Arguments in favour of Traumatic Brain Injury (TBI) and Degenerative Diseases.

Traumatic Brain Injury (TBI)

TBI can occur as a consequence of a focal impact upon the head, by a sudden acceleration or deceleration within the cranium, or by a complex combination of both movement and sudden impact.

In addition to this primary injury, secondary

injuries may occur minutes, even days following the injury.

TBI can be categorised as mild, moderate or severe by the Glasgow Coma Scale.

Prevalence

1 million- minimum estimate of people in the UK living with long-term effects of TBI

558- UK residents per 100,000 sustaining a brain injury (1/200)

Every 90 seconds- someone is admitted to hospital in the UK with TBI

353,059- UK admissions to hospital with acquired brain injury between 2011-2012

Risk Factors

TBI is a condition that any of you could experience, at any time, without any predisposition.

On top of this, the highest incidence of TBI is 15-24.

Males are twice as likely to have TBI, however, when matched for severity the prognosis of females is worse.

Although categories of mild, moderate and severe are derived from the Glasgow Coma scale, alone, these cannot predict the long term effect of TBI.

Instances of TBI is greater in lower socioeconomic groups.

Thinking more globally, the prevalence of TBI in developing countries is increasing significantly. This is due to the rate of automobile use increasing much faster than safe infrastructure on which to drive.

Symptoms

Aside from the communication and social aspects we have touched on, such as impaired executive functioning, there are many more consequences.

Physical impairments, such as loss of co-ordination.

Sensory impairments, such as loss of smell, taste or sight.

Mood and personality changes which may lead to a

loss of self for both the individual and their friends and family.

Degenerative Diseases

Degenerative diseases are a result of a continuous process based on the degeneration of cells, affected tissues or organs deteriorate over time.

Strongly linked with age. Currently 16% of the European population is 65+ and expected to each 25% by 2030.

Therefore, the prevalence of degenerative disorders will increase.

Degenerative diseases may be genetic, or a result of medical conditions such as alcoholism, a tumor or stroke. Others may be a result of viruses and often the cause is unknown.

Commonly cited diseases and prevalence

Alzheimer's- 850,000 people living with dementia in the UK alone. Expected to rise to £2 million by 2051. One person diagnosed every 3 minutes. That is 325 so far today….. Majority of cases not inherited, but family history of the condition is a risk factor.

Parkinson's- 127,000 people in the UK. A suspected genetic element.

Huntington's- 10,000 people in the UK. Inherited faulty gene.

Quality of LifeSome examples:

TBI, Parkinson’s Disease and Dementia

TBI (1)

Work implications (returning to normal life) Tested a number of areas including

speaking under time pressure Production of oral language Verbal reasoning

Result – 85% of time successfully predicted whether someone was in employment.

Isaki, E. and Turkstra, L. (2000) Communication abilities and work re-entry following TBI. Brain Injury 14 (5) 441-453.

TBI (2)

Living with cognitive communicative difficulty following TBI

Concluded that communication difficulties plus memory problems,

fatigue and irritability = “unsatisfactory interpersonal relationships”.

O’flaherty, C. and Douglas, J. (1997) Living with cognitive-communicative difficulties following traumatic brain injury: using a model of interpersonal communication to characterize the subjective experience. Aphasiology 11 (9) 889-911.

TBI (3)

Carer impact…Study assessed impact of 5 different disabilities

arising from head injury (1 of which was speech and language)

Looked at 2 measures: caregivers’ ‘perceived stress’ ‘strain’

Results for – Speech and language link for both stress and strain (statistically significant for ‘strain’)

Connolly, D. and O’Dowd, T. (2001) The impact of the different disabilities arising from head injury on the primary caregiver. British Journal of Occupational Therapy. 64 (1) 41-46.

Parkinson’s Disease

NICE guidance – CG35 SLT “should be available”

In particular LSVT (or similar) Speech intelligibility Effective communication (e.g. AAC) Swallowing

Dementia

RCSLT position paper on dementia Key area relating to QoL:

Specific assessment of dysphagia Reduce stress on caregivers – by providing management

strategies Assessment of consent to treatment Reduced social exclusion

• RCSLT (2005) Speech and Language Therapy for people with dementia. London, RCSLT.

Current provision/ initiatives for TBI

Inpatient rehabilitation-

- A prospective study looked at 3 inpatient centres between 1989 and 1996. Patients received a MDT approach with physical, occupational, psychological, and speech therapy. It found that increased therapy intensity potentiallyenhances outcomes (Cifu et al, 2003).

- Another study looked at patients with aphasia after TBI who were admitted in the post-acute phase for a late inpatient rehabilitation programme. They found all functional, cognitive and language scores increased significantly, suggesting inpatient rehabilitation may even be beneficial at later stages (Demir et al, 2006).

Current provision / initiatives for TBI

Community based SLT:- 52 people with TBI who were at least 1 year post injury, received 12 weekly group sessions (1.5h each) working on social communication skills. All patients had improved social communication compared to controls, which was maintained at 6 months post treatment (Dahlberg et al, 2007).

Current provision / initiatives for degenerative diseases

Dementia- Asking every hospital to appoint a ‘dementia

champion’- It has been found there is now a shift towards more positive and person-centred approach and participants’ perceptions about dementia being challenged and altered (Alzheimer Scotland, 2014).

- Providing online dementia training resources- over 377,000 NHS staff have already received Tier 1 dementia training (Department of Health, 2015).

Current provision / initiatives for degenerative diseases

Parkinson's disease--LSVT has the most evidence of effectiveness (Ramig et al, 2007). 90% of people with hypokinetic dysarthria will show improve in speech and voice after LSTV (Theodoros et al, 2006). - Noble et al (2006) found that 80% of patients with Parkinson's disease felt SLT had helped them, but around 43% of patients have no contact with SLT services (Miller et al, 2011)- This shows that although there is effective treatment, there needs to be better access to this provision.

References

Alzheimer Scotland, (2014). Evaluating the impact of the Alzheimer Scotland Dementia Nurse Consultants/Specialists & Dementia Champions in bringing about improvements to dementia care in acute general hospitals http://www.nes.scot.nhs.uk/media/2711490/impact_evaluation_-_executive_summary.pdf

Cifu,D.X., Kreutzer,J.S., Kolakowsky-Hayner,S.A., Marwitz,J.H. and Englander,J., (2003). The relationship between therapy intensity and rehabilitative outcomes after traumatic brain injury: a multicenter analysis. Archives of Physical Medicine & Rehabilitation, 84, 1441-1448

Dahlberg,C.C., Cusick,B.A., Hawley,M.S.W., Newman,J.K., Morey,C.E., HarrisonFelix,C.L. and Whiteneck,G.G., (2007). Treatment efficacy of social communication skills training after traumatic brain injury : a randomized treatment and deferred treatment controlled trial. Archives of Physical Medicine & Rehabilitation, 88, 1561-1573

Demir, S.O., Altinok,N., Aydin,G. and KÃseoglu,F., (2006). 'Functional and cognitive progress in aphasic patients with traumatic brain injury during post-acute phase. Brain Injury, 20, 1383-1390.

Department of Health, (2015). Dementia. https://www.gov.uk/government/policies/improving-care-for-people-with-dementia

Noble, E., Jones, D., Miller, N., and Burn, D., (2006). Speech and Language therapy provision for people with Parkinson's disease. International Journal of Therapy and Rehabilitation , 13 (7) 323-327.

Miller, N., Noble, E., Jones, D., Deane, K., and and Gibb, C., (2011). Survey of speech and language therapy provision for people with Parkinson's disease in the United Kingdom: patients' and carers' perspectives. International Journal of Language & Communication Disorders., 46 (2). 179-188

Ramig et al, (2007). Intensive voice treatment (LSVT®) for patients with Parkinson’s disease: a 2 year follow up. Journal of Neurology & Neurosurgical Psychiatry, 71, 493–498

Theodoros et al, (2006). Treating the speech disorder in Parkinson’s disease online. Journal of Telemedicine and Telecare, 12, 3, 88–91

Speech and language therapy:a long-term investment

UK – NHS – we all contribute to it.

Cost to the NHS: TBI - £4.9 bill; Dementia - £19.1 bill; Multiple sclerosis - £2.3 bill; Parkinson’s disease - £2 bill (Imperial College London, 2013).

Speech and language therapy – prevent later, potentially avoidable expenditure.

Malcolm’s story

Idiopathic Parkinson’s disease.

Speech deterioration due to lack of speech therapy.

Issues with self-esteem -> social isolation -> depression -> unemployment.

Costs on different levels

Financial implications for Malcolm and his wife.

Relationship problems.

NHS paying for clinical psychology, counselling, medication.

State benefits an additional cost.

Preventable?

Early speech and language therapy input.

Benefits of speech therapy to Malcolm: improved breathing, clearer, louder speech -> more confident -> improved relationship -> independence.

Financial benefits on micro and macro level.

Pre-emptive

Local health services can save £20,000 yearly with coordinated approach to Parkinson’s disease – includes speech therapy (National Institute of Clinical Excellence, 2006).

Therefore – pre-emptive approach with these types of illnesses -> avoid later costs.

Long-term investment that pays off.

Conclusion

A broader picture of Traumatic Brain Injury

Thomson et al’s (2000) Cochrane review reported that cycling helmets redcued the risk of brain injury by 88%

Vehicle safety laws have significantly reduced rates of TBI in high-income countries

In the US, firearms are the leading cause of TBI with a survival rate of 9%

Contrast this with the UK, where fall-related incidences are the leading cause, and survival rates are 89%

This may not be a case for funding, or relevant to speech therapy, however, it may be an interesting point to raise to the NRA.

Traumatic Brain Injury

As mentioned the costs of TBI are vast and long-term and have both a micro and macro affect.

Speech and language therapy has proven to better equip individuals post-TBI for autonomy. In turn this reduces the cost to society, increases their contribution to the economy and in doing so, reducing the likelihood of depression.

Degenerative Diseases

In terms of Parkinson’s, speech therapy has proven able to increase the volume and clarity of individuals speech. This has a significant impact on their ability to communicate effectively and enable socialisation.

Speech therapy can enhance the QOL of those with degenerative diseases. Equally, if confidence is maintained the likelihood of them staying in work is increased.

REMEMBER

Any one of you, at any point, particularly if you are between 15-24 could get TBI. So think of this not only as an investment into healthcare but as an investment in yourself.

Wear your helmet (hair-met)