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

For our terms of use and disclaimer follow this link: https://coulthursts.co.uk/legal-terms-of-use/

On the ever-changing horizon of developments in the imaging of brain injuries, one approach recently generated international interest. It was not the launch of another piece of sophisticated new imaging technology kit, but a simple blood test.

It was developed in the US working with injured veterans via the Department of Defence (DoD) and researchers from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) Network using the principle of measuring biomarkers. The test measures two types of proteins, GFAP and UCH-L1, that are released from the brain and into the blood when the brain is injured.

A strength of the test, called the i-STAT® Alinity® system, is in its simplicity and utility: it is contained in a hand-held device, providing results within minutes. Trials are ongoing to see how the accuracy of the blood test system compares with results from CT scans; it is a promising but unproven addition to the brain injury assessment methods.

The assessment of brain injury is an area where the weaknesses of currently available imaging technology are widely recognised. In UK hospitals, if a scan is considered necessary when a patient presents to A&E, this will be a CT scan to help determine the extent of the injury, risk of complications and whether surgery may be required.

CT stands for computerised tomography (CT), using x-rays and a computer to create detailed images of the inside of the body. CT is the main imaging tool of hospital emergency departments; it is effective at identifying fractures and severe bleeds and is useful in the first 48 hours after an injury.

However, CT is less effective at showing damage within the brain where they may not be bleeding, such as injuries to microscopic nerve fibres. Research shows CT scans will miss a large number of mild Traumatic Brain Injuries (mTBI): an estimated 80 to 90 per cent of injuries will not be visible on standard CT imaging. Equally, the injury may produce damage within the brain which continues to take place after the initial time of presentation at an emergency department in hospital.

Here, MRI (magnetic resonance imaging) can be helpful and is often used to help explain enduring symptoms when the CT scan is clear. MRI is an area of rapid development, with variations in weight, diffusion and the enhancement of image quality improving the ability of scans to detect damage and changes at a microscopic level.

The range of technology introduced in recent years is broad, encompassing terms such as MR spectroscopy, Diffusion Weight imaging (DWI), Diffusion Tensor Imaging (DTI) / Diffusion Kurtosis Imaging (DKI), perfusion imaging, PET/SPECT, and magnetoencephalography (MEG).

Of course, for the affected individual and their family, this is very challenging to understand and navigate. Patients are heavily dependent upon the NHS services available within their area and the imaging available to services where they receive care. But for some, it can be valuable to explore other imaging options and second opinions.

We can help, advise and signpost families to specialist MRI imaging which may not be available within their local service, but could play an essential role in establishing a full and precise diagnosis. Although there is still some progress to be made, imaging technology in brain injuries is rapidly developing and particularly for individuals living with difficult symptoms without an accurate diagnosis, imaging can be essential in developing a more effective, targeted treatment plan.

For our terms of use and disclaimer follow this link: https://coulthursts.co.uk/legal-terms-of-use/

Every three minutes, a patient attends a UK hospital after suffering a head injury. Traditionally, the much greater proportion of these patients were male.

This picture seems to be changing, however, according to figures collated by Headway, the UK brain injury association, which shows a 24 per cent increase in hospital admissions among females since 2005.

The reason for this increase is not fully understood. Certainly, the last decade has seen an increase in female participation in contact sports such as football and rugby and sports such as cycling, which also present elevated head injury risk. But the connection remains hypothetical, without a body of research evidence.

Where better understood is how concussion seems to affect women differently to men. Women appear to be more at risk of concussion, more likely to experience the most severe effects of concussion and take longer to recover from concussion, studies have shown.

Tracey Covassin of Michigan State University in the US has been a leading researcher in the field of female concussion, finding in ball sports, females were almost twice as likely to suffer a concussion as male players. Different symptoms were reported: male concussions were more likely to produce amnesia, while females reported prolonged headaches, mental fatigue and difficulties with concentration and mood changes.

Another study of young sportspeople found on average, females took 76 days to recover from a concussion, compared with 50 days for males. Another study has shown differences in cognitive impairment measured after a concussion.

Three theories have been put forward to explain these gender differences. One focuses on the physiology of female necks, emphasising the way injuries can be caused as much by the sudden jerking of the head as much as being the impact of a specific blow. As such, male necks, with a wider average circumference and muscle density are better able to mitigate sudden force and its effect than female necks.

The second theory focuses on how female brains are thought to have slightly faster metabolisms than male brains, with greater blood flow to the head. Therefore, if a head injury momentarily disrupts that supply of glucose and oxygen, it has the potential to cause greater damage.

The third theory considers different hormone levels during the menstrual cycle. One study found injuries during the follicular phase (after menstruation and before ovulation) were less associated with symptoms enduring beyond a month, while an injury during the luteal phase (after ovulation and before menstruation) resulted in more severe and lasting symptoms.

Head injuries can temporarily disrupt the production of various hormones, including progesterone. During the luteal phase progesterone levels are highest, and the researchers suggest the sudden dramatic fall in progesterone due to head injury throws the brain off balance and contributes to the worse and longer lasting symptoms. In the follicular phase, by contrast, progesterone levels are already lower; the drop in progesterone is therefore less dramatic.

There have been some concerns about the effect of emphasising gender differences in concussion: whether this might contribute to male sportsmen feeling their concussion is less serious, exacerbating male tendencies to underplay symptoms and return to activities too soon. Equally, there have been concerns about how differences could work against female participation in sport more generally, which has many recognised health benefits.

The American football player Brittni Souder, who retired from the sport due to a number of concussions, seems to strike a positive balance, working with young players to raise awareness of concussion for females and how to mitigate risks, while also advocating for participation in football.

For our terms of use and disclaimer follow this link: https://coulthursts.co.uk/legal-terms-of-use/