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Brain injuries on the refugee trail

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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.”

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Parliament launches concussion in sport inquiry

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A Parliamentary inquiry is to be held to examine the link between sport and long-term brain injury.

The Digital, Culture, Media and Sport (DCMS) Committee will look into the issue over two sessions, the first of which will be held next Tuesday.

Through the inquiry, the cross-party group of MPs will consider scientific evidence for links between head trauma and dementia and how risks could be mitigated.

It comes at a time when legal actions across football and both rugby codes are being considered or have already been launched, and follows the 2019 FIELD study which found professional footballers were three-and-a-half times more likely to die of neurodegenerative disease than age-matched members of the population.

Announcing the inquiry, DCMS Committee Chair Julian Knight MP said: “This inquiry will consider scientific evidence to link sport with the incidence of long-term brain injury.

“We will look particularly at what role national governing bodies should be taking and their responsibilities to understand risks involved for players and what actions might be taken to mitigate them.

“We’re seeing a number of cases involving brain injury in sport likely to reach the doors of our law courts and we will also look at the implications for sport in the longer term of any successful legal claim.”

Among those invited to contribute to the inquiry is brain injury charity Headway, which has campaigned on the issue of better safety in sport for years.

Chief Executive Peter McCabe will outline the charity’s long-standing Concussion Aware campaign and its aims of improving concussion awareness, particularly at grassroots and junior levels.

He will also call on the Government to encourage sports’ governing bodies to do more to address the issue.

“Increased scrutiny from this influential cross-party group of MPs is very much welcomed. We hope it will lead to greater pressure on all sports to do more to instil a cultural change in the way head injuries are perceived and treated,” he says.

“It has taken many years of campaigning and Headway repeatedly speaking out in the national media to get to this stage.

“There has been progress in that time, but there still remains a lot to do in terms of elite-level sport consistently setting a good example for grassroots sport to follow.

“We look forward to sharing the charity’s views with the Committee.”

Dr Michael Grey, UKABIF trustee, will also be taking part in the inquiry.

“We are really pleased to be involved in this inquiry,” he says.

“UKABIF has been raising issues surrounding brain injury in sport for a number of years and devoted a section of the APPG Report: Neurorehabilitation and Acquired Brain Injury: A Time for Change to this subject setting out some clear recommendations.

“We will be able to ensure that our evidence-based recommendations are heard at the highest level.”

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‘I’ve seen the effects of stroke personally and professionally’

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Chloe Hammond is raising money for the Stroke Association

As a nurse working with stroke patients, Chloe Hammond supports people in their recovery every day – but the effects of stroke have also touched her own family. Here, she shares her reasons for fundraising for survivors by walking 1.2 million steps.

A stroke nurse has committed to walking 1.2 million steps to raise money for the Stroke Association, having dealt with the effects of stroke in both her personal and professional life.

Chloe Hammond is completing the challenge as a symbolic reminder of the 1.2 million stroke survivors in the UK, and aims to complete it by walking 10,000 steps a day for 120 days.

Chloe, a nurse at Sunderland Royal Hospital, works in neurorehabilitation but is currently deployed to the hospital’s acute stroke ward, where she sees first-hand the impact that stroke can have in the earliest days of recovery.

And with two members of her own family having had a stroke, she is well aware, both personally and professionally, of the impact it can have on individuals and their loved ones.

“Being on the acute ward and seeing the acute side has been quite challenging, as usually I’m working with patients while they’re in recovery and having their rehabilitation,” says Chloe.

“I absolutely love seeing the progress they are making in neuro rehab, but I’m really pleased to be in the acute setting giving these patients support in the very early stages after their stroke.

“I’ve had two family members who have had haemorrhagic strokes, so I know all too well the effect this has on a person and their family, I’ve been there myself and experience it first-hand.

“So by raising money for the Stroke Association through the Stride for Stroke challenge, we can hopefully make a big difference to them after they are discharged from hospital.”

Currently, with restrictions on visiting, Chloe and her colleagues are giving medical, practical and emotional support to patients in the absence of visits from their families.

“The pandemic, and particularly the lack of visits, has definitely taken a massive mental health toll on a lot of patients,” says Chloe.

Rodney the Pug

“Often, where they could have further rehabilitation in hospital, they say they don’t want it as they don’t want to be here, they want to be with their family at home. So that’s hard, but we support them every step of the way while they’re with us.

“I think for families too, as they can’t come in and see their loved ones, they don’t fully know the impact the stroke has had on them as they haven’t seen the effects for themselves. So they don’t really know what to expect when their loved one comes home.

“But we’re always on hand to give all the support we can, and we often help patients use the technology like FaceTime so they can have those calls with their loved ones, which are now more important than ever.”

Through the Stride for Stroke challenge, Chloe is aiming to raise vital funds, as well as awareness of the importance of exercise which can prove crucial in reducing risk of stroke.

“I’m trying to walk to and from work and do a little bit more exercise than I normally would on my days off to get to the 1.2 million target,” says Chloe.

“I’m enjoying going on some longer walks with my pug Rodney too, he gets me out even despite the bad weather and snow we’ve had recently.

“But exercise is so important, and particularly working on the acute stroke ward at the minute, it reminds you of how important it really is to keep active, and do all you can to reduce the risk factors.”

* To support Chloe in the Stride for Stroke challenge, visit www.justgiving.com/chloe-hammond6

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Study reveals undetected rare neurodegenerative disorder that looks like Parkinson’s disease

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A joint study by the National Neuroscience Institute (NNI) and Singapore General Hospital (SGH) has revealed that patients who have been diagnosed with Parkinson’s disease might actually have NIID instead.

NIID is a disabling neurodegenerative condition due to a gene mutation and has no effective treatment. Symptoms of NIID include dementia, Parkinsonism, poor balance, as well as numbness and weakness in the limbs.

A patient with NIID may or may not experience symptoms, depending on age and stage of disease. The severe form of NIID is usually seen in older patients, where the disease has progressed to an advanced stage.

The team studied more than 2,000 study participants, comprising healthy individuals and those with Parkinson’s disease (PD), over more than a decade. They were surprised to find NIID-causing mutations in those diagnosed with PD.

Dr Ma Dongrui, first author of the study, says: “To our knowledge, this is the first study reporting PD patients with NOTCH2NLC gene mutations as seen in NIID patients. Thankfully, they responded to PD medications better than most PD patients do. This suggests that there must be factors that can influence why some develop PD while many others develop the more severe form of NIID.”

While analysing the NIID gene, the team found a group of healthy participants who had a “milder” form of mutation. Such mutation in the NIID gene could indicate that they are at risk of developing NIID or PD. Since NIID can go undetected, a high index of suspicion may be needed even in PD patients.

Professor Tan Eng King, deputy medical director and director of research, NNI, says: “With what we know now, it might be beneficial for clinicians to be watchful of early cognitive impairment or imaging evidence that may suggest NIID in patients diagnosed with PD. As NIID is caused by a genetic mutation, it also may be worth looking out for family members of PD patients who may show signs of NIID.

“Our findings suggest that many neurodegenerative diseases overlap and may share a common etiology. Finding a common link and uncovering the reason why a similar gene mutation leads to both mild PD and a severe form of NIID can help identify new drugs for these conditions.”

Following this study, the team plans to conduct more studies to better understand the mechanism behind NIID and identify new drugs for this condition.

More research is needed to understand if the broad clinical phenotype of NIID is related to the subtle genetic differences at the NOTCH2NLC gene locus, race or other factors. Long-term follow-up of carriers of the gene mutation with PD phenotype may provide additional clues.

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