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The future of UK brain injury care



Concussion in football campaigner Dawn Astle at the UKBIF event

The shuffling and whispers of the conference crowd ceased entirely when Yorkshireman Stephen shared his story. The brain injury survivor recalled the last thing his wife ever said to him before the overdose that killed her. “I just want my old Steph back”, he quoted to a watching audience of delegates.

Even battle-hardened brain injury professionals with years of experience in the field were captivated by his account, which formed part of a video montage to introduce the new Time for Change report.

The All-Party Parliamentary Group for Acquired Brain Injury’s paper is designed to highlight the many challenges facing
brain injury care in the UK and was covered in detail at UKABIF’s 10th annual conference in London.

However tragic, testimonies like Stephen’s provide invaluable support to those trying to push brain injury higher up the national agenda. Patients with first-hand experience of brain injury able to share it in conversations not littered with medical jargon are vital allies for the lobby fighting the corner for neuro- rehab services.

But the cold hard facts of ABI may be equally persuasive to decision makers at Westminster, delegates at the Royal Medical Society were told.

Chris Bryant MP, chair of the ABI APPG, said at the UKABIF event: “If you take an 18-year-old who has been in a road traffic accident and maybe needs three or four people’s support

to be able to clean, wash, feed and dress themselves, and you take them to a place through rehabilitation where they only need one person, then across a lifetime you have saved the taxpayer millions and millions of pounds. So there is a real saving for the whole of society.

“This is not the argument I prefer using. The argument I prefer is, if we can give someone a better quality of life then that’s the moral imperative, not a financial one. But there are people who will respond well to that other argument.”

Bryant, one of several speakers at the event in November, focussed his speech on the ongoing lobbying campaign surrounding the issues and recommendations set out in its APPG report.

“I’m dedicated to this cause because ABI is a hidden epidemic. I’ve campaigned so hard because it impacts on so many government departments.”

He also reiterated the mission of the APPG to unite government departments and drive change for brain injury survivors.

“The campaign is far from over. I feel that it’s only just begun and there are other issues we haven’t even touched yet.”

Also taking to the stage was Colonel Alan Mistlin, chair of the clinical reference group for rehabilitation and disability. He detailed the continual development of specialised neuro-rehab.

Neuro-rehab is crucial in order to maximise recovery after ABI and remains one of the most cost-effective interventions available to the NHS, he said.

It reduces acute hospital stay, provides functional independence and facilitates a return to work. Yet there are large variations in provision and access to services and a lack of neuro-rehab personnel, he warned. “The current services are probably not what we would set up now, but there’s lots of work in progress,” he said.

Colonel Alan Mistlin at the UKABIF event The updated Rehabilitation Prescription (RP) was discussed at the event, by Hannah Farrell, of University Hospitals Birmingham NHS Foundation Trust.

The RP documents the rehabilitation needs of the individual with ABI and identifies how those needs should be addressed longer term. Farrell reminded delegates that the RP should be given to the patient on discharge and a copy sent to their GP to facilitate ongoing rehabilitation.

Farrell said: “The RP is not just a tick box exercise to generate money. It should be used for every patient with rehabilitation needs and a copy sent to their GP; this is a major challenge going forward.”

Meanwhile, the much-debated issue of brain injuries in the prison system was discussed. Brain injury can make offending behaviour more likely, while being an ‘offending type’ can make having a brain injury more likely. Also, having a brain injury can make people far more prone to the effects of alcohol which also increases their probability to offend.

The prevalence of ABI in the offender populous is significantly higher than in the general population. There is clear evidence of the different causality of brain injury between men and women in prison, with females being at greater risk of repeated brain injury from domestic abuse. Dr Ivan Pitman ofvthe Brain Injury Rehabilitation Trust (BIRT), discussed the findings from BIRT’s Brain Injury Linkworker service in a women’s prison which is based on a stepped care model and focusses on identifying brain injury and implementing interventions to support the offender.

On the issue of young people with an ABI, Professor Nathan Hughes, University of Sheffield said: “Recognising brain injury is key to being able to provide the right support in schools, to prevent disengagement, exclusion and possible offending behaviour.”

He explained the issues surrounding the recognition and response to ABI and the discriminatory criminal justice processes. He also emphasised the need to change systems and processes to ensure young people obtain appropriate and timely support, and ultimately prevent their propensity to go on to offend.

“The cornerstone of disability law is that the employer has a duty to make reasonable adjustments for the employee,” said Emma Satyamurti, Leigh Day looking at the challenges of returning to work following a brain injury.

She reviewed examples of ‘reasonable adjustment’ including a change of tasks, location, working hours and different approaches to managing absence and performance behaviour.

Dawn Astle concluded the formal conference programme by telling the story of her father, Jeff Astle, the footballer nicknamed ‘the King’ by fans, who won five caps for England.

Jeff was the first British professional footballer to die from chronic traumatic encephalopathy (CTE), aged just 59.
The impact of sport-related concussion on late dementia, CTE and other chronic neurological conditions is uncertain and further research is needed, she warned.

The Jeff Astle Foundation was established in 2015 to raise awareness of brain injury and to provide support to those affected.

The UKABIF event was sponsored by Cygnet Health Care, Elysium, Irwin Mitchell solicitors, Leigh Day and Sintons Law.

Also at the UKABIF event…

Cheers to a college champion

A physiotherapy manager has been recognised for her groundbreaking work with college students.

Verity Fisher, of the National Star College in Ullenwood near Cheltenham, is this year’s winner of the UKABIF Stephen McAleese Award for Inspiration.

She received her award at UKABIF’s 10th annual conference from the parents of Stephen McAleese, who sustained a brain injury after contracting meningitis when he was 15 and dedicated his life to promoting understanding of brain injury. He passed away in 2010.

Verity said: “I’m really pleased to receive this award. The young people at the college have a wide range of physical disabilities, acquired brain injury and associated learning difficulties, and my work is all about helping them achieve greater independence. I try to ensure that as many opportunities as possible are made available to our students.”

Among Verity’s achievements was the initiation and organisation of a therapeutic and learning ski trip to Andorra for young people.

The project originated as a one-week trip for those with moderate physical disabilities which was then rolled out to also include those with very complex disabilities.

Verity worked closely with the Andorran resort, ski school and airlines, as well as the Andorran ambassador, to ensure that all the young people at the college had the opportunity to learn to ski.

The trip has developed as a key element of the college’s therapeutic and education programme. Her work has been recognised by many organisations, including Ofsted and the Care Quality Commission, during inspections at National Star, and was covered by the BBC breakfast programme.

UKABIF chair Andrew Bateman said: “Verity’s innovation, enthusiasm and determination are a great inspiration to us all. Her excellent work has also been carried through in the form of training packages which, alongside the publicity generated, will have a far wider impact in raising awareness of acquired brain injury.”

The winners of the UKABIF Film Award 2018 were also announced at the recent conference in London. They were Kathryn Cann for the County Durham and Darlington NHS Foundation Trust, Lauren Nicholas for the Royal Hospital for Neuro-disability, Anne Johnston and Jeremiah Humphreys-Piercy.

Whitehall screening

MPs will have the chance to undergo the brain injury screening process that many would like to see implemented in prisons across the UK. The move, announced by MP Chris Bryant

at the UKABIF annual conference, will see ministers at Westminster being given the option to complete the test in January. The initiative, led by the Disabilities Trust and supported by the acquired brain injury APPG, is aimed at raising awareness of the importance of brain injury detection and management in the prison system.

“We hope at least two thirds of MPs will take part,” Bryant said.


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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 to register for a live demonstration, sign up for a free trial or request a bespoke tour through the platform and its features.


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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.


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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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