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Sleep disturbance linked to slower progress in rehab

New evidence that post-brain injury sleep problems can slow the pace of recovery has emerged from an obervational study.

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Researchers analysed the sleeping patterns of 59 people with brain injury staying in a rehabilitation unit in Oxford, and 55 people who didn’t have a brain injury and were at home.

Participants were asked about their quality of sleep over a month and wore a monitor on their wrists that recorded movement, which would suggest sleep disruption.

Those with brain injuries reported having lower quality sleep, and the monitors recorded more disrupted sleep compared to the control group.

People with brain injury who had less disrupted sleep recovered quicker than those who had more disrupted sleep. They scored higher on arm/hand function tests, showed less overall movement impairment in their affected arm and legs and were more mobile.

This is because disrupted sleep can impair learning, says Melanie Fleming, researcher at the Wellcome Centre for Integrative Neuroimaging at the University of Oxford, who led the study, which was published this month in the ‘Neurorehabilitation and neural repair’ journal.

“Our main hypothesis is the idea that if you don’t sleep well, you don’t consolidate what you learnt from your physio session that day, and don’t make improvements day to day as quickly as you might if you consolidate what you learnt better,” Fleming says.

“There’s a lot of research showing that if you learn a sequence of movements then sleep overnight, you learn it better in the morning than if you were to stay awake during the night and try again it in the morning.”

Fleming didn’t directly measure how much patients engaged with rehabilitation, although she did measure how much time people were sedentary and active, but didn’t see any patterns.

“Some studies have looked at staff from rehabilitation units who say they feel people don’t engage as well when they’re reporting having bad sleep, which is easy to see – if you’re exhausted in the morning after a terrible sleep it’s very hard to then go to a physiotherapy session,” Fleming says.

Between 30 and 70 percent of patients experience sleep disturbances after a brain injury and have at least one sleep disorder, research has found.

This can partly be attributed to the noises and other disturbances ongoing throughout the night in hospital environments, but it’s not the sole cause.

Fleming says brain injuries themselves can also impact sleep quality due to damage to parts of the brain that control sleep, as well as low mood, which occurs more often in people with brain injuries, and is associated with difficulty sleeping.

Fleming’s study was observational, which means it couldn’t prove a cause-and-effect relationship between sleep quality and recovery. The most effective way to find this out would be to do an interventional study where researchers try to improve people’s sleep in hospital and see if it effects recovery. Fleming is currently in the process of applying for funding to carry out research of this nature.

“This study can’t say if people are sleeping poorly, but it’s common sense,” she says. “Low mood and poor sleep are really linked. Quality of life is better if you can improve a person’s sleep, and they engage better in rehabilitation.

“The main takeaway from this study is that when people say they’re sleeping badly, they really are – we need to be thinking about this when we think about the rehabilitation environment.”

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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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