Social distancing, stay at home and COVID-19; the hashtags that have dominated our screens for what seems an eternity.
But lockdown is just a couple of weeks old, and this is only the beginning.
Our first thoughts in community cognitive rehabilitation were; how do we see our clients? How do we practice function? What about goal attainment, orientation training, functional transfer and providing evidence? How do we support staff out there in the field?
There was an urgent requirement to shift focus, almost overnight, in order to support one of the most vulnerable groups in society.
This is a group which relies on specialist support to learn new skills and practice and habituate new tasks, suddenly being asked to move to a completely new way of being supported and living.
There are many that still need a presence in their homes due to complex needs and safety requirements.
But there is also a large proportion of individuals with brain injury who fall out of that category but still require support to enable them to maintain independence – and to move forward in their lives.
They cannot be forgotten; their desires to attain their goals have not changed, nor should they.
And it is for these individuals, who thrive on and require structure, routine and repetition, that this interruption is even more disabling. Months, maybe years, of repetition and consolidation has been brought to an abrupt halt. Or have they?
Those of us working in rehabilitation are a resourceful bunch. Our automatic processes always navigate us towards solutions to problems.
We are adept at thinking outside the box to come up with innovative and imaginative methods of engaging and motivating clients.
The COVID-19 challenge is another opportunity for us all to get our creative processes flowing yet again.
And what better time to be doing so when the world is so engrossed in online processing and information gathering, with us all spending more and more time engaging in online activities than we do real life ones?
Now is the time to bring together all the knowledge we have gained from navigating different social media platforms, computerised systems, conference calling options and celebrity ‘how tos’.
The challenge we all face, as we did in our pre-crises existence, is making it relevant and personalised to the needs of our clients, and how we get the clients on board. Literally.
The answer? Whatever it takes. Trial and error. There will be glitches, frozen screens, frustration, probable swearing, a lot of late pyjama wearing sessions and a cacophony of ‘No’s.
But we must persevere, we must be flexible, adjust, adapt and constantly monitor. It is what we always do in rehabilitation.
The most important element is to ensure that individuals living within the uncertainly of life with a brain injury, feel safe, and secure that the teams they have built around them can weather this storm, and have their needs at the forefront of their thinking. That these individuals, often burdened with rigidity of thought and concrete behaviours, know that those supporting them will just make it work for them, however that may be presented.
Wellbeing is top of the list right now. A Skype, Zoom, or Facetime call, albeit not a replacement for face-to-face skill practice has a place, a very important one.
Isolation is not welcome for these individuals, a time when negative thought patterns and behaviours can take over, when rumination becomes the norm and when motivation plummets.
Teams must engage and enable initiation, via even the subtlest methods. Even a text conversation now is a lifeline for many.
Bring groups together, offer peer support, allow individuals to be frustrated, listen to their tirades that they are angry that their favourite food outlet has shut down, or that they can’t workout; this matters.
Individuals will new learn skills and engage in the virtual method of rehabilitation, and it will work, just with some bumps along the way.
But is this not how we always expect rehabilitation to be? Service providers and community staff will learn along the way and will build their own toolboxes further.
When this temporary change becomes the new norm, we can then move to focus on the cognitive elements of every activity that we present during tele-sessions.
Every skill and goal that was identified prior, will continue, just with a different slant. We will recover with a new method of delivering services in the community that will only serve to support people with brain injuries even further.
It will take time, but right now we have a lot of that.
Natalie Mackenzie is director of BIS Services
Study reveals if body weight could increase the risk of stroke
Could body extra body weight have an effect on the brain? A new study investigates if it could have an increased risk of stroke or diabetes
A new Australian study using UK data has shown that extra body fat could lead to brain atrophy which increases the risk of dementia and stroke.
Researchers found that increased body fat could lead to increased atrophy of grey matter and consequently the higher risk of declining brain health. They compiled the data from 336, 309 UK Biobank participants.
The team analysed the genetic data of the participants within three metabolically different obesity types – unfavourable, neutral and favourable. This established if some bodyweight groups were more at risk than others.
The unfavourable and neutral adiposity subtypes were associated with lower grey matter volume. Metabolically favourable adiposity was tentatively associated with a higher grey matter volume.
The study was published in the journal Neurobiology of Ageing.
Results on body weight
The study did not find any conclusive evidence to link a specific obesity subtype with dementia or stroke. It did suggest that the possible role of inflammation and metabolic abnormalities and how they contribute to obesity and grey matter volume reduction.
The researchers highlighted that maintaining a healthy weight is key for public health. They stressed that there is a need to examine the type of obesity when assessing the impact on health.
Dr. Anwar Mulugeta, a researcher in the Australian Centre for Precision Health at the University of South Australia said: “While the disease burden of obesity has increased over the past five decades, the complex nature of the disease means that not all obese individuals are metabolically unhealthy, which makes it difficult to pinpoint who is at risk of associated diseases, and who is not.”
He added: “Generally, the three obesity subtypes have a characteristic of higher body mass index, yet, each type varies in terms of body fat and visceral fat distribution, with a different risk of cardiometabolic diseases. We found that people with higher levels of obesity especially those with metabolically unfavourable and neutral adiposity subtypes had much lower levels of grey brain matter, indicating that these people may have compromised brain function which needed further investigation.”
Police must be monitored for brain injury, argue researchers
Twenty-one police officers out of the 54 who took part in their study, all from the same police constabulary, reported having a traumatic brain injury (TBI).
“Most of the head injuries were from general life experience, such as contact or extreme sports, and some officers were ex-armed forces,” says Huw Williams, associate professor of clinical neuropsychology at the University of Exeter.
Those with TBI were more likely to have experienced post‐concussion symptoms, which was associated with greater severity of PTSD, depression and drinking to cope.
The research supports findings that head injury can compound PTSD, which almost one in five officers have, and exacerbate drinking as a coping strategy.
The study is the first of its kind, and came about when researchers saw there was no data on the relationship between brain injury in police officers and their mental health.
“We did a brief scoping exercise of the literature, and were fascinated to see there was no research on brain injury in police officers, particularly in connection with brain injury and adverse mental health,” says Nick Smith, graduate research assistant at the University of Exeter.
Williams and Smith were surprised how many officers reported having a brain injury, although they expected there to be a relationship between TBI and adverse mental health.
“We found that, when officers have a mild brain injury, where they were assaulted or in a car accident, they could have PTSD. When they have this with head injury it can be long lasting, and they can exacerbate each other,” says Williams.
“Despite being a relatively small group, the findings were robust enough to say head injury, in the mix with PTSD, depression and drinking to cope, might lead to negative long-term outcomes,” says Williams.
The findings, the researchers argue, highlights a need to tackle TBI and the consequences of post-concussion syndrome, which can cause irritably, poor concentration and memory issues.
The paper states that exploring TBI in the police could, identify a major factor contributing towards ongoing mental health difficulties in a population where, based on previous research, the implications of TBI should not be overlooked.’
“If it’s not properly treated, it could lead to greater absence from work, so it’s reasonable for police forces to pick up on these issues to mitigate risk of long term sickness,” says Williams.
“Otherwise, I can see it snowballing – chronic stresses increase over time and the weight of negative experiences become harder to carry.
“This leads us to think we need a better system in place to identify TBI, an alert system to allow people come back into operations or situations in a way that’s healthy so they’re not exposed to more risk,” Williams says.
In sports, for example, the protocol following a concussion is much clearer, Williams says, and helps to lower a player’s risk of having a second concussion while recovering from the first.
“England Rugby does a great job with concussion management protocols, they identify the problem then do something about it, ensuring people are in the right mindset to be doing a very demanding job,” Williams says.
Increased awareness of TBI in the police would be a natural progression from being aware of prisoners with TBIs, says Williams.
“I’ve worked in prisons looking at how common head injury is in people who end up in prison, and various police forces became interested in working with us in a trauma-informed manner, taking on a more broad view of the vulnerabilities of people they’re working with.
“But working from this perspective involves understanding trauma of people who provide services as well,” he says. “Sixty, 70 percent of the time, police are trying to manage and look after vulnerable people. It’s important to recognise how they can become vulnerable themselves.”
There needs to be a system and trauma-informed principles in place for police officers to manage their own vulnerability, Williams says – and he’s hopeful this will happen in the future.
“Initial conversations with forces indicate a healthy attitude towards trying to improve how can improve psychological wellbeing,” he says.
But this isn’t just up to forces themselves. It’s also important, Smith adds, to lessen divide between police and public.
“Police need help like us – it’s important to understand how trauma might affect them.”
Williams says police are often portrayed negatively in the media, and it’s important that the public is aware of why they make the decisions they make and the laws they have that could lead to them suffering trauma.
PTSD, he says, is more likely to occur when officers don’t feel like society is backing them and the public doesn’t understand why they do what they do.
“It’s important for police to be understood as operating as people for people,” Williams says.
This will also require efforts from across probation, healthcare and education, Williams says, to better understand people from different backgrounds and how to build up empathy across society and reduce violence, as well as educating on the importance of identifying brain injuries when they occur.
Ultimately, Williams is hopeful that police forces want to give officers better protection from the consequences of TBI.
“Police officers need to think about myriad factors at same time, and we want them to be optimum capacity to do that,” Williams says.
This study was a pilot, and Smith hopes to do a much larger study in other police forces across the UK that controls for PTSD and depression to see if increases in post-concussion syndrome are due to head injury and not any other factors.
The first step, Smith says, is finding out the rate of TBI in the police force, then developing a tool to measure and monitor brain injury over time. The research, he says, will be done to help rehabilitate people with TBI, with the aim to help police understand the people they’re meeting, and vice versa.
Williams argues that this work is very relevant to public protection, and it’s important it continues.
How two community services are making tentative steps to normality
As pandemic restrictions lift, brain injury services are starting to come back out of hibernation. Jessica Brown speaks to two Headway groups across the country to see how they’re resuming support offline.
In Portsmouth, the local Headway has had a difficult time in recent months. Two service users have died from Covid-19, and another has been sectioned and taken to a secure facility after their mental health took a downturn.
There’s been a huge spike in mental health problems, and a few service users, who wouldn’t have done so under normal circumstances, have got in trouble with the police.
Most service users are gradually building their contact with the outside world again, with Headway’s help.
When lockdown began in March, service manager Deborah Robinson decided the best course of action was to identify the most vulnerable users and make sure she and her team maintained regular contact with them. The next challenge was gradually exposing them to more contact as restrictions began to ease.
“We regard it as a graduation – first is phone contact, then sitting in the garden with them, then inviting them on a walk once they’ve got confident enough to come out of their homes with us, then eventually we’ll suggest they come to a session with the group,” she says.
“Some people are too frail or anxious, so they won’t come out,” she says, “So we’ll have to carry on popping in to see them.”
This approach has proven particularly helpful in some ways, Robinson says. Before the virus, staff members hoped service users would speak up in sessions when they had a problem, but visiting people at home has allowed staff and volunteers to pick up on issues faster and get to know them better.
“One staff member met a service user in his garden, and noticed that the recycling bin was overflowing with alcohol. We knew he’d been a drinker in the past, so the staff member talked to him about his drinking, teasing information out,” Robinson says.
“He said he was drinking a lot, so we’ve been able to put in place goals to help him cut down on his drinking and put him in touch with AA, as well as various other things to help with a problem that reared its head in lockdown.”
Employees and volunteers, she adds, are also getting better at texting group members and touching base.
“It’s a mix of phoning people regularly and picking up the ones where there are issues. We’re getting more adept at that because it wasn’t something we did, and we’ve also picked up almost everyone’s carers because we’ve been talking to them to hear their concerns, too.”
Forty miles west in Salisbury, Headway arranged Zoom groups every week, but recognised that this option wasn’t suited to everyone.
“We were conscious to get actual face-to-face contact again, so as the guidelines have changed, we’ve thought about how we can work with that,” says Sarah Allen, service manager.
In recent weeks, online groups have continued, but staff members have started arranging small group meet-ups in various locations, including the outdoor café at Salisbury Museum, which Allen says provided a good learning opportunity.
One of Robinson’s major concerns in Portsmouth is how service users will react when they see other people not wearing masks or standing too close, and are told they have to adhere to guidelines themselves.
Allen, however, hopes meeting up in public places will help service users slowly accustom to these new ways of life.
“Some people coming to the groups haven’t been outside during the pandemic because all their activities have stopped, so it’s really important to model social distancing and hygiene behaviours,” Allen says.
“Somewhere like an outdoor café has been really useful because it’s about giving group members social contact in a setting where they can see people all around them modelling social distancing, staff wearing face masks and putting on hand sanitiser,” she says. “Then, when group members do go out and about more, it’ll be more familiar for them.”
In recent weeks, groups in Salisbury have also met up in a park, where they were able to socially distance.
Allen says coming out of lockdown and resuming services has been a learning curve for her, and she is realising that it’s sometimes more beneficial to have smaller groups than the maximum allowed by government guidelines.
She knows she will have to continue to adapt in unknown ways as government guidelines change.
But the future remains uncertain. Headway Salisbury doesn’t have its own centre, so rents community rooms to host sessions instead – and none have reopened yet. Allen plans on continuing outdoor activities for as long as possible, but is uncertain of what will happen as temperatures cool.
“Going into autumn and winter poses a new challenge,” she says. “I’m not sure how we’re going to meet if the government guidelines if the maximum number of people who can meet indoors stays the same,” she says.
Meanwhile in Portsmouth, premises have been locked up for the duration of lockdown. Robinson has seen an increase in demand for services, so as things resume back to pre-Covid 19, she says here’s a lot of thinking to be done about how the service is going to expand to accommodate increased need. She anticipates the service will need to expand by a third.
Both Portsmouth and Salisbury Headway services adapted quickly when the lockdown came in March. Adapting back to how things were before looks like it will be a longer, more difficult path – but while Allen and Robinson have faced slightly different challenges over the last few months, there’s no doubt they’ve both found silver linings in the challenges thrown at them so far.
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