The neurophysiology of sex
Sexuality is part of being human. Our sexuality affects how individuals perceive themselves and how they interact with those around them. Sexuality is a complex area of functioning encompassing sexual development which begins in utero; sexual awareness which develops through childhood and adolescence; sexual responsiveness and awareness (Bancroft J 2009).
It is a key element in the formation of meaningful relationships in adult life. It is an area of strength but also of vulnerability to internal and external factors such as health, self-esteem, societal and family pressures and values.
At the most basic level, sexuality is the means by which a partner is found for reproduction and the passing on of genetic material and this is evident in the animal kingdom as a whole.
However, for humanity, it is about relationships. Neurological trauma or illness can have a major impact on sexual responsiveness and the capacity for relationships. More often than not sexual expression is something that occurs within a relationship.
Part of the normal sexual experience includes masturbation and fantasy but it is in relationships that sexual expression is generally fulfilled.
Why relationships matter
The dynamics of a relationship have a profound effect on sexual functioning. Sexual expression begins with desire which is a function of the brain.
Within the neural pathways there are both inhibitory and excitatory neurotransmitters. Dopamine is excitatory and Serotonin is inhibitory in the pathways linking desire to arousal of the autonomic and peripheral nervous system.
Desire is influenced by a variety of cognitions and emotions such as mood – excited, happy, fearful, oppressed memories of previous good sexual experience or memories of painful abusive relationships.
It will be affected by fatigue which is a very common symptom of neurological disease or trauma. It may be influenced by social context – is this relationship developing in a private setting or is it within a nursing home where privacy is diffcult to establish?
The most recent imaging studies have demonstrated that certain parts of the brain are active in sexual desire, including the anterior cingulate cortex which connects to the amygdala, which in turn has a key role in emotional responsiveness (Zeki A 2007).
The central nervous system, through a complex set of pathways involving the higher levels of cortical functioning, provides a delicately balanced system to allow sexual expression within relationships.
Any part of the system can be affected by physical, psychological, social and emotional factors.
The brain in turn connects through the spinal cord to the periphery. The sacral segment of the spinal cord is a key area from which nerves travel to the genitalia. The parasympathetic output to the genitalia comes from the sacral cord and the sympathetic nerve supply from the thoracic and upper lumbar cord.
In response to sexual arousal the nervous system connects to the genitalia via the spinal cord leading to a neurovascular response with the parasympathetic nerves triggering erection in the male and vasocongestion in the female.
The sympathetic system is involved in ejaculation. Any disease or trauma to the nervous system or medications acting on the nervous system can interrupt the pathways. For example, a thoracic spinal cord injury will separate the sacral spinal cord from control by higher centres so that in the male reflex erections may still occur in response to a variety of stimuli including full bladder or irritation to the skin, but psychogenic erections in response to sexual desire may not occur.
What makes a good couple?
Key factors include mutual attraction, love, having fun together, enjoying sex together, trusting each other, ease of communication and being special to each other.
As relationships move into longer term commitments, there are additional factors, including shared experiences and future plans, hopes and expectations.
Demands are placed on relationships such as financial commitments, bringing up children, looking after elderly relatives.
Meanwhile, each individual brings into that relationship their own health, beliefs, values and approaches to managing stress; their past experiences both good and bad, their need for autonomy and their need for intimacy.
Each person has their own self-image and an image of their partner, which can be quite different to how other people see them. Impacting on the relationship are external pressures which can be social, financial, work and family pressures.
Many factors can challenge the dynamic balance of the relationship and the onset of disease or trauma can have a profound impact.
When everything changes…
The context of most sexual expression is within a relationship. It is also within this context that many people will experience the life-changing impact of chronic disease or acquired disability.
For some couples, problems of adjustment to the changes can be significant and place a strain on the relationship, sometimes leading to separation. For others, the impact of such stress can enhance their closeness.
Different roles tend to be assumed as a relationship progresses. One of the commonest divisions of roles within a long-term relationship is with the arrival of children when, in some cases, one partner assumes the ‘bread-winner’ role and the other home-maker.
Each partner has an image of self and of their partner, and this includes an awareness of their physical and psychological health. The onset of neurological disease and/or disability can present a great challenge to the stable state of a relationship. This may result in a change of physical appearance and cognitive ability.
The couple, having been partners in a familiar relationship, may find now that there is a carer and a partner who requires care. New roles may be taken on by one partner whilst roles must be relinquished by the other.
The shared hopes and expectations for the future may alter. It is important to note that the greatest impact comes from disorders that alter cognitive and emotional responses – rather than just physical functioning.
Most often, the problems are multi-factorial in origin. For example, there could be loss of sensation because of MS, which alters the sexual experience, together with fatigue causing a change in overall lifestyle; low mood as a response to loss; medication resulting in specific sexual dysfunction, such as delayed orgasm with the selective serotonin reuptake inhibitors (SSRI anti-depressants); social changes resulting from the loss of income; or practical issues at home, such as no longer managing stairs and therefore, sleeping in a separate room from the partner.
Brain injuries can also lead to impaired self-monitoring, which means the individual may be unable to suppress commenting on things that come to mind no matter how offensive they may be. Self-centredness is also a common trait, as is a lack of empathy.
The ability to take note of how the other person is feeling – whether they’ve had a good or a bad day – without speaking to them, is quite important in relationships.
With acquired brain injury, non-verbal questioning can be lost (Wood R Williams C 2008). Sexual problems are common post brain injury and, in one study, 50% of men identified dysfunction (O’Carroll et al. 1991).
In a minority of patients, increased sexual drive and sexual dis-inhibition can be a problem.
This is more likely to occur with damage to the frontal lobes. Reduced sexual desire and interest are most common and result from the brain damage itself, the effect on the relationship, fatigue, depression, anxiety, low motivation and, sometimes, low testosterone secondary to damage to the hypothalamic pituitary tract.
The partner’s plight
A common observation from partners of people with acquired brain injury is ‘this is not the person I married’. Often in relationships, partners face challenges together. In the event of a trauma, the able-bodied partner may face this new challenge alone.
While this is going on they may also feel a desire to grieve for the old loved one they have lost. But there is no acceptable way for them to do this.
They may feel isolated and in a state of social limbo, in which it feels inappropriate to go out and have fun without their partner. Also, friends may say that the patient looks good, but only the partner sees the major behavioural changes that have occurred. Sometimes we see situations where the relationship had been on the verge of splitting up before the injury or onset of disease.
With the patient, unable to make the decision to end the relationship afterwards, the partner becomes trapped in a loveless or failing relationship out of guilt.
Despite all the pressures trauma and neurological conditions can put on a couple, relationships can be rebuilt. In relationship therapy, we are always honest and explain that things will never get back to how they were.
But, for all the behavioural changes, there may be factors that the partner still finds very attractive. We encourage couples to find new ways to have fun together and to start getting to know one another from scratch.
For men, drugs such as phosphodiesterase inhibitors have proved to be useful treatments for erectile dysfunction. These work on the relaxation of smooth muscle which allows vasocongestion in the genitalia in response to a chemical messenger cyclic GMP.
However, it is always important to approach treatment of sexual disorders in a holistic manner. It is rarely simply a mechanical problem that can be fixed with a pill.
Therefore, taking a full history and if possible seeing the individual with their partner allows the psychosocial aspects of the sexual dysfunction to be explored as well as the physical aspects.
Healthcare professionals need to be alert to the stresses and strains that can be experienced in this area of life which generally people view as very private and personal.
The P-LI-SS-IT model (Annon 1976), which was proposed over 40 years ago, emphasised that the first and most helpful approach to sex and relationship problems was giving people permission (P) to speak about the issues.
People may drop hints that all is not well in a relationship and it is up to the health professional to pick up on that hint.
Even if you are not certain how to help, acknowledge that there is an issue; allow the individual to talk about it and then, if you feel it is beyond your remit or skill, offer to refer to another agency – perhaps to the GP or to a sex and relationships clinic or to an organisation such as Relate.
The most important response is to say, “this is a valid issue to raise and there is help available”. In the PLISSIT model the next three stages are the provision of Limited Information, Specific Suggestions and Intensive Therapy. Most people will be helped in the first one or two steps of this model.
TEN STEPS: How healthcare professionals should approach their patients’ intimate relationship problems.
- Be honest and realistic with patients and partners. They may never recover their old relationship, but could still build a positive new one.
- Consider the difficulties the partner may be going through and how that may be impacting on their health. Do they look exhausted? Have they been crying? A doorstep conversation in private might encourage them to open Perhaps ask them if they have considered visiting their GP about their own concerns.
- Be careful not to overload partners with too many responsibilities, such as helping out with cognitive therapy at home. Although outwardly willing to help, inside they may be feeling drained, isolated and depressed.
- Often patients going through rehab can feel their sexual identity is threatened, leading to low self-esteem. Give them time to do the little things they usually would to look their best. For women, this might include shaving their legs or putting make-up on; for men it might be having a shave or doing their hair.
- Consider implementing some training on sex and relationship problems within your ward, unit, service or centre.
- Remember that, ultimately, your primary responsibility is to get the best outcome for the patient – not to influence whether or not their relationship survives.
- Get to know the sources of professional help available in your local area. Relate is a charity offering relationship support across the UK. Some areas are also served by specialist clinical psychology services. Patients should also be encouraged to consider visiting their GP about such matters.
- Remember that sex and relationships are very sensitive topics and most people will not be comfortable talking to strangers about them. Create a safe and secure setting to discuss them. Relationship issues should be presented as a normal and important element of the patient’s overall health and wellbeing.
- Always acknowledge there is a problem if the patient or their partner mentions it or even just hints at it. Never ignore the problem and certainly do not make light of it or embarrass or make fun of the patient.
- If you suspect there are sex and relationship concerns, try asking a non-threatening question. Perhaps as the patient is leaving, ask how things are at home. This gives them an opportunity to get the issue off their chest without bluntly asking them an awkward question.
Barbara Chandler is a consultant in rehabilitation medicine in NHS Highland. Previously she ran a sex and relationships clinic for people with neurological disability in the North of England. She teaches health and social care professionals on sex and relationship issues and has been published extensively on the topic.
Relate: www.relate.org.uk: www.relate.org.uk
The Institute of Psycho-sexual Medicine: www.ipm.org.uk
The College of sex and Relationship Therapists: www.cosrt.org.uk
Now is the time to embrace better ways of working
By Merryn Dowson, assistant psychologist and part of the team behind rehab goal-setting platform Goal Manager
A stitch in time saves nine. Rome wasn’t built in a day. The best things take time.
We are all too aware that some of the most important parts of our lives have been crafted, carved and developed over months and years. Consider your education, for example: you may well have been to primary school, secondary school and then sixth form college. Perhaps you went on to do an undergraduate degree.
You may even have taken another leap and completed a Master’s degree or a Doctorate. This took years. You learned, revised, sat exams, sat resits, applied for places, got results, got rejected, got accepted, and made it here.
One thing is certain: compared to all of this expertise, someone who completed a two-hour online course on the same topic does not come close. We know that putting time and effort into something gives us better results than if we tried a quick approach.
We do not always lead by this example though. Despite the knowledge that great results are only achieved through hard work and perseverance, sometimes we decide just not to bother. Often, a room in our home might look cluttered, worn down and unloved and it could be made to look incredible.
The walls could be painted, clutter cleared, carpet cleaned, furniture patched up, curtains updated, but it is so much effort. We see the effort it would take and keep living with it. It does the job. It’s fine.
We heard this a lot when we began to develop our software. Goal Manager was designed from within a clinical neuropsychology service with young people with acquired brain injury, and we recognised how goal setting was becoming an intimidating concept within our service and our colleagues across the field.
To combat this, we developed an online goal-setting platform which streamlines the key processes of goal setting into one system and allows members of multi- disciplinary teams (MDTs) to collaborate on goal data remotely.
Crucially, it was designed to fill a hole. The more daunting goal setting became, the more it was shied away from, and the guidelines for goal setting that had emerged from the literature were falling to the wayside.
While we designed our platform to save time on completing all of the gold-standard processes of goal setting compared to doing them manually, we found that people had often not been completing them at all. It was all too complicated.
As a result, we recognise that adopting a software solution like Goal Manager can come with its own problems to solve. It requires relearning a lot of
what we know about a concept like goal setting, understanding properly how these key processes work and how they can be applied clinically to benefit clients.
It is only then that you can start to think of ways to make it more efficient. To help with this, our users are offered bespoke demonstrations, guided MDTs through meetings to help with the clinical application of the data, and training on assessments and goal attainment.
This takes time. Our users are often throwing out their previous guide and writing a new one. When surveyed, however, every single one who responded said that it was worth it.
This brings us back to where we started: the best things take time; Rome was not built in a day; a stitch in time saves nine. By taking time to develop an understanding of goal setting and being able to apply it to a software solution, users experience all of the benefits of best-practice goal setting outlined in the literature both for their clients and for their teams.
Clients are motivated, rehabilitation is meaningful, important areas to address are highlighted, MDTs are focussed, clinical practice is evidenced – the list continues. None of this would have been possible without the initial investment of time.
While simple enough to read, this is no doubt overwhelming to apply to your service or practice and, with this in mind, there are some key points to remember. The most significant is that there is no better time than now.
The world is slowly opening its eyes, sitting up in bed and having a good stretch after the darkness of the Covid-19 lockdown. It is not yet certain if we are going back to snooze or if we are leaping out of bed afresh.
What we do know, however, is that we are heading into a brand new day. Even for those of us who continued in practice throughout the pandemic, services have been slightly paused in one way or another, whether that be refraining from home visits or having fewer people in the office.
We are all very aware that we are heading into the “new normal” rather than our old ways. Use this time to bring new and innovative ways of working into your practice. You might completely change your filing system, consider how you approach your waiting lists, or change how you approach MDT meetings.
Whatever you have been wanting to do for you and your service for so long, now is that time.
Perhaps you decide that you are going to welcome change but not all at once. That works too! For users of Goal Manager, we often suggest that starting with one or two clients might feel more manageable than a whole caseload.
This can help get to grips with the new concepts and ways of working without feeling like everything is completely disrupted. This applies elsewhere too. If you are wary of integrating a system into your whole service, start with one corner of it, evaluate, take what you have learned and then look to apply it more widely.
Finally, remember that all time taken to improve and grow impacts more than just what you set out to do. When people lose weight, they rarely conclude
by saying they just lost weight: they often enthuse about how they feel more energised or move easier or feel more positive or experience less anxiety.
This applies to any time you invest in developing your clinical practice or your service.
While time spent learning how to use Goal Manager and establishing it within a caseload is designed to improve goal setting, that investment also leads to improved assessment processes, more effective meetings, improved digital literacy, increased patient involvement and so much more.
The potential is enormous. To motivate you to start the process, look at what you want to achieve and how that might trigger other improvements.
While the world is still trying to drag its head off the pillow to open up the lockdown curtains, look to invest in addressing those needs you have always been aware of but never felt like you could justify the time.
Walk around your “house” and look into each room: is this the best it can be or could I give it a lick of paint?
Is now the time to bring meaningful solutions into my practice? Maybe grab a tester pot and try a new shade on the walls. Sign up for a free trial. Plan to grow and improve. Start building Rome.
To invest in improving your goal setting, visit www.goalmanager.co.uk to register for a live demonstration, sign up for a free trial or request a bespoke tour through the platform and its features.
Researchers unlock key prognostic tool for brain injured patients
In 1974, leading neuroscientist Graham Teasdale co-created the Glasgow Coma Scale (GCS) while at the Institute of Neurological Sciences in Glasgow. This scale has since been used to assess coma and impaired consciousness in patients who have had a brain injury.
The scale is used to describe variations in a patient’s eye, motor, and verbal responses. Each feature is assigned numerical scores depending on the quality of the response, and total scores range from three, which is a deep coma, to 15, which is full consciousness.
The GCS is used in clinics all around the world by physicians, nurses, and emergency medical technicians; and is also applied more widely in other, more complex systems that are used in assessing acute brain damage.
However, all three features of the GCS can’t always be determined in patients. Most commonly, the verbal response can’t be tested, as it’s not possible to determine this response in patients with severe brain injury who are intubated.
When the verbal score cannot be measured, the GCS can still be used in routine assessment and communication about a patient’s condition.
“The GCS should be reported in its component parts, so there is still useful information in the motor and eye components, and the verbal score can simply be reported as not testable,” Paul Brenan, senior clinical lecturer in neurosurgery at the University of Edinburgh says.
“The missing verbal score is problematic, though ,when determining the GCS sum score (eyes + verbal + motor). The sum score is used in clinical prognostic tools, such as the GCS -pupils score, so until now, missing verbal data has prevented clinicians from using these tools.”
But now, Teasdale and Brennan, along with Gordon Murray at the University of Edinburgh, have created a tool to use to assess impaired consciousness when the verbal component of the GCS is missing.
The researchers first examined a database of GCS assessments, and found that the verbal component of GCS was missing in 12,000 patients with traumatic brain injury (TBI), which made up 11 per cent of GCS assessments. These verbal scores were most often missing in patients with low eye and motor scores.
Using GCS data recorded in a database of 54,000 patients, the researchers calculated the distribution of verbal scores for each combination of eye score and motor score. They then combined GCS eye and motor scores into EM scores, and determined the distribution of verbal scores for each EM score. Based on this, they identified a verbal score that clinicians could impute for every EM score.
“Without the verbal component of the GCS, the GCS sum score (eyes + Verbal + motor) cannot be determined, so we developed this imputation tool to enable clinicians to benefit from these prognostic tools for decision making in patients with the most severe brain injuries, where the verbal score is not testable,” Brennan says.
To test these imputed verbal scores, the researchers substituted imputed verbal scores for actual verbal scores within the framework of prognostic charts, which the authors had previously developed.
These charts take into account the total GCS score, pupil response, age of the patient, and findings of abnormalities. The charts provide predictions about patient outcomes, and are designed to help clinicians make decisions and communicate across teams.
The authors outline in their paper, ‘A practical method for dealing with missing Glasgow Coma Scale verbal component scores,’ published in the Journal of Neurosurgery, that they found that the information gleaned from imputing verbal scores according to each EM score was similar to the variations between precise eye and motor scores, and from full information on verbal, eye, and motor responses.
Imputing verbal scores doesn’t add new information, but allows clinicians to use prediction and prognostic models by filling in verbal data needed for those systems to work.
“We have developed several tools related to the GCS that enhance its ease of use and clinical application, including the GCS Aid, the GCS-pupils score and the GCS pupils Age CT prognostic charts,” Brennan tells NR Times.
“These have been designed to address specific needs. For example, the GCS Aid was developed to support training in assessment of the GCS and to enhance reproducibility of assessment. The GCS pupils score and prognostic charts provide a simple but robust prognostic tool that can be used in the clinic.”
“Prognostic scores are helpful for clinicians to get a reliable prediction of patient outcome, to inform clinical decision-making and to support communication with a patient’s family.
“We know from previous research that clinicians can tend to predict overly pessimistic outcomes for patients, particularly those with severe brain injuries, so these prediction models are designed to prevent that. With our imputation tool, the sum score can be determined and prognostic models used in real-time in the clinic.”
The researchers believe that being able to add verbal scores will help clinicians quickly determine the severity of acute brain injury and estimate patient outcomes.
“We know from the enquires we get and from the number of downloads of materials from our website, that these are very popular and are having a positive impact on clinical care around the world.
“We are confident this missing verbal score imputation tool will be just as positively received,” Brennan says.
Update:concussion in sport
A run through the latest developments in concussion in sport research and protocols.
A study published in the May 27 in the medical journal of the American Academy of Neurology, looked at a biomarker called neurofilament light chain, a nerve protein that can be detected in the blood when nerve cells are injured or die.
Levels of the protein in the blood were measured and it was found that those with three or more concussions had an average blood levels of neurofilament light 33 per cent higher than those who had never had a concussion.
“The main finding in the study is that people with multiple concussions have more of these proteins in their blood, even years after the last injury,” said study author Kimbra L. Kenney, M.D of the National Intrepid Center of Excellence.
“Additionally, these proteins may help predict who will experience more severe symptoms such as PTSD and depression. That’s exciting because we may be able to intervene earlier to help lessen the overall effects of concussions over time.”
Following on from our article on the game changing tests into concussion in children it has been found that concussions sustained by high school athletes continues to increase.
Injury data collected from 100 high schools for sports including football, volleyball and wrestling found that, between the academic years 2015 and 2017, the average amount of concussions annually increased 1.012-fold compared to the previous four academic years.
Approximately 300,000 teens suffer concussions or mild traumatic brain injuries each year while playing high school sports.
Wellington Hsu, M.D, professor of orthopedics at Northwestern University’s Feinberg School of Medicine said: “It’s understandable to think that with increased awareness among practitioners who diagnose concussions, the incidence would naturally rise; however because we’ve studied and reported on concussions for a number of years now, I feel that enough time has passed and I would have expected to see the numbers start to level out.
“What we found was that the overall average proportion of concussions reported annually in all sports increased significantly, as did the overall rate of concussions.”
The data also revealed that in gender-matched sports, girls seemingly sustain concussions at a higher rate than boys.
The effects of concussion in young people continues to be a key concern, with links between concussion and football, specifically when heading the ball leading to some big changes when it comes to training guidelines.
Coaches have been advised to update their rules connected to heading the ball in training, with no heading at all in the foundation phase for primary school children and a “graduated approach” to introduce heading training at under-12 to under-16 level. This guidance is expected to be issued across the continent later this year.
These new guidelines were recommended following a FIELD study, joint-funded by the English FA and the Professional Footballers’ Association, published in October last year, finding that professional footballers were three-and-a-half times more likely to die of a neurodegenerative disease than members of the general population of the same age.
The study did not identify a cause for this increased risk, but repeated heading of a ball and other head injuries have been identified as possible factors.
Dr Carol Routledge, director of research at Alzheimer’s Research UK, said: “Limiting unnecessary heading in children’s football is a practical step that minimises possible risks, ensuring that football remains as safe as possible in all forms.
“As such, measures to reduce exposure to unnecessary head impacts and risk of head injury in sport are a logical step. I would, however, like to see these proposals introduced as mandatory, rather than voluntary as present, and a similar approach to reduce heading burden adopted in the wider game of football, not just in youth football.”
A similar stance, that also includes restrictions during matches, has been in place in the US since 2015 after a number of coaches and parents took legal action against the US Soccer Federation.
There is clearly a need to educate coaches and athletes about the concussion recovery process while equipping physicians with quick diagnostic tools.
A partnership between Neurotechnology and brain health analytics player SyncThink and concussion education technology specialist TeachAids aims to offer the latest concussion education combined with mobile, objective measurement technology.
EYE-SYNC, which allows a clinician to use analysis to decipher between brain systems to determine whether a patient may be performing poorly or impaired, will create a brain health education and evaluation system based on the implementation of CrashCourse, an interactive educational module that teaches athletes, parents and coaches about concussions.
This implementation will be available to all SyncThink partners which include top athletic organisations and clinical partners providing medical care and education for over 10,000 high school and college athletes.
This implementation could make tracking those who receive concussion education easier while complying with sport governing bodies educational requirements.
SyncThink founder and medical advisor to TeachAids, Jamshid Ghajar said: “Using the SyncThink platform to feature the CrashCourse educational technology for athletes and coaches is brilliant.
“Now clinicians can use the Eye-Sync tests and metrics alongside CrashCourse’s latest evidence-based information on concussion.”
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