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Brain injuries in children – what we do and don’t know

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Clinical psychologist Célia Demarchi has been involved in helping shed light on brain injuries in children. Here, she talks about her recent research into how brain injuries affect this growing demographic, and why it’s important that research continues.

Outcomes following traumatic brain injury (TBI) are difficult to predict and NICE guidelines have emphasised the need for UK-based research into predictors of long-term conditions after brain injury.

Advances in medicine mean that more and more young people are surviving catastrophic injuries each year, but this does also mean that we now have a growing number of people with needs that aren’t always being met.

Childhood TBIs are often linked to persistent problems, and failure to recognise these problems limits a child’s access to appropriate healthcare and educational programmes, which in turn exacerbates the long-term effects of the injury. It is therefore really important that we are understanding the impact and intervening so that having a TBI does not have adverse life effects for a child.

This research was developed by a team of clinicians and academics at Great Ormond Street Hospital (GOSH) and Imperial College London (ICL), who had a keen interest in paediatric TBI. They felt that there were huge gaps in our understanding of what happens when children have a TBI and what the injury means for their future outcomes.

The team at GOSH have world class expertise in paediatric health and the team at ICL have world class expertise in TBI, so it was a good match and the start of a long and fruitful collaboration. I was fortunate enough to be brought onto the project in 2016 once it had been set-up, and immediately knew that we had lots of work ahead to do justice to the largest cause of death and disability in this age group.

We designed a cross-sectional study to investigate neuropsychological outcomes, and try to better understand how they relate to brain imaging in children and adolescents who had sustained a moderate-severe TBI.

We recruited over 40 young people with a TBI and their families to our study. Many families travelled from across the country, and even across the Irish sea, to take part. We have been so humbled by the support we received from families who wanted to contribute to a better understanding of outcomes following TBI.

We also recruited some control participants who were children in the same age range who had not sustained a TBI. This helped us to compare differences in both the neuroimaging and clinical neuropsychology of these two groups and try to disentangle the effect of the brain injury on development.

We are still in the midst of analysing our data, but so far we are finding that our TBI group and controls differed significantly on a range of cognitive measures. The largest effects were in domains of processing speed and executive functioning, with young people who had sustained a TBI experiencing more difficulties completing these tasks.

These cognitive skills are important for learning, and without the correct support at school, children will begin to fall behind as they may need a bit more time to get through the class work and also need support in organising their learning. Often, a child will recover well physically from a TBI and therefore teachers don’t always realise that the nature of these brain injuries means that it can lead to long-term hidden disabilities and needs.

Recognising these difficulties is really important. We don’t want children to fall behind and feel that they are doing poorly at school because of unrecognised needs following a TBI. It is our role as adults to ensure that a child grows up with the best education and that includes correct support, to not only support their learning but their developing self-esteem and sense of self. If we were to get things right at the child level, we would have happier and healthier adults.

Our research is novel as it combines detailed clinical neuropsychogical assessments with advanced neuroimaging. A key effect of TBI is to produce damage to the white matter connections of the brain, disrupting efficient communication between brain regions and networks. This type of damage has been difficult to diagnose in the past, but our advanced scans are now able to diagnose this damage.

Our cognitive functions depend on the efficiency of these connections and damage to these white matter tracts was found to relate to cognitive outcomes in our sample. We found that young people who had sustained a TBI had lower fractional anisotropy (FA) in some key white matter tracts and these reductions were associated with neuropsychological outcomes.

For example, damage to the splenium of the corpus callosum was associated with poorer processing speed. This effect was unique to our TBI group, not found in our healthy controls, thus suggesting a unique relationship between the effects of TBI on the brain and cognitive outcomes in children.

The exciting thing about this work is that the models can be applied at an individual level. My colleague Amy Jolly has developed a pipeline for processing single subject FA values against a group of healthy age-matched controls. This means we can look at one individual’s white matter tracts and make an assessment of the health of these tracts.

In our sample we found that FA values are better associated with neuropsychological outcomes than standard MRI scans. This is important for healthcare settings and clinicians need to be looking beyond standard structural imaging, which may not be telling us the whole picture when it comes to understanding the effects of the TBI on the brain.

If this advanced neuroimaging was offered routinely following a TBI, children at risk of developing cognitive difficulties could be identified and then referred to clinical neuropsychology in a timely manner.

Currently, services are vastly underfunded and therefore it is important to have a system for identifying children at-risk to ensure they are being adequately supported and we do not see them in our services only once they have started falling behind and problems have been flagged up by school and parents.

The All Party Parliamentary Group on Brain Injury recently reported that every primary school class has on average at least one child who has a brain injury so this is a sizeable problem and one that I think deserves our attention.

Owing to our successes with recruitment and building a network of interested parties across the whole country, Action Medical Research have funded us for two further years in which we hope to bring back the same young people. This will enable us to look more closely at brain development and neuropsychological development across childhood and adolescence and learn more about how TBI intersects with that.

This work is key in improving our understanding of why some children do well after a TBI and why some children go onto struggle, and this is key to ensuring that no child is left to struggle with unmet needs.

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Abnormal proteins unleash latent toxicity in neurodegenerative diseases

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Most neurological diseases have one thing in common: an accumulation of abnormal proteins around neurons. Researchers agree that these improperly fabricated proteins become progressively more toxic by interacting with healthy proteins, disrupting their functions. This picture, however, may be incomplete, according to a study.

In a recent study published in the Journal of Cell Biology, scientists from Daegu Gyeongbuk Institute of Science and Technology, Korea, have discovered the mechanism of action by which abnormal proteins actually unleash the inherent, but normally latent, toxicity of a natural protein in neurons, causing defects in dendrites (branched parts of a neuron that connect to the next neuron). Therefore, their results provide some clarity as to what actually goes on in diseased neurons. Though the researchers focused on Machado-Joseph disease (MJD), the implications of their results are relevant to other diseases as well.

First, they screened existing data to find candidate genes that were abnormally expressed in MJD patients and mice models. Then, based on the results and using MJD flies as animal models, they identified a problematic transcription factor–a protein that controls and regulates the transcription from DNA of other proteins–called NF-κB. Though this transcription factor is essential for the proper functioning and development of dendrites, the researchers found that something went awry with it when abnormal MJD proteins were around.

Through multiple subsequent experiments, they elucidated a long chain of inhibitory/promoting interactions between native proteins that, at a certain point, clashes with the accumulated abnormal proteins and cascades into a “deregulation” of NF-κB. In turn, this improper regulation unlocks the latent toxicity of NF-κB.

Professor Sung Bae Lee, who led the study, remarks: “Our results open-up a new avenue toward finding cures for neurodegenerative diseases by creating inhibition-based drugs that target improperly regulated latent toxic factors.” Such new potential treatments would directly target the early stages of neuron damage, stopping neurological disorders right on their tracks.

This study lights a beacon of hope for many countries that are struggling to deal with the problems of an aging society. “Korea will become a super-aged society in the near future and establishing an appropriate social system to care for and treat people with neurodegenerative diseases is turning into an urgent social issue,” comments Professor Lee. This might be the first step in a completely new road toward treating these chronic age-related diseases.

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Individualised brain stimulation therapy improves language performance in stroke survivors

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Canadian scientists are pioneering the use of individualised brain stimulation therapy to treat aphasia in recovering stroke patients.

Aphasia is a debilitating language disorder that impacts all forms of verbal communication, including speech, language comprehension, and reading and writing abilities. It affects around one-third of stroke survivors, but can also be present in those with dementia, especially in the form of primary progressive aphasia.

“Aphasia can be very isolating,” says Dr. Jed Meltzer, Baycrest’s Canada Research Chair in Interventional Cognitive Neuroscience and a neurorehabilitation scientist at Baycrest’s Rotman Research Institute (RRI).

“It can negatively affect people’s personal relationships, and it often determines whether or not someone can continue working.”

In a recent study published in the journal Scientific Reports, Dr. Meltzer and his team tested language performance and used magnetoencephalography (MEG) to measure brain waves in 11 stroke survivors with aphasia before and after they underwent brain stimulation therapy.

The scientists found that the participants had abnormal electrical activity in brain regions close to but outside the area destroyed by the stroke. This abnormal activity was mainly a shift to slower brain waves, a pattern they have also observed in individuals with dementia.

“We mapped that abnormal activity and targeted it using non-invasive brain stimulation,” says Dr. Meltzer.

“We found that the stimulation made the activity more normal – that is, faster – and improved language performance in the short term.”

Previous research has demonstrated that brain stimulation can improve language performance in aphasia patients. However, this study is one of the first to link this performance improvement to changes in the brain activity surrounding the tissue destroyed by stroke.

In other words, this study suggests not only that brain stimulation works in aphasia patients, but also that the reason it works may be because it addresses abnormalities in the brain surrounding the destroyed tissue.

Another novel aspect of this work is that the scientists targeted each individual’s abnormal brain activity with the stimulation treatment. In contrast, the standard approach in previous studies has been to use the exact same treatment, targeting the same brain areas, on every patient.

“Our results demonstrate a promising method to personalise brain stimulation by targeting the dysfunctional activity outside of the destroyed brain tissue,” says Dr. Meltzer.

“Aphasia patients are highly variable in terms of where their brain damage is and what part of the brain should be stimulated for therapy. By mapping individuals’ brain waves, we are finding ways to target the right area to improve their language performance.”

While the participants in this study were stroke survivors, individuals with dementia have similar dysfunctional tissue in their brains, and the scientists are also examining the use of brain stimulation in this group.

Dr. Meltzer and his team looked at the immediate effects of single stimulation sessions in this study. As a next step, they have received funding from the Heart and Stroke Foundation to conduct a full-scale clinical trial looking at the longer-term impacts of repeated stimulation for stroke survivors with aphasia.

However, this study has been suspended because of the restrictions on in-person research participation due to the COVID-19 pandemic. In the meantime, the scientists have pivoted to optimize other aspects of aphasia treatment.

With additional funding, the researchers could test different types of stimulation with more patients over more sessions, allowing them to make faster progress in developing this treatment for individuals with aphasia.

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Living with a spinal cord injury and maintaining good mental health during lockdown

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In conjunction with Mental Health Day 2020, Irwin Mitchell organised a webinar offering valuable insights into maintaining good mental health for those affected by Spinal Cord Injury (SCI).

The speakers were a mixture of professionals and people living with a SCI.

Dr Parashar Ramanuj, Consultant Psychiatrist gave an in depth clinical insight as to what a person who has recently sustained an SCI may be dealing with and what ‘coping’ really means

Sophie Lester, a case manager and spinal occupational therapist provided some really helpful guidance on how to maintain good mental health alongside rehabilitation and sustaining a healthy balance.

Ian Younghusband and Anne Luttman-Johnson provided first-hand insight into specific challenges of living with SCI and offered tips, advice and practical strategies to develop coping mechanisms in support of you and/or your loved ones.

The webinar offered some invaluable tips, but after seven months of different degrees of lockdown there were two key points that struck home with me. These were firstly the importance of reaching out to friends, family and charities and secondly keeping to some sort of daily routine and structure which includes hobbies, interests and exercise.

Lockdown was difficult for everyone, but especially for those who were deemed to be high risk. For those living with a SCI, a common cold has the potential to be life threatening. Most people with a SCI live with suppressed immune systems and/or possible respiratory issues, and so the possible impact of coronavirus has the potential to be devastating. Accordingly, people with a SCI were considered to be potentially high risk and were advised to shield.

For anyone who was asked to shield, in order to protect themselves, they were advised to isolate and effectively cut themselves off from their families, support networks and normal daily routines. This would have undoubtedly had an impact upon their mental health and wellbeing.

#TogetherInIsolation

In response to the growing situation, a number of positive and innovative projects have been launched to support the tens of thousands of SCI people who were isolating.

The Spinal Injuries Association (“SIA”) set up a movement, Together in Isolation. The SIA along with other charities and partners, joined forces to support and provide advice to those living with a SCI.

This included weekly inspirational blogs, an online drop-in café at 3pm every Wednesday with SCI Nurse Specialists and Horatio’s Garden providing gardening tips. Back Up, another national SCI charity also set up an online BackUp Lounge for people to just chat.

NeuroKinex is a not for profit organisation which in usual times, provides hands-on activity based rehabilitation for those living with an SCI. They continued to provide therapies and treatment virtually for a number of their clients, providing continuity of their rehabilitation, treatment and routine.

Online accessible experiences

Accessible exercise and fitness and wellness experiences have also become available online, to assist wheelchair users to continue to access exercise from home.

AirBNB launched their ‘experiences’ back in 2017, but when travel had to stop, these converted to virtual experiences with the option of filtering your results to those designed for accessibility. The experiences which have been featured include seated fitness and wellness experiences including Cardiobox, seated adaptive yoga, wheelchair dance and fitness, Mindfulness and Positive thinking with Paralympic heroes. Back Up moved their national wheelchair skills to virtual videos.

Additionally a number of free accessible exercise videos have been shared on social media. Ella, a GB U25 Wheelchair basketball player created Ella’s Wheelchair Workouts, a page on YouTube and Facebook offering and sharing exercise videos to do at home. She does this in conjunction with GymPossible an accessible gym in the North East who then started to produce adaptive fitness videos online.

Looking forward

The last seven months have been tough for everyone, and I am sure that it has had a huge impact on mental health across the country. But I am encouraged by the innovation and sense of community fostered by the use of online and virtual communication which has been sparked by this pandemic, and hope it has assisted some people to be able to continue with accessing their support networks and connecting with others, while participating in their hobbies and exercising from home.

Having access to positive experiences, friendships and exercise virtually when we can’t be there in person helps maintain good mental health. And although it doesn’t replace face to face in person experiences, I am hopeful that this positive community movement continues when life returns to what will be our new ‘normal’.

For those who are interested, I would really recommend watching the webinar recording which gives practical tips and guidance. This can be seen below:


Written by Jessica Bowles, a solicitor specialising in serious injury with a specific interest in Spinal Cord Injuries and rehabilitation at Irwin Mitchell.

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