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“She started playing, and then spoke for the first time”

Andrew Mernin reports on how neurologic music therapy is delivering “amazing” results on a busy London stroke ward.

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When a music therapist first came to Karima Collins’ stroke ward, her NHS- issue sceptic alert fired up.

“We’re trained to be quite critical and to focus on the evidence,” she says.

“When someone makes grand claims about what the therapy can do, like improving attention, communication and reducing neglect, I was sceptical. How on earth could it do all these things?”

Then she saw the video evidence – and heard more about how neurologic music therapy (NMT) can transform outcomes in stroke patients.

Karima is clinical lead at London’s Charing Cross Hospital’s acute stroke ward, and a speech and language therapist.

The music therapy consultant was Daniel Thomas, from specialist therapy provider Chroma.

A five-week trial of NMT on the ward spiralled into a nine-month project funded by the Imperial Health Charity, which supports Charing Cross as part of Imperial Stroke Services.

The initiative, the first programme of its kind in an acute stroke unit setting in the UK, has won widespread acclaim, and the support of bodies including the UK Acquired Brain Injury Forum.

The idea was to embed a neurologic music therapist on the ward, delivering NMT in conjunction with other rehabilitation therapies to accelerate recovery.

Would the results match the impressive video evidence that swayed Karima at the outset?

Music therapy in long-term residential care environments is well-established and publicised.

YouTube is home to an abundance of clips showing people with dementia and other neurodegenerative diseases being lit-up by music therapy interventions. But the obvious difference when attempting any kind

of comparison is that this is a local stroke unit in a busy public-funded hospital, where stroke survivors from across North London come after their three days of immediate medical attention and stabilisation in the hyper acute unit.

“People can still be quite acutely unwell,” says Karima.

“Their levels of how awake and alert they are can be quite low, and they can be very fatigued.

“We weren’t sure it would work with these very sick, very early stage stroke patients, because we knew it was a very different setting to the traditional neuro- rehabilitation unit.

“The average length of their stay is only around 19 days, which is very short compared to the type of neuro-rehab unit you might associate with NMT, where people stay for eight to 12 weeks.

“We were also mindful of the fact that we didn’t want to reduce the amount of existing therapies patients were getting.”

While it may not initially appear the ideal setting for such a project, the results speak volumes in terms of NMT’s effectiveness.

An impressive 100 per cent of patients receiving NMT for aphasia achieved their target language in one session, with the project scoring the same level of success among patients who received NMT for dysarthria – increasing their decibel output by an average of 72 per cent.

Furthermore, 88.2 per cent receiving NMT for cognitive impairments were able to achieve one of their MDT goals in under two NMT sessions, and 85.7 per cent of patients with gait irregularities improved on average by over 40 per cent in a single session.

Patient stories themselves help to articulate those statistics even more powerfully.

Karima remembers one patient who had not spoken during her time on the ward, did not want to interact with staff or patients and engaged reluctantly with the NMT project.

“She eventually agreed to sit at the keyboard. We found out from a relative of hers, as we conduct a music history questionnaire with the patient and their relatives, that she had in the past played piano and was very musical.

“So she sat and actually put her hands on the keyboard and played the notes from something she remembered, and then started speaking.

“That was the first time she came out of herself and initiated any kind of communication with anyone. It was amazing.

“Another patient was finding it difficult to stick to one thing, even in communication she was very distracted, going off topic and looking around, losing track of herself.

“But when she sat at the drums and played a rhythm, even while being distracted by other rhythms that were added in, she was really focused, absolutely 100 per cent focused on that activity.

“It was only beating a drum, but she really concentrated on that task and it really helped her.”

Through a combination of individual and group sessions, adapted to the needs of the individuals involved, and under the careful guidance of music therapist Charlie Flint, the project helped to uncover new ways of inspiring patients.

It motivated them through a love of music, helping the medical team to find new ways of joint working on the ward.

Charlie was regarded as ‘one of the team’ on the ward through delivering NMT two days a week.

“One of the benefits we found came as a result of Charlie being able to conduct the team.

He could say, ‘if we are working towards these functional goals, like the patient making a cup of tea or a sandwich in order to be able to go home, then how can we use music to integrate the same goals? Can we get them into the kitchen, standing up and reaching to get their cup from the cupboard?’

“Even though we strive to devise realistic goal settings, often it’s easier to goal set within disciplines. So, for example, if the physios were working on walking, they would just focus on that, and their goal would be to just get a patient up and walking.

“Then the speech therapist looks at the stuff around language or speech. There isn’t always very much crossover.

“NMT had an interesting effect on how people thought about goals, with music at the centre of everything. Also, attention is so core for any physio, occupational or speech and language session the patient needs to be able to attend.

“We found that having music therapists there enabled us to speed up the process of getting the patient paying attention.

“So we could use music to improve attention faster because patients were very engaged with the music and the types of activity it offered.

“That would then speed up the process of opening them up to the next stage of their therapy.

“For example focus might start at ‘music for attention’, then ‘music for the finding words you need to say’.

“It meant there was an extra tool in our toolkit for addressing the difficulties a patient has.

“It’s very difficult to sit and make an interesting session around finding a word for something, whereas actually attending to produce something based around music is much more motivational.”

Karima and the team’s hope is that funding can be accessed so that the NMT project can not only continue in the stroke unit, but also to enable it to be extended to the neuro-rehab unit onsite at Charing Cross.

“We know it will work very well in the neuro-rehab environment, albeit with a slightly different model, because the patients stay there for longer.

“This means you can plan and predict how many sessions they might engage in.”

Like many therapy types within neuro-rehab, proving cost effectiveness of NMT is vital.

“Ideally we would have set a trial up with some patients receiving NMT and some who weren’t. That would have provided a control group where we could have compared and contrasted, but that takes a lot of time and we really just wanted the patients to have the benefits of NMT as soon as possible.

“The data we’ve gathered certainly suggests that it is cost effective and has a very strong influence on patient outcome and motivation.

“Also, patients and families tell us they love it. Staff feel that patients respond differently to it than traditional, slightly more boring therapy.

“We’re also hoping to be able to bring in some volunteers – perhaps music therapists who want to specialise in NMT. That might be a great way of extending the impact.”

Chroma has secured funding to continue its work at Charing Cross for three days a week throughout 2020.

For more on NMT see: www.wearechroma.com.

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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

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A blue measuring tape to mark a study on the effects of body weight on stroke and dementia

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.

Stroke studies

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.

Read More: Investing in the future of rehab robotics

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.

Read more: Osteoarthritis: breaking the cycle

Further investigation

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.”

Read more: New report reveals a higher number of people with a brain injury in the criminal justice system

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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).

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“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.

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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.

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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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