Case study – Upper limb rehabilitation using the Biometric E-LINK exerciser


On the 17th of October 2005 whilst on holiday abroad, Amy experienced a sudden onset of acute Type I diabetes.  The sudden destruction of insulin producing cells resulted in Amy going into a coma.   The severity of Amy’s illness resulted in her having a brain injury with significant physical weakness to right sided limbs.  Amy required intensive medical, nursing and therapeutic care before being discharged home many months later. She achieved an excellent recovery but needed ongoing therapy due to physical disabilities of lower and upper limbs. Amy had learnt to compensate upper limb weakness of her dominant side by using her left hand for functional activities, she had developed learnt non-use.


The Biometric E-Link machine is a computerised exerciser and was introduced to Amy in 2013 by her occupational therapist.  This machine gave Amy an opportunity to build on her achievements (i.e. range of movement, strength and stamina) in different ways and also provide Amy with the objective data she needed to know which encouraged Amy to continue with rehabilitation as it offered her information which objectively tracked her progress over time.


On initial assessment Amy’s right hand grip strength was less than 1 kilogram.  Over a period of 14 months Amy has used the Biometric E-Link machine, making use of the various attachments including a dynamometer, pinch meter, and resistive control unit (as shown in the photograph). The Biometric-E-Link machine has assisted Amy in increasing active range of movement and strength of upper and lower limbs.  She has been able to carry over these achievements in a range of functional activities where she now engages her right hand.  Grip strength has peaked to over 10 kilograms and she is still making improvements.


Amy’s occupational therapist continues to set more challenging tasks for Amy to work on and also encourages and supports her, along with Amy’s family and friends, to carry over her achievements in function.


Amy has expanded the range of functional activities she can now participate in using her right arm/hand and is currently using her achievements to aid her when carrying out personal care including when putting her glasses on, to hold crockery, to pick up small objects, when playing board games, opening doors and drawers and more recently she can now push and steer a supermarket trolley when out shopping with her mum.


If you would like to know more about the Biometric E-LINK and how it is used in occupational therapy or about occupational therapy rehabilitation provided by Independent Rehabilitation Services, please do not hesitate to contact us.



Angela Gordon

Specialist Neurological Occupational Therapist






The Value of Supervision

Providing supervision is a familiar requirement for many health care professionals. Receiving and giving supervision within most therapy departments is accepted as a normal procedure and indeed expected amongst qualified and unqualified staff. Good supervision has been recognised as a vital pre-requisite to the delivery of high quality services by highly skilled staff (Skills for Care and Children’s Workforce Development Council 2007 cited in Davys and Beddoe 2010 p 16). Accountability for ensuring efficient and effective services to all individuals who require health care has been endorsed by many health care organisations and also the British government which has also reinforced their expectations of quality standards via legislation of national service frameworks and other Department of Health papers. Supervision therefore, is not a practice to be taken lightly.

The College of Occupational Therapy in its Code of Ethics and Professional Conduct states:

5.2.1. Occupational Therapists shall provide supervision appropriate to the level of competence of the individual for whom they have responsibility.

There is a common understanding within Occupational Therapy of ones responsibility to participate in supervision on a regular basis. This responsibility normally handed over to practitioners, even those who are still at the novice stage of their practice. Developing skills in supervision can take considerable time and when it works well can be rewarding and satisfying for both supervisor and supervisee. Irrespective of when a practitioner supervises, expectations of supervision can influence a participant in several ways. Supervision should enable the development of professional competence, introduce a mechanism for clinical practice accountability, support continuous professional development, provide personal support and help practitioners engage with the strategic plan of the organisation (Davys and Beddoe 2010 p25).

A number of models of supervision exist. The developmental model devised by Butler in 1996 distinguishes the various stages of professional development from novice to expert and within this process acknowledges the changing role of each participant as they journey through their own stages of development. The reflective model of supervision is also likely to be another approach used. Reflection is one of the four phases of experiential learning, created by Kolb in 1984. Creating an atmosphere of constructive critical reflection may be a particularly useful approach used in supervision to aid another person’s development.

A range of supervisory models exist, however the evidence for promoting the use of any particular model over another is sparse. Sadly, the evidence based research for identifying effective supervisory models has not been studied to the same extents of clinical trials. What is apparent is a growing and demanding need for organisations to be creative as they grow in complexity and as the demands for patient quality care increases. A recent article written by Clark (2013) refreshingly writes of positive outcomes following exploration of the supervisory role and process within an Occupational Therapy Department based in Fife, Scotland. This department eventually achieves provision of formal supervisory training, introduction of audit procedures as well as achieving COT endorsement of supervisory processes which are now in place.

The skills of a good supervisor include excellent communication skills. Being attentive to information being shared and demonstrating a high standard of active listening skills are crucial. Providing an atmosphere where information can be explored, analysed and carefully and sensitively challenged may help develop professional and personal confidence. There is a relationship of mutual respect between both participants. Supervision should always be time protected with no interruptions. Participants should also be allowed time for self-reflection including how their experiences made them feel and how they may improve or alter actions or behaviour should they encounter similar challenging experiences in the future. A competent and experienced supervisor will be able to offer many examples of professional experiences which have impacted on the way they approach particular clinical or personal situations. It is recommended to always conclude supervision with a summary of what has been discussed, actions agreed and who will be responsible for achieving them. This should prevent any misunderstanding or misinterpretation of information.

It is recommended to formally agree the terms of supervision by agreeing a supervision contract. Conditions of supervision may include any of the following however this is not an exhaustive list:

· Who will be involved in supervision
· Frequency of supervision
· Duration of supervision
· Maintaining confidentiality, other factors that may alter the confidentiality rule should also be discussed and agreed
· Responsibility of agenda preparation
· Responsibility for note taking
· Period when supervision review to be completed and who will be involved
· Procedure should supervision relationship not be amicable

Clinicians at Independent Rehabilitation Services are highly skilled in providing supervision to health care professionals. We have supervised qualified and unqualified staff over many years both in the National Health Service and Private sector of health care. It is a responsibility we take seriously but also get a great deal of satisfaction from. If you would like to discuss supervision or are seeking formal supervision either for yourself or your staff and would like to discuss opportunities for regular supervision we would be most happy to explore this with you. Please do not hesitate to contact either Angela Gordon or Birgit Rathje-Vale at Independent Rehabilitation Services.


Clark N (2013) ‘OT clinical supervision: a journey of service development’, OT News, 21(3) 42-43

College of Occupational Therapists (2005) College of Occupational Therapists Code of Ethics and Professional Conduct London: College of Occupational Therapists

Davys A and Beddoe L (2010) Best Practice in Professional Supervision. London: Jessica Kingsley Publishers


Splinting within Neurology

hand thermoplastic splintSplinting the neurologically impaired limb can be a challenge. A splint is defined as an appliance used to support or immobilise a part while healing takes place to correct or prevent deformity’ (Bailliere’s Dictionary, 2000).

Occupational therapists working with individuals who have experienced a neurological event are often required to assess and where appropriate fabricate splints.

Currently there is insufficient evidence to support or refute the fabrication of splints.  Studies have supported splinting, particularly for preventing contractures, reducing spasticity and pain and also improving range of movement (Hill, 1993, Pizza et al 2005). Although randomised controlled trials are few in number the demand for splinting continues to increase both in the acute setting and also during rehabilitation and beyond.

Occupational therapists with a multi-disciplinary team will agree treatment goals which may involve the fabrication and issue of splints supporting a person’s treatment plan and longer term care programme.   Although the majority of splints are mainly fabricated for the upper limb, occupational therapists also make splints for lower limbs.  The range of splints available are extensive and although off the shelf splints do exist, occupational therapists have specialists skills in fabricating splints for individuals which meet their specific needs.

In accordance with professional guidelines (College of Occupational Therapists Code of Conduct 2010) and also national guidelines (National Service Frameworks for Long Term Conditions, 2005) an occupational therapist will always conduct a full assessment prior to proceeding with any treatment. An upper limb assessment will not only entail a physical assessment but will also involve ascertaining from the person their functional needs, current difficulties in managing or using their affected limb, and also any psychological/emotional difficulties. A person is encouraged to be involved in discussions regarding treatment and also agreeing treatment goals, for example, what does the person want to achieve? How would they like to use their arm or hand? How does the arm/hand affect them psychologically or emotionally? These are all important questions to ask in order to ascertain what the person expects from wearing a splint.  Determining this will be important, particularly if the person will be responsible for maintaining a daily regime for wearing a splint.  In the same way, the views of carers is also important and also their agreement to support a regular splinting regime.

Reasons for splinting are varied and may include any number of the following reasons:
•    To align joints (corrective)
•    To reduce oedema
•    To prevent further flexion of joints
•    To promote active movement by fabricating a dynamic splint
•    To maintain a resting position of limb
•    To reduce abnormal muscle tone
•    To maintain range of movement of limbs
•    To prevent shortening of soft tissues

Splinting by no means is the be all and end all of treatment for anyone who presents with any of the above difficulties.  In my experience, splinting works best when supplemented with activity if this is possible.  Many people will receive advice and support in how to use their affected limb in function. This may involve formulating an exercise programme which incorporates functional tasks promoting specific joint movements.   If function is not possible, a person will receive practical support to help them better manage a weak limb so as to prevent problems in the future which many include:  pain, swelling, poor alignment of joints, flexion contractures, learnt non-use of a limb and muscle tone changes.

As an occupational therapist with considerable experience of splinting within neurology, the benefits of splinting have become more apparent, particularly when used in conjunction with other therapies such as physiotherapy and injection therapy.  An occupational therapist may also advise and support individuals with therapeutic activities and other functional tasks as a treatment media to splinting.  It is understandable why an individual may choose not to use a weak arm or hand which also has limited range of movement.  If movement of the limb is precarious an individual may dedicate considerable time and effort learning to use their less dominant arm or hand.  However, if this practice continues they will quickly forget how to use their dominant limb (learnt non- use).  By giving a weak limb attention, whether it is by wearing a splint, carrying out an exercise routine and/or using the limb in function, skills may be relearnt.  Weak limbs may be better managed with a splint resulting in less pain, swelling or deformity.

An occupational therapist will advise on SMART goals and support a person as they work towards achieving treatment goals. Functional goals may involve the use of a weak limb, for example:
•    To open a door independently
•    To make a drink and snack
•    To lift a cup with two hands
•    To hang my coat independently
•    To fasten a shirt requiring no help
•    To play games with my grandchildren
•    To use a knife and fork at meal times
•    To continue with gardening tasks


functional use of hands

Treatment goals can be endless, the most important aspect is that goals are meaningful and purposeful to the person.  It is this situation that can motivate people in continuing to work on recovery of a weak limb and which in many cases has proven very successful.  Benefits are seen and people show commitment to their recovery which may continue over months and years.


Weller B ed. (2000) Bailliere’s Nurses Dictionary, 23rd Edition, Bailliere Tindall, London
College of Occupational Therapists, Code of Ethics and Professional Conduct (2010), College of Occupational Therapists, London
DH Long –term Conditions NSF Team (2005) The National Service Framework for Long-term Conditions, London
Hill J. (1994) The Effects of Casting on Upper Extremity Motor Disorders After Brain Injury.  The American Journal of Occupational Therapy (48) 3 p219-p224
Pizzi A, Giovanna C, Catuscia F, Verdesca S, Gripo A (2005) Application of a Volar Static Splint in Poststroke Spasticity of the Upper Limb. Archives of Physical Medicine and Rehabilitation 86 1855-9

Driving: A lifestyle choice

Reasons for driving

Driving has become a major part of our lives and tends to both reflect and govern our lifestyles.

We adapt our social lives through driving and the ability to drive has broadened our horizons. For many the ability to drive is a fundamental part of their occupation, and therefore an important component of their financial, as well as emotional wellbeing. It provides self-esteem or self identity (what car do you drive?) and can both facilitate and actually be a pleasurable activity or hobby.


New Developments

Before 31 March 2009, regulation of health and adult social care in England was the joint responsibility of the Healthcare Commission and the Commission for Social Care Inspection, with the Mental Health Commission monitoring the operation of the Mental Health Act 1983.

With the passing of the Health and Social Care Act 2008 there emerged an organisation to replace these three bodies and to regulate health and adult social care in an integrated form - the Care Quality Commission. The Commission began its operation in shadow form on 1 October 2008 and began operating on 1 April 2009.


Newsletter Autumn 2009

Autumn is usually a time of decline and hibernation, but for Independent Rehabilitation Services (IRS), this is a time of growth, expansion and development of our service. With the addition of two new members to the team, we are now in a position to offer the multidisciplinary model, generally accepted to be the most effective and cost efficient model of rehabilitation for neurological disorders.



We have recently been invited by Norman Wright (editor of Choice magazine and Jaynes husband)to write for Choice.
Below is our first articles published in September 2008 and in the next two blogs I will be publishing the articles for October 2008 and November 2008.


Over the last few weeks the weather has become warmer, trees and plants have come into leaf and flowers are blooming. When we have time, we love to get out in the garden.

Gardening is a wonderfully diverse, adaptable leisure activity that can be enjoyed by people of all ages and disabilities. You don't need a large piece of land to enjoy gardening, a patio, balcony or window boxes can give just as much pleasure.


We continue to enjoy working with clients with a range of difficulties, both physical and cognitive. Additionally we have been working with a number of organisations providing a variety of services. This includes training of support workers with specific clients and training re specific conditions to staff of a local charity. We are also writing regular features for a national general interest magazine for the over 50's and have contributed articles to a specialist Occupational Therapy magazine.


This article has been published in the June 2008 edition of the newsletter for the specialist section for neurological practice in Occupational Therapy.

Reversing the Symptoms of Chronic Fatigue Syndrome/M.E.

Birgit Rathje-Vale BSc (Hons) OT, AinstLM, of Independent Rehabilitation Services (IRS) came across an effective treatment for Chronic Fatigue Syndrome. IRS started working with Caroline Khambatta BSc (Hons), a Fully Licensed Reverse Therapist and Clinical Supervisor a couple of years ago. "Since working with Caroline we are able to put ‘client centred’ treatment approach into practice in a much stronger way that addresses the clients emotional needs in line with their physical, cognitive and overall functional needs" says Birgit.


Having enjoyed a few warm and sunny days recently the British weather is again living up to its reputation becoming wet and grey again. This can make us feel low and lacking in energy, so mailing out the second article by Caroline Khambatta, we promised you in Spring, on the treatment of Depression using Reverse therapy, seems quite apt.


Declan McNichol

Bill Young

Angela Gordon

Birgit Rathje-Vale