Rehabilitation Matters

Mark Pollock stands up with Ekso

I wrote about client Mark Pollock in an earlier article.  An adventure athlete, entrepreneur and author, Mark has competed against professional explorers like Sir Ranulph Fiennes, Olympic gold medalists and special forces personnel.  And he's done so in a world of total darkness.  For the last decade, Mark Pollock has been blind.  After his last expedition to be the first blind man to walk to the South Pole he fell from a window and became spinal cord injured.

I first met Mark in Stoke Mandeville and was pleased to work with him using FES to strengthen leg muscles - first with our RehaStim unit and eventually with a full RehaMove FES cycling system.

Mark is an inspirational guy who has impressed many people with his determination to push back the barriers of what we currently believe is possible.

On Mark's blog he recently posted a video of his adventures with the Ekso Bionics exoskeleton system.

The Ekso Bionics system is evolving rapidly from an original development project in Berkeley California aimed at "soldier enhancement".  This ground breaking technology is finding application in the world of rehabilitation and one day soon may become a practical choice for many persons with a physical disability.

Knowing personally some of the people working with Ekso Bionics, I have no doubt that this system will be the one to emerge as the acknowledged leader. 

Of course the technology is only part of what will make this a success - this development and its introduction must be made with a sensitivity to the expectations of potential users. 

Those of us who have worked in this field for decades can point to times when expectations were unfortunately far ahead of what could be achieved in practice.

Arm rehabilitation post-stroke - Separating fact and fiction

Improving arm function post-stroke - Hemiparesis is by far the most common limiting symptom resulting from a stroke, affecting 80 percent of stroke survivors.  Unfortunately, many persons recovering from a stroke find that the health service doesn't really focus on helping them recover arm function.  When I first studied in this area (admittedly a while ago now) it used to be thought that it wasn't possible to recover much function anyway.  Now we know that functional recovery can take place given the right degree of support and the right tools.  Such a tool is the Tailwind product from Encore Path Inc.

We have been working with the Tailwind product in the UK for a couple of years now.  I was quite excited when I learned about it and keen that we should work with it - even if it meant working sometimes against the skeptics.  The Tailwind product was created by Kris Appel in the USA, based on research at the University of Maryland which focused on the concept of a Bilateral Arm Trainer with Rhythmic Auditory Cueing (BATRAC) device.

The investigators carried out controlled scientific studies that showed how their method significantly improved function in stroke patients suffering from the loss of function in one side of the body.  The BATRAC method is specifically aimed at the loss of function in one arm, and tackles the problem by literally retraining the brain. The BATRAC device requires the patient to use both arms to carry out the motion of reaching forward for an object and bringing it in toward the body. The movement is "cued" by a rhythmic auditory signal that apparently entrains the motor cortex of the brain.

In a study published in 2000, the developers of the BATRAC method reported significant improvement in the use of the affected arm with as little as one hour of training per week for six weeks.

This initial study showed improvement from 12 percent to 26 percent on two different motor improvement scales.  The study subjects were also asked to assess their ability for daily use of the affected arm in everyday tasks, and this self-assessment revealed an even higher rate of improvement, up to 43 percent after training.

The BATRAC investigators conducted further studies that compared BATRAC results to a more commonly used method of physical therapy — a technique referred to as dose-matched therapeutic exercises, or DMTE.

In a report published in the Journal of the American Medical Association, functional magnetic resonance imaging scans were gathered from subjects in a study that compared BATRAC and traditional training techniques.  Blood oxygenation-level dependent scans were made of the entire brain as the subjects moved the unaffected arm first, and then the paralyzed one.  The scans were taken before and after training with the two methods.

The investigators noted significant changes in brain activity in most members of the BATRAC group after training, but no changes in brain activity for the DMTE group. In addition, those members of the BATRAC group whose brains showed evidence for rewiring had improved function, while the control group showed significantly less improvement.

It's quite interesting that in the USA few therapists question the validity of the technique whilst we still have many in the UK who are skeptical.  We belive that Tailwind has shown itself to be an effective tool for stroke rehabilitation - what we need now in the UK is the correct, timely input from therapists

The Truth of the Quiet Box

A few weeks ago a friend was fund raising for charity by paticipating in the Iron Man Wales event.  My wife and I went to see him off - from a safe distance.  It's quite a challenge starting with a 3.8 km swim, followed by a 180k bike ride and finished off with a 42.1 km run. Not exactly something to take casually. 

Andy had just finished the bike section and was starting the run when he heard the PA system announce ".. And here comes the oldest competitor!" 

Just for a second Andy thought the announcer was referring to him but then as he looked back he saw right behind him was indeed the oldest competitor - a 75 year old man. 

I think most of us would think that a 75 year old doing Iron Man Wales was beyond belief.  After all we have evidence all around us that suggests such a feat would be impossible.

Isn't that the trouble with beliefs. We all hold them - and yet they have an often silent and unconscious grip on our lives.  My one time mentor, Michael Breen used to say something like, "If you are going to have beliefs - make sure you choose useful ones".  Sadly most of us don't.  We don't even know how strongly our lives are shaped by the beliefs we hold.  Our beliefs can be like stealthy parasites that steal our lives and infect those around us.

Working in rehabilitation I am very interested in my client's beliefs about what they can achieve in their lives as they recover from their injuries.  I meet many spinal cord injured people who would like to believe that they might walk again some day.  The challenge is that all around these people are others that want them to stay "realistic" - to accept that they will never walk again.  So often well meaning observers manage to "kill hope" rather than nurture realism.  Certainly this world requires that we take action in the moment; we can't neglect that.  However, the purpose with which we act shapes the way our world becomes.  Without mankind stretching what is possible and believable we would still be living in caves.

Here is a nice story from Kensho Furuya (Kodo - Ancient Ways)

The Master said, "Think about this.  I have here two small wooden boxes of the same size."  Holding up the boxes one at a time he told his students, "Listen. When I knock on this one, a loud sound resonates around the room.  When I knock on this other one, there is hardly any sound at all."

"Now tell me, from our experience of such things, what do we already know about the loud-sounding box?" asked the Master.  The students understood that the box was empty.

"And what do you make of the quiet box?" asked the Master again.  The students recognised that this box was full of something.

So the Master posed a question.  "Tell me, with human enterprise in mind, do we use the lessons of the wooden boxes?"

A student answered at once, "We certainly do not, Master.  We only take notice of who makes the loudest noise.  We don't pay attention to the quiet one."

A second student spoke up.  "I can see what you are suggesting but in our democracy the majority rules.  What the majority believes is desireable is supported and will grow in influence as a result."

"I agree," replied the Master.  "But keep in mind that the value of an idea or of a belief is is not determined by how many people believe it or choose to follow it."

In times gone by the majority may have believed that the world were flat or that the sun moved around the Earth.  The majority idea it didn't make it a fact.

There may be a deeper truth that is separate from the ideas of majority and minority.  If this truth exists it will lie within each of us awaiting cultivation.

Using Tailwind when the User has Limited Arm Movement post-Stroke

Tailwind is an arm rehabilitation training device that stroke survivors can use at home to recover gross arm function.  I've wrote about this product before as we have been enthusiastic about working with it in the UK.  Despite the product having an excellent evidence base, we still do come across clinicians who are skeptical.  All too often, rather than study the evidence, clinicians speak from their past experience and manage to kill the hope and belief of patients before they even get started.

Tailwind is not a silver bullet of course. It needs to be set up and used correctly and with consistency.  In the USA where the device is manufactured, their experience is that every single user can report positive gains after using Tailind for two weeks. This  is entirely consistent – in two weeks, users will see changes—such as being able to lift the arm overhead which they never did before, putting a coat on, being able to swing the arm at the side naturally while walking.

It's important to get off to a good start using Tailwind and for many users this means dealing with a weak wrist that can prevent many users initially from using Tailwind effectively.

Here are some some guidelines for this situation

1. Hand/wrist support. Most of these users will require at least the hand strap in order to hold onto the handle, and some may also require a soft splint in order to keep their wrists from buckling. A soft wrist splint is suggested, and the user should be reminded not to become dependent on it. It should only be used for a short time.  Avoid moderate and firm wrist supports. Use the soft to mild support to make the wrist align with forward movement, but not to weaken overall wrist muscles.

2. Elbow support. It may be necessary for the therapist or caregiver to gently guide the elbow of the user for the first few weeks of exercise, until the user can do the movement on their own. Gently supporting the wrist by placing the caregiver’s hand under the wrist may also be necessary, at first.

3. Length of movement along the track. Some individuals may only be able to move the handle ½“ to 1" along the track. Do not be discouraged by this – the goal is to learn the exercise and practice it repeatedly.  Start low and go slow.  It may be best to start off with this small movement only, with just the affected arm.  After the user is comfortable with this movement, then the other arm may be added, then the metronome.  Trying to do the complete movement in the beginning may be very challenging for some users – just focus on the affected arm, then add the other arm, and build up to using the metronome. Proper posture and movement is important.

4. Other suggestions
• Make sure the user’s chair is high enough so that the arms and wrists clear the pod
• Make sure the user is not too high which can cause downward weight on tracks
• Have users do mild arm stretching for a few minutes prior to using the device
• Have the user change their grip from the top of the T-bar to the side of the handles. This will
allow a lower grip to extend arms outward

After a few sessions, the user should be able to move farther along the track, and eventually do the
exercise without the wrist support. Users with even a small amount of movement can be helped by the Tailwind.

 

 

Visit to Pace Rehab - An Excellent UK Prosthetic Rehab Centre

Too often I see that we do not give rehabilitation the attention it deserves in the UK.  Most of us have no idea of what such services could or should do for us until we have a personal need.  Even then, when we have the need we do not truly know what is possible.  We trust our clinicians to guide us but what are the beliefs that underly that guidance?  As we recover from amputation, stroke or other condition we are likely to have many years of life ahead of us; we would all prefer these years to deliver a decent quality of life but too often that's not the case. 

The fact is that NHS can't live up to our expectations for rehabilitation - the resources are not there - and increasingly clients who are able will find alternative ways of not only meeting their needs but exceeding their expectations.

Im just back from spending the day with PACE Rehabilitation in Cheadle near Manchester.  Their ethos in delivering prosthetic rehabilitation is about providing benefits to clients rather than just meeting their needs.  There is a vast difference between simply meeting peoples needs and equiping them for a full and happy life.  They work with clients to understand their hopes and dreams and work with them mentally, physically and technically to bring about great results.

PACE was started by an old friend and prosthetist Toby Carlsson along with Consultant in Rehabilitation Medicine, Earnest Van Ross.  They are very passionate about what they do and it shows.  Toby describes the work they do as "a priviledge".

At yesterday's referrers meeting we saw demonstrations and presentations to showcase the work done by PACE.  In addition to hearing from Toby and Earnest, we had presentations from Sue Turner on the counselling and the "buddy scheme" aspects of their work.  Howard Wolley demonstrated prosthetic cast taking and limb alignment whilst physiotherapist Carolyn Hirons involved us all in demonstrations of physiotherapy techniques for gait and improved function.

Colin Lynch, Paracycling World Champion, gave a very interesting presenation and demonstration that described how PACE had worked with him to imporve his cycling prosthesis. Taking him from top 10 to number one in the world.  Alan Roberts, a bilateral amputee following military trauma shared his rehab experiences with us to complete the day.

I have no vested interest in PACE - and I highly recommend them.

Client Daniel Eley Heads Back to Columbia

Our client Daniel Eley, 33, was working with disadvantaged children and teenagers living on the streets in Colombia when he broke his neck on New Year's Day 2010.  It was the internet that came to Mr Eley's aid in the wake of his accident, as more than 8,000 people from around the world joined a Facebook appeal group to help him.  We wrote about him here at the time.

Undaunted by his accident, Dan now has an ambition to forge ahead with a new charity to continue his humanitarian efforts.

I've posted a short clip of an interview with Daniel by the BBC, last week.  It does show him using our RehaMove FES Cycle.  Despite his spinal cord injury Dan is off to Colombia and on his return, in November, he will be doing a sponsored "ride" around Great Britain to raise funds for the Spinal Research Institute.

 

Help for Clients - and Helping Ourselves

We have set up a new support site for the business using Zendesk.  It seems quite simple to use so Im hoping that it will be a very useful tool for us on a few levels and become vital to customer support in the long term. 

As our business has grown - more products - more clients - more locations - its become really important to have a way of capturing some of the knowledge and problem solving expertise we have and put this in a central location.  It's also vital that we have a way of tracking and dealing effectively with any issues that clients have. 

Once upon a time my partners and I would be totally "hands-on" but after a few years of weekend and holiday "emergency" calls, the novelty of that approach starts to wear off.  And you know what, these days with Smart Phones we are never far away from that email or voice mail.  Just a week ago I was in the Cairngorm mountains on holiday-  and still trying to email a client and fix an issue.  I don't find it all that stressful but I cant say it's nice for family harmony.

There is another issue too.  One day we will wish to exit from the business and hopefully someone will want to carry on.  How much easier that will be if we have robust and useful support processes in place.

http://acuk.zendesk.com/home

Henry Ford and physical rehabilitation

Rehabilitation after spinal cord injury aims to restore each person to their physical potential.  Nevertheless, I have been in this field for around 40 years now and I still see that this rarely happens.  Im not blaming anyone but I do feel that a change in thinking and attitude is needed for rehabilitation to truly live up to its promises.  

You know how it is.  Recovery from spinal cord injury is a great personal challenge requiring many adjustments to previous patterns of life.  Medical science provides terrific acute care through the NHS but many people quickly grasp that maximising their rehabilitation is going to have to be their personal responsibility - or it's not going to be great.

Who’s job is rehabilitation anyway?
Let me ask you something. 

Is rehabilitation something that is simply done to us - or is it something we should participate in and even shape to our own individual aspirations?  It used to be that rehabilitation was a process that “swept us along” and usually without too much influence over where we could finish up.
 
Of course the NHS would say that care is already highly individualised - but I suppose it is a matter of degree.  Having spoken to hundreds of people who have been injured they are often delighted with their overall care but less than satisfied with how their time in the spinal units truly equipped and developed them for the longer term. 

Within the NHS, someone’s level of spinal cord injury creates an expectation, based on clinical consensus and experience, of what that person is likely to be able to achieve in terms of functional independence.  This naturally gives shape to the individual’s therapy plan and once that plan is completed the “system” can do little more.  This in some ways is an entirely rational approach to a situation where NHS resource is limited.

What we are learning though is that given the right tools, the investment and the effort, individuals can actually achieve far more fitness, independence and quality of life.  The NHS wants to spare you from unrealistic expectations, but sometimes manages instead to kill hope.  These limited expectations are based on past-experience but as new ideas, technologies and approaches emerge then these process-driven ways of thinking and acting can limit what is possible.

Many years ago, Henry Ford demonstrated that producing items such as cars in large, identical batches, was a good idea.  It was efficient and effective.  Mass production brought consistency - the Henry Ford quote that “You can have it any colour so long as it’s black”, just about sums it up. 

However, society moved on and our expectations for products and services have grown too.  We don’t just want black anymore.  We want the best available and to feel that our individual needs are welcome - not somehow an inconvenience.  This societal trend is common to most developed countries, is very relevant to health care, and these trends will accelerate. 

Nature always acts to fill a vacuum.  If patients didn’t get their needs met within the system the natural tendency has been to network and learn from each other. With technology lubricating the process this activity is reaching new levels and new models of care are emerging.  For example, the US Society for Participatory Medicine brings together patients and health care professionals on-line.  The idea is to create a movement in which

Patients shift from being mere passengers to be the responsible drivers of their health; a movement in which care providers encourage and value them as full partners.

Ok so here is an obvious thought.  Why can’t rehabilitation be much more personalised? More about customisation around the needs of the individual and less about mass production?  What products and services are there out there to help me enhance my personal abilities and life satisfaction?  To think this way offers the prospect that many more persons can truly achieve their full potential.

Molecules of Emotion

We are all designed, as human beings, to respond to change as if our lives depended upon it.  Often our lives do depend on how we respond.  Change has effects that ripple not just through the structures and processes of an organisation, but down to the level of a single cell in each of our bodies. 

When we actively feel something, it is truly engaging our whole physiology and not just our thoughts and imagination.  Science tells us that every single cell in our body is influenced by our feelings through our nervous system and the flow of our “molecules of emotion”.  Candice Pert (1999) came up with this term to describe the many hormones within our body that literally act as a chemical nervous system having the power to make us well or make us ill.

In this article, we step back a few years to glimpse how science once viewed human physiology, before we can pin down why this is relevant to us.

Communication begins and ends with a single cell
It’s common knowledge that the computing power inside our skulls greatly exceeds that of any supercomputer in the world.  But for decades people thought of the brain and its extension, the central nervous system (CNS), as primarily an electrical communication system.  The CNS seemed to function in a manner not too different from the semiconductor-based electronic computer. 

It was common knowledge that the tiny neurons, or nerve cells, form something resembling a telephone system with miles of intricately criss-crossing wiring.  The dominance of this image in the public mind was due to the fact that science only had convenient tools to see and study the electrical signals.  Only relatively recently did we develop the tools that allow us to observe what we could call the “chemical brain”. 

Candice Pert coined the term molecules of emotion to describe the flow of chemicals that make up this very special part of us.  Even when we had the evidence, it was hard for science to grasp the idea that we had this second nervous system; one that operated on a much longer time scale and over greater biological distances. 

Especially difficult to accept was that this chemical-based system was indisputably more ancient and far more basic to the human organism than the one we had studied before.  There were peptides such as endorphins, for instance, being made inside cells long before there were dendrites, axons, or even neurons – in fact - before there were brains. 

Since the 1980’s, scientists have been abe to talk of information molecules – the basic units of a complex language used by cells throughout the body to communicate across systems such as the endocrine, neurological, gastrointestinal and even the immune system.  Our bodies literally listen to our emotional state and respond accordingly.  In this respect thoughts are things.

Hundreds of hormones flow through our bodies because of our emotions and then our bodies will ultimately manifest the consequence of those feelings.  Sad feelings actually produce sad bodies.  Depressed feelings produce depressed and ageing bodies and happy feelings produce healthier and youthful bodies.  This is important because it implies what science confirms.  In the developed countries of the world, the three things that kill most people – cancer, heart attacks and stokes, are linked to how we respond to change.

The human body is a dynamic, constantly changing system in it’s own right.  A Greek Philosopher said - “You cannot step into the same river twice – new water is always flowing in”.  In fact, science now knows that our bodies are very much like that river.  In every second of your existence you are creating a new body.  Every year you replace 98% of the atoms in your body. You make a new liver every 6 weeks, a new skeleton every 3 months, a new stomach lining every 5 days and a new skin once a month.  Even the very brain cells you think with today weren’t there last year. When faced with stress we are influencing how that change takes place.  The organisational response to change is echoed by a response within the living cells of each member the organisation. 

Did you know that our physiology has hardly evolved since sabre tooth tigers roamed the Earth?  In those days our “fight or flight” physiology equipped us very well for survival and allowed our hormones to naturally achieve balance once a threat was relieved. 

In comparison, the environment in which we must live and work today changes unceasingly.  A swarm of emails, aggressive or demanding colleagues, sales targets, more plans and pressure to perform, an unreasonable Board of Directors, and so on have replaced the sabre tooth tiger. 

The trouble begins because even though these daily demands may not be consciously perceived by us as a threat, their effects can still be profound.  This is because our bodies just might tend to respond in a way that true balance is rarely achieved.  These stress hormones may feel temporarily energizing but when they circulate for too long they promote symptoms such as aggressiveness, impatience, anger and insensitivity. Not exactly a recipe for good health or effective leadership. 

I know plenty of carrot and stick entrepreneurs. They believe and act to gain and keep control.  In some cultures, this is still a persistent view of what it takes to lead; unconsciously built on the fact that stress hormones may actually be addictive.  However, work with such an adrenaline fuelled feeling for too long and business performance, relationships and individual health will suffer.

The good news is that it is not necessary to withdraw from work and life to achieve balance again.  Our body does have the ability to achieve balance in real-time and the key is in recognising when stress is at work for us and in learning techniques to adjust our own state.  Leaders therefore have a particular responsibility and a great opportunity.  A single word can have great impact.  A misplaced gesture or inappropriate tone from a leader can add to the turbulence and the perception of stress of hundreds, perhaps thousands, of people.

When leaders learn how to manage their personal state they can be calm and balanced in the most turbulent business conditions.  Such calmness and balance also brings clarity of thought and the opportunity to speak and act clearly and confidently. 

Science tells us that in our times of greatest stress our ability to think clearly is compromised – we are literally disconnected from the ability to be creative, thoughtful, intelligent or reasonable human beings.  When we can learn to be calm and balanced and in the right state others will entrain to our coherent words and actions.

Perlow and Williams (2003) point out that even silence – lack of communication – can set in motion powerful, destructive forces.  Referring to “vicious spirals of silence” the authors point out that often – behind failed products, broken processes, political wrangling and mistaken career decisions, are people who chose to hold their tongues.  Breaking the silence can bring an outpouring of fresh ideas from all levels of an organisation, potentially taking performance to a whole new level.  Leaders need to do better.

On a brighter note, Frans de Waal (2003) author of a book on “Chimpanzee Politics”, also hints that leadership just might have other privileges.  He describes the contests for leadership amongst male chimps in a Dutch zoo.  The contests appear to be mainly about the ability to build a coalition of supporters and to outwit rivals rather than anything to do with size and strength. 

Michael McGuire, a neuroscientist found that high ranking monkeys had high levels of serotonin – one of those natural chemicals associated with feelings of calm, well-being, confidence and general absence of stress.  The high level of serotonin appeared to be the consequence rather that the cause of the attainment of high rank.  When a leader was removed from the group his serotonin levels crashed.  As a new leader emerged, his levels started to climb until they were twice that of the next dominant male.

We aren’t going to stop change but we can learn to notice and influence its effects upon us.  From this balanced foundation, leaders can communicate coherently and effectively.  Balance is an important word.  It implies a position of effortless, stillness from which it is possible to move instantly in any direction. 

A senior manager in the pharmaceutical industry commented on an early draft of this document and told me that one of their key organisational values for leaders was a “sense of urgency”.  But what happens when everything is urgent?  Sometimes the most urgent thing to do sometimes is – nothing.

Leaders are masters of balance.  Sensing the time to act and the time to do nothing as well as understanding that they provide the leverage from which a whole organisation can turn.

References
Frans de Waal (2003) quoted in “Creating Leaders” from The Economist, “Tough at the Top – A survey of corporate leadership”, October 25th 2003, p 8

Perlow, L; Williams, S (2003), “Is silence killing your company?”, Harvard Business Review, May 2003, Vol. 81, Issue 5, p 52

Pert, C (1999), “Molecules of Emotion: The Science Behind Mind-Body Medicine”, Simon & Schuster, ISBN: 0684846349

The Crime of the Peach

Most of us - most of the time - choose to look at the world in a way which will best suit our self centered convenience at that particular moment.  And we mistakenly believe that our view is authentic and the views of another are false.

Long ago there was a powerful Lord in China who was blessed with an extremely loyal minister.  One day an urgent message arrived to inform the minister that his mother had fallen seriously ill.  The minister rushed to his mother's side in his masters carriage.

Unfortunately, this was actually a serious crime - punishable by having both feet cut off.

However, when the Lord was informed of his ministers actions, he declared, "What a wonderful minister, to be so concerned for the welfare of his mother that he risked losing both feet as the price for using the royal carriage!"

Some time later the minister and his Lord were in the royal gardens.  The minister picked a peach from a tree and upon biting into it, found it so delicious and sweet that he immediately offered it to his lord.

The other ministers were shocked that he had offered a half eaten peach to his lord - but yet again the lord was impressed and immediately praised the minister for his actions.

However, eventually the lord and his faithful minister had a falling out over some minor thing.  The lord all of a sudden recalled the events of the apst in a different light.  "How dare he use my carriage to see his mother and how dare he offer me a half-eaten peach - Guards! execute him at once!!"

As this story illustrates, it is as well to remember that our view of the world and it's events is shaped by the attitude we use to perceive it. 

Most of us - most of the time - choose to look at the world in a way which will best suit our self centered convenience at that particular moment.  And we mistakenly believe that our view is authentic and the views of another are false.