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Brain injury in the new normal: Fitting COVID-19 guidelines into your routine

Consultant clinical neuropsychologist Dr Keith G Jenkins and Dr Jenny Brooks, consultant clinical psychologist, on how to manage the pandemic guidelines.

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COVID-19 has had a significant impact on our ability to meet up with friends and family and engage in our normal activities. For some people, it’s also changed the way that care and rehabilitation are delivered.

Lots of people have been left feeling more isolated, and missing important people in their lives, as well as the activities they enjoy.

At the time of writing, government guidance in England allows groups of six people to meet in an open space, keeping two metres apart.

For those in England that have been shielding, however, while they can leave their house once a day, it must be with members of their household. If you are shielding, it is still strongly advised that you avoid shopping or your place of work. (Please note social distancing and shielding rules are different in Scotland, Wales and Northern Ireland).

Given how changeable the guidance is, it may be difficult to remember what you can and can’t do safely. Keeping a written note of the current guidance to check before making plans or going out, is therefore advised.

The current advice is to wash our hands regularly for 20 seconds at a time and to use the correct technique.

For many people, this will mean more hand washing than normal and this changing routine can be difficult for us all to get used to, but can be even more difficult if you have memory difficulties.

There are some reminders of correct hand washing techniques available in ABIL’s resource pack. It may be helpful to put them up next to your sink, bin, letter box and wherever else you might think is necessary.

Throughout the pandemic, there have been various rules and guidance that we have to follow. This has meant that we all have had to make changes to the way we live our lives and develop new routines.

The government website has the most up to date information. However, there is a lot of information to process understand and remember, and it is important that we all adhere to the rules set out by the government.

There are many organisations that have broken down this information to support us all in understanding and following the rules.

We’ve included one of these in the resource pack. Headway also provides a helpline which, although can’t answer medical questions about the virus, is able to offer reassurance and a friendly voice.

This is one of five blogs in a series on living in the new ‘normal’ with a brain injury, based on a webinar produced for ABI London (ABIL). See below for links to all other articles in the series. Dr Keith G Jenkins is consultant clinical neuropsychologist at St Andrew’s Healthcare and chair of Headway East Northants. Dr Jenny Brooks is a consultant clinical psychologist working independently and a director of The ABI Team. For any questions about this topic email update@standrew.co.uk.

Fitting COVID-19 guidelines into your routine

Keeping a check on your wellbeing

How to keep in touch with loved ones during the pandemic

How to keep a routine during the pandemic

How to get a good night’s sleep during the pandemic

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Repeated head injuries linked to depression – study

Repeated head impacts may be associated with depression symptoms and worse cognitive function later in life, new research suggests.

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It’s well established that a traumatic brain injury (TBI) can cause memory and cognitive problems, as well as depression, but now, researchers have looked at the consequences of repetitive head impacts.

They found that people exposed to repetitive head impacts may be more likely to experience difficulties with cognitive functioning and depression years later.

The researchers analysed data from the Brain health Registry on 13,000 adults, five per cent of whom reported having had repetitive head impacts through contact sports, abuse or military service.

They were asked about depressive symptoms and completed cognitive tests.

The paper, by researchers at Boston University and the University of California, San Francisco, reveals that participants who’d had repetitive head impacts and TBI reported greater depression symptoms than those who hadn’t.

Repetitive head injuries were a stronger predictor of depression than TBI, and those who had a history of repetitive head impacts and TBI with loss of consciousness reported the most depressive symptoms.

“The findings underscore that repetitive hits to the head, such as those from contact sport participation or physical abuse, might be associated with later-life symptoms of depression.

“It should be made clear that this association is likely to be dependent on the dose or duration of repetitive head impacts and this information was not available for this study,” said Michael Alosco, associate professor of neurology at BU School of Medicine (BUSM).

Those who’d experienced repetitive head impacts or TBI also performed worse in some of the cognitive tests.

“It should be noted that not all people with a history of repetitive hits to the head will develop later-life problems with cognitive functioning and depression,” says Study author Robert Stern, professor of neurology, neurosurgery and anatomy & neurobiology at BUSM.

“However, results from this study provide further evidence that exposure to repetitive head impacts, such as through the routine play of tackle football, plays an important role in the development in these later-life cognitive and emotional problems.”

The researchers point out, however, that one limitation of the research is that researchers didn’t have data on the extent of participants’ injuries.

Last year, BUSM researchers found that longer someone was exposed to tackle football, the higher the risk of developing the degenerative brain disease chronic traumatic encephalopathy.

For every year of exposure to the sport, footballers had a 30 per cent increased chance of having the disease.

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City dwellers “more likely to die in hospital” after stroke – US study

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Compared to those living in urban areas, stroke patients treated at rural hospitals were one third less likely to undergo a procedure to remove a blood clot that caused the stroke and were more likely to die of stroke before leaving the hospital.

Researchers examined national data on almost 800,000 adults hospitalised after a stroke between 2012 and 2017.

In their paper, published in the American Stroke Association’s Stroke journal, the researchers warn that this urban-rural divide may be getting worse. This gap, the paper states, could be caused by the slower take-up of newer treatments and technologies, and because rural hospitals are less well-resourced and have poorer access to specialist care. Rural hospitals may also be more likely to lack specialised clinical support, such as dedicated stroke units.

Other causes for poorer stroke care could be a lack of clinical expertise in urban areas, due to difficulties attracting and retaining experienced staff, and poorer access to emergency services and longer responses to emergency calls due to distance.

“The lack of access to specialists is often a limiting factor in adequate care for rural stroke patients, and in this case, that could mean a neurologist to guide the initial care, an interventional neurologist or radiologist to do a procedure, or having a neurosurgeon available for backup in case of any complications,” said Gmerice Hammond, author of the study and a cardiology fellow at Washington University School of Medicine.

“Clinicians need to work to improve access to high-quality stroke care for individuals in rural areas. That means partnerships between hospitals for rapid transfer, as well as telehealth when appropriate. And clinical leaders and policymakers should prioritize improving access, care and outcomes for stroke in rural communities.”

The study had some limitations, including a lack of data on the severity of patients’ strokes, or factors that would determine whether a patient received advanced therapies, sich as the size of the clot and where it is located.

Karen Joynt Maddox, senior author of the study and assistant professor of medicine at Washington University School of Medicine, calls the differences in care, and the lack of improvement over the five-year period, ‘striking’.

“Future studies using more detailed clinical data will be important to follow up on our findings and to determine why patients in rural areas aren’t receiving advanced therapies. Is it because their stroke severity is different? Or because delays in getting to the hospital meant they weren’t eligible by the time they arrived?

“Those questions can’t be answered with administrative data, but they’re very important to look into so that we can develop effective solutions.”

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One charity’s challenging move to online group sessions

Since lockdown began in March, many people recovering from brain injuries have had to adapt to remote sessions with health workers.

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But it’s not just outpatients that have seen a change. One neuropsychologist in York is trying to sustain momentum with her support group, but navigating the new online world with patients has brought its challenges.

Just before lockdown, Diana Toseland, consultant clinical neuropsychologist, was celebrating. Her charity, Café Neuro York, became officially registered. Café Neuro is a social support network that allows people with long term neurological conditions in York to learn new skills, help others and learning to be mindful, after they’re discharged from health services.

Group members were meeting face-to-face for morning and evening meetings, and once a month on Thursday evenings there was an interactive presentation for members to enjoy. When lockdown began, Toseland wanted to continue her twice-weekly sessions online.

But adjusting hasn’t been easy – Toseland had built up a loyal user base, but sessions were very much based offline. Adjusting hasn’t been easy.

“People need this in York. People with a neurological condition need ongoing support,” Toseland says. “People with brain injuries found it helpful to come along to meet people without having to explain – they can just be who they are. It’s about what people can do, not about their condition or disability.

Since lockdown, Toseland has been struggling to know how to support people.

“I’ve got up to speed with Zoom. This week we had six people call in, but their difficulties are quite profound and they’re finding it hard to get onto Zoom. Some call in late because they forget or find it difficult, others call in with help from families.”

Toseland has found there are many technical difficulties to overcome before the sessions can begin.

“You need so many things – good internet connection, distraction-free environment, working microphones and speakers.

“One woman managed to set it up herself, her career before the injury was IT, but then she didn’t have sound. Then she tried headphones, which worked, but then she took them off and couldn’t get the microphone on the computer to work without the headphones – she was the most successful in that meeting.

“Another has poor signal so she has to sit under a tree in her garden, which means she can only do it when the weather’s good.”

Once the call is up and running, Toseland says some members find it difficult to navigate the conversation, which has entirely different unspoken social rules than offline conversations.

“They’ve found it difficult because you can’t have two people having a conversation, it’s got to be one person at a time, which requires intense concentration. People can’t sustain that level of attention long enough to fully participate in the conversation.

“Some go quiet, it leaves people with headaches, it’s fraught with disaster. They might dominate the conversation and not pick up on cues; one finds it’s too much stimulation, so she closes her eyes.”

But Toseland hopes to continue the groups, as when it does work, it works well.

“On the other hand, for those who have joined it, they’ve used it as a bit of a lifeline.”

But Toseland is looking forward to getting meetings back into the real world. She’s been runnin Café Neuro for over a year and a half, and she’s seen more progress in some members than they ever made coming to her clinical practice.

“It’s made a difference in ways I couldn’t have predicted, and an impact wider and quicker than I could’ve possibly hoped for,” she says.

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