We are all too accustomed to television images of refugees and asylum seekers. We often hear their stories; of persecution and suffering in their home countries and their struggles to reach the relative safety of the West.
What we do not hear – because it has until now been a largely unexamined problem – is how many of them have suffered traumatic head injuries and have sustained brain damage.
Now, however, a team of medical experts in Glasgow have conducted research among asylum seekers and refugees in the city and have uncovered the problem, which not only adds to the suffering of vulnerable people, but which can also – potentially – harm their chances of a successful asylum application.
The result was a report published in Global Mental Health. The research was conducted using 115 asylum seekers and refugees in Glasgow who had been referred to a community psychological trauma service with moderate to severe mental health problems associated with psychological trauma. Using interpreters where required, the subjects were screened for a history of head injury.
One of the report’s authors, Professor Tom McMillan, explains: “Given their background and the reason why they are seeking
asylum, there’s a likelihood they may have sustained a head injury in a circumstance where it has gone undetected.
“They have not attended hospital, not been detected and on average the head injury was 10 years earlier, so they themselves would not necessarily attribute their current difficulties to brain damage.
He adds: “We had to be careful about going too much into symptom areas because sometimes they were undergoing treatment or were about to undergo treatment for other issues. So, we asked more generally if they thought the head injury had had a long lasting effect.”
Head injuries can result in long term impairments in attention, pre-existing memory and ability to form new memories, word finding and executive function. The Glasgow study revealed similar problems among the refugees. “The kinds of problems were related to cognitive function,” says Prof McMillan.
“Typically people’s memory is poor for new events, for things that have happened recently, and they can’t concentrate or attend as well, while they also can have difficulty with judgement, solving problems and integrating cognitive information.
“Sometimes there can be changes in personality where they can be more irritable, aggressive, more fatigued and tired or just lacking energy and the ability to get up and do things.
“You can see how all of these factors might be difficult for people seeking asylum in the UK who have come here from another country.”
The overall average age of those studied was in the 30s. For those believed to have suffered head injuries, it was about 35; with 59% of the sample being female.
Previous studies had indicated that asylum seekers and refugees are more likely than the general population to have experienced physical assault and injury in their country of origin; and to have been victims of torture, including blows to the head and asphyxiation, which can result in brain damage.
Research revealed that more than three quarters (78%) of Vietnamese ex-political detainees resettled in Boston reported a history of head injury.
The Glasgow study found that the overall prevalence of head injury was 51% and at least 38% of those had a moderate to severe head injury that could cause persisting disability.
The prevalence of head injury of a severity likely to cause persisting disability is estimated to be about 2% in the general population in Western countries. The causes of the original trauma were also different.
“The head injury was certainly different from what you would expect from the general population,’’ says Prof McMillan.
“Among the general population in Glasgow, the most common cause of head injury is fall, then assault, then road tragic accident.
“You would expect an accidental cause, like a fall or a road traffic accident in about 70% of people. Whereas in the asylum seekers it’s the other way around.
“Accidental injuries accounted for a third, with assault in two thirds. The assault was associated with causes you wouldn’t normally find in Western countries – they were domestic violence, torture, violence through sexual trafficking, so a different kind of grouping of causes from what you’d commonly find in the general population.”
One conclusion that might be drawn from this is that, assuming those who make it to the West as refugees and asylum seekers tend to be the fittest and most able, then head injury sufferers among the asylum seekers and refugees would be under-represented and the prevalence of head injury in their home countries would be even greater.
“Logic would tell you that it is,” concedes Prof McMillan, but he points out that many of those suffering head injuries might only have made it to the UK with the help of family members or others.
Another serious potential implication is that the injuries sustained by these people might endanger their chances of getting asylum.
“That’s the hypothesis arising from this study; that they might not be able to form a credible evidence provider because their evidence is unreliable and they can’t remember information that people think they should be able to remember.
“It could be that they had a significant head injury at some point during that time period.” He would like to see a greater awareness of the risk of brain injury in such cases.
He adds: “This could be significant in some cases where an individual may be seen to be being a bit di cult or not remembering things or remembering things differently between interviews.
“Perhaps there should be some consideration as to whether there’s any biological basis to this, like traumatic brain injury.”
Furthermore, head injuries can cause emotional problems which can lead to the breakup of relationships, social isolation and unemployment. This can further complicate the fallout of psychological trauma.
There is also the possibility that clinicians may not be alert to the likelihood of head injuries when recording symptom complaints among vulnerable and often traumatised groups, such as asylum seekers, where there is already a high incidence of mental health problems, including post-traumatic stress disorder and depression.
“At a very basic level, NHS services, and particularly mental health services that deal with asylum seekers and refugees, should be screening for head injury when they are assessing people. Therefore, they could, if necessary, carry out a more detailed assessment and take into account any persisting disability when they are working with them.”
Prof McMillan would also like to see greater liaison between those services which deal with asylum seekers and refugees and the brain injury services which could provide advice.
“I’m not suggesting they should be swamped with referrals but at least they can advise in cases where there might be a concern on how to carry out a screening assessment, a kind of link in the NHS care pathways to brain injury services for any cases that require more detailed investigation.”
People referred onto mental health services would be seen by people qualified to identify brain injury, but those being dealt with at an earlier point in the process could still be identified as potentially having a problem.
“I think just having a link with brain injury services could provide them with some education and some simple screening tools so that, if they had a concern, they could perhaps triage a bit and link through.
“Even these fairly simple contacts could be quite important,” says Prof McMillan. In terms of how screening for head injury might be carried out, he says: “There are some formal tools you can use, but you routinely need to identify whether they’ve been in situations where there have been knocks to the head.
“You’re wanting to know how often this is happening, because it can be fairly mild, but if it’s repeated enough it has a cumulative effect.
“We need to know if it resulted in loss of consciousness and, if so, how long that loss was for and whether they were confused for a time afterwards – and how long that was for. By finding that information you can get a reasonably good idea of how severe the injury was. It can be difficult, especially if somebody was drunk at the time or were tortured and can’t actually remember.”
Now the report has been published, the Glasgow team behind the research is trying to make its findings and implications more widely known both in the UK and in other countries taking in refugees and asylum seekers. It has already made a difference in the city where the research was done.
Prof McMillan says: “In Glasgow the mental health team are now routinely assessing and screening for head injury, so there has been a local impact.”
There’s a ‘dire’ need for more VR rehab studies, researchers argue
Researchers analysed twelve studies that looked at VR-enhanced rehab, and concluded it can offer long-term positive outcomes for patients with traumatic brain injuries (TBI), especially those with motor skills and cognitive deficits, and those experiencing difficulties with their balance.
One of the benefits of VR rehab is that it can provide a safe environment for people to practice skills with minimal risk of harming. Some VR platforms, the paper states, can model almost any type of environment that may be useful for rehabilitating motor skills including walking, balancing and moving on different types of terrain.
The researchers, from the College of Public Health at the University of Kentucky, US, looked at six studies that examined gait and balance. All six of the studies showed that VR-enhanced rehab made moderate improvements to TBI patients’ gait and balance.
The four studies researchers looked at that around VR’s effect on upper limb functioning was more limited, and drew mixed conclusions. The use of VR to enhance cognitive rehab had the least amount of supporting evidence. The six studies the researchers looked at measuring VR and cognitive rehab found limited evidence.
The researchers state that their review not only provides helpful data, but also shows the gaps in research. They concluded that their findings highlight a need for more research that can inform providers, policymakers and the public to draw conclusions about the effectiveness of VR-enhanced rehab, especially around newer, immersive VR-enhanced rehab.
“VR-enhanced rehabilitation has been utilized for almost two decades, yet data regarding its clinical effectiveness remain limited by multiple lower quality studies,” the paper states.
“This lack of data impacts the generalizability of findings and conclusions about such important factors as physical effectiveness, motivational improvement, and cost-effectiveness that healthcare providers, policymakers, and the affected public are able to draw.”
There needs to be more research in this area as newer VR tools become available in rehab, the researchers urge, to better understand how VR can help neuroplasticity, which is the brain’s ability to learn new things by making new neural connections.
“With the advent of newer generation VR tools utilising 3D visual and auditory stimuli such as mixed reality (MR) and immersive VR platforms, new hypotheses can be tested with the Hebbian theory of neural plasticity concepts at their core,” the study states.
Studies, the researchers say, now need to adapt to include more advanced and improved technology, which will allow new opportunities for clinical rehab.
“For example, in a healthy population, improvement potentials were found in balance and visuo-motor reaction time after MR action game play,” the study states.
There is a ‘dire need’ for future studies to improve the current understanding of the potential for VR-enhanced rehab, the researchers state. This is particularly the case in the US, whose healthcare system underperforms or ranks lowest across multiple health outcomes, including access and cost-efficiency, compared to other developed countries.
“Although we must be cognizant of the potential for initial higher costs associated with the purchase, maintenance, and staff training of some of these VR platforms to be incurred, many VR platforms could actually help provide more cost-effective care,” the paper states.
The researchers argue that more broadly available commercial VR systems could avoid altogether the need for more costly interventions.
Virtual rehab “effective” for stroke recovery, research shows
Since the beginning of the pandemic in March, therapists have adapted face-to-face services to comply with social distancing measures. While many patients and practitioners alike seemed to adapt well, now research has confirmed that it can be a practical way of delivering rehab for stroke patients.
A new paper, co-authored by Brodie Sakakibara, assistant professor at the Centre for Chronic Disease Prevention and Management has found that remote, virtual rehab works for people recovering from a stroke.
Six clinical trials were launched across Canada as part of a Heart and Stroke Foundation initiative, where people recovering from a stroke were given interventions including memory, speech and physical exercise training.
Researchers from each of the six trials found that the telerehabilitation was just as cost-effective as traditional face-to-face rehab, and that patients mostly reported that they were satisfied with their telerehab.
They reported in the paper, published in the Telemedicine and e-health journal, that patients were most satisfied, the researchers found, when there was some social interaction and clinicians were appropriately trained.
Overall, clinicians reported that they prefer face-to-face interaction, but will use telerehab where this isn’t possible.
“Telerehabilitation has been promoted as a more efficient means of delivering rehabilitation services to stroke patients while also providing care options to those unable to attend conventional therapy,” Sakakibara says.
“These services can be provided to remote locations through information and communication technologies and can be accessed by patients in their homes.”
The researchers also highlight a need for technology in stroke rehab to be easy to use and well suited to the user’s needs.
“The older adult of today, in terms of technology comfort and use, is different than the older adult of tomorrow,” Sakakibara says. “While there might be some hesitation of current older adults using technology to receive health and rehab services, the older adult of tomorrow likely is very comfortable using technology. This represents a large opportunity to develop and establish the telehealth/rehabilitation model of care.”
These findings are important because telerehab is becoming much more widely implemented.
“Prior to the outbreak, telehealth/rehabilitation was highly recommended in Canadian stroke professional guidelines, but was underused,” Sakakibara says.
“Now in response to COVID-19, the use of telerehabilitation has been accelerated to the forefront. Once these programs are implemented in practice, it’ll be part of the norm, even when the outbreak is over. It is important that we develop and study telerehabilitation programs to ensure the programs are effective and benefit the patients.”
Rehab groups call for pandemic-fuelled change
An influential group of rehab organisations has issued a set of recommendations to the Health and Social Care Select Committee (HSC) aout managing rehab amid COVID-19.
While the healthcare system rightly initially focused on saving lives and stopping the spread of the virus, there is an array of patients that remain with unmet needs which The Community Rehab Alliance, a consortium of 22 charities and professional bodies – has submitted a joint response addressing.
Having identified that many COVID-19 survivors are being discharged without any rehabilitation plan in place, the report gives a series of recommendations for services that support rehab across a range of conditions to aid getting the country back on its feet and back to work.
It has been argued that this is a time to learn from the pandemic to shape rehabilitation services for the future, as well as addressing the weaknesses within the arguably under-developed part of the current healthcare system.
Rehabilitation is the process of assessment, treatment and management of a patient’s condition, within which they are supported to reach their maximum potential for physical, cognitive, social and physical participation in society and quality of living. Rehab needs to empower people to recover and build up resilience at their own pace which, for COVID-19 survivors is wide-ranging.
While there are some excellent examples of regional and local responses and pathway development, overall planning and guidance on COVID-19-related rehabilitation appears inconsistent and disjointed. The Rehab alliances recommends a national, strategic approach including integrated care systems carrying out audits, agreement on common rehab needs assessment frameworks and building up multi-disciplinary community rehab teams with the skills and staff required.
By redeploying the workforce – permanent and temporary – back into the community, it is more possible and likely to deliver commitments that will increase step-down rehab capacity.
During the crisis, it hasn’t been only coronavirus patients who have required healthcare. Throughout the pandemic, people are still having falls and fractures, strokes, heart attacks, preparing for cancer treatment or recovering from it, having accidents and illnesses that result in spinal cord and brain injuries and having exacerbations and acute episodes related to long term conditions, including cardiovascular, respiratory, musculoskeletal, rheumatology and neurological.
In all these situations, early, timely and sufficiently intensive rehabilitation will often be critical to people’s long-term recovery and the level of wellbeing and independence people regain or maintain. For older people timely rehabilitation is key to support people to prevent decline, optimise independence, prevent hospital admissions and the need for long-term care. Rehabilitation enables people (including key workers) to return to work and participate in society after lockdown.
During the pandemic, some essential and time-urgent elements of rehabilitation have continued, while supporting shielding and social distancing.
Local managers need consistent advice and time to assess when rehabilitation interventions are essential and on how community rehabilitation can recommence fully. National support and guidance for the provision of telehealth and digital rehabilitation options where appropriate is necessary, with professionals bodies needing to play a critical role in providing guidance on how practice might be adapted from face-to-face rehab from outpatients centres to home, as well as finding alternatives to clinic-based appointments and services.
As services recommence, there should be a positive risk approach, supporting ongoing guidance on social distancing, testing for professionals and carers, PPE at the appropriate level, and prioritisation on the phasing in of aspects of services.
The pandemic is shining a light on the poor state of community rehabilitation provision. While there are many excellent services, access to rehabilitation is a postcode lottery, with services being under- resourced and under-developed for decades. Planning and commissioning is inconsistent, and there is significant variation in standards.
There must be a plan to meet the wave of pent-up demand for health and care services that have been delayed due to the coronavirus outbreak, as well as meeting demand for additional mental health services.
As part of this plan, the Rehab Alliance recommends that there is a strategy to expand both community rehabilitation provision and, where necessary, retain planned additional capacity for step-down (bedded) rehabilitation units.
Through the forthcoming NHS People Plan, deliver an expanded rehabilitation workforce, including allied health professionals with advanced practice skills, support workers and care assistant trained to add capacity, sports and exercise professionals, postural stability instructors, coaches working in the voluntary sector and rehabilitation medicine doctors.
Because COVID-19 is a multi-systemic condition, with significant physical and mental health consequences, it illustrates very well the continued importance of shifting an approach to rehabilitation away from one that is based on neat medical specialisms and condition silos.
The experience of Covid-19 recovery should provide an impetus to adopting a personalised, multi-condition, biopsychosocial approach that can respond to the needs of increasing numbers of people having multiple conditions impacted by multiple factors. This approach needs to support greater inclusion of vulnerable and hard-to-reach groups, who have the worst health outcomes and experience barriers to services. This includes people with learning difficulties, dementia and serious mental illness.
Services need to make reasonable adjustments to make them accessible – for example, adapting communication.
The pandemic has necessitated a shift at scale to online management systems in the community and tele-health. As services get back to normal, it is highly likely, this could be continued to make this a much more prominent option for people in how they access and receive services.
This must be appropriate, evidence based and result in increase choice and access, not in greater marginalization of some groups and increased health inequality.
Learning from the experience of the pandemic should be captured by robust research and shared so that evidence underpins the future shape of rehabilitation. These should include the perceptions of the patients, staff and carers as well as their clinical effectiveness.
So while there is a certain amount of support available, the necessity to address and reform the rehabilitation services available throughout the UK is significant and immediate.
The Rehab Alliance, which includes industry bodies and charities such as Age UK, the Royal College of Psychiatrists and the UK Acquired Brain Injury Forum, is working to see a change across all rehab services offered nationwide to combat the challenges faced as a result of COVID-19 and strengthen those survivors in the best possible way, setting a new standard and practice in services that will better serve residents across the board.
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