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As many as one in two homeless people could be brain injured…

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Half of all homeless people may have had a traumatic brain injury (TBI) at some point in their lives, research shows.

Studies in the UK and North America over the last decade have found levels of past TBI experiences among homeless people to generally range between around 45 and 55%

Research also suggests the vast majority of TBIs happened before homelessness occurred (90% in one study in Leeds in 2012).

Such stark figures prompt serious questions about the way brain injuries cases are diagnosed and handled.

With homelessness rising sharply in recent years – by 55% in England alone between 2010 and 2015 – there is also a pressing need to better address the many TBI cases out of reach of the vital interventions they may need.

Closing the road from brain injury to homelessness requires work from every angle, including healthcare, social services and politics.

Getting the many homeless people with a past brain injury o the streets and receiving adequate care requires a similarly all-encompassing approach.

A solution to this escalating, labyrinthine challenge may well be taking shape in the West Midlands, thanks to a small band of pioneers.

“We’re not suggesting what we’re doing
 needs to be rolled out as it’s too premature
 for that,” says Dr Andrew Worthington, a neuropsychologist who runs Birmingham- based rehabilitation group Headwise.

“We 
are giving an example of one model and we’re going to evaluate its impact.”


Headwise has joined forces with the charity Headway Birmingham and Solihull to employ a ‘homelessness caseworker’ to assess the needs of homeless brain injured people and help them move their lives forward.

The post, funded by Headwise and based at Headway, is part of a wider research project by the partnership to explore links between brain injury and homelessness.

At the time of writing, the scheme is nearing the first six-monthly follow up with homeless people and Worthington is hopeful of some meaningful data.

“We’re primarily doing an intervention study. The idea is to provide a support and signposting service for people with a brain injury. When the needs of an individual are related to a brain injury we will provide that support.

“Where they just happen to have a brain injury, but their primary needs may be drug or alcohol abuse, domestic violence or simply that they have nowhere to sleep at all, we’ll signpost them to other services.

“We don’t necessarily think everyone’s problems are all down to the brain injury, but it’s important to have a point of reference where they can be properly assessed and provided with support.

“Previously they might have been given a leaflet and left to get on with it, with nobody following them up. We’re providing a dedicated case worker who’ll work with them.”

The main research element of the scheme is to compare the results between people accessing this new model and those receiving the usual standard of care.

“It’s very early days but hopefully we’ll have some evidence as to what works and will be able to develop a model that can be tweaked and may be rolled out elsewhere.

“It’s only the last 10 years or so that we’ve become aware of the problem of homelessness and brain injury so we’re still trying to work out the scale of the problem.”

Solutions which emerge in the future to stop TBI acting as a catalyst for homelessness will need to address several major challenges; including the disjointed nature of services which come into contact with vulnerable people.

“There’s a broader need to educate the agencies which work with the homeless, such as social services and the voluntary sector, to recognise amongst all the other problems, signs of head injury.

Although an individual may be drunk, for example, have they got behavioural difficulties because of a previous head injury? We’ve also got to give them some options for services to refer on to.

“What’s at the heart of this, and the reason why the government and local authorities have struggled to deal with it, is the fact that it cuts across boundaries.

“Homeless individuals can have multiple problems, one of which may seem more urgent than others at different times.

“Any service that comes into contact 
with homeless people, whether that be a shelter, dentist or GP, needs to be aware of what specialist services are available.

“Currently there is a problem in trying to provide joined-up services. If everyone is focusing only on their area, no-one is looking at the bigger picture.”

A homeless person living out of reach of regular contact with local services might reappear on the radar with a trip to A and E. In this pressured environment, with the immediate health of the individual taking priority over anything else, previous brain injuries often go undetected.

“They may have been assaulted or be drunk. Understandably the pressing problem is dealt with and they are discharged. Rather than getting to the root of the problem, they may go back to the streets. So we have this revolving door syndrome.

“Often it’s difficult to know how to help, because the problems can be very complex and usually hospital staff aren’t aware of the specialist services available for homeless people.

“On the other side of the coin, homeless services are often unable to identify the relevant medical problems.”

Furthermore, if the police or social services come into contact with a homeless person, they may also deal with the individual’s most urgent need rather than tracing the reasons for their homelessness. Finding that person a place to live is effectively treating their symptoms with a “sticking plaster”, says Worthington.

Even if past head injuries are identified,
getting someone at risk of homelessness to partake in rehabilitation and engage in brain injury services can be hugely challenging.

“They might move out of the area and, if they don’t turn up for an appointment, a lot of services won’t bother to enquire why.

“Also, they often have certain problems with mental health and substance abuse disorders which then makes it difficult for them to
 meet the criteria to be helped by brain
 injury services.

“Some brain injury services have exclusion criteria which means that many people who are homeless and need the service can’t
access them.”

Preventing homelessness among people with brain injuries, rather than getting them o the streets and on the road to recovery, presents an entirely different challenge.

“It’s quite likely that individuals who have had head injuries as children or adolescents may be at a greater risk of being homeless in later life, although there is no evidence of this yet.

“They might not develop normally, their education may be interrupted and they may not acquire the skills that adults to a certain degree might have. If it can’t be addressed early on or isn’t addressed quickly enough then this changes their trajectory for the rest of their life.”

There is an argument that some people who are considered risk-takers might be susceptible to both homelessness and head injuries – rather than one being a result of the other.

“Certain antisocial behavioural activities could have caused them to be on the streets, such as drug-taking, which could have also contributed to a brain injury.

“What we do know quite clearly is that having a brain injury massively increases any existing problems you might already have.”

While the Headwise/Headway project remains at an early stage, there are examples of successful models that are already improving the way homeless people with head injuries are treated.

Worthington cites the PIE (psychologically informed environment) system as one approach to learn from.

“The idea is to provide an environment, perhaps in an accommodation setting, that meets the person’s needs for shelter but also their psychological and emotional needs too.

“These have been known to reduce offending behavior among homeless people with
mental health issues and could have possible implications to help people with brain injuries.”

Worthington’s long-term vision is for a system that helps, not hinders, homeless people with brain injuries.

“In North America they have collaborative models of care that cut across boundaries. We’ve struggled with that here because everyone has their own ring-fenced budgets,” he says.

“We need a coordinated system that will pick people up after discharge from hospital, which is staffed by people with knowledge of head injury who are able to undertake assessments of their social and health needs and then help them access the relevant support. We need a network of services for people
that are homeless.

“Currently in hospitals, if they haven’t got a discharge destination, they are either kicked onto the streets or kept in for longer than they need to be, ultimately blocking beds.

“There needs to be a service to which these individuals must be referred. We can find them temporary accommodation and get the assessments done and refer them on to other services to give them the support they need.”

Before that ideal is realised, support in tackling the issue is needed from many sources, including charities – especially against the backdrop of austerity measures.

“The third sector is going to play a critical role in this. NHS budgets are so stretched and are skewed towards acute services. Social services budgets are also stretched.

“It would help if we could make social services more informed. But ultimately they are not going to have
the resources to address these complex needs, so I think a lot of responsibility is going to fall on charities.”

If charities are to take on this burden, they 
will need considerable support.

“Often a charity might lack medical 
expertise. What’s innovative in our model
is that we’ve got a partnership between
my professional, medical organisation and Headway, the charity.

“The future needs to be collaborative and it’s going to be incumbent on the charities
 to develop or access professional support.”

For now, Worthington takes optimism from the way in which brain injuries among criminals have been handled over the last decade.

What was once a suspected link between brain injury and criminal activity, now has a vast weight of evidence behind it.

With as many as 60% of prisoners reporting a head injury, according to one study on male inmates, the issue has infiltrated politics and is beginning to influence decisions and discussions about the future of the justice system.

In October, for example, the House of Commons justice select committee mentioned the increased risk among young offenders of head injury in its report on why the under-25s should be kept out of adult prisons.

In contrast, a parliamentary report published in the same month related to the Homelessness Reduction Bill 2016/17 made no mention of TBI among its list of the causes of homelessness.

In fact, there was no mention of head or brain injury anywhere in the document.

“A few years ago we were in the same position with brain injury and criminal activity and now we have a much better understanding of it.

“So I think in 10 year’s time that’s where we’ll be with homelessness and brain injury.
 It’s taking a while and we remain at a very early stage, but we’ve made a good start.”


TBI and homelessness: The evidence

A 2012 study by the Disabilities Trust found that 48 of the
100 homeless people it questioned in Leeds had experienced a head injury.

Of those, 90% suffered the injury before they became homeless.

The 48% figure was more than double the proportion of head injuries reported by those in a comparator control group of non-homeless people.

Another Disabilities Trust study, in Glasgow, used hospital records of admission to assess the city’s homeless population.

It found that the frequency of admission to hospital with head injury among the homeless was five times higher than that of the city’s general population.

In Toronto in 2004/05, 601 men and 303 women at homeless shelters and meal programmes were surveyed.

Overall, 53% had experienced a TBI, with 12% reporting a moderate or severe TBI. In this study 70% of respondents sustained their injury before they were homeless.

In 2014, researchers at St Michael’s Hospital in Toronto surveyed 111 homeless men and found that 45% of them
 had suffered at least one TBI in their life, and 87% of those injuries occurred before they were homeless.

Among the general population, TBI rates are estimated to be 12%, according to a 2013 meta-analysis of studies from
 developed countries.

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How mental health impacts physical rehabilitation

Breakthrough Case Management discuss how a client’s physical rehabilitation is inextricably linked with their mental wellbeing

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Mental health issues are all too common, with the numbers of people impacted by mental ill health rising significantly, particularly as the effects of the pandemic continue to be realised. 

And while the true extent of such problems is probably yet to be fully understood, research is continually uncovering the power of the connection between the body and mind. 

For those of us working with individuals who have experienced a life changing injury, the impact of mental health on physical rehabilitation is clear to see – in both positive and negative ways. 

With around one in four people in the UK experiencing a mental health problem every year, it’s possible that someone living with life-changing injury faced mental health challenges before their accident – which only amplifies the situation they now face.  

But even if someone has no pre-existing mental health concerns, such injury will most probably adversely affect their wellbeing. 

This can manifest in feelings of overwhelming distress, confusion, anger, fear, hopelessness, anxiety and depression or the development of phobias, panic disorder, catastrophisation or post-traumatic stress disorder (PTSD).

Awareness of mental health and its implications is vital knowledge for any case manager. Because of the close connection between the health of the body and mind, and the potential for mental struggles to impact on physical recovery, mental health support is an important element of nearly all our rehabilitation programmes.

From a Breakthrough Case Management perspective, our rehabilitation programmes will almost always bring in a qualified psychologist. We understand the impact mental turmoil can have on a client, and we work with a team of psychologists who we match with a client depending on their requirements and their injury or situation.

Mental health support should always be considered as part of a holistic approach to rehabilitation, so we work collaboratively with the entire multi-disciplinary team, to understand the challenges our clients are facing and deliver the support they need to move beyond them. 

There is so much going on for someone who has experienced a life changing injury, which might include anything from sleep problems and financial difficulties to relationship issues. We understand that when we ask someone to be motivated and push themselves physically, it’s going to be even harder if they aren’t feeling well mentally.

But while many people struggle badly with significant mental health issues, the situation can vary greatly from person to person. It doesn’t need to be a mental health crisis or severe depression to require attention and action, the symptoms can be less severe. 

Feeling overwhelmed and fearful is common after a traumatic injury, which can lead to lower motivation, reduced engagement or a wish to isolate. All of these factors can cause great distress to a person (and their family), which can also delay or impact the success of physical rehabilitation.

We see clients who sometimes feel the effort required may not be worth it. This might be because the gains don’t seem big enough, the status quo feels more comfortable, or they are frightened they will injure themselves further. 

They can withdraw, feel helpless and become anxious – but staying in that place limits potential. We’re here to help our clients take back control and look towards a more positive future.

So, what can we do when a client is struggling to cope with their mental health? The psychologist’s role in the multi-disciplinary team is vital, to identify the problem and develop a plan to address it. But every member of the team needs to be involved if a client is going to reach their goals, whether that’s getting themselves out of bed in the morning or walking a mile.

At Breakthrough, our case managers work with each client as an individual to find out exactly what they need to reach their goals and then bring together the best possible team to support them. 

This might involve a personal trainer, occupational therapist, neuro-physiotherapist, vocational therapist and psychologist for example. They will also identify any other issues that might be interacting to affect ongoing rehabilitation – such as sleep, appetite or medication – and organise professional, practical or financial help to address them.

Even before establishing a team, the starting point is to set realistic SMART goals broken down into achievable milestones, which a client can get behind and truly believe they are able to achieve. 

These goals must be backed up by trust – in the case manager, team and whole rehabilitation process. Developing this trust starts from the very first time we meet a client, where we start to build their confidence in our professional expertise and experience.

When someone has been traumatised, rehabilitation can take a long time and it is, of course, not always easy. But with a plan and the right support it is possible to overcome obstacles that might have previously felt insurmountable.

The more people push themselves forward and see the benefits of the work they put in, the more resilient they become.

A positive attitude is also important. At Breakthrough Case Management, we are naturally optimistic, and this positivity, alongside our tenacity, supports our clients. 

We won’t ever give people false hope – we never promise that everything is going to be all right when it isn’t. But what we will always do is work together to find out what is possible, set realistic goals and make the most of a client’s potential to reach those goals.

Through our own experience, we know the physical, mental and practical challenges our clients face are inextricably linked. 

We know we can support their mental health, and in turn physical rehabilitation, by taking some of the anxiety away. 

This might be something as simple as organising payment of bills or sorting out basic house maintenance, and while these practicalities are peripheral to the main problem, they are often the straw that breaks the camel’s back.

We are here to help and ensure our clients feel cared for physically and mentally, because effective physical rehabilitation isn’t possible without good mental health support.

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Are we neurological time travellers?

Lisa Beaumont looks at the similarities between young stroke survivors and people living with Young Onset Parkinson’s Disease

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Advocating for Neuro ProActive has provided many introductions to numerous neuro visionaries.

For example, my response to a recent LinkedIn message from the national charity Spotlight YOPD, representing those with Young Onset Parkinson’s, saw CEO Gaynor Edwards pop in for a socially distanced cuppa. She brought fellow YOPDer and former neuroscientist Dr Jon Stamford with her. 

Therefore, since I am always keen to talk to the best brains in the sector I was happy to host – they brought cake to make the meeting all the sweeter. Rapidly, I discovered that young ‘strokies’ and young ‘Parkies’ have a lot in common – the conversation was easy and animated.

In both cases we were living with conditions more commonly associated with the elderly than those in midlife – as the three of us are.

Sitting round the kitchen table we all had hope – and a belief that as advocates for our conditions we could and would make a difference. As the generation of personal computers and mobile phones, we will probably be using AI to make some of that difference. Three smartphones sat alongside the mugs of tea and cake plates on the table. 

Health technology apps like Neuro ProActive in the hands of the right people – those impacted neurologically – is a potential game changer. 

I was  fascinated to hear from them about how much they feel an affinity with young stroke survivors, like me.

Three reasons for affinity between stroke survivors and YOPD 

1. We defy expectations

Most importantly, both groups, ‘Strokies’ and ‘Parkies’ face a shared challenge in that our conditions are popularly associated with elderly patients not mid-life people, like us.

2. Digitally capable

Thanks to our relative youthfulness, we are a tech savvy patient community and have the confidence to ask questions and demand attention from medics and peers.

Both our charities, West Kent Different Strokes Peer Support Group and Spotlight YOPD are so excited about the roll-out of Neuro ProActive nationally and internationally.  We both support cohorts of  young patients who will welcome the opportunity to have some agency in their treatment programme by being empowered to self-manage their condition digitally.

3. Multi-disciplinary teams

Despite the clear difference between stroke rehab’s management of rehabilitation and YOPD’s need to manage its degenerative symptoms, both groups share the need of input from a range of AHPs.  

Access to neuroproactive.com will give us an easy platform to reach those practitioners with whom we will be able to communicate, record progress and set goals in one place.

The identification of these three similarities between stroke survivors and YOPD reminded me of this quotation from Shakespeare: “Misery acquaints a man with strange bed-fellows”.( Tempest Act 2, scene ii).

Neither group feels miserable. By contrast, we feel excited. We are happy to promote the possibilities for improved care for our conditions in future.

I have discovered a new empathy for those who are diagnosed with Young Onset Parkinson’s Disease, and those who remain undiagnosed. It is significant that reliable data is hard to find for this condition.

It is a game-changer for Neuro ProActive that Ian Pearce tweeted  news in December 2021:

Delighted to announce that, following a public tender, ⁦@NeuroProActive⁩ will be adopted by the South Wales Trauma Network. This will involve integration with EPRs and an independent research study on 500+ patients funded by The World Economic Forum. 

Value Based Healthcare Wales. Likewise the news of its adoption by Leeds Children’s Hospital. 

More patients and data will deliver better outcomes for all neurological conditions, which like Shakespeare’s themes can apply to any age. Strokies and Parkies feel old and young simultaneously.

Therefore, we feel like time-travellers.

You can get your own glimpse of the future by visiting www.NeuroProActive.com

And follow @neuroproactive on Twitter for the latest news.

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The desire for discharge home

Renovo Care Group share a case study of delivering the rehabilitation and goals to help achieve the return home

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One of the most common patient goals we work towards in acute neurorehabilitation is often the one to be discharged home or to an alternative placement.

We recently had a patient admitted for a six-week assessment period to determine whether an escalation of distress was psychologically driven, neurologically driven or a mixture of the two. To give a bit of context to this situation, this gentleman had cerebral metastasis in his right frontal lobe secondary to lung cancer and had been sectioned several times over the past year due to risky behaviours towards self and others. Whilst he had a few goals that he wanted to achieve during his time with us, the main one was to go home to his family after rehabilitation.

Given that we had a short assessment period, the first question we asked ourselves was how were we going to work with him to achieve his goal?

Upon his inpatient admission, the gentleman was seen twice a week by physiotherapy and two to three times a week by neuropsychology for assessment. Physiotherapists and neuropsychologists are guided by evidence-based practice in their professions and use their knowledge from practice to develop the evidence.

After understanding the cause of an injury, they work to ease physical and psychological symptoms using a variety of techniques. Assessments using outcome measures and formulations are conducted to gain a holistic view to help to determine the best course of treatment for a patient. 

The main goal of physiotherapy sessions for this individual was to improve his endurance, strength, and participation in activities that he enjoyed. He was measured for his upper/lower limb strength using the Oxford scale. ROM (Range of Motion) and MAS (Modified Ashworth Scale) were also used to identity that he had a normal passive and active range of motion over all joints, and no muscle spasms were evident.

Finally, we assessed using the Berg Balance Scale, which is an objective way of determining how well a patient can safely balance during a series of predetermined tasks. He scored 55/56 which indicated a low risk of falls.

Initially the main goal of neuropsychology was to assess the gentleman’s cognition, behaviour, and emotions to hypothesis whether the distress he displayed was neurologically driven.

Maja Kreninger, physiotherapy assistant

Whilst he was previously screened using a brief cognitive test several years earlier, there did not appear to be a reassessment since the cerebral metastasis diagnosis. Therefore a comprehensive baseline to measure any further changes was required.

During inpatient sessions, the gentleman completed a battery of psychometric assessments to measure his current level of cognition. This included a test of premorbid functioning to find out an estimate for intellectual level before diagnosis, a current level of cognitive functioning (after diagnosis), language, attention, memory, and executive functions (higher-level thinking skills such as planning, cognitive flexibility, decision-making etc).

His behaviour and emotions were tracked over time using a mood/ behaviour diary filled out by ward staff. Mood and quality of life measures were also completed.

Our second question then became, how ethical is it to just provide an assessment when an intervention may also prove effective?

The simple answer is that it is not ethical. What is the point of putting a person through intensive assessment that may evoke anxiety or frustration if you aren’t going to provide them with the tools or strategies to support the areas of difficulty? It was obvious that this individual wanted to go home after his assessment period, but it was likely that he would still benefit from having neuropsychology and physiotherapy input.

The model we jointly decided on with him was for him to come in as an outpatient one day per week. With input from his family, he concluded that Wednesdays were a good day for him to travel to the hospital, engage in his sessions and travel back home. That way his preference of living at home and receiving neurorehabilitation could be adhered to.

Initially he was scheduled in for two neuropsychology sessions and one physiotherapy session with rest breaks in between. However, it became apparent after the first outpatient appointment that he was unable to cope with the high cognitive and physical demands placed on him in his sessions and catching the bus all in one day.

In order to manage his fatigue levels neuropsychology sessions would reduce to once a week to and the number of weeks that he would be an outpatient would be extended to ensure that he received the intervention required. 

As part of the physiotherapy intervention, the gentleman commenced a personalised strength training program using multiple gym machines. He was given a booklet with details about the exercises, correct methods, resistance, and repetitions so that he could access the gym on his own.

Joint sessions with Occupational Therapy were completed to ensure he could access the community, and exercises helped increase aerobic tolerance. This proved to be successful as he was able to independently go into town to complete activities of daily living, e.g., buying presents, going to the hairdressers etc.

As fatigue was one of the challenges encountered during sessions, physiotherapy focused on gradually increasing the amount of activity completed in a graded, flexible way that was monitored continuously. 

Similarly, neuropsychology also created an individualised intervention to help build his awareness into his brain injury. The intervention consisted of six sessions to improve knowledge of the structure and function of the brain, neuroplasticity, fatigue, and cognitive and emotional changes after brain tumour.

The sessions highlighted strengths and weaknesses of his cognitive, behavioural and emotional profile providing feedback from the neuropsychological assessments. It also included strategies which could be implemented to support the gentleman at home. He was given his

Ellie Knight, assistant psychologist

own folder with all of the session information to use as a memory aid and to share with family. 

Over time, he began to recognise his limitations in relation to fatigue and understood that he could take breaks, complete tasks when he was less tired and show self-compassion.

He reported that his brain injury awareness improved, and he felt much steadier on his feet. He started to engage in community activities such as going to the cinema and regularly walking near his home. After seven weeks as an outpatient the gentleman was discharged from our neurorehabilitation service – his main goal achieved. 

Upon reflection, the first step of his rehabilitation was setting SMART (specific, measurable, attainable, realistic, and time-related) goals that were tailored to his needs and wishes. This improved his motivation and confidence to participate in sessions knowing that we were all working with him to achieve discharge home.

Developing a sense of strength is a personal journey for every patient, whether it is physical, mental or in an everyday setting. As rehabilitation practitioners it should be our duty to assist them in this journey which will lead to improving their wellbeing and quality of life.

  • Written by Maja Kreninger (physiotherapy assistant) and Ellie Knight (assistant psychologist) of Renovo Care Group

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