chair the scientific committee of the Amsterdam meeting.
IRCM set to open registration by end of the year
The new body created to hold a publicly-accessible register of case managers - the Institute for Registered Case Managers
(IRCM) - is aiming to open registration for case managers later this year, in a major stride forward for the profession. The IRCM has developed strongly since its inception almost two years ago, with significant time and effort invested from its leadership team and the case management community in helping to shape its future.
The body is being established to focus on standards for case managers, bringing new levels of accountability and endorsement to the profession, for the protection of clients
and assurance of their families, authorities and commissioners.
And now, the IRCM - created jointly by the British Association of Brain Injury and Complex Case Management (BABICM), the Case Management Society of the UK (CMSUK) and the Vocational Rehabilitation Association (VRA) - is looking to open registration for case managers soon, with the target of accreditation by the Professional Standards Association (PSA) remaining on track for 2023.
It is also building a supporter community, which now comprises stakeholders from across case management and associated sectors, with the IRCM particularly keen to add the support of more personal injury lawyers, law firms and Insurers.
While its public profile continues to grow, work continues in the background to ensure its application to the PSA is as comprehensive as possible before submission. Once registered, the IRCM will develop a voluntary register of registered case managers, endorsing their capability to practice.
Angela Kerr, chair of IRCM, said the hard work and co-operation of individuals and organisations from across the sector has enabled it to progress at the rate it has.
“We have a very clear plan and that is what we are all working to deliver, and I must say it is going really well,” she said.
“A big part of it has been getting the right team in place, which extends through our sub-groups and all of our volunteers and
those who have shared feedback and insight, and we’ve had fantastic support for which we are very grateful and extend our thanks.
“People have been so engaged and our supporter community, which is growing all the time, have been excellent. The engagement from the start has been brilliant.
“We are hoping registration will open in by the end of this year , which is really not long, and that we will submit the application to the PSA towards the end of this year also . We’re working hard on that behind the scenes.
“But what is so important to us in what we are creating is that the public and commissioners are aware of IRCM, our goals and our reasons for doing what we’re doing.
“This has been a huge task, probably bigger than I envisaged it would be, but the fact we have such a great team of people with us on this journey is wonderful."
The IRCM is seen as a huge step forward in the professionalisation of case management and its greater recognition - but awareness among those who need to know is fundamental, says Angela.
“What we really need to do is make sure the public and commissioners are aware of the work we’re doing and what being a registered case manager means ,” she says.
“That’s probably our next challenge, to make sure all of those people who need to know about the IRCM, do know about us.
“By the process of registration, case managers demonstrate competence against case manager specific standards and their commitment to providing quality case management , which gives a greater level of assurance. There has never been this level of accountability within case management, so it’s a very big step forward.
“A very small percentage of the population will encounter a case manager, but for those who do, we want them to know the stringent standards they are working to as a registered case manager. That is very important in giving protection to clients and reassurance to commissioners.
“A big part of this awareness is growing our supporter community further and encouraging more of those who
commission our services to be part of what we are creating.”
Revolutionary robotic spinal surgery ‘could cut recovery time’
Spinal patients at The Walton Centre NHS Foundation Trust have begun to benefit from a groundbreaking new surgical robotic navigation system – hailed as having the potential to change the future of spinal surgery in the UK.
Called the ExcelsiusGPS, the new innovation will see patients spend less time in theatre and potentially reduce recovery time after major spinal surgery.
Consultant spinal surgeon and metastatic spinal cord compression surgical lead Miss Maggie Lee said: “This amazing piece of technology enhances what we currently have in surgery.
“The system enables us to operate with a higher degree of accuracy in navigation, so we can progress through the stages of the procedure much quicker. There is also a reduction in X-ray imaging needed during the operation.
“This means patients will be in surgery for a much shorter time and therefore hopefully have a much shorter stay in hospital.”
The system at The Walton Centre – which has Centre of Excellence status for its work in fully endoscopic spinal surgery –involves a rigid robotic arm, tracked and fully navigated by a camera, which is then programmed to follow a trajectory pre-planned by our surgeons. This allows them to facilitate placement of spinal screws and interbody cages to an incredibly high level of precision.
Consultant spinal surgeon and clinical lead for complex spine Mr Simon Clark said: “Research into robot assisted navigation for spinal procedures shows that it’s considerably more accurate than previous freehand methods.
“This incredible system is not only going to allow us to improve accuracy and therefore clinical outcomes, but enhance patient experience and also improve training the next generation of spinal surgeons.”
Chief Executive Jan Ross said: “This exciting new innovation is going to change the face of spinal surgery here at The Walton Centre and beyond.
“Our surgeons have already successfully operated on patients with the ExcelciusGPS navigation system and are planning to
apply benefits of this new tech to many more procedures.
“The team has worked incredibly hard to get this project across the line, they are pioneering how spinal operations can be modernised for the NHS going forward. This system will mean
a more efficient service for our patients.”
In collaboration with Globus Medical UK Ltd, the Trust will use the revolutionary equipment to deliver robotic spinal services. The Trust will also have the unique opportunity to become a training and education centre for the UK, showcasing the services provided to its patients on a national and international platform.
President of imaging, navigation and robotics at Globus Medical, Jay Martin, said: “It’s a significant milestone for both Globus Medical and the NHS Trust to collaborate through technology innovation to fundamentally change the future of spine surgery in the UK.”
Significant rise
in stroke among
young adults
A sharp increase in the
incidence of stroke among
young adults has been
seen in a new study.
Using data from the Oxford Vascular Study, which includes data from 94,567 people registered with GP practices across Oxfordshire over a 20 year period, the occurrence of stroke was analysed by a team of researchers.
They found that between 2002-2010 and 2010-2018, there was a 67 per cent increase in stroke incidence among younger adults aged under 55, and a 15 per cent decrease among older adults. A similar divergence in incidence was not found for other vascular events, such as heart attacks.
Among young people who had a stroke, there was a significant increase in the proportion who were in more skilled occupations, particularly for professional or managerial jobs. This could suggest a role for work-related stress, low physical activity, and long working hours, each of which were more strongly associated with risk of stroke than heart attack.
The study, funded by the Medical Research Foundation, looked at all types of stroke, such as ischaemic strokes, caused by a blockage of arteries, ‘mini-strokes’ (transient ischaemic attacks) and bleeding in the brain (intracerebral haemorrhage and subarachnoid haemorrhage).
Findings from this new study reflect emerging evidence that young stroke is a growing problem in high-income countries. A separate, linked paper by the same authors – Dr Linxin Li, Dr Cathy Scott and Professor Peter Rothwell from the Nuffield Department of Clinical Neuroscience at the University of Oxford – showed similar divergent trends across other high-income countries in the 21st century, with a fall in incidence at older ages not being seen at younger ages.
The traditional view is that vascular risk factors, such as high blood pressure, diabetes and obesity, play a minor role in young stroke, but recent studies have begun to contradict this view.
Medical Research Foundation Fellow, Dr Linxin Li, said: “Our studies show a worrying rise in young stroke cases both in Oxfordshire and in other high-income countries.
“We need better ways of identifying young people at risk of stroke, as current risk models are designed mainly for use in
older people.”
Professor Peter Rothwell said: “We are not yet sure what is driving the increase in incidence of stroke in younger adults, but it is important that doctors don’t dismiss the warning symptoms and that risk factors are treated.”
Dr Angela Hind, chief executive of the Medical Research Foundation, said: “Historically, we’ve thought of stroke as only affecting older adults, but studies like this suggest a growing problem in young adults.
“Stroke in young adults can have a huge impact, often occurring when they are starting a family or already have young children to look after, and have yet to reach the peak of their careers. The economic, social and personal consequences can be devastating.
“More research needs to be done to increase understanding of the causes of young stroke and the best ways of preventing it. This is why we’re supporting researchers like Dr Li, who are pushing forward the boundaries of knowledge surrounding young stroke.”
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