Karl Welborn, Consultant Occupational Therapist and Company Director of Well Way Rehab Solutions, explains:

Coulthursts contacted me about a young client who had been badly injured in a car accident while driving. He had been in hospital for a month and the hospital wanted to discharge him. Coulthursts contacted me to see if I could contact the discharge coordinator and help with the discharge planning and immediate rehabilitation. I therefore spoke with the discharge team at the hospital and also spoke to the client’s wife.  

As well as suffering a brain injury, he had a fracture to his right clavicle, a complex facture to the ulna and radius on his right side and fractures to his right and left tibias. It was recommended that he could not be weight bearing for at least ten weeks and it might be longer. We had to arrange for him to be discharged to his home with a bed downstairs and the use of a wheelchair and the challenge was how to make it a smooth and seamless transition.

He had been a strong, muscular man who was the main provider for his wife and one year-old son, but he had become very weak, had lost over one-and-a-half stones in weight and was not eating. He was also stressed and panicked and, while in hospital, had been in a state of post traumatic amnesia and did not know where he was, for some time following the accident.

My holistic assessment of him was physical, psychological and cognitive and it was important to ascertain what his needs were and what we needed to get in for him, that would allow him to function within his home safely and proficiently, as well as his access to community requirements. I found out that he was experiencing sensory changes to his legs and arm, that he was worried and depressed about the future and that he was struggling to retain information. He also sometimes used expletives which he would never have done before and sometimes discussed things which he did not realise were upsetting to other people.

He was also very tired all the time. He thought that this was caused by being in hospital and that it would get better at home after his discharge, but it didn’t. He had cognitive and emotional fatigue and that took away a lot of his energy, which can be a sign of brain damage. He needed therapy to improve his range of movement, to improve his strength and to improve his range of movement in his lower and upper limbs as well as in his core stability. We therefore gave him exercises he could do while lying down and sitting.

I needed a rehabilitation assistant to make sure he was doing these exercises and the client also needed two transfer boards to help him transfer from bed to wheelchair and wheelchair to toilet and back again.  I recommended a foot spa to improve his circulation and to help with the personal hygiene of his feet and he needed a bath board and a higher seat for the toilet. I sent a list of these things to Coulthursts who immediately purchased the equipment.

At around the same time the weather was improving, so when his wife took their child out for a walk, he understandably wanted to go with them. Thanks to Coulthursts support we were able to hire an electric wheelchair which really helped his mental health. So much so, in fact, that he no longer felt worthless and felt he was fulfilling his role as a father.

We are also working out his fatigue management package so he can make his energy function and recharge his battery during the week.

Meanwhile, our physios have been getting him out to the gym and into the pool, but he still struggles to retain information. A joint gym membership was arranged for him and his wife. You can see that he has broken legs but you cannot see what he is thinking, so we talk about this. He has ongoing problems and we are working out ways of tackling this.

With our rehabilitation programme, he has made so much progress that he can now walk for 2 miles a few times a week and he is now able to get up the stairs.  He has advanced this far because Coulthursts have provided the funding that has made it possible. In contrast, all that was available for him on the NHS was one therapy session of 30 minutes once a week.

He says that he is still not the person he was and there are things he will have to live with all his life. There are his fatigue and his memory problems, and he will never have the same physical status and will likely be limited in how he can work.

We have set a number of goals, namely improving his posture, cognitive behaviour, optimising hand dexterity, maintaining lower limb use and improving power, managing his fatigue and enhancing his mental health with the ultimate goals being returning to a vocation and returning to driving again.

This case is unique because of the way Coulthursts have provided the resources for it. They agreed with my recommendations without any delay, arranged funding and for any equipment and for other items such as the gym membership.  It is a really positive outcome and I have never had a case quite like it before.

Philip Coulthurst, Managing Partner at Coulthursts, The Brain Injury Lawyers, replies:

Enabling the recovery of our clients is always our first priority.

Long before any legal settlement is reached on their behalf, we know how important it is to support our clients’ rehabilitation first and foremost.

It’s why we already work with some of – and aim to work with even more of – the UK’s leading charities and neurorehabilitation treatment centres in our specialist legal field of traumatic brain injury.

And it’s why cases such as the one outlined by Karl above are so important to us, a company wholly focused on working with individuals and their families after a brain injury.

About the Authors:

Karl Welborn graduated from Coventry University with a first-class degree with honours in Occupational Therapy. He has since studied at master’s level in the field of leadership and innovation and Injection Therapy (Neurology). He has over 20 years of dynamic experience working in healthcare and is the Director and Consultant Lead Occupational Therapist for Well Way Rehabilitation Solutions. Karl has great knowledge of working in the National Health Service where he was clinical lead for Occupational Therapy in the hyper-acute, acute and community stroke, neurology and complex rehabilitation services.

Philip Coulthurst has more than 20 years’ experience as a solicitor, with a specialty in brain Injury. Philip is committed to taking a genuine, client-centric approach to working with people who have life-changing injuries. Philip regularly delivers training and lectures on traumatic brain injuries, encompassing neuroscience, epidemiology and socioeconomic effects and the need for better, integrated care pathways. He is a Member of the British Neuroscience Association, the Federation of European Neuroscience Societies and the Association of Personal Injury Lawyers. Philip has graduated from an Accelerated Leadership course at Harvard Law School.

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Coulthursts founders’ – managing partner Philip Coulthurst and chairman Dr Richard Newland – reveal why they have combined their professional skills to fight for a better deal for accident survivors

It is common for brain injured patients, whose lives have been saved by magnificent surgery, to then face years of trauma while they fight for compensation before they can start rebuilding their lives and securing the necessary aftercare that is often so desperately lacking within the state sytem.

That is why we have combined our experience of the devastating effects that traumatic brain injuries (TBIs) can have on people’s lives – Richard’s as a medical practitioner, and Philip’s as a brain injury solicitor – to set up Coulthursts. We are the UK’s only law firm dedicated entirely to providing legal  services for TBI claimants – founded on the realisation that there was a need for a fresh approach to supporting survivors. The first thing that makes Coulthursts different is that we fund clients’ rehabilitation costs up front, which can be long before any interim payments or settlement is reached. This not only means they are able to get on with their rehabilitation and recovery whilst we start working on their case, but can also expedite their discharge from hospital and therefore accelerate their recovery.

Secondly, we specialise in helping TBI sufferers by making sure our solicitors are experts in brain injuries and each solicitor never has more than five or six cases on their books at any one time.

Thirdly, we are different because we work with some of the UK’s leading charities and neurorehabilitation centres in this field which means we are well placed to help and support TBI patients throughout both the legal claim and facilitating excellent rehabilitation and care packages.

The effect of this joint legal and medical approach can produce results way beyond the expectations with which our clients begin their journey in their quest for both the compensation they need and the access they require to early and comprehensive rehabilitation and support. TBI cases can often take four to five years to reach settlement, but we are committed to getting that down to two to three years where appropriate.

For example, we recently settled a case in two years with an excellent compensation package and, equally importantly, involved a comprehensive rehabilitation and support package to help their recovery and maximise the chances of returning to work.  As well as expediting the process though our specialist knowledge and lower case load, this settlement was also reached by working closely with the Defence team who were open to collaboration and also genuinely focused on helping the Claimant with their rehabilitation.

We are always committed to getting the best possible settlement for all our clients. Philip once took a referral from a solicitor who had a client with a mild TBI and was seeking a second opinion. At the time, they had been offered a £30,000 settlement. Philip looked at the case, had the specialist knowledge to realise its complexities and the true extent of the injury’s effect on the Claimant and they went on to settle with the other side for £1 million.

That represented an increase of 3,333 per cent.

People who have suffered a TBI, and those who are supporting or caring for them, are about to embark on a legal journey that can be very variable depending on the route they take.

At present, most will either knock on the door of a local solicitor or go to one of the big personal injury firms. In the latter instance, their solicitors are could  be dealing with around 100 cases at any given time, and covering a whole range of injuries.

Unless you know what you are doing, TBI claimants can often be sold short in getting the kind of settlement they both deserve and need and may not access early and comprehensive rehabilitation and care packages that could make a difference to their recovery and outcome. Our goal is to give people the best chance of the best recovery, outcome and quality of life.

We know what we are doing and have created partnerships with some of the UK’s leading neurorehabilitation centres so we can offer the very best recovery for Claimants alongside what we believe is the very best legal support.

It’s why we pay for rehabilitation as soon as we take on a case – and long before any settlement is made or even interim payments. This means we can get on with every case immediately whilst our clients focus on their recovery.

We put the client front and centre, work to their timeline and deliver settlements in line with their ongoing rehabilitation needs and the effect a TBI has had – and will continue to have – on their life.

It’s what makes us different. It’s what makes us Coulthursts.

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Returning to work is one of the main benchmarks of recovery and of overall well- being following a brain injury.

Therefore, a major review of 101 studies exploring relturn to work rates after a mild traumatic brain injury (mTBI) provides a valuable insight into what supports recovery and what are the main predictors of a delayed or non-return to work.

What do the studies tell us about likelihood of return to work after a brain injury?

Three of the four studies suggest most workers with MTBI do return to work. For example, one study showed 76% of participants (152 of 201) were fully back at work six months after their original injury. Another study, which included individuals making legal claims for their injury, found 72 per cent of people were back at work after 72 days. However, five per cent had not returned to work and were full time unemployed two years after their injury. A fourth study reported more pessimistic outcomes: more than half the individuals with brain injuries had not returned to work six to nine months after the original injury. Overall, considering all of the studies reviewed, it was found that after a mTBI, around 5 to 20 per cent of injured workers face persisting problems and unable to return to work one to two years after their original injury.

What predicts problems with returning to work?

The review of 101 studies found there were a number of factors which predicted a stronger possibility of return to work. These included: having more than 11 years of formal education, absence of nausea or vomiting on hospital admission, absence of additional extracranial injuries, absence of severe pain immediately after injury. Younger individuals (aged 20 to 29 years) were more likely to return to work and there was no significant difference between genders. One study found that after an mTBI, people whose jobs had greater independence and scope for decision-making did better in terms of return to work than those with less. Student, homemaker, professional/semi-professional, and management categories were defined as occupations offering more independence and opportunity for decision making compared with the clerical, sales and service, manual labour and trades occupations. This echoes another study which individuals holding professional and/or managerial positions are three times more likely to return to work
than those in the manual labour occupations.

What does this mean in terms of support and rehabilitation for people with brain injuries?

The review provides a really interesting and valuable insight into what might support a good recovery and what might be risk factors for long term, disabling difficulties. There is a mixture of physical and social aspects; we might expect, for example, the presence of nausea and vomiting to be linked to increased risk of poor outcome and equally we might expect, for example, for younger individuals to do a little better in terms of returning to work. What stands out is the links between educational achievement prior to injury, occupational scope for independent decision making and type of occupation. It seems that there are a number of factors that make a person in a lower skilled, less independent job with lower prior educational attainment less likely to return to work after a brain injury. We already know the importance of a holistic and comprehensive support and rehabilitation approach to support best outcomes for each individual. This review suggests there is perhaps a need for this support to be more precisely personalised to meet the distinct challenges in certain job types and for older individuals. This might encompass, for example, an early focus on what the specific difficulties are and what support there could be and if needed, support to find an adapted role or even a move to a different job in order to mitigate against the debilitating prospect of failing to return to work and loss of confidence and capacity to work.

References

Systematic Review of Return to Work After Mild Traumatic Brain Injury: Results of the International Collaboration on Mild Traumatic Brain Injury Prognosis. Carol Cancelliere et al. Archives of Physical Medicine and Rehabilitation 2014;95(3 Suppl 2):S201-9.

Walker WC, Marwitz JH, Kreutzer JS, Hart T, Novack TA. Occupational categories and return to work after traumatic brain injury: a multicenter study. Arch Phys Med Rehabil 2006;87:1576-82.

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A woman who had experienced a brain injury would often say, “I still haven’t really come to terms with it.” Whenever she said this, the word ‘still’ was very significant; it was always expressed with a clear sense of regret and sometimes of guilt – the brain injury had occurred 11 years ago and she felt that she ‘ought’ to have come to terms with her injuries and its effects ‘by now’.

But the process of coming to terms with a brain injury is neither straightforward, automatic, nor time specific, particularly for some types if impairments. One study found individuals were better able to recognise physical impacts than behavioural and cognitive difficulties arising from their injury (O’Callaghan, 2012). For example, one man was able to precisely identify all the different parts of his vertebrae that were fractured in his accident, but when reflecting about the impairment to his memory, gave wide ranging and contradictory accounts of how much his memory had been affected.

It is known, however, that self-awareness and insight about impairments of Traumatic Brain Injury is critical to the process of rehabilitation and therapy. Fleming (1998) shows people with poor awareness of their impairments are poorly motivated to follow therapies and strategies to address difficulties they don’t believe exist

What is helpful in terms of this process of coming to terms with the long-term impacts of a brain injury? The woman who described her difficulties coming to terms with her brain injury had a previous life which was fundamentally and wholly different to her current life. Before her brain injury, she had a well-regarded professional job, friendships through that job and lived in an area that she liked. Her brain injury meant loss of job, status, identity, networks and also a change of location to an area she did not feel safe in.

A practitioner working with her recognised this was a change almost akin to a bereavement and the loss of this former life needed to be acknowledged and mourned. It was helpful, for example, when making long applications for disability allowances, to refer to and talk about the processes the women had managed in school management during her professional life.

This echoes Charmaz’s studies of people who are coming to terms with different forms of chronic illness, describing how ‘they reminisced about a past self in order to create value in their present selves’ in a process that has many features which echo bereavement. This is an important stage before moving on to the next stage of the process which involves reconciling the new self and the impairments faced to the old sense of self (Charmaz, 1997).

This is a process of negotiation between old and new self; recognition of what cannot be accomplished any more at all, or only with support and also, importantly, what may be brought from the old life into the new. For example, the women who had lost her former professional life really enjoyed reading, but had difficulty obtaining books because of poor mobility and lack of money. The practitioner recognised that reading was an important and also viable part of the old self which could be support and indeed, finding a suitable mobile library service was just as important as assisting more functional daily living capacity.

When working with or supporting people with brain injuries, it is helpful to notice where they seem to be in terms of insight and acceptance of impairments. It is vital to think of ‘coming to terms’ with the injury as a process of unknown duration and different stages, which is likely to be as acutely painful as a bereavement. Thinking of the individual’s reconciliation as a search for identity negotiated between old and new self can provide real insight, empathy and opportunities for effective support.

References

Anna O’Callaghan, Lindy McAllister & Linda Wilson (2012) Insight vs readiness: Factors affecting engagement in therapy from the perspectives of adults with TBI and their significant others, Brain Injury, 26:13-14, 1599-1610, DOI: 10.3109/02699052.2012.698788

Charmaz K. The body, identiy and self: Adapting to impairment. The Sociology Quarterly 1995; 36:657–680.

Fleming JM, Strong J, Ashton R. Cluster analysis of self-awareness levels in adults with traumatic brain injury and relationship to outcome. Journal of Head Trauma Rehabilitation 1998; 13:39–51.

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There is growing recognition of the risks from concussion in football, both in terms of single head injury events and the cumulative effects of head impacts during playing career.

A particularly sharp focus on this concern has come after the results from the FIELD study (Football’s Influence on Lifelong health and Dementia risk), were released last month.

The study compared former footballers to people of similar age and background and found there was an increased incidence in footballers of chronic traumatic encephalopathy (CTE), a degenerative brain disease linked to head trauma and dementia.

The risk was dependent upon player position: defenders were found to be five times more likely to develop dementia than the average person. The risk for goal keepers was found to be lower; this was no different to the average person. A striker/forward player had 2.8 times the risk of the average person.

The strong hypothesis was that defenders are at the greatest risk because they need to head the ball more frequently than players in other positions.

The FIELD study involved 7,676 former professional footballers, who were playing between around 1930 and 1998. It was the first peer-reviewed study of its kind which has firmly placed concerns about football, head injuries and long-term damage at the centre of the policy agenda.

A challenge, inevitably, is that footballers within the FIELD study were playing across a very wide time span, when the weight and density of football was very different and head injury awareness far less developed.

What does the evidence from the present-day game tell us about risks and what steps might be protective for players?

Although heading the ball is strongly linked to concussion, several studies suggest in today’s game, it is not the header itself which confers the greatest risk; the main risk is of players’ heads clashing as jump to contest the ball (O’Kane, 2016).

Studies assess other individual factors amplify this risk: for example, lower head to neck circumference and overall neck strength is linked to greater injury risk.

This is believed to be one reason why there is an overall increase in risk from heading the ball for female footballers compared to males, where neck strength and circumference will be lower. This would also confer a greater risk for younger players contesting headers.

Another risk factor was found to be a higher proportion of time spent playing competitive matches, compared with training time. The theory is not only that more competitive play is, unsurprisingly, more likely to confer risk but also that controlled training can be protective in terms of building strength and technique.

It is too early to be able to fully assess the impact of the Football Association’s ban on heading the ball in training for 12-year-olds and younger, but this policy, introduced in February 2020, seems well aligned to the evidence.

An under-explored but emerging area is the link between aggressive play and injury risk and from this, the role match officials may be able to play in managing the way football is played in terms of applying rules, particularly around aggressive and dangerous play and in managing the way a match is played.

In their review of 18 studies of concussion injuries in sport, Waltzman and Sarmiento (2018), suggest ‘referees play a critical role in calling fouls and limiting dangerous play’ and could be more assertive and consistent in the way they do this (2018).

References

The FIELD study was led by Professor Willie Stewart, consultant neuropathologist and Honorary Clinical Associate Professor at the University of Glasgow. Results published in August 2021.

Waltzman D, Sarmiento K, What the research says about concussion risk factors and prevention strategies for youth sports: A scoping review of six commonly played sports. Journal of Safety Research.

O’Kane, J. W. (2016). Is heading in youth soccer dangerous play? The Physician and
Sports medicine, 44(2), 190–194. https://doi.org/10.1080/00913847.2016.1149423.

Kerr, Z. Y., Collins, C. L.,Mihalik, J. P., Marshall, S.W., Guskiewicz, K.M., & Comstock, R. D.
(2014). Impact locations and concussion outcomes in high school soccer player-to-player
collisions. Pediatrics, 134(3), 489–496. https://doi.org/10.1542/peds.2014-0770.

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The location of the frontal lobe, just behind the forehead, makes it particularly susceptible to injury-causing blows. The frontal lobe is a large section of the brain which is responsible for thinking skills, organisation and decision making.

Sometimes called ‘executive functions,’ it is harder to identify the extent of frontal lobe impairments after a brain injury, compared with other functions, such as speech and movement, which are more obvious. This is particularly difficult when professionals make assessments of individuals with a frontal lobe injury. Assessments of mental capacity (Mental Capacity Act, 2005) typically take the form of a single interview with a social worker asking questions about what a person can or cannot do, together with office-based tasks. If tasks are observed, this may be within a high support and controlled environment, such as a hospital ward or brain injury unit.

A person with a frontal lobe injury may have unaffected speech and verbal reasoning within the normal range, so they are likely to perform well in interview-based tasks. One specific impact of a frontal lobe injury – lack of insight – means an affected individual is likely to over-estimate their ability to accomplish their abilities, if the professional is asking them to report on what they can do, rather than observe them actually doing tasks. If the individual is being observed in a healthcare environment, where there is high support and structure, the sort of deficits which manifest at home in ‘real life’ may be less evident.

This anomaly between what a professional observes in a typical single assessment of an affected individual, compared with the true extent of their difficulties in all domains of life, was termed ‘the frontal lobe paradox’ (Walsh, 1985). The paradox lies in the way the context of the assessment means difficulties caused by the brain injury are minimised or unseen, the result of the assessment is the individual has a much lower level of support then they truly need.

The specific impacts of a frontal lobe brain injury mean they are more complex to recognise and assess. People with frontal lobe injuries experience difficulties with decision-making, goal-setting, multi-tasking and particularly behavioural organisation in non-routine situations (Burgess et al, 2009). It is not difficult to imagine of this range of difficulties could very significantly impair the way a person manages their daily life, relationships and if working, their functioning at work. But little or none of these difficulties may not be evident in a single interview-based assessment, outside the person’s ‘normal life’ setting.

Professionals working with people with frontal lobe injuries need to ensure that their understanding draws in real-world behaviour as broadly as possible. This means bringing in perspectives of different family members, friends, others from work or other networks. Be curious about emerging patterns, unusual behaviour and risk. Similarly, for family members and loved ones around a person with a frontal lobe injury, there may be patterns which are difficult to understand but may not seem instantly connected to the original injury. Different people supporting the individual may hold ‘parts of the puzzle’ of frontal lobe impacts; there may be difficulties for the partner in the home with domestic tasks and the relationships while work colleagues observe different impacts and difficulties. Frontal lobe injuries are often at the mild to moderate end; it may take careful observation, patience and a very holistic approach to build understanding.

References

Burgess, P.W., Alderman, N., Volle, E, Benoit, R.G., Gilbert, S.J. (2009) Mesulam’s frontal lobe mystery examined. (2009) Mesulam’s frontal lobe mystery re-examined. Restorative Neurology and Neuroscience, 27, 493-506.

George, Melanie & Gilbert, Sam. (2018). Mental Capacity Act (2005) assessments: why everyone needs to know about the frontal lobe paradox.

Walsh K. W. (1985) Understanding Brain Damage: A Primer of Neuropsychological Evaluation. London: Longman Group Ltd.

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One of the momentous changes brought by Covid is a wave of people turning to digital ways of staying in touch and finding support. Many charities and specialist services quickly turned their work digital as soon as we went into lockdown. But in the brain injury field, this switch is not straight forward. An occupational therapist working with brain injured individuals observes: “It is no good saying to the people I work with, ‘try this support group on zoom’ because the impacts of their brain injury work against them accessing this sort of support.” A person living with the effects of a brain injury explains – “I know that I’ll just get really irritated looking at lots of people on a small screen…that’s not going to work for me at all.”

It is recognised that Traumatic Brain Injuries (TBI) can profoundly effect vision by damaging parts of the brain involved in visual processing and/or perception, for example the cranial nerves, optic nerve tract or other circuitry involved in vision, such as the occipital lobe (Powell et al, 2014).

What this means for individuals and their families in their daily lives can include: blurred vision, photophobia (bright light hurts or irritates the eyes), reading problems such as slower reading speed and loss of place when reading, diplopia or eyestrain, particularly after looking at a screen for a long time, difficulties in visually crowded environments, such as fluorescent lighting and light sensitivity, particularly to the light from phone and computer screens (Greenwald et al, 2012). These sorts of visual impairments are often missed or overlooked in the first year after a brain injury while other impacts may be more apparent. But such impairments are likely to limit the effectiveness of rehabilitation if, for example, vision problems trigger anger, frustration or withdrawal. Sensitivity to the light of screens, reading problems and cognitive overload can specifically make it difficult to use smart phones, computers and tablets for any length of time or with much complexity involved.

Although there are challenges for people who have had brain injuries, social media and digital platforms can have many potential benefits for people with brain injuries,  including making and maintaining connections (Brunner et al, 2018). Brunner’s in-depth study of the social media experiences of 13 individuals with brain injuries shows although people reported cognitive fatigue, with support, these difficulties can be addressed. It also shows that people with brain injuries primarily use social media to connect with their family and friends and to a lesser extent to others with brain injuries or to professional support. There is a recognised benefit in using platforms like Facebook to connect with family and friends (and indeed this sort of digital contact may be easier for people with a brain injury than a long phone call).

This is an area that could be more fully developed by more peer-to-peer and brain injury professional support offered digitally, as it has been for other areas of disability, Brunner concludes.

One legacy of the pandemic is likely to be continued use of digital connections for health and disability groups; the recognition of things which have worked well during lockdown can be continued in some form, even after in person support can fully recommence. What might this mean for brain injury? It could be a catalyst for overcoming notions that people with brain injuries simply don’t get on well with screens. Through the Covid experience, there may be improvements in the way people with brain injuries use screen-based support and social media, together with individuals growing in their confidence in using technology after a brain injury. Although there are some impacts of a brain injury which may affect the way affected individuals get on using social media, with the right strategy and support in place, there are clear benefits in the connections offered by the digital world.

References

Vision after Brain Injury by Janet M. Powell, Ph.D., OTR/L; Alan Weintraub, M.D.; Laura Dreer, Ph.D.; and Tom Novack, Ph.D., in collaboration with the Model Systems Knowledge Translation Center.Vision Problems and Traumatic Brain Injury | Model Systems Knowledge Translation Center (MSKTC)

Brian D. Greenwald, Neera Kapoor & Adeepa D. Singh (2012) Visual impairments in the first year after traumatic brain injury, Brain Injury, 26:11, 1338 https://www.tandfonline.com/loi/ibij20

‘I kind of figured it out’: the views and experiences of people with traumatic brain injury (TBI) in using social media—self-determination for participation and inclusion online. Melissa Brunner, Stuart Palmer, Leanne Togher and Bronwyn Hemsley,International Journal of Language & Communication Disorders DOI: 10.1111/1460-6984.12405

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The Olympic rower James Cracknell has provided a powerful and very personal narrative on the relational impact of a brain injury. James was cycling across America in 2010 when he was hit by a fuel truck travelling at 70mph. He suffered a contrecoup injury to the frontal lobe of his brain.

Soon after the original injury, James and his wife Beverley spoke of the stark warning a neuropsychologist gave them: three out of four marriages end after a brain injury, due to the multiple, devastating effects upon relationships. The couple vowed to beat the odds but by 2019, announced their separation.

Speaking with deep honesty, James has suggested his brain injury meant Beverley had a ‘different husband’ before and after the accident and despite their best efforts, the effects of the injury overwhelmed their relationship.

The relational impact of a brain injury is widely recognised but is difficult to measure. The original evidence for high divorce rates comes from several European studies which suggest post injury divorce rates range from 48 per cent to as high as 78 per cent.

More recently, work in Virginia suggested a different picture, with a study showing of 977 people from different backgrounds finding 85 per cent remained married for at least two years post injury (2008, Virginia Commonwealth University TBI Model Systems researchers).

Further work (Kreutzer, J., et al) has shown after a brain injury, there are relatively high levels of marital dissatisfaction (50 per cent and above) but marital stability nonetheless (72 per cent).

Despite variations in reported divorce rates, brain injuries clearly present a significant additional pressure on relationships. This may be in terms of behaviour changes which can be mapped quite precisely to the original injury. Equally, there are often challenges in the wider relational pattern established before the injury: for example, the caregiving spouse or partner may need to take on new roles and obligations which were previously the domain of the injured partner.

The injured partner may not be able to return to their pre-injury employment and families often find themselves facing severe financial pressures. Tasks such as caring for young children or living with teenagers may become particularly challenging after a brain injury.

James Cracknell described becoming ‘more of himself’ after his brain injury; meaning, characteristics such as being stubborn and single-minded which served him well as an elite sportsman, were amplified by his brain injury. He observes these amplified characteristics were not as helpful in married family life.

Trying to map these kinds of individual observations into a broader map of psychological change after brain injury is an interesting task. In one mapping exercise, researchers measure four key factors widely recognised as brain injury effects: behavioural regulation, affective regulation (the ability, for example, to lift yourself from a negative mood), engagement and restlessness. They found between 64% and 82% participants reported moderate or severe changes in at least one of each of these factors after a brain injury (Obonsawin et al, 2007).

Another study, which also shows there is a significant personality change after a brain injury, suggests there may be a link between the location of injury and the type of personality change. An injury to the frontotemporal part of the brain seems to be associated with an increase in neuroticism (Norep and Mortensen, 2015).

There does seem to be agreement on one positively mitigating factor: family and professional support. A study of 279 siblings of individuals with traumatic injury to explore their perspective on their siblings’ quality of life after a brain injury (Degeneffe & Lee, 2010) found among those assessing quality of life as positive, the most commonly cited reason for this was family and professional support. Education about the multiple impacts of a brain injury and rehabilitation needs to be provided to the whole family in a holistic way in order to be as effective and supportive as possible.

While the work is still ongoing to better understand the long term emotional and behavioural impacts of brain injuries, it is clear that for relationships, there will be very significant challenges. The presenting behaviours can be really hard for partners and family members; in the heat of the moment, it is not always possible to ‘unpick’ the way difficulties are a result of the original injury. However, recognising the many ways brain injuries affect relationships is key to negotiating the new relational context in which couples find themselves.

References

Cracknell, J. Touching Distance

Degeneffe, C., Lee, G,. Quality of Life After Traumatic Brain Injury: Perspectives of Adult Siblings, Journal of Rehabilitation (2010)

Kreutzer, J., Sima, A., Marwitz, J., & Lukow, H. (2016). Marital instability after brain injury: An exploratory analysis. NeuroRehabilitation, 38

Norep, A. and Mortensen, E. Prevalence and Predictors of Personality Change After Severe Brain Injury, Archives of Physical Medicine and Rehabilitation

Obonsawin, M. A model of personality change after traumatic brain injury and the development of the Brain Injury Personality Scales, Journal of Neurology, Neurosurgery and Psychiatry

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These are cases which evoke fascination and wonder: a woman from Virginia who fell down the stairs and woke up speaking in a Russian accent; a German woman involved in a road accident who started speaking her native language with a pronounced British accent.

Foreign accent syndrome (FAS) is a recognised disorder caused by damage to the brain due to trauma or stroke. It is defined as occurring when a person speaks with an accent which is measurably different to their own. FAS is not a motor speech disorder; typically, those affected produce grammatically correct language, with a broad range of sounds and vocabulary.

There is no clear evidence of people speaking a different language after a brain injury; it is accent, not the language itself, which changes. The production of vowel sounds seems to be more affected than that of consonants.

What does this mean for the affected person? A well-known early case of FAS was that of Norwegian woman, Astrid L., who was hit by shrapnel during the Second World War. Following her injury, she started speaking in a German accent, causing her to be turned away from shops and shunned because of the strong anti-German feeling in her country.

In studies of people who have experienced FAS, there is growing recognition of the impact upon the sense of self when a person’s native accent suddenly changes. One interviewee observed: ‘‘Where has the old self gone, and where has the new person come from?”

Researchers at the University of Oxford have carried out extensive work to help understand what part of the brain might be involved in these changes (Gurd & Coleman, 20016). The affected area is almost always the left-brain hemisphere, which is dominant for language, rather than the right. Their work pin-points areas linked to FAS as follows: Broca’s area (frontal operculum and posterior third of the inferior frontal gyrus), premotor cortex, insula, striatum, pallidum, thalamus, brainstem, white-matter pathways such as the internal capsule.

However, it is not fully understood whether accent changes occur because of damage itself, or more subtly, disruption within the feedback processes involved in speech production.

In many cases, damage will not be visible on an ordinary CT scan. Although changes may be evident on an enhanced functional MRI scan, such small lesions can also be present but ‘clinically silent’ in healthy people over the age of 50.

Case studies show that some people return to their normal speaking accent within a duration of about two years; FAS is usually a temporary condition. In one reported case study (M. Lippert-Gruene, 2006), an individual who also experienced amnestic aphasia after a brain injury (difficulty retrieving words) described FAS as helpful, because people assumed she was speaking a second language and tended to be patient and understanding; one language difficulty masked the other.

Although FAS is very rare, with no more than several hundred cases reported in the literature, it does provide a fascinating window into the way language is produced, the processes that occur in the brain and equally, the psychology around the way we speak and the experience for a person who suddenly loses their language identity.

References

Gurd, J. M., & Coleman, J. S. (2006). Foreign accent syndrome: best practice, theoretical issues and outstanding questions. Journal of Neurolinguistics.

M. Lippert-Gruener, U. Weinert, T. Greisbach & C. Wedekind (2005) Foreign accent syndrome following traumatic brain injury, Brain Injury.

Rosalie A. Perkins , Jack H. Ryalls , Cecyle K. Carson & Janet D. Whiteside (2010) Acoustic analyses of two recovered cases of foreign accent syndrome,APHASIOLOGY.

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As we pass more than a month in lockdown, we are beginning to understand a little more about its multiple impacts. Although current circumstances are difficult for everyone, for some people and some groups, there are specific challenges and pressures. Here, we consider some of the difficulties which may arise for individuals and their families affected by a brain injury.

A big feature of the lockdown is people using digital technology to maintain relationships: pensioners have quickly embraced Zoom for virtual family get togethers; teenagers, already adept with technology, prefer apps such as House Party. How is this move to digital communications for people with brain injuries? A study published in the journal, Brain Injury last year, Flynn suggested the use of computer mediated communication can worsen the social isolation people with brain injuries already experience.

It is widely recognised that people with brain injuries have smaller friendship networks and lower levels of social participation, on average, than the broader population. When Flynn considered how people with brain injuries used social media and text messages to maintain friendships, she found people with brain injuries used text messages less frequently than the general population, due to the impact of their injury on the fine motor skills required. It is also recognised that many people struggle with screen glare after a brain injury.

Although there will be wide variation from person to person, it seems likely that people with brain injuries may be less comfortable and able to move to digital technology to maintain their relationships during lockdown.

There is also an increasing recognition of the pressures on relationships during lockdown. Looking at brain injuries, a recent study based on in-depth interviews with couples provides some useful insights (O’Keeffe, 2020). The changes in relationship dynamics caused by a brain injury are described as multiple, encompassing emotions, empathy, communication and functions. These changes are described as being profoundly destabilising for relationships. Clinical interventions and focused support is essential to support relationships, the research concludes.

It follows that for individuals and their loved ones already facing these challenges from a brain injury, the pressures and isolation of lockdown will be particularly difficult.

Equally, there may be some people struggling with challenging feelings and presentations which are not yet identified as being linked to a brain injury. A recent study (Rachelle, 2020) of post-concussive depression describes the overlap between symptoms of depression and symptoms of post-concussion depression, particularly in children and adolescents. For this reason, individuals can be diagnosed with depression with the link to a concussion missed. Younger patients tend to score better on cognitive tests after a concussion compared with adult populations, but high levels of emotionality, irritability and nervousness should be noted and considered as a possible indication of post-concussion depression.

In the current circumstances, there will be many households with difficult relationship dynamics, which now face the additional pressure of lockdown. The challenges may not be linked to a concussion; they may be interpreted as part of family conflict and tensions during a particularly difficult time. As such, families will be struggling on their own without the benefit of a diagnosis and tailored clinical support.

This is part of what is increasingly being recognised as another impact of Covid-19: with many face-to-face services closed and people are reluctant  to seek help at their GP or hospital, there is a risk that non-Covid health problems remain undiagnosed and thus left without essential treatment or support.

References

Margaret A. Flynn (2019) Characterizing computer-mediated communication, friendship, and social participation in adults with traumatic brain injury, Brain Injury, 33:8, 1097-1104, DOI: 10.1080/02699052.2019.1616112

Rachelle A. DeMatteo (2020) Post-concussive depression: evaluating depressive symptoms following concussion in adolescents and its effects on executive function, Brain Injury, 34:4, 520-527, DOI: 10.1080/02699052.2020.1725841

Fiadhnait O’Keeffe (2020) “The things that people can’t see” The impact of TBI on relationships: an interpretative phenomenological analysis, Brain Injury, 34:4, 496-507, DOI: 10.1080/02699052.2020.1725641

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