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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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More Delicious Innovations from Wiltshire Farm Foods

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The latest Softer Foods creation from Wiltshire Farm Foods features an innovation which is entirely unique to the market: the shaping of a Level 5 Minced meal.

The company’s development team decided to incorporate this particular feature to enhance the visual element of its new Minced Cod in Parsley Sauce to further support those with swallowing difficulties in ensuring they receive the nutrition they need.

Committed to creating meals as delicious as they are visually appealing, Wiltshire Farm Foods understands how the aesthetic appeal of a plate of food can impact the appetite. Giving its customers the ability to eat independently with meals that look enticing ensures dignity in dining; something the company is passionate about.

Wiltshire Farm Foods Minced Cod in a Parsley Sauce

Emily Stuart is the registered dietitian for the company and comments on importance of texture when it comes to those with swallowing difficulties:

“The texture of the main meal component has been designed in line with the requirements for an IDDSI Level 5 meal, in an extremely thick sauce.  A Level 5 meal should require little to no chewing, ensuring a safe consistency for those on a Minced and Moist diet.

“All our Minced meals come ready-prepared, delivered directly to customers’ doors, to eliminate the risk that often accompanies home-blending.  There are numerous challenges in creating safe, compliant meals via home blending with the process being both time consuming for carers and potentially hazardous for patients.”

Stroke survivor, Kate Allatt, knows first-hand how debilitating living with dysphagia can be, having experienced social isolation and embarrassment around mealtimes when friend and family were eating solid food that she was unable to consume herself:

To view the full Softer Foods range from Wiltshire Farm Foods along with more information on the latest Minced meals visit: specialistnutrition.com

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Forget brain regions, it’s all about networks in neuroscience

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Dr Ginny Smith - Neuroscience communicator and author of Overloaded

Having worked for some of the biggest media outlets in the science industry, Dr Ginny Smith has been making brain science accessible for several years. With the release of her first solo book, she sits down with NR Times to discuss the ever-changing world of neuroscience.

The neurotransmitters in our brains and the chemicals that go with them continue to puzzle scientists and academics.

Making sense of it all is Dr Ginny Smith with the release of her new book.

Overloaded: How Every Aspect of Your Life is Influenced by Your Brain Chemicals explores how chemicals control what we do, from basic survival instincts to more complex processes, like forming relationships.

Overloaded by Dr Ginny Smith

Recognised by New Scientist as one of the top science books in 2021, Overloaded was two years in the making.

One of its central themes is the brain working within networks which are all connected, rather than the traditional notion of individual regions performing specific tasks.

Speaking to NR Times, Dr Smith – who has produced science programmes for the BBC, Cosmic Shambles and the Naked Scientist – explained how changes in technology have brought about different interpretations of how the brain works.

“This idea of regions of the brain that do X or Y is starting to feel a bit outdated,” she said. “Talking to neuroscientists now, it’s all about networks and combinations of regions that talk to each other.”

And this shift in our understanding of the brain could shape new treatments in future.

“The drugs we have at the moment are the best thing that we have, but boosting things everywhere is a bit of a blunt instrument in something so precise as the brain.

“It’s not about if you need something to function, then having more of that is good. No, it’s all about finding that Goldilocks spot.

“One of the things I’m quite excited about for the future is the idea that we might be able to get more granular as to which areas of the brain are actually affected, perhaps on a person-by-person basis.

“It may be that at some point in the future, if you go to your doctor experiencing depression or anxiety, they could scan your brain to find out which area is actually affected and somehow target drugs specifically to that area.”

Overloaded brings together over 30 experts to give a clearer insight into how molecules like adrenaline, dopamine and serotonin work.

These chemicals may sound familiar but they often bring a lot of confusion around what they actually do – something Dr Smith was keen to address.

She explained how the misrepresentation of these substances in the media motivated her to set the record straight with the book.

“I started seeing a lot of mentions of these various brain chemicals. But they were often really oversimplified; like this idea that serotonin is the ‘happiness chemical’.

“It was stuff that takes a kernel of truth from real neuroscience, but simplifies it to the point where it no longer makes any sense at all.

“So I thought that it would be quite interesting to delve into a bit more complexity and find out what is actually going on and how much do we actually know about these chemicals?”

Although now hugely passionate about neuroscience, Dr Smith admitted that she fell into the subject after initially applying to study chemistry at the University of Cambridge.

“The way I’d encountered it before had been much more at the social psychology end of things, but the way it was taught here was like it was it was a real science where you did experiments.

“The complexity of the subject attracted me to it and I like a challenge. But also that the questions around it seemed so important to me. They seem like such vital questions to answer.”

Dr Smith switched her focus to neuropsychology and from here worked part-time in a lab. Due to her self-admitted short attention span, however, she found herself more drawn to the communication aspect of the field.

“I’ve been talking about the brain to anyone who will listen since then,” she said.

Her ability to make neurochemistry coherent was the catalyst for Braintastic! Science, the platform she founded to educate young people about how their brain works.

“Psychology and neuroscience aren’t sciences you necessarily meet at school. But one of the things I like is them explaining that there’s this whole other branch of science that they might not come across.

“It’s important to have a basic understanding of the brain. It can be so useful in so many ways.”

Indeed, a good understanding of the brain is something Dr Smith would liked to have had as a youngster.

“I wish that when I’d been a teenager, I had known a bit more about how a teenager’s brain works. I think it would have made life so much easier.

“Parents also understanding more about how young people’s brains develop would help them understand and relate to them.”

In fact, greater brain knowledge across the board in wider society would be beneficial, she believes.

“I think everyone can benefit from knowing a little bit more about how their brains and how other people’s brains work. I think it would make us a kinder, more tolerant society.”

While covering big neuroscience topics, the book is characterised by personal experiences and stories.

“One of the things I really like when I’m talking to scientists is hearing their passion and their stories for why they got into doing what they do.

“It also shows how science relates back to everyday life. That’s the thing about neuroscience and psychology, it’s all about us.

“I can’t tell you everything about the brain in one book, but I hope it sparks readers’ curiosity, and makes them want to go out and find out more about their brain.”

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How the C-Brace is opening up a new world of possibilities

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The C-Brace is big news in the progression of Orthotic treatment for neurological conditions. The integration of microprocessor technology into a carbon fibre Knee Ankle Foot Orthosis (KAFO’s) opens up a whole new world of possibilities and mobility for patients dependent on full leg support to stand and walk.

As standard, KAFO users are supplied with locked knee KAFOs. This is where the knee is locked in a straight position throughout their gait cycle, but manually unlocked to allow the user to sit down with their knee flexed. The use of a locked KAFO brings about stability of the knee for users with reduced lower leg muscles strength, when walking on level ground.

However, it also results in the development of multiple gait compensations for the user to progress through the gait cycle with a locked knee. Compensations include; hip hitching on the contralateral side, circumduction during swing phase, and vaulting of the contralateral ankle.

Gait can therefore be slower, require more metabolic energy and increase mechanical stress on the sound leg. Walking on slopes and stairs with a locked knee joint is very difficult and often situations avoided by KAFO users.

An alternative option to the locked KAFO is a Stance Control Orthosis (SCO). In a similar way to the locked KAFO, the knee joint is locked straight during stance phase, but unlocks at terminal stance to allow the knee to flex through swing phase, providing a more natural gait pattern and reduction in compensatory motions to achieve ground clearance.

SCOs require considerable confidence from the user, a consistent step length and are again limited on slopes, stairs and uneven ground. In order to prevent accidental disengagement of the knee lock on challenging surfaces, the user often manually locks the SCO.

Where the C-Brace comes into its own is the significant control available in both stance and swing phase of gait. The system provides stability for the foot and ankle, and stabilises the knee in the sagittal plane with the hydraulic unit replicating the eccentric and isometric muscle contraction of the quadriceps and hamstrings.

It controls both the stance and swing phases of gait with microprocessor sensor technology that can adapt to everyday situations in real time. The technology normalises gait by allowing controlled knee flexion during weight bearing, giving patients the ability to safely navigate quick stops, walk on uneven terrain, and descend slopes, curbs and stairs step over step.

The C-Brace calculates the orientation and movement of the system in space in three dimensions, using this information to control the flexion and extension valves of a hydraulic unit that provide varying levels of resistance to knee flexion. In turn, this allows for physiological knee flexion during loading response, absorbing the shock of weight transfer during heel strike.

In a locked KAFO or SCO, that shock is directly transferred to the pelvis and lumbar spine. Additionally, the C-Brace provides microprocessor swing control that adapts to the varying walking speeds of the patient. It does not require consistent step lengths to function as SCOs do.

Variable step length means a patient can increase or decrease walking speed and length of steps based on the instantaneous activity/mobility needs, making walking safer in unfamiliar or dangerous scenarios like crossing roads.

The C-Brace is also able to provide assistance descending stairs and slopes, allowing step-over-step gait, mimicking the contraction of the quadriceps for lowering the body down a stair or slope. The C-Brace considerably reduces stress to the sound limb in unilateral users, and allows bilateral users to descend stairs and slopes and ambulate on uneven terrain.

Additional features of the C-Brace include:

Stumble recovery: The microprocessor swing control of the C-Brace provides a stumble recovery feature that activates high knee flexion resistance during swing phase extension, in preparation for stance phase, allowing the patient to fully load their orthosis and stabilise the body in case of a stumble.

Intuitive Stance Function: This feature allows the patient to stand in a safe and relaxed manner with a flexed knee without the threat of knee collapse, and automatically switches back in to ambulation mode, turning off the blocked knee flexion when the patient moves. This feature allows the patient to unload the sound leg and rest while securely standing on level or non-level surfaces.

Sitting/Kneeling Function: The C-Brace assists the patient when sitting down and standing up from a chair by providing resistance to flexion or extension.

This adds an extra degree of safety and reduces stress to the upper extremities and the sound limb. The microprocessor automatically detects when the patient begins to sit down, adjusting the hydraulic resistance against bending during the transition to sitting.

Allowing the patient to sit in a controlled manner and at a controlled rate. When standing up from a seated position, the C-Brace blocks knee flexion as soon as the knee reaches a flexion angle of 45° or less, allowing the patient to reposition the foot and load the orthosis, for improved leverage to stand. The kneeling down function allows the patient to kneel down safely with controlled flexion of the knee joint, supported by increased flexion resistance.

Activity specific modes/Freeze mode: The C-Brace is programmable for activity specific needs of the patient in addition to ambulation. For instance, resistance can be reduced to a minimum for cycling, or a flexed knee joint position can be fixed for activities such as Yoga. The user, on their personal C-brace App, can control these modes.

So how can you know if the C-Brace might be right for your patient? The first stage is a thorough assessment, considering both the indications and contraindications of the system.

Indications:

  • Flaccid Paralysis or partial paresis of the lower limb
  • Quadriceps deficiency leading to poor knee control during stance phase

The patient may present with regular ‘giving way’ of the knee, reporting stumbles or falls when walking on flat, graduated or uneven surfaces. The C-Brace may be appropriate for a number of neurological conditions, including but not limited to:

  • Spinal cord injury between L1 and L5
  • Polio
  • Multiple sclerosis
  • Neuromuscular disease
  • Muscular atrophy or Traumatic paresis

Essential requirements for the use of the C-Brace:

  • The user must be able to stabilise their trunk and stand without support.
  • The muscles strength of the hip extensors and flexors must allow the controlled swing of the affected leg, or this must be possible through compensatory hip/trunk movement.

Contraindications of the C-Brace:

  • Swing phase initiation is not possible
  • Insufficient trunk stability
  • Severe spasticity
  • Knee or hip flexion contracture of more than 10°
  • Non correctable genu varus/valgus greater than 10°
  • Body weight less than 40Kg or greater than 125Kg
  • Height <140cm
  • Leg length discrepancy >15cm
  • Fluctuating Oedema or severe skin irritation that precludes the use of an orthosis

The C-Brace Dynamic Test Orthosis (DTO) is a trial orthosis, which features the C-Brace joint unit. The DTO can be set up to each individual user and programmed to their individual gait requirements, allowing users to test the function of the orthosis within the clinical setting.

The DTO can also provide valuable evidence to the function and benefits of the C-Brace for payers. The DTO can be trialled with support from the Ottobock Orthotic Academy Clinician or through Ottobock’s clinical partner Dorset Orthopaedic.

For more information about the C-Brace contact Ottobock or Dorset Orthopaedic through their website enquiry pages: www.ottobock.co.uk or www.dorset-ortho.com.

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