An interview with Colin Green: Neurological Physiotherapist

Ashwini Kamath: Hello and welcome to Brain Injury Bites where we provide help and advice for people after a brain injury. Hi, I'm Ashwini and I'm a trustee at Headway Warrington. I'm also a senior associate solicitor focusing on catastrophic injury including brain injury.

Brooke Trotter: My name is Brooke and I've lived with a traumatic brain injury since 2007.

Ashwini Kamath: We're absolutely delighted to welcome Colin Green today to Brain Injury Bites. Colin is a neurological physiotherapist at PhysioMatters in Oldham. Colin, would you perhaps like to introduce yourself to our listeners?

Colin Green: Of course, and thank you very much for inviting me to come and speak today. It's a pleasure to just get the message out about neuro rehab and brain injury.

My name is Colin Green. I qualified as a physiotherapist back in 1992 and worked in the NHS for eight years. And then started to think that there was perhaps a little bit more that I could do for clients and that we could do for clients and telling people that they'd achieve the potential when really there was so much more that could be done.

So my real interest is in longer term rehab, managing long term conditions. So I feel really privileged now that we've got a fantastic team that was set up in 2000. So we've been going 23 years now and we've got a team of 15 of us based up in North Manchester and we provide treatment across the Northwest for people who have acquired brain injury, so that may be traumatic brain injury, or stroke, or head injury, or Parkinson's, MS. So a wide range of conditions, but my particular interest is brain injury.

Ashwini Kamath: So you were in NHS practice beforehand, was that more on a general physiotherapy sort of route? And what brought you into neurological physiotherapy?

Colin Green: That's a really good question. Because initially when someone comes into physiotherapy, they feel they're going to be the physio for Manchester United. Everyone's going to be the physio for Man United or probably Man City now.

Ashwini Kamath: There are other football teams available!

Colin Green: When you first qualify as a physio, you do everything.

So you go around every three months on a different speciality. And I soon realised that the areas I wanted to work in were longer term rehab. So it was neurological rehab. It was amputee rehab. It was complex orthopeadic trauma. So quite soon I started to specialise, which is fairly unusual. But then over my eight year career, by the end of it, I was a Senior One, which would now be a band seven physiotherapist setting up a community neuro rehab service in Oldham, but it felt like it, you could do so much more. So yeah, in answer to your question, it is a general education to start off with and then you get more and more specialised. And I did my master's degree as well since that. I went back into study 15 years after qualifying.

Ashwini Kamath: Wow, okay.

Brooke Trotter: That's the problem with brain injury, isn't it? Because it can keep, I don't know how to say this, but with the NHS, they, you know, they can only take, due to, you know, funding restrictions and so on. They can only take you so far, but it's one of those things you can keep having treatment for the rest of your life, really, because it's something that you have to live with.

Ashwini Kamath: Yeah, it's not going away, is it?

Colin Green: Yeah, that's really good, Brooke. It is that ongoing, it is a lifelong condition and there are, there are different phases, which I'm sure we'll talk about later, different phases of treatment. But yeah, the problem doesn't go away, but a lot of the work is it's treatment, but it's also management of a condition - How do you manage your condition? How would you move forward with that condition? And certainly, my experience of when I worked in the NHS back in the past was from a kind of the initial acute setting when someone's in intensive care is fantastic. But kind of after that, people who've had traumatic brain injury don't really sit anywhere in the hospital.

So are they an orthopaedic injury? Probably. Are they a psychological - is there psychological components? Definitely. Is it possibly psychiatric elements of it? Yeah, there could be. Are there behavioural issues? Quite possibly. You know, are there wider family issues? Are there, and how are all these different conditions?... There may be respiratory issues.

So it's kind of where does that patient at that point, where do they sit in the hospital? And it was always quite a difficult thing for someone who had a traumatic brain injury, where do you put them?

Ashwini Kamath: Yeah, it's multifactorial, it's not a single issue, is it? And that kind of leads me a little bit to just for the benefit of our listeners, if you could just explain the difference, or rather what neurological physio is? Because I think most of us when we think about physiotherapy, you know, we do think like somebody's broken their leg, it's rehabilitating the mobility back into that or, you know, arm, whatever. But how do you work with patients with traumatic brain injuries? Or other neurological conditions?

Is there a sort of an interplay between what's going on in the brain and the sort of physiological issues?

Colin Green: Certainly, I mean, the big overarching heading for the kind of brain injury rehab would be multidisciplinary. That it has to be… If you're a physiotherapist treating someone on your own with none of the other professions, you're going to probably struggle.

And that's where we're really privileged now that in every team we work in, there is a multidisciplinary team involved, but yeah, coming back to the, I suppose you could split it into three phases.

So you've got the acute phase straight after your injury. So that's from ambulance to possible surgery, intensive care through to high dependency and going on to the acute ward.

So that would be the first phase and the next phase will be the sub-acute. So you're still in hospital, but looking at plans to go home. So what's… or to go wherever you're going to be going.

And the third phase would be that chronic phase, which I don't really like. I'd rather use the word long term - that you're looking at how to manage someone's condition.

And then you've possibly got a fourth phase of kind of adjustment and condition management in the longer term.

So if we discuss the acute phase to start off which is the intensive care, the physiotherapist there would be looking at, with their experience, spotting problems that could occur in the future So for me that would be… a big one would be preventing any contractures that are happening So if you're on intensive care, the priority is obviously to preserve life at this stage. It is to create the best, I'm going to use you as an example, the best Brooke to be able to work on in the future. So we need to make sure that all your limbs are moving, that you've got the range of movement in all your limbs, so that later on, there's something to work with. Because if you're really contracted at that stage, there's a lot of undoing.

Ashwini Kamath: Yeah. Just explain again, for the benefit of our listeners, when you say contractures.

Brooke Trotter: Yeah, I was going to say, explain for me as well”

Colin Green: Yeah, sorry! So contractures would be a soft tissue shortening. So a good example would be... It doesn't work very well on an audio podcast. But if I was bending my elbow, my biceps muscle, if I kept my elbow in that position, my biceps muscle would shorten in that position. So over a period of time, then straightening your elbow would be difficult.

So that's a really simple, simple idea. But where we find it most commonly after neurological damage is in the calf muscle. So if the calf, especially if someone's been laying on the back, they may have been ventilated and the toes are pointing down to the bottom of the bed. So the calf has been in a shorter position for a long period of time. If you then start looking at sitting, standing, walking in the future, if you've got a really short calf, your heel is not going to touch the floor. So you can prevent those problems or aim to prevent those problems.

Initially, after a brain injury, you often have a period of what we call flaccidity or where the muscles are very floppy. But over a period of time, as you have to do more and the demands on you are more, that floppiness or flaccidity changes to be in high tone. So it becomes tight. So rather than the muscles being floppy, they become tight. And that's where you can potentially get contractures at that stage.

Ashwini Kamath: So I guess the important thing is like early intervention to keep things moving rather than wait for it to become a problem and then try and resolve it.

Colin Green: Yeah. So we, at that stage we'd use stretches. So it might be that your physio or the carers or the staff are doing quite a range of stretches even before someone's conscious.

It may be that you have to use splinting. So that would be where a device is put on you or cast on you where like it could be a plaster of paris kind of cast -they're not quite plaster of paris, but that kind of thing that keeps your foot in a good position.

Yeah, so it stops your toes pointing down to the floor. It stops your calf muscle tightening and also in your arms, on your elbows. It may be that you have splints to keep your arms straight at that point. Really important for the future.

Brooke Trotter: So what happens then if the muscles go hard?

Colin Green: If the muscles go hard and if they go tight? It can be quite difficult to undo. It's much easier to prevent than it is to sort out later on. But if your muscles are tight and if it has gone from a tightness through to a contracture, which is something that doesn't move, it's kind of stuck.

Brooke Trotter: Is that permanent then?

Colin Green: Yeah, but there are ways of dealing with that in the subacute and chronic stage. So it would be things like, you might have heard of botulinum toxin injections, yeah Botox, but a bit higher doses injected into the muscles to relax the muscles and you would use that in conjunction with splinting, like we were saying where you put a device on to give the joints a stretch.

It would be positioning as well, so trying to avoid it happening in the first place. Sometimes, and we have some clients who have to have surgery in the future, but that has it's complications and it has it's pros and cons.

So, what do you remember, Brooke, about the really early days after your injury?

Brooke Trotter: Not a lot to be quite honest, but I tend to lean on my parents and stuff because they've got all the memories of it.

They were talking to me and my sister was saying as well that the physios came in when I was actually still in a coma and did quite a bit of work with me there. I'm not sure what they were doing, but I guess to prevent me just laying there and having no…

Colin Green: Yeah, that would be, that would be really good practice that if they were coming in, doing stretches, making sure you're positioned right.

And perhaps telling your parents, if they could help. Because it's quite a nice thing at that stage to be able to ask relatives to be involved because what else can they do? They feel quite helpless.

Brooke Trotter: Yeah, I think it was quite traumatising for my mum because I was still in a coma when they were doing it.

Colin Green: Mm hmm.

Brooke Trotter: So, that's what you think they were doing, just stretching my muscles?

Colin Green: Yeah. Yeah. So sometimes it can be quite painful and some people who come out of a coma remember some of the pain of the stretches. Yeah, physios would have been coming at least daily.

Brooke Trotter: You get all those stories don’t you of people remembering what's happened in the coma, and they can see a white light and all that, but I can't remember anything.

Colin Green: Nothing that dramatic was it?

Brooke Trotter: Nothing at all!

Ashwini Kamath: Probably just as well!

Colin Green: But more, or quite often, you'll hear someone saying the first thing they remembered. I saw someone yesterday and the first thing they remembered was three months after their injury and they woke up in the rehab center.

Brooke Trotter: That's pretty much exactly what I remember, yeah. About three months after, yeah.

Ashwini Kamath: So you were saying in the acute phase you look at management of, you know, making sure that muscles are being used and stretched and so on to avoid contractures.

Are there any other things that you would be doing at that stage? Or is that kind of the main priority.

Colin Green: No you'd also… it depends on the unit, but sometimes you'd be looking after a respiratory function. So if someone's being ventilated, you'd be involved in their kind of breathing exercises, perhaps some suction, working alongside the intensive care nurses in terms of maintaining airways.

Ashwini Kamath: And just explain why suction is important for our listeners, if you wouldn't mind.

Colin Green: Yeah. When you are being ventilated in it, especially quite often after an injury, you may have broken some ribs. So it will be difficult for you to take those deep breaths, especially some of the lower rib fractures.

So it tends to be that the bottom of your lungs get full of rubbish at this point. So yeah, the top part of your lungs are getting aerated well up here, but the bottom can, you can get a bit of gunk. So…

Ashwini Kamath: Technical term there!

Colin Green: Yeah, technical term! You get sputum on there, which… But then you need to be able to get rid of that because it makes your lungs much less effective.

Ashwini Kamath: And I suppose there's also, it's managing risks of chest infections.

Colin Green: Yeah. And that's where the dieticians come in as well. And the speech and language therapists in terms of managing. It's a little bit later on, but managing diet, because at this stage you may have a problem with your swallow. So it may be that if you take in any oral diet, that it's going down the wrong tube.

So you don't want that lying on your lungs. So suction sometimes, we would use to get rid of that stuff while you're still asleep on the ventilator.

Brooke Trotter: It's quite grim that though, isn't it?

Colin Green: It's a long time ago thought, isn't it?

Ashwini Kamath: So after you treated a patient in the acute phase, how would the physio journey change in the subacute phase?

Colin Green: Yeah, so in the subacute, so I would say that's when you're out of kind of medical danger. So when you're, and you... Like you said, you, you start to develop more of a consciousness of where you are, of what's going on, of what's happened to you, and you're at this stage, you would often be still looked after, so you still are being transferred…

This is probably the time where you start to remember things, so it, you may be having to be hoisted you know, from the bed to a chair, you may be unable to sit. So we'd work on how you do those transfers, how you sit, how you stand how you do that transfer from bed to chair, bed to toilet. And those kinds of things are really important at that stage.

And it's quite often, I would say the probably heaviest workload for a physiotherapist in terms of manual handling, you know because you may have very little active movement to keep yourself sat up and you may get fatigued very quickly in terms of if you sat out in the chair, it might be for 10 minutes and that's enough to be able to go back to bed.

This probably seems a long way ago…

Brooke Trotter: I do you have sort of memory of that? When people were saying, you know, don't walk and stuff, and I was like, I think I was just confused at the time, like what are they talking about, I can’t walk, of course I can walk, and I walked, which this is not again, not good for audio, but I walked to like the corner of the room where there was a, you know, those hospital chairs. And so I'd walked, which would probably be about 10 paces and it was waddling, you know, just sort of staggered and more or less collapsed in the chair and I remember being absolutely exhausted from doing that.

Colin Green: Mm hmm. So was that a positive experience?

Brooke Trotter: I think it was, yeah. You just didn't really understand like why I was, I mean because I was… Luckily, I’d got into the gym before my accident, and I still have sort of memories of that. I thought I'd be, you know, I thought I was as strong as I was. And I suppose it was like a big element of shock that I wasn't, and people were telling me, you know, just, you know, be careful, and you know, I didn't really like to be told that, and I, just in sort of frustration, I got up and walked, and just, yeah, I just remember having to, having to go to bed after that, because it was just so exhausting.

Colin Green: You’ve brought up some really good points there, because there will have been quite a lot of work that happened before that memory. So before your memory there. So you've already described that you were sat in a chair. That you were able to get out of a chair. That you were able to stand up. That you were able to move across. So there would have been work on how did you sit? How did you manage to get from the bed into the chair? So there's all those parts of work prior to it.

Brooke Trotter: That I just don't remember. Yeah.

Colin Green: But what's really interesting is that, as you've said there, I was told not to walk. Can you think why you were told not to walk at that point?

Brooke Trotter: I just can't remember, really. I don't know if anybody specifically said to me, don't walk. I was just like, it was not… That might be my mum and dad, I don’t know.

Colin Green: Because when I qualified, they used to say, you were… We used to stop a lot of people walking right early on. You'd be saying, Please don't do that. Please don't. And it was because they weren't doing it perfect. So we didn't want bad movement patterns to be reproduced. But we'd go around the ward saying, No, sit down you, sit down, don't get up, don't get up. Don't, you'll spoil everything that we've done, you just stay there. And obviously now we’ve realised, that's an unrealistic expectation. That people have to, after hospital, have to go and live in the world and they'll do whatever they like. So, but your safety may have been a prime concern there.

Brooke Trotter: I'm sure it was, yeah. You just don't like to be told that you can't do something! I was 24 at the time, you know. I didn't really, didn't really understand. I remember people telling me what had happened to me, but just not really believing it. And I thought, not that they were lying to me, but they were just like, I just, I thought that they'd got the wrong end of the stick or something and just not really understanding why I was in this hospital.

Because I'm from a small town, Scarborough, and people were saying hospital. So to me, I've only ever known one hospital, it was Scarborough Hospital. So I always assumed that I was in Scarborough Hospital, and they took me once downstairs, outside at Hope hospital it was called then, but it’s Salford Royal and just being really confused and like...

Colin Green: Did you wonder where the sea had gone?

Brooke Trotter: Yeah. And just like, what's going on here?

Colin Green: We're not in Scarborough anymore!

Brooke Trotter: No absolutely not, so urm.

Colin Green: No, but that's... Why would you know where you are? Because probably a room in Scarborough Hospital would be very similar to a room... It's only when you go out there that the disappointment starts.

Brooke Trotter: I had this memory of, because I was in hospital, I'd done this stupid thing. I'd jumped off a hay bale a couple of years before and I'd broken my ankle. And I spent the night in, I was having an operation, I spent the night in Scarborough Hospital. And I'd, in my head, that I was in the same room or very sort of similar part of the building anyway because, to look out the window, I couldn't really see much, you can only really see the sky. So I just kind of assumed that I was, assumed that I was in there and then yes, to be taken outside. It was quite a shock to me, but you know, obviously pretended I'm not shocked, all was fine. [00:19:20]

Colin Green: But that's a common kind of experience that you're saying about feeling that this… either it isn't happening to you or it's another orthopaedic kind of, I've just broke something, which we quite often have with clients, but we really have it quite a lot with relatives who think it's just something else that's broken. It's another broken leg. It will get better. And it might be that you've got broken bones and they will get better.

But I try with our clients to reinforce quite early on that you will be different. This will always be different. It doesn't mean it's going to be bad but it will it will be a… we had Brooke one before the injury and we've got Brooke 2 now.

Brooke Trotter: I just didn't, yeah, just confusion, just didn't really understand what had happened and obviously now I've, you know, got the benefit of hindsight of, you know, all that stuff I've learnt about it and I've read about it and stuff, but then I just, I just, just confused and I just thought at first, you know, am I visiting somebody in hospital because I didn't really feel like anything was broken or anything, you know, I was obviously in no plaster, you know, plaster casts, and it was just… All I can just only think I can describe it as a massively confusing time with obviously pretending to know what's going on and…

Colin Green: And this is a time where we get lots of falls. So people think no, I'm fine, off we go… bang, or I could do that, crash... you know, and because the very fact of someone having a lack of awareness means their attitude to risk is very different because ‘there's nothing wrong with me’. So obviously I can go up and do this. And it's a long journey to kind of accept what's happened.

Brooke Trotter: I fell pretty badly in hospital actually. In the middle of the night, I got up and I stood up on my bed. And obviously there's a bed guard, isn't there, that comes to the side. And I tripped over the bed guard and I'd fallen, I'd fallen on my elbow, which luckily nothing was broken, but it's still a bit, it's a little bit dodgy now, but…

Colin Green: But you'd had 24 years of nothing being wrong. To wake up one day and I'm not quite as mobile as I used to be, then your brain initially thinks No, I can still do that’ and that's why you have the accidents.

Brooke Trotter: I think what probably happened was I woke up and I needed the toilet and there was these guards on so I probably tried to climb over it. Looking back that's probably what happened but then again I don't have a clue what happened so...

Colin Green: Yeah, that's not, that's really not uncommon and often in this kind of subacute phase moving into the longer term phase, the more mobile someone becomes, the more likely they are to fall in that period, especially if someone has a poor insight or a poor awareness into their limitations.

So for some clients, it would appear that their condition actually deteriorates a little bit. Or, especially if they've got limited cognitive function, do you know, if they're struggling to process the information around and they get mobile quite quickly, it can cause all kinds of problems.

Ashwini Kamath: Yeah, yeah, yeah.

Brooke Trotter: Yeah, I can see that.

Colin Green: That you've got the ability, but you've not got the cognitive ability to do with it.

Brooke Trotter: Again, I can see that now, but I didn't know then.

Ashwini Kamath: And I guess, I mean, fatigue also comes into it. You were saying, you know, you walked those ten paces, or you waddle those ten paces.

Brooke Trotter: I suffered so badly from fatigue at first.

I mean, I still do now, fifteen years later, but obviously to a much lesser extent, but yes, fatigue at first was horrific.

Colin Green: And I think the word horrific is, is about right, isn't it? Because it's I think, differentiated between tiredness and fatigue.

Brooke Trotter: Yeah, and add that to the frustration that nobody understands, that you just, particularly, it's more when you get out of hospital, isn't it?

When you're in the hospital, you know, you're surrounded by people that know, and you obviously... You know, your activities there are planned and, you know, you do some fun activity and you have a rest. And then, when you come out of hospital, you just, you know, you've got no structure to you, no structure to your life, so you're just, you're just exhausted all the time.

Colin Green: I think people often have a, people look forward to being discharged from hospital thinking, it'll be brilliant when I'm home, it'll be brilliant when I'm home.

Brooke Trotter: It'll be just like it was.

Colin Green: And when you get home, it… especially if you go back to where you came from, do you know, if you go back to your old place and it's like, it's a slap in the face to say, look what you used to be and look what you can't do now.

But fatigue can be split into two sections. It can be a kind of cognitive or a thinking fatigue, and it can also be a physical fatigue. Could you explain how yours showed itself?

Brooke Trotter: Well, I guess it was right before the, you know, the incident, I was the fittest I've ever been in my life and and in the best shape, which obviously helped me make a good, good recovery.

But I just remember just like, it's, there was a thinking fatigue that really got me. Obviously, my fitness had gone down, my strength had gone down. You still, in your head, you still think you're the same person, don't you? But obviously I was quite, you know, physically strong before it, and I was, you know, physically fit as well.

But all of a sudden this, it was, it was really the, the thinking fatigue, because just to, I don't know, concentrate on something like, even for five minutes, I couldn't follow anything on TV, I couldn't even... Just conversation, just everything, you know, all these things that come into your life, you know, you slowly realize what's happening, like, slowly realise that the different light of a room would… I always, I always equate it to like a battery on a mobile phone, I suppose that was something that was in my life at the time, and it's in everybody's life now, isn't it?

The more things that went on in my life, you know, like for instance, the room was poorly lit, you'd have to, you know, squint to see and that would impact on your battery life. And if you could, if you could, you had to, there was other factors, like there was other external noise that would, you know, and you're having to filter out conversations that would tire you out.

Ashwini Kamath: Yeah, because I don't think you realise just how much is going on.

Brooke Trotter: No, no.

Ashwini Kamath: For you to be able to filter that out.

Brooke Trotter: Yeah, this would come later, realising that, but obviously at first it was all hitting me. I didn't know what to, you know, I didn't know what to avoid and what to look out for. So it was just, I was just getting flat out exhausted and it was just tiredness that, you know, you try and understand, you're trying to explain it to people and you just think that you're really physically fatigued.

But the only thing I've ever could really liken it to was if you've ever been awake for 24 hours for whatever reason, and then just trying to have a conversation, then you would just, it was just like that all the time.

Colin Green: Someone once described it to me. They could feel after a meeting, say after something like this, where they had to concentrate that they felt like they'd been hit by a train.

Brooke Trotter: It's kind of, yeah. Yeah.

Colin Green: It was so severe. And it wasn't a ‘I'm a bit tired’. No. Bang.

Brooke Trotter: And people would say just, you know, go and have a nap. Obviously, the thing with just going for a nap is there was obviously like so much stuff going on in my brain that I just couldn't rest. And I remember that being a thing that I couldn't, I couldn't turn off, couldn't rest.

And when I got to this flat in Scarborough, my first flat. I remember there was a Buddhist meditation group, and I thought, Buddhist meditation, you know, an ability to calm the mind down, and that helped. But yeah, it was just, you know, you were so tired, but then you couldn't really rest neither. So, it was just like a constant thing.

Colin Green: Sometimes the rest can be in other activities, so it could be, rather than trying to sleep. It could be, I'll listen to some music or, you know, I'll listen to an audio book, or I'll go sunbathing if you're in Scarborough.

Brooke Trotter: Yeah, sunny Scarborough, it's always sunny in Scarborough!

Colin Green: But could you compare that with, did you experience any aspects of physical fatigue? Because you'll have known physical fatigue from, you know, exercising in your gym.

Brooke Trotter: I guess it was like just a mixture of both.

Colin Green: It's hard to, it's hard to differentiate sometimes, isn't it?

Brooke Trotter: Yeah. And I mean, like I said, it's only, you know, with the benefit of hindsight and the benefit of accruing different, you know, knowledge about my condition.

But at the time, I just didn't have a clue. So it just used to hit me, full-on, like a train.

Colin Green: I think that would be really useful for people listening to this who, who have got fatigue, because they kind of can look and hear your lived experience of, you know, what does it feel like? Oh, I feel... I feel like that, and it's, it's horrible.

Brooke Trotter: It is, yeah.

Colin Green: But it can change as well.

Colin Green: Obviously, you know, it does change over time. You don't notice it changing though. Well, with me anyway, in my experience, it changes that slow that you don't really, you don't think you're any better.

What tends to, what tended to happen was like, if I'd not seen somebody for like a couple of months or something, they would always remark about how much better I was, but then in your head you're just thinking, they're only just saying that to make them feel better.

Yeah, you don't notice it yourself.

Colin Green: Someone gave a really good analogy one time. They said it's like a train journey from Manchester to London. You get on the train in Manchester and it's pitch black. You get off the train at Euston and it's a beautiful sunny day. But you don't realise on that journey when the light started to go up.

Brooke Trotter: Yeah.

Ashwini Kamath: Yeah. Yeah.

Colin Green: But you can spot parts that probably when you're in Stoke, it was miserable. But as you got to Northampton, you know, you could see the sun coming up and by the time you get into London… So it's that kind of journey sometimes, isn't it? There's not one Eureka moment where you're like, ta da!

Brooke Trotter: And it's better now. It's, I mean, it's, yes, obviously now it's immeasurably better than what it used to be, but it's, it was, yeah, it was pretty grim at the start. I think what helped was… exercise helped. I was always, I was dead keen on exercise from the start. But you can, that, you know, that has its dangers as well, because you can, I used to overdo it, always overdo it and I used to just tire myself outmore.

You'd read these things about people exercising in the morning and I worked out that exercising in the morning was kind of the worst thing for me because that would kind of ruined my day because I’d never really recovered from it.

Colin Green: Right, quite often our work with clients is making exercise consistent, reliable, not over demanding, that it's something you want to go back to because we've all done the thing, haven't we? We eat too many mince pies at Christmas and then January we're going to go for it.

Brooke Trotter: Full on mentally, yeah.

Colin Green: You join the gym. And then by mid January, the gym's empty.

Ashwini Kamath: All manageable changes rather than big changes.

Brooke Trotter: Yeah.

Colin Green: We had a client very recently and we said, Right, what are we going to do? He said, I'm going to go to the gym five days a week.

Alarm bells immediately start ringing because the one week that he doesn't go five times.

Brooke Trotter: And it's ruined.

Colin Green: The weel after he’d probably not go at all.

Brooke Trotter: Yeah. I found that to do well, if you could, if you do something step counters, that's really good. If you're going for a certain amount of steps in a day, that's really good because it's something that you can, you know, you can keep your eye on can;t you. But I found that like doing something every other day is good because you've got a recovery day.

Colin Green: And from a training point of view rest days are just as useful…

Ashwini Kamath: Yeah.

Brooke Trotter: Yeah

Colin Green: …as exercise days.

Brooke Trotter: Yeah,

Colin Green: So I think to get that pattern in and as a physiotherapist, if we can kind of say, you do need those rest and fatigue diaries can be really helpful.

Brooke Trotter: Yeah,

Colin Green: So we can plot "Right? What have you done, what's your fatigue been?" So you could put it on a battery level or you could do it on a like traffic light system and see, you know, where your fatigue's going and we can look at it. In fact, we did this with a a client who was an ex-professional golfer and his fatigue was terrible and he said to me not so long ago, he said, Colin, can you believe how bad his fatigue was? He would do one thing. He might do 10 balls at the driving range and then he'd sleep for two days. But now he'll go all over the place. He'll play golf all over the place. And he's fine. He said, I can't believe how fatigued I was in the past and over five years where I am now.

Brooke Trotter: That's, that's a good point actually, because to sleep for two days, it really is that bad and people don't really get it.

Colin Green: And there doesn't look often to be anything wrong.

Brooke Trotter: No.

Colin Green: So, especially if someone's going back into employment, if they're going back into education or back into family life, the family can be ‘Well, are you doing all right? You're walking, you're moving, you're doing a bit of exercise. Off we go. We'll go on a holiday’.

Brooke Trotter: Yeah.

Colin Green: Going on the holiday might be... Sound good, but it might be the most stressful.

Ashwini Kamath: Yeah. And very cognitively demanding as well as.

Brooke Trotter: And the stuff that goes on in your head as well.

What are they thinking about me? Are they on to me? What do they think? You know, do they think I'm weak?

Colin Green: So fatigue is a really crucial thing.

Ashwini Kamath: Yeah.

Colin Green: That's a useful diversion, I think!

Ashwini Kamath: Well, just coming back to the sub acute phase, something that you mentioned earlier, which I just wanted to pick up on. I mean, I'm guessing it's probably a very challenging thing time in somebody's rehab journey, because, you know, when you're talking about the acute phase, it's very much management of, but somebody's out of it - so you're just working with their body to make sure that things are sort of ticking over if you like, but when once somebody's in that sub acute phase, you're learning, they're learning about how their brain injury is actually impacting them and what their limitations are and where those challenges come about. And I guess there's also a lot of expectation management, just like Brooke was saying, you know, I want to walk, you know, why are people telling me I can't walk, but it's actually, you know, literally don't run before you can walk.

Colin Green: Yeah. And this is the time where we set ourselves up for the long term, for kind of success or failure. So you can set really good foundations for future recovery at this stage. Getting good habits in how you're moving and getting those habits in, getting good habits about fatigue management or exercise, about how you function, set you up for the future.

But the opposite can happen as well, that if someone really goes at it like a bullet in a china shop and he's doing too much and he's practicing the wrong movements in the wrong manner and he's getting fatigued, then they will reinforce bad movement patterns. And the body is quite pragmatic, it will do what it needs to do. So a simple example would be if I was out running I sprain my ankle within two or three steps I'll have developed a new way of running.

Ashwini Kamath: Yeah. You’re compensating.

Colin Green: It might be rubbish and it might be painful, but you compensate so quickly, but the brain does that as well. The brain compensates and neuroplasticity, it's the way that the brain compensates after injury. So, what will happen there is, like, I can't move the way I used to, but I still need to get to that chair in the corner of the room that you mentioned before.

Brooke Trotter: You find a way that's most comfortable for you.

Colin Green: And it might be a bit of a clumsy way.

Brooke Trotter: Yeah.

Colin Green: It might be an inefficient way. So it would be for the physiotherapist to kind of identify that and say, actually, why don't you try this? Or why don't we look at that? So looking at quality of movement and the physiotherapist should have a really good knowledge of what normal movement looks like, because then they need to analyse it - What's changed? Now the tricky thing with that sometimes is I know what normal movement looks like by a textbook, but I don't know what Brooke's normal was before your injury.

Brooke Trotter: Probably not that normal!

Colin Green: But nobody comes in for a pre brain injury check. I'm going to have an accident next week, just check me over this week. It's not going to happen, we don't know how people move. But what I'll quite often ask is, have you got a video of you running before? Have you got a video of you walking down the aisle at your wedding? Do you know, you've got those things because you think... Right. I can see it. I can see quite subtle things.

Ashwini Kamath: Yeah. Somebody's gait pattern…

Colin Green: So we're looking at how we revisit that. And then we're looking at how we put that into practice. So from the sub acute, so you've had your hospital time and you're going home. And this is sometimes where things can start to fall apart a little bit. So you go home and you realie actually, you know, this is really difficult. I can't move as well as I used to. In the hospital, everything was done to me. Cups of tea were brought to me, food was brought to me. I was washed, I was... But now I've got to do all that myself, and that's really tiring.

Ashwini Kamath: Yeah, and I might have to walk up several flights of stairs, which I didn't really have to do in hospital.

Colin Green: Yeah, so, and there's often a bargaining at this stage in terms of, right, you want to go home. Obviously you want to go home. Some people try and get themselves discharged too early. I was seeing someone the other day and he said, I really wish I'd stayed in for another few months.

Brooke Trotter: Yeah, because you're eager to get out aren't you.

Colin Green: But getting the rehab later on can be tricky. It's alright getting it while you're in hospital because there’s kind of an expectation that you'll get the therapy in hospital. But what happens when you go is a bit of a, I hate to use the phrase postcode lottery, but it depends. Sometimes you'll get really good therapy, but how long that lasts for.

But you said at the beginning of the discussion, this is a life, you're going to need some input for life. And I know you still do stretches, you still do exercise, you still manage your condition. And what we've got there quite often is how engaged is the client in their long term rehab? So that's my particular interest.

How do we keep you engaged? And how do we keep you doing what you’re doing? Because one thing I'm certain of, and you can tell me I'm wrong if I'm wrong here, Brooke, that at some point you've been given sheets of exercises by a physiotherapist and they've said do those and we'll see you in a week.

Brooke Trotter: Probably. Yeah. Yeah.

Colin Green: Did you do them?

Brooke Trotter: No, I would say no because…

Colin Green: But if you didn't do them, you're probably part of 99 percent of people who wouldn't do them.

Ashwini Kamath: I can definitely say I fall within that category. I've previously injured myself, been given that sheet, done nothing.

Colin Green: Yeah, and that happens, but it doesn't stop physios giving sheets of exercises out.

And one of the tricks we do - here’s a little inside knowledge is - if you go along to see a client and you've given them some exercises and you'll say, and have you done your exercises in last week? They go, Oh yes, of course. What do you want to just run through them for me? And you see a look of panic on their face.

That they obviously haven't and they'll fudge something together that looks like it might have possibly done. And then you say, well, I left you an exercise sheet. Where's that? And you can see another look of panic as you think, oh, I crikey haven't got it.

Ashwini Kamath: Crumbled up at the bottom of a bag somewhere!

Colin Green: I would suggest the physio saves the time and doesn't give them the exercise sheet.

Ashwini Kamath: So how do you keep somebody motivated and engaged?

Colin Green: This is what I was steering the conversation!

Ashwini Kamath: I feel like you're a podcast professional here, Colin.

Colin Green: What we'd look at there is the kind of therapeutic alliance, which is what I did my master's looking at is that relationship between therapist and client. How do we get the most engagement from a client?

And there were two, there were three things. There was something called Goals, Tasks and Bonds. So, it was an old article and they looked into the goals. So what, you Brooke, what do you want to be able to achieve?

Brooke Trotter: Yeah.

Colin Green: The tasks, how are you going to achieve it? But really importantly is the bond. So, do you believe the person who's asking you to do it? Have you got a relationship with that person? Now, if I came into your house and said, right, what's your goals? What's your tasks? And then you thought, he's an idiot. You know, I'm not going to trust, I don't believe a word he says. I mean, look at him, he looks like he never exercises himself anyway. So you could think all those things.

And the likelihood of you actually doing that exercise goes down so there's a real link between that bond between the therapist and client and clinical outcomes.

Ashwini Kamath: I never thought about that the importance of the therapeutic relationship I mean, I know in my practice I talk about the therapeutic relationship between my clients and their therapists and clinicians, but I never really thought about how important that is for the success of that person's rehabilitation from a very practical, emotional point of view.

Colin Green: And quite often we'll have clients who say, I do it because I don't want to let you down, which is, it's partway there, isn't it? At least you're doing it. But when I'm not there and when they've been discharged and when they get on with their life, I'm not, you know, they've got to have an inner drive.

So the way that we work at it and within our practice at Physiomatters, what we encourage is looking at this kind of an activity based thing. So if we can get someone involved in an activity that is engaging, that is fun, that is exciting. A lot of the clients we see are young lads who are risk takers and love excitement.

So for me to give them a sheet of exercises, just save the paper. So, but if I say, right. Wait, let's do some work on your skiing. So let's go skiing or let's play football, let's do kayaking and get that person a new hobby.

Ashwini Kamath: Yeah.

Colin Green: Or a hobby they previously did that they then engaged in.

Ashwini Kamath: Yeah.

Colin Green: So kayaking would be a good example. So what kayaking would look at is it would look at trunk control. It would look at trunk rotation. It'd look at strength. It'd look at aerobic capacity. It'd look at balance. So there's loads of different ways you can get the same thing. Whereas the client won't necessarily equate that with, I'm not doing physio, I'm just going kayaking for an hour.

Ashwini Kamath: Yeah, I'm having fun.

Colin Green: Yeah. And the same with skiing.. Loads of benefits. Yeah. So we've got about 18, 20 different activities that we can offer and some of them are adaptive activities. Most of them are adaptive activities.

So we can get clients engaged in those and that's the way we want to push our rehab and we get really good results.

Ashwini Kamath: I mean, I suppose that's true of anything in a way that if you're invested in something, you're more likely to keep on at it. If somebody said to me, go, you know, you, you want to lose weight, go running. It's not gonna happen. I go swimming most mornings because it's something that I genuinely enjoy and I'm motivated to do so, you know, that will have the benefit that I'm seeking in the longer term. And I guess the same is with that, like you say, sheet exercise is not going to work, but get somebody engaged in the activity, enjoying it.

And I suppose in the background, you've got those subtle benefits that they're not necessarily aware of, but, you know overtime they are making that progress.

Colin Green: But as a pysiotherapists, we're still monitoring how they're doing, but we're doing it in a slightly more subtle way. So I would be the opposite to you. So if someone told me to go swimming, I couldn't, I'm not good enough at swimming to get any aerobic benefit from it.

Ashwini Kamath: Yeah.

Colin Green: Go running. I could run for days. I'm quite happy running. So, so it's looking at what... the individual things. Yeah, and so for some people it might be relating to a pre injury activity. So we've treated some professional footballers and would they want to go back to football? Possibly not.

We saw a rugby player and we mentioned about him doing wheelchair rugby and he said there's no way I'd go near it because it's not the activity that he did previously, but then someone else was a golfer and he wanted to go back to it because he wanted to see how close he could get his handicap to how it was prior.

Brooke Trotter: Yeah.

Ashwini Kamath: And I suppose for some people it is about rediscovering it in the same way we talked about Brooke one, Brooke two, it's kind of who is this new person and what interests them and what will keep them motivated to keep going at the rehab.

Colin Green: We had a lovely client that we'd been seeing and prior to her injury she didn't do a lot of exercise at all, and she did lead quite an unhealthy lifestyle and what we've got her involved in is a walking netball group. And now she does the walking netball group, regardless of physio, it's her thing that she does every week. And one of the important things there is she's got the activity, but she's also got a group of friends who know her, who kind of make allowances for her difficulties and she's incorporated in this and they will do all different activities. So it's almost there that the walking netball is a way to other things.

Ashwini Kamath: Yeah.

Colin Green: And because she's done walking netball, she’s just started looking at paddleboarding.

Ashwini Kamath: Oh, wow. Okay.

Colin Green: But these are activities she'd have never done prior to her injury.

Ashwini Kamath: That's amazing.

Colin Green: So, yeah, it's really exciting. And I mean, from our physio point of view, it means that sessions are engaging and dynamic. Yeah, much more exciting. Yeah, much more exciting. You look forward to that.

Ashwini Kamath: Yeah. And I guess it's going on the journey with them, discovering, like you're discovering who that new person is in as much as they are discovering their new identity.

Colin Green: One of the key things to success here is engaged and active and fit support workers. We really need support workers that are going to go on that journey with the client in between our physio sessions. Yeah, so we want clients who are going to be positive, sorry, support workers who are going to be positive role models and can keep up with a client to be honest because we've got a lot of quite fit clients and because the client was really fit prior to the injury, like you,you need a support worker who can keep up.

Ashwini Kamath: Yeah I mean,we've kind of gone into some of the, I'm not going to call it chronic either, I'm going to call it longer term physio, particularly talking about some of the running aspects, but I guess moving into that phase what are the sorts of, how does your journey as the neurophysio evolve with your clients there?

Colin Green: I think a few different ways it can evolve. With some clients we know that we're going to have to maintain a kind of hands on approach, probably for life, you know, they're going to need stretches that are quite complicated or the handling needs might be quite difficult or the level that they're functioning at might be quite hard. They might still be wheelchair based. They might still always need transfers. So for some clients, that is the kind of steady plateau stage is that they’re wheelchair users. And sometimes that can be working with a client to say walking isn't the end for everyone. For some people, being a wheelchair user gives you more independence than someone who's going to be walking. So you you may be able to get further, you may be less fatigued, you may be able to function at a much higher level.

I had this discussion recently with a chap who's a very high level amputee and he tried for three years to walk on a prosthetic leg and it didn't work because his stump was so short so he wasn't able to fit his leg effectively on there. So we had to talk about him, sorry, with him, saying what is independence? And for him, independence is being a wheelchair user. It means he can get out. He can be independent. Whereas, had he been having to put on a big clumsy leg all the time, he was much less independent. And he actually spoke to me a few weeks ago, after the session. He said, Colin, can I have a word with you? I thought we were in trouble. But he said... You've saved my life.

Brooke Trotter: Oh, that's nice.

Colin Green: He said, you've saved my life. He said, because I had no hope before we started coming here, but I've got hope. I know the direction I'm going in. And that was someone that we'd had quite a frank discussion with saying, you're never going to be able to use a limb. Your future is a wheelchair future, but being able to do some work on your single leg. And he said, I can't believe the difference. He said, I wouldn't be here had you not been involved. Although that's not brain injury, it's still relevant.

Ashwini Kamath: No, no, but I mean, it's reframing identity, which, you know, we've talked about in the context of brain injury and it's also that as a clinician, as a therapist, sort of that expectation management. And I think it also brings into focus that although you are a neurological physiotherapist, it's so much more than just physiotherapy. That it is that kind of multifactorial approach. It's almost psychological in many respects. As well as, you know, looking at sort of the OT angle of what can somebody actually do and yeah.

Colin Green: That's why at the beginning of the discussion I said a multidisciplinary approach, I think it's more than just when you have a multidisciplinary team meeting every three months, that approach needs to go into every professions sessions. So everyone is aware of what are the things I need to consider. So say if I'm communicating with you, what are their speech and language therapy guidelines for this. If there's psychological issues, what's the best way of framing these questions? So taking the whole MDT into each session.

Ashwini Kamath: It's holistic.

Colin Green: That's a better way of putting it!

Ashwini Kamath: It absolutely is because I mean, I suppose, you know, every individual is a complex ball of everything. You can't just look at single issues.

Colin Green: This is why it's so fascinating. And this is why, coming back right to the beginning of the discussion, this is why I work in this area because it is so fascinating, so multifactorial, so holistic and yeah, it's, I always say, because people compare themselves with other people, but I always say to clients, but you weren't the same before. So you weren't the same as someone else for a brain injury before the accident. So why on earth would you be the same now?

Ashwini Kamath: Yeah.

Colin Green: Things are different.

Ashwini Kamath: Moving into sort of the your fourth phase if you like - adjustment and condition management. I take it you probably don't need to do that with every client?

Colin Green: Yes. Sorry. I didn't answer your last question, thank you. So it is looking at you know, what the next phase is and what we'd look at as well is, does someone always need physio? How do we, with the nicest phrase, how do we get rid of you?

Ashwini Kamath: I suppose you don't want to over therapise somebody.

Colin Green: Yeah, exactly. So sometimes it might be that the physio needs to carry on being involved. Other times it might be that the support workers need to be involved. And we pull back a little bit.

Brooke Trotter: They need some input, though don’t they, because that's one thing that can happen with brain injury, is that your treatment can stop, and then that's when, you know, there could be so much more done with them, but the, you know, the input stops, and that's when depression kicks in, because they don't know what to do.

Colin Green: And sometimes you could say, right, sometimes people benefit from a therapy holiday, because by this point, they've had a lot of therapy, and they can be a bit sick of us all. So to have a break from therapy and then, but to come back to it. Andif someone says to me, yeah, well, let's have a break from therapy and I'll give you a call in the future. That's never going to happen. Let's, say in three months we'll give you a call. All right, better still, I'll come out and see you. And let's, I might be able to spot things that have gone a little bit awry that we could just tweak and then send you on your way again. So it's much easier to tweak things and get the improvement.

Ashwini Kamath: Yeah.

Colin Green: Rather than have to undo things.

Ashwini Kamath: Yeah. Yeah.

Colin Green: So, so, yeah, so sometimes our work would be handed over to support workers, family or to you yourself. But sometimes people need a kick up the bum as well.

Brooke Trotter: Yeah,

Ashwini Kamath: I wanted to talk about goal setting because we talk about this a lot in multidisciplinary team meetings and, you know, getting people to where they want to be in the goals that we look at tend to be very sort of client focus. It's the client setting those goals. I want to be able to achieve this and so on. But, you know, again, coming back to the point before about making sure that we're managing expectations, not setting people up to fail, not trying to run before we can walk. Can you give us from your, again, from your sort of own experience, examples of, you know, somebody might have a longer term goal, but it's the steps in between to get them to that.

Colin Green: I've got a good example of this is one lady, she wants to be able to walk without any walking aids. At the time that I went to see her she was not able to get out of a chair. So, but all she could see as well, I just want… but that wasn't just, she wasn't going to jump from that to that. So she loved doing crafts, arts and crafts.

What we decided is we'd split the goal up into little stages. So there was 15 stages between where she was there and where she would be in the future. So what I got her to do is she liked building models. So she built a model, 15 steps. So she built a staircase and we got... She decided she'd draw a happy face on a tangerine, so she moved, each step was one of her goals. So the first step would be that she could sit without any support behind her back. The next stage would be that she could bring her bottom to the front of the chair. The next stage would be that she could come up into standing with someone in front of her, etc, etc.

So we built them down and put them on a sheet. And each of the steps, for the sake of argument, went 1 to 15. And each time she achieved one, she moved the tangerine up the steps until it was at the top. So she could see that every day. She put it on a fireplace and she could see this, it was massive, this model of this tangerine moving up. So she could...

Ashwini Kamath: I was picturing a wilting tangerine.

Colin Green: It was, yeah, it was like the... Could the lettuce last longer than the Prime Minister? It was that kind of analogy.

Brooke Trotter: That's a good, yeah, good analogy though, isn't it?

Colin Green: So we learnt two things there. She didn't get to the end.

Ashwini Kamath: Okay.

Colin Green: But she got part way up the steps.

Ashwini Kamath: Yeah.

Colin Green: And also that tangerines are quite resilient.

Brooke Trotter: Perfect.

Colin Green: So, so looking at that visual representation is what I'm saying. That's quite an extreme version. But to have a visual representation of this is where I am now. This is where I want to be. But give little goals in between so you can see that you're making progress.

Ashwini Kamath: And I suppose perhaps part of that process sometimes that person's eventual end goal changes as they get partway through the rehab and realise that actually maybe that's not what I want anymore.

A bit like you chat with the your high level amputee who's, you know, adamant that he wants to walk with a prosthetic and then actually reframe that to say, you know, I'm a wheelchair user, but a very active wheelchair user. And that can be quite an important realisation from this.

Colin Green: So I think there is that, and I'm sure you'd agree, Brooke, there's that reframing of your goals, as you go along.

Brooke Trotter: Yeah, yeah. You don't necessarily understand it from the start, do you? So, as you learn it kind of changes.

Colin Green: The number of people when I worked on the Stroke award who would say, so long as I get walking and you send me home, don't worry about my arm not working. We'll sort that out later on.

So they get up walking, they get home and then they go, what about my arm? Then it becomes a priority. But I really love the fact that clients are so motivated and still keep pushing. Yeah, I said I wanted to be able to achieve this. I've achieved this now, but I'm still not happy. I want to be able to achieve the next stage.

So, which is, sounds lik your kind of journey, especially with your Great North Run exploits. Well done.

Brooke Trotter: Well yeah, you’re never satisfied, are you?

Colin Green: You’re never satisfied and you’re never finished. You're always a work in progress.

Ashwini Kamath: But that's a good thing. I think that's human nature as well. We're never static. We always have to keep pushing forward.

Colin Green: And after a neurological condition, I often say it's like trying to stay still on an escalator, on a down escalator. Sometimes you've got to work really hard to maintain. And that's one of our functions in the longer term, in this kind of long term condition thing, is you've got a long term condition, but also you're getting older.

Brooke Trotter: Yeah.

Ashwini Kamath: Yeah.

Colin Green: So we need to work.

Brooke Trotter: That's something that's happened with me recently.

Colin Green: But it's a privilege to get older, isn't it?

Brooke Trotter: Yeah. Yeah.

Colin Green: The other option's not brilliant.

Brooke Trotter: No.

Colin Green: So, I mean, I do expert witness work and it's one of the things we'd obviously build into treatment, you know, into a report, sorry, is that you need a contingency of funds for the future when, okay, perhaps you're going to keep improving, keep improving, plateau, plateau. Then as you get older, you might need more. You might need more input to keep at that same level.

Ashwini Kamath: Yeah, to maintain that because yeah, body changes. We're all crumbling away.

Colin Green: Slowly.

Ashwini Kamath: Just to change tack completely. I just wanted to ask you a little bit about some of, just to give some examples of some of the equipment that you use and also, you know, where you do your physiotherapy with your clients? Do you do it in clinic? Do you do it out in the community? And just the benefit of some of the sort of technology that there is?

Colin Green: If I answer the location wise, one first is I think we're quite unique as a practice at Physiomatters in that we do treat people in a massive range of locations in terms of, so it might be at the ski slope.

It might be at one of, I think we've got seven different hydro pools we use. It might be at countless gyms, kayaking facilities, loads of them. It might be a rifle range. It might be an axe throwing. It might be doing work up on the hills or on the fells or, you know, so there's, it, it, or in someone's workplace.

So there's really, wherever someone has the issues and we really feel that the community is the focus of where people are having the problems, especially later on. And a lot of our clients have had a lot of therapy in the past. So they've been through the, like we said before, the acute, the subacute, the chronic. And it's what are you going to do with the recovery you've made? Where is it going to be most appropriate? How are you going to live your life to the fullest?

Ashwini Kamath: I suppose, yeah, because if you do it in a gym all the time, it's quite an artificial environment in that it's a gym, but it's not dealing with negotiating rocky paths on, in the hills, for example.

Colin Green: And that would be something I'd try and build in as much as possible to expert reports. So, you know, if I see someone walk from one end of the room to the other, that's not giving me an idea of someone's balance. That's telling me they can walk from one end of a room to the other. It's not, not giving that, but so I think location is really important.

Also getting clients out of the house and getting, you can build a physiotherapy session into a much busier day. Into a much more active day. So if you're going to one place, what else can be involved in that day? The other thing you asked about was about equipment.

Ashwini Kamath: Yeah, so I'm just thinking about things like the old is it the AlterG?

Colin Green: Yeah, so we use we've got I think we've got access to three or four different AlterG machines, which for listeners is it's an anti gravity treadmill. So you put a pair of cycling shorts on, zip yourself into a big plastic bag on top of a treadmill. I'm sure on the website, they describe it better than this. Inflates it and you can reduce your body weight by 80%.

Ashwini Kamath: Wow.

Colin Green: So it's like walking on the moon. So I use it particularly for people who fatigue easily in activities, but also for people who are at a higher level and looking at running, looking at, and because it's a really safe way of exploring movements, you can do lots of fun things on it.

You can do work backwards, you can do work forwards, uphill, downhill. You can do a look at running and you're not going to fall over in it.

Ashwini Kamath: Does it also ease some pressure on joints and things like that?

Colin Green: Yeah. And that's why it was brought over. It was brought over for the likes of Paula Radcliffe. So she could do higher levels of training at low impact.

So, but we can use it for slightly different ways. We could use it for clients who have MS. So for that same kind of reason that it's, it's not effortful, but you can still look at patterns of movement.

Brooke Trotter: Sounds interesting. I'll have to look it up.

Colin Green: Yeah, it's good. It's good. And all the football teams have them, so they can increase volume whilst reducing impact.

Ashwini Kamath: So how does that I mean, in the context of someone with a brain injury, how does that benefit them? I mean, leaving aside the physical benefits in terms of you know, low impact, et cetera. How does that interplay with the neurological side of things?

Colin Green: For me, it would be because often confidence is an issue with mobility. So if you've got that safety blanket, we can try and the neuroplasticity happens by trying novel things.

Ashwini Kamath: Okay.

Colin Green: So we can try novel things in a safe environment. Which, hydrotherapy is really good and we do lots of hydrotherapy, but the resistance and the turbulence create a slightly different feeling than it would be in the AlterG.

Ashwini Kamath: Yeah.

Colin Green: So, and if I'm looking at really fast walking or running, then we can get the neuroplasticity working better in that kind of safe environment because you've not got the fear of falling and that impacting on performance. So yeah, we can get, it's not, it's not the same as in the real world, but it's pretty close and it's a risk free way of working.

Other piece of equipment that we use is we use a functional electrical stimulation. I think all the L 300 go, which is a um, a stimulator that helps you lift your toes up when you're walking. So it's got some fancy gadgetry in it in terms of as soon as you lift your heel up off the floor. So if you're walking, you have heel strike, weightbearing through your foot, as soon as you heel comes up, it stimulates the anterior the muscle on the front of your shin to lift your toes up so it stops foot drop.

Ashwini Kamath: Okay.

Colin Green: So you can use that and what's good is because of the electronics in it, it learns your pattern of walking and it can vary between if you're walking fast, if you're walking slow, it will go with you. So we can prescribe that.

Brooke Trotter: So the more you use it, the better it gets.

Colin Green: Yeah, and you can use it at walking really fast and you can now use it without wearing any shoes. You can use it, you know, on the beach, sort of. Which is much better than the splints that I was talking about before that are a plastic thing that you just have to strap on you. But we, we could do assessments for those.

And then just next week we're doing a trial of another piece of equipment called the Mollii suits, which is the same manufacturer, which is a Lycra garment that has 58 different electrodes on that kind of give you help with your postural control. So we're quite excited to see how that will go. So we'll be releasing more information.

Ashwini Kamath: I'm interested to know how that would work, like how those electrodes would actually help your posture.

Colin Green: I mean, what you can do is, there's 58 electrodes kind of sewn into this suit, and the suits are bespoke. What we can do then is, we program which of the electrodes fire. So if you're doing a particular activity, we can put a bias on some of the electrodes are firing and others are switching off so we can we can… so I'll tell you more when I've done the training.

Ashwini Kamath: Yeah, I suppose that would be really helpful if somebody's, the impact of somebody's injuries, that you know, they might neglect certain parts of their body and so by having that stimulation, you can get those parts sort of reactivated in a way.

Colin Green: Yeah. Yeah. And sitting and working up against gravity can be hard work. So initially when we looked at where initially when you were in hospital, Brooke, just being able to sit is fatiguing because gravity is pushing down on you. Whereas if we can use these suits that would keep that position and that'd be less effortful.

Ashwini Kamath: Yeah, it's amazing how much you take movement for granted.

Colin Green: And that's why when movement becomes a cognitive activity rather than automatic activity, it's really tiring.

Ashwini Kamath: Yeah.

Colin Green: Because ordinarily you wouldn't have to think about walking, you'd just crack on with it.

Brooke Trotter: If you add thinking in there as well…

Colin Green: Yeah, so that's why when... If you're walking through a busy street and you're trying to remember what you need to get from the shop, you've got various demands on you, on you there.

Brooke Trotter: That's what brain injuries done for me. It's just made me aware of all the different functions that go on in your body and how they all are.

Colin Green: We're bloody marvellous, really, aren't we?

Ashwini Kamath: Well, that was absolutely fascinating, Colin. I'm really looking forward to learning more about the advances in technology that that can assist with physiotherapy. But I think it's been really, really interesting just understanding how important physiotherapy is as part of somebody's rehabilitation journey following a brain injury. So just from Brooke and myself, thank you so much for coming in. For our listeners as well, we will put Colin's details on the notes to the episode, but perhaps Colin if you just want to give some of your contact details out now if anyone wants to get in touch.

Colin Green: We will be publicising about any new developments we have at Physiomatters and our website is physio-matters.org, so that's really easy. And we're on all the different social medias. Yeah, our phone number is 0161 681 6887, but I'm sure all these details are on the notes. And yeah, if you've got any questions, feel free to contact us in any way, through the website.

Ashwini Kamath: Yeah.

Colin Green: And ask us questions. We'd be happy to talk through issues.

Ashwini Kamath: Oh no, that's really helpful. Thank you. And yeah, once again, just thank you so much for coming in, talking to us about all those interesting issues.