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.
Now is the time to embrace better ways of working
By Merryn Dowson, assistant psychologist and part of the team behind rehab goal-setting platform Goal Manager
A stitch in time saves nine. Rome wasn’t built in a day. The best things take time.
We are all too aware that some of the most important parts of our lives have been crafted, carved and developed over months and years. Consider your education, for example: you may well have been to primary school, secondary school and then sixth form college. Perhaps you went on to do an undergraduate degree.
You may even have taken another leap and completed a Master’s degree or a Doctorate. This took years. You learned, revised, sat exams, sat resits, applied for places, got results, got rejected, got accepted, and made it here.
One thing is certain: compared to all of this expertise, someone who completed a two-hour online course on the same topic does not come close. We know that putting time and effort into something gives us better results than if we tried a quick approach.
We do not always lead by this example though. Despite the knowledge that great results are only achieved through hard work and perseverance, sometimes we decide just not to bother. Often, a room in our home might look cluttered, worn down and unloved and it could be made to look incredible.
The walls could be painted, clutter cleared, carpet cleaned, furniture patched up, curtains updated, but it is so much effort. We see the effort it would take and keep living with it. It does the job. It’s fine.
We heard this a lot when we began to develop our software. Goal Manager was designed from within a clinical neuropsychology service with young people with acquired brain injury, and we recognised how goal setting was becoming an intimidating concept within our service and our colleagues across the field.
To combat this, we developed an online goal-setting platform which streamlines the key processes of goal setting into one system and allows members of multi- disciplinary teams (MDTs) to collaborate on goal data remotely.
Crucially, it was designed to fill a hole. The more daunting goal setting became, the more it was shied away from, and the guidelines for goal setting that had emerged from the literature were falling to the wayside.
While we designed our platform to save time on completing all of the gold-standard processes of goal setting compared to doing them manually, we found that people had often not been completing them at all. It was all too complicated.
As a result, we recognise that adopting a software solution like Goal Manager can come with its own problems to solve. It requires relearning a lot of
what we know about a concept like goal setting, understanding properly how these key processes work and how they can be applied clinically to benefit clients.
It is only then that you can start to think of ways to make it more efficient. To help with this, our users are offered bespoke demonstrations, guided MDTs through meetings to help with the clinical application of the data, and training on assessments and goal attainment.
This takes time. Our users are often throwing out their previous guide and writing a new one. When surveyed, however, every single one who responded said that it was worth it.
This brings us back to where we started: the best things take time; Rome was not built in a day; a stitch in time saves nine. By taking time to develop an understanding of goal setting and being able to apply it to a software solution, users experience all of the benefits of best-practice goal setting outlined in the literature both for their clients and for their teams.
Clients are motivated, rehabilitation is meaningful, important areas to address are highlighted, MDTs are focussed, clinical practice is evidenced – the list continues. None of this would have been possible without the initial investment of time.
While simple enough to read, this is no doubt overwhelming to apply to your service or practice and, with this in mind, there are some key points to remember. The most significant is that there is no better time than now.
The world is slowly opening its eyes, sitting up in bed and having a good stretch after the darkness of the Covid-19 lockdown. It is not yet certain if we are going back to snooze or if we are leaping out of bed afresh.
What we do know, however, is that we are heading into a brand new day. Even for those of us who continued in practice throughout the pandemic, services have been slightly paused in one way or another, whether that be refraining from home visits or having fewer people in the office.
We are all very aware that we are heading into the “new normal” rather than our old ways. Use this time to bring new and innovative ways of working into your practice. You might completely change your filing system, consider how you approach your waiting lists, or change how you approach MDT meetings.
Whatever you have been wanting to do for you and your service for so long, now is that time.
Perhaps you decide that you are going to welcome change but not all at once. That works too! For users of Goal Manager, we often suggest that starting with one or two clients might feel more manageable than a whole caseload.
This can help get to grips with the new concepts and ways of working without feeling like everything is completely disrupted. This applies elsewhere too. If you are wary of integrating a system into your whole service, start with one corner of it, evaluate, take what you have learned and then look to apply it more widely.
Finally, remember that all time taken to improve and grow impacts more than just what you set out to do. When people lose weight, they rarely conclude
by saying they just lost weight: they often enthuse about how they feel more energised or move easier or feel more positive or experience less anxiety.
This applies to any time you invest in developing your clinical practice or your service.
While time spent learning how to use Goal Manager and establishing it within a caseload is designed to improve goal setting, that investment also leads to improved assessment processes, more effective meetings, improved digital literacy, increased patient involvement and so much more.
The potential is enormous. To motivate you to start the process, look at what you want to achieve and how that might trigger other improvements.
While the world is still trying to drag its head off the pillow to open up the lockdown curtains, look to invest in addressing those needs you have always been aware of but never felt like you could justify the time.
Walk around your “house” and look into each room: is this the best it can be or could I give it a lick of paint?
Is now the time to bring meaningful solutions into my practice? Maybe grab a tester pot and try a new shade on the walls. Sign up for a free trial. Plan to grow and improve. Start building Rome.
To invest in improving your goal setting, visit www.goalmanager.co.uk to register for a live demonstration, sign up for a free trial or request a bespoke tour through the platform and its features.
Researchers unlock key prognostic tool for brain injured patients
In 1974, leading neuroscientist Graham Teasdale co-created the Glasgow Coma Scale (GCS) while at the Institute of Neurological Sciences in Glasgow. This scale has since been used to assess coma and impaired consciousness in patients who have had a brain injury.
The scale is used to describe variations in a patient’s eye, motor, and verbal responses. Each feature is assigned numerical scores depending on the quality of the response, and total scores range from three, which is a deep coma, to 15, which is full consciousness.
The GCS is used in clinics all around the world by physicians, nurses, and emergency medical technicians; and is also applied more widely in other, more complex systems that are used in assessing acute brain damage.
However, all three features of the GCS can’t always be determined in patients. Most commonly, the verbal response can’t be tested, as it’s not possible to determine this response in patients with severe brain injury who are intubated.
When the verbal score cannot be measured, the GCS can still be used in routine assessment and communication about a patient’s condition.
“The GCS should be reported in its component parts, so there is still useful information in the motor and eye components, and the verbal score can simply be reported as not testable,” Paul Brenan, senior clinical lecturer in neurosurgery at the University of Edinburgh says.
“The missing verbal score is problematic, though ,when determining the GCS sum score (eyes + verbal + motor). The sum score is used in clinical prognostic tools, such as the GCS -pupils score, so until now, missing verbal data has prevented clinicians from using these tools.”
But now, Teasdale and Brennan, along with Gordon Murray at the University of Edinburgh, have created a tool to use to assess impaired consciousness when the verbal component of the GCS is missing.
The researchers first examined a database of GCS assessments, and found that the verbal component of GCS was missing in 12,000 patients with traumatic brain injury (TBI), which made up 11 per cent of GCS assessments. These verbal scores were most often missing in patients with low eye and motor scores.
Using GCS data recorded in a database of 54,000 patients, the researchers calculated the distribution of verbal scores for each combination of eye score and motor score. They then combined GCS eye and motor scores into EM scores, and determined the distribution of verbal scores for each EM score. Based on this, they identified a verbal score that clinicians could impute for every EM score.
“Without the verbal component of the GCS, the GCS sum score (eyes + Verbal + motor) cannot be determined, so we developed this imputation tool to enable clinicians to benefit from these prognostic tools for decision making in patients with the most severe brain injuries, where the verbal score is not testable,” Brennan says.
To test these imputed verbal scores, the researchers substituted imputed verbal scores for actual verbal scores within the framework of prognostic charts, which the authors had previously developed.
These charts take into account the total GCS score, pupil response, age of the patient, and findings of abnormalities. The charts provide predictions about patient outcomes, and are designed to help clinicians make decisions and communicate across teams.
The authors outline in their paper, ‘A practical method for dealing with missing Glasgow Coma Scale verbal component scores,’ published in the Journal of Neurosurgery, that they found that the information gleaned from imputing verbal scores according to each EM score was similar to the variations between precise eye and motor scores, and from full information on verbal, eye, and motor responses.
Imputing verbal scores doesn’t add new information, but allows clinicians to use prediction and prognostic models by filling in verbal data needed for those systems to work.
“We have developed several tools related to the GCS that enhance its ease of use and clinical application, including the GCS Aid, the GCS-pupils score and the GCS pupils Age CT prognostic charts,” Brennan tells NR Times.
“These have been designed to address specific needs. For example, the GCS Aid was developed to support training in assessment of the GCS and to enhance reproducibility of assessment. The GCS pupils score and prognostic charts provide a simple but robust prognostic tool that can be used in the clinic.”
“Prognostic scores are helpful for clinicians to get a reliable prediction of patient outcome, to inform clinical decision-making and to support communication with a patient’s family.
“We know from previous research that clinicians can tend to predict overly pessimistic outcomes for patients, particularly those with severe brain injuries, so these prediction models are designed to prevent that. With our imputation tool, the sum score can be determined and prognostic models used in real-time in the clinic.”
The researchers believe that being able to add verbal scores will help clinicians quickly determine the severity of acute brain injury and estimate patient outcomes.
“We know from the enquires we get and from the number of downloads of materials from our website, that these are very popular and are having a positive impact on clinical care around the world.
“We are confident this missing verbal score imputation tool will be just as positively received,” Brennan says.
Update:concussion in sport
A run through the latest developments in concussion in sport research and protocols.
A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.
Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.
“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.
“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”
Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.
Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.
Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.
Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.
“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”
The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.
The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.
Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.
These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.
The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.
Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.
“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”
A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.
There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.
A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.
EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.
This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.
This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.
SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.
“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”
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