Therapies in action

NR Times learns more about the role of speech and language therapy and physiotherapy combining to support patients at Nottingham Brain Injury Rehabilitation Centre to exceed expectations, regain independence and rebuild their lives

In supporting a person to rebuild their life after brain injury, or in the event of neurological illness, the input from the multi-disciplinary team and their specialism across a breadth of aspects of neurorehabilitation is vital.

Two of those disciplines, physiotherapy and speech and language therapy (SLT), can work particularly closely, supporting each other to restore some of the independence in communication and movement which can make such a huge difference to a person’s life.

At Nottingham Brain Injury Rehabilitation Centre, SLT and physio work together on a daily basis with clients across its residential, slow stream rehab and high dependency units, supporting them from the very earliest stages of recovery to secure outcomes often beyond all expectations.

The impact of the individual disciplines can be powerfully felt within the wider rehab picture – both as inpatients within the centre, and as outpatients, with the re-launch of its specialist outpatient service – enabling clients to establish the channels of communication and movement which will allow them to move forward.

Eden Akiatan

“We work with a very complex client group and are dealing with cognitive impairment. It’s essential that from the start we establish communication in whatever way we can,” says Eden Akiatan, a senior neurophysiotherapist at the 59-bed centre, owned by Active Care Group.

“For this reason, we work hand in hand together with SLT. Once we have that communication, then we can engage with them.” “It’s building that relationship and building the trust,” says speech and language therapist Nicholas Sobieraj.

“The more we can work together as an MDT, the more we can support them in their recovery.

“Often our patients come to us and they can tolerate five minutes of something, sometimes not even that. So by working on different aspects of therapy you can build the tolerance. Over time, you suddenly realise they can now do something for half an hour, even an hour. And it’s about giving the support for them to get to that point.”

Eden adds: “We want our patients to live their lives, that’s what we want to help them achieve. I always tell them ‘Let go and just live’. Live your life and do what you love.

“That’s our aim, to help them to get there, and working together we can help them to do that.”

Sarah* arrived at the centre in a minimally conscious state after a left-side stroke which left medics fearing for her future. After discharge from hospital, Sarah, who is in her 50s, was unable to communicate and had severely limited movement on her right side. She also had a tracheostomy in place.

Progress was slow, with no major improvement for over a year. But while Sarah’s rehab potential may have been questioned by some, for Eden, Nicholas and the Nottingham team, they resolved to continue rehab and wait as long as it may take to support Sarah in achieving the long-awaited breakthrough.

“Even during the time we were seeing no progress, we continued to work,” says Eden.

“We did a lot of bed exercises. We supported the rehab assistants in working on a passive range of movement, we worked with the occupational therapists to do hand work and upper limb work.

“Even if you can’t see them responding, we keep believing that the bits we are doing will add up to something.”

And the persistence of the MDT paid off, with significant improvement coming suddenly, after more than a year of Sarah being at the centre and in a minimally conscious state.

“It was sudden, but then we had the momentum. And from there, she was able to do more of the things that we’re asking for,” says Eden.

“We were no longer doing the passive work for her. She was doing more and more herself. The momentum in therapy really picks up.

“Everything we do is based on the individual person’s tolerance and endurance, working within their capability and levels of fatigue.

Fatigue can be very difficult, but by working at a pace that is right for them, we can make great progress.”

Sarah’s tracheostomy has also been removed and she is managing well with her consumption.

“We worked with her as an MDT and looked at deflating the cuff, we considered very carefully when was the right point in her rehab journey to do this. We trialled removing the cuff and monitoring her saturation levels so they didn’t decrease too much,” says Nicholas.

Nicholas Sobieraj

“This went well so we started to look at eating and drinking again, starting really slow with teaspoons of water then building up from there, really working on the swallow – the more you’re able to practice it, the more it will improve.

“We cautiously monitored everything over the weeks and months, and she is now on a pureed diet. The goal is to improve as far as we can go. We have reached a point where things have been constant for a while, but that is not to say things will not improve further.”

Physically, Sarah is also making great improvements in her right side strength.

“She still uses the hoist but she has made good progress with the upper and lower limb. Initially when she came to us she had no movement on the right side, but now she can fully use her right lower limb and can pick up with her right hand,” says Eden.

“When sitting, her balance is brilliant. She can sit independently on the edge of the bed for 30 minutes and she can also do sit to stand with us.”

The motivation seen in Sarah, alongside the support of her family have been key factors in her strong progress.

“She can now have conversations with her family and has a much better quality of life now than when she first came to us,” says Nicholas.

“She is very motivated and wants to progress, which does make a difference, alongside the fact she has a very supportive family. They give us a lot of feedback and we have very open channels of communication with them – if there is ever anything they want to raise, they know they can discuss it with us.

“If they aren’t visiting, they’re video calling every day, which really helps with the cognitive side of the recovery as well. The stimulation from the family and the familiarity are very important.”

While two years ago when Sarah came to Nottingham, the outlook was very uncertain, now the topic of discharge is being considered.

“We will always work with the family in achieving this, and the family in this case will be ready to give the support that is needed,” says Eden.

“But when we look at discharge back home, we will do a home visit to look at whether the home is appropriate for this person’s needs. We need to make sure we are discharging with the appropriate support there. We can make referrals to community teams if there are needs that need to be met.

“But with our outpatient service, we can always be there with further rehab, if a person maybe still needs some physio or OT input. That way they can be independent, but with the support when they need it.”

Committed to person-centred therapy Working across the three units at the centre – Millwood, which specialises in slow stream rehab; high dependency service Fernwood; and Hazelwood, the residential care service – the needs of clients in therapy can differ greatly.

But from the very earliest point, the approach to person-centred care and rehab is the same, whatever a person’s level of injury or need.

“We will always do what we can for the client and their needs and interests,” says Eden.

“We recently bought a boxing bag because one of our clients used to go to the gym before the injury. He was a bit apprehensive when he came to us, there was a lot of anxiety around him engaging.

“So one way of getting the most of our people is engaging them in something they really enjoy. We bought the boxing bag for him and he is loving it.

“It’s great for him because it’s working on the upper limb, working on the standing tolerance, working on the core, while at the same time working on the cognitive performance and cognition. You’re able to look at the entirety of the person, which is the approach we like to take.

“For this client, just as one very recent example, this approach has worked very well.”

Nottingham has a range of support mechanisms available to help clients, from assistive technology and eye gaze devices, through to cutting-edge sensory equipment to give feedback on posture and movement. This is in addition to the expertise of its in-house therapists, nurses and rehab assistants.

“The needs of people in Millwood can be very different to those in Fernwood, there can be a very different level of communication difficulties, but all of our sessions are designed on getting to know the patient and support them as best we can. It’s very bespoke,” says Nicholas.

“This starts from the very first point, when we will do an assessment from head to toe,” says Eden.

“Cognition, orientation, movement, communication, everything is assessed. We work very closely with SLT and OT to establish the impairment, usually mostly cognitive impairment, and work out how we go forward from there.

“We will consider every way in which we can progress. It might not be quick, but we’ll look at the techniques and equipment we can use to support that. We want our clients to engage with us and communicate with us in whatever way they can – and from that relationship comes progress.”