The force exerted on the brain during traumatic injury is linked to damage years after the initial event, research has revealed.
Findings of the new study have been hailed as having the potential to predict the severity of brain injuries and help influence new approaches going forward, particularly in the field of sport.
TBI has a number of immediate impacts, including physical effects like unconsciousness and bleeding, alongside the ‘hidden’ symptoms of memory loss, mood and personality changes, which may take much longer to develop.
However, the link between the mechanical forces that act on the brain during TBI and the resulting long-term changes is poorly understood.
Now, researchers from Imperial College London have shown a clear link between the forces acting on the brain during TBI and its associated long-term changes.
The study – ‘From biomechanics to pathology: predicting axonal injury from patterns of strain after traumatic brain injury’, which is published in Brain – combined a computational model of brain injury with experimental studies on rat brains.
“The initial damage during a traumatic brain injury takes only milliseconds to occur, but it triggers many changes that result in ongoing effects which can be felt years later,” says Dr Mazdak Ghajari, from the Dyson School of Design Engineering.
“Understanding the link between the two is crucial for predicting who is at risk for long-term damage, and how protection may be better designed to prevent this damage.”
The findings have the potential to make positive impacts in protective equipment, such as in the design of helmets.
Professor David Sharp, from the Department of Brain Sciences, says: “We are also looking at how the type of impacts experienced by American football players affects whether they lose consciousness, and whether new helmet designs might protect soldiers from the effects of blast waves following explosions.
“These types of studies can also help explain whether repeated small impacts, such as heading the ball in football, could lead to similar long-term brain injury.”
Previously, the team had built a human computer model to predict the location of long-term brain damage following TBI, focusing on the ‘white matter’ of the brain, which contains nerve fibres called axons which play a large role in the brain networks that are altered in long-term brain damage.
Now, they have tested this modelling approach to see if it can accurately predict the pattern of white matter damage in rats given mild or moderate TBI.
They simulated the rats’ brains during injury, revealing the location and duration of mechanical forces linked to damage. Using a precise experimental model, this damage was induced in the rat brain and followed up after several weeks, which correlates to years of changes in a human brain.
They found that the effect of shear stresses on the white matter helped to predict the location of long-term damage. Shear stresses push two parts of the same object, in this case the brain, in different directions.
The intensity of the shear at different locations caused by different impacts, for example what angle they come from, predicts where the most severe white matter damage will occur. This could potentially help doctors predict the likely long-term effects in patients who have suffered a TBI.
“Different types of injuries will cause different kinds of shear. With this new model we can now more accurately predict which injuries will cause severe, long-term damage, and potentially avert it,” continues Dr Ghajari.
“For example, motorbike accidents involve a lot of rotational movement, which causes lots of shear. We are studying dozens of bike helmets to see which best protect against excess rotation.”
Case Study: Lynda’s Story
Lynda’s story provides an uplifting insight into how neurorehabilitation following a brain injury can have positive, long-lasting effects on an individual’s physical and mental wellbeing. This is even when there is a significant time period between the brain injury occurring and starting rehabilitation.
Lynda was an independent woman who had a job, family and friends. However, she had a history of battling with substance misuse and was at risk to the influence of others. The exposure to these negative influences resulted in her suffering a hypoxic brain injury following an overdose in 2010, from which she remained in a coma for three months.
Lynda’s story highlights her dedication and the commitment of the specialist care team at Richardson Care in her rehabilitation journey.
Unique and Supportive Environment
Lynda was admitted to The Richardson Mews in December 2014, more than four years after sustaining her brain injury. The home is run by Richardson Care, a specialist residential care provider in Northampton. What makes it unique is the family atmosphere that is created and the uncompromising commitment to putting the service user at the heart of every decision that is made about their care. Richardson Care is an independent family business with a 30-year track record. Their expertise and experience in creating a homely and supportive environment encourages people with acquired brain injury to engage in their therapies. Combined with a person-centred and innovative approach to care delivered by a multi-disciplinary team, enables Lynda and others, to transform their lives.
When Lynda arrived at Richardson Care she was wheelchair-bound and she had been told that it would be very unlikely for her to walk again. Her ability to mobilise was minimal: she was only able to mobilise for extremely short distances and required a walking aid. She expressed her wishes to be as independent as possible and to walk again. However, she had little insight into her own physical limitations. Lynda also needed frequent prompting and encouragement with all aspects of daily living (such as personal care).
“The day Lynda arrived she was withdrawn, unable to walk and had limited speech. Lynda has shown great determination throughout her rehabilitation. Today, she has a voice. It is a pleasure to be part of Lynda’s journey.” – Jane Payne, Operational & Clinical Officer
Lynda’s personal care and treatment plan
In addition to her physical disabilities, Lynda presented with behaviours that could be described as challenging. The multi-disciplinary team at Richardson Care worked with her to devise a care and treatment plan that would address her physical, behavioural and emotional needs.
The following gives us an insight into some of the different elements of her care plan, that when consistently applied, lead to lasting benefits. They are helping Lynda towards her goal of independence.
- Psychology input – Cognitive Stimulation Therapy, Relaxation Group and 1:1 sessions that focus on improving and maintaining her emotional well-being. She is encouraged to use her coping mechanisms when facing challenges, and staff are aware of her early warning signs. These sessions also provide Lynda with the opportunity to discuss any issues or anxieties and receive reassurance and positive feedback on her behaviour.
- Physiotherapy input – weekly physiotherapy sessions to work on balance, strength and stamina and to help maintain flexibility. They focus on improving Lynda’s physical well-being and strength, working collaboratively to reach her goal of independence.
- Positive Behaviour Support (PBS) Approach – care plans, risk assessments and intervention guidance; working with Lynda to recognise and reinforce positive behaviours and increase her independence.
- Consistent support from care workers enables Lynda to develop and maintain a good therapeutic rapport with staff, helping her to manage her surroundings and behaviour.
- Social and environmental influences offered at Richardson Care allow Lynda to utilise her independence and build confidence. These include: meaningful activities, consistent structure and routine, trips to the community with staff support, opportunities to socialise and build positive relationships with other residents and staff.
Progress and Current Presentation:
Throughout her time at Richardson Care, Lynda’s strive for independence has been a prominent motivating factor for her. This is reflected in the significant progress she has made at every stage of her rehabilitation.
In 2019 (after being at Richardson Care for around four years) Lynda reached the stage where her strength, balance and confidence had been built to a level where she could walk independently with no aids. Throughout her physiotherapy sessions, staff adopted a person-centred approach to maintain engagement and compliance and to work with and around her cognitive difficulties. This approach has proved extremely effective with Lynda and has increased both her physical and mental well-being.
Timed Up & Go Test
“Lynda is the prime example of how a person living with a brain injury can still make considerable physical improvements given the right environment and therapy approach. Lynda was not in the early stages of her rehab and her injury was more than 12 months prior to coming to The Richardson Mews.” – Guy Stewart, Physiotherapist
The graph below provides a visual representation of Lynda’s substantial progress whilst at Richardson Care. The ‘Timed Up and Go Test’ is used to monitor Lynda’s improvements in walking 12 metres unaided, where the average time is taken from three attempts.
On admission in 2014, it took around 60 seconds for Lynda to complete the test. There was then a significant improvement in the following year and her average time decreased to 28 seconds. The years following have continued to see small improvements.
The most recent test, completed in January 2021, reported an average time of 14.90 seconds. Despite Lynda’s average time only being 0.35 seconds quicker than the previous year, it highlights how she is maintaining her mobility status and not showing decline. This is a vast achievement considering the restrictions in place due to the pandemic that has ensued between these two time points. Even with the limited access to physiotherapy and a reduced opportunity to go outside for walks, Lynda has remained consistent and motivated in her recovery with the support of her care team.
In addition to her physical progress, Lynda has been supported by care staff and the psychology team to ensure the quality of her emotional well-being and improve her resilience. Lynda still requires support to build a healthy resilience to stress by using effective management techniques, particularly regarding her experience of health anxiety, and this is less frequent.
Through psychology sessions, such as relaxation and 1:1 coping skills sessions, Lynda has developed a good inventory of skills to use when experiencing frustration or anxiety. She appears to have developed more insight into her emotions, knowing when to seek out staff support. This has aided in the development of self-esteem, confidence and resilience.
“Lynda has become a part of The Richardson Mews family and I have witnessed her growth since her admission. When Lynda first came, she was told she would not be able to walk and would be wheelchair bound. Now she can walk without any support. Lynda is very bubbly and always welcomes new residents with open arms. The day she leaves will be a sad day for The Richardson Mews, but it will be good to see her progress and she deserves to live the life she wants.” – Gill Ayris, Admissions & Referrals Manager
Daily Living Skills
Lynda continues to make significant improvements in her daily living skills; these include cooking her own meals with little support, and under normal circumstance, attending the local swimming pool, visiting the local shops to complete her shopping, going to cafes for coffee, going to bingo and socialising with staff and residents. She often encourages other residents during group activities.
Lynda secured a part-time paid job at Richardson Mews, where she completes office tasks. This is in line with her ASDAN (Awards Scheme Development Accreditation Network) courses, which she thoroughly enjoys and shows dedication to.
Challenging and Risk Behaviours
Lynda is a caring and empathic lady. She is usually calm and pleasant but at times presents with behaviours that can be described as challenging. These behaviours highlight her vulnerability and her impulsivity. However, the positive interventions and consistent staff support offered at The Richardson Mews is contributing to a reduction in such behaviours.
Lynda could be viewed as a model resident at The Richardson Mews where she continues to progress in her rehabilitation journey. The continued staff support she receives, coupled with her own determination means it is reasonable to say that her goal of moving on to supported living in the future is well within her reach.
“I love it here and I have grown as a person, but I am ready to move on all because of the decent services I have received here.”
“I love having physio, the food is lovely, and the staff are very friendly and I have achieved a lot with Sallie (ASDAN coordinator) and gotten loads of certificates.”
To find out more about the unique and specialist residential services provided by Richardson Care, call 01604 791266 or visit www.richardsoncares.co.uk
ABI and eating disorder
The impact of brain injury on a person’s life can be vast, with the effects many. But what if an eating disorder comes into the equation? Solicitor Ewan Bain explores the issue.
The effects of an acquired brain injury (“ABI”) are truly multi-faceted, ranging from dysexecutive syndrome, neuro-behavioural issues, to more obvious physical disabilities.
It is well known that mental health issues and conditions can arise from acquired brain injuries; the well-known ones being depression and anxiety. However, what about Eating Disorders arising from ABI; is that possible and are they linked?
Whilst there have been massive strides in the neurological sciences over the past half century or so, there is still much more we do not understand fully.
Eating Disorders (which encompass conditions such as anorexia, bulimia, amongst others) are yet to be truly understood; it is still difficult amongst clinicians treating in this area what is often the best method to treat people with such disorders.
The clinical studies and clinical treatment of Eating Disorders is still evolving; so what does one do when presented with an individual who has an ABI and has thereafter developed an Eating Disorder?
The short answer is: it’s complicated.
Treating Eating Disorders per se is phenomenally tricky and if it is compounded with someone who has an ABI, which can bring with it other co-morbidities associated with that, it makes for a very convoluted clinical mix and a huge challenge for those clinicians trying to treat the individual affected.
What is an Eating Disorder?
An Eating Disorder is when an individual adopts an unhealthy attitude towards food. It does not necessarily mean eating too little, it can also involve eating too much, or being obsessive with one’s weight and body shape.
The goal of any intervention towards an Eating Disorder is to essentially:
- Restore physical health
- Develop normal patterns of eating habits/attitudes;
- Reduce the impact of illness and day to day functioning.
The goal is fairly obvious but achieving it is not. For a start there a number of differing disorders:
- Anorexia Nervosa – this condition involves where one tries to keep their weight as low as possible. They do this through not eating enough, excessive exercise or a combination of both.
- Bulimia – with this condition, people lose control and binge eat before then being deliberately sick or using laxatives.
- Binge Eating Disorder – losing control of your eating by consuming large portions of food at once which leads to feelings of guilt
- Other specified feeding or eating disorder (OSEED) – this is where a person does not have what classically fall under the above conditions but nonetheless have an issue.
The above conditions have differing approaches ranging from pharmacological to the psychological, or a combined approach of the two. The environment and setting of how such treatment is delivered can differ too and depends largely on the person’s wishes, the availability of specialist services and the clinical presentation of the person affected.
The impact of Eating Disorders should not be underestimated. As well as the personal impact on the individual and their families, it has wider social and economic connotations as well. PwC recently conducted research and prepared a report on the commission of the Eating Disorder charity, “BEAT”. That report estimated that the cost to UK society of Eating Disorders was circa £15 billion per annum, which is simply staggering.
Eating Disorders tend to affect the younger population and young females are the more prevalent group. One study found that there was mean incidence for anorexia, as an example, of 4 to every 100,000 in people aged 10-39 years.
What is more disturbing, using Anorexia again as a graphic illustration, is that Anorexia is often reported to have the highest mortality rate amongst all of the psychiatric disorders.
ABI with an Eating Disorder
It is uncommon to find individuals who have sustained an ABI, with no previous history or risk factor for Eating Disorders, to then develop one post-accident.
However, whilst it is uncommon, suffice to say, it does not mean it does not occur.
The clinical community are aware of the link between ABI and Eating Disorders but it is perhaps not as clearly agreed or understood amongst them is how best to tackle it.
There have been some reports and studies but it is understood that these are not vast by any stretch of the imagination. There is little data that exists which concentrates on food behaviour patterns with this cohort of people with eating disorders.
In one particular case study, the authors found that the cases “all had a frontal subcortical syndrome, expressed by neuropsychologic dysfunction, neuroimaging (frontal and basal ganglia lesions) and also as personality changes.”
They went on to discuss how patients with cognitive deficits might not be affected by behavioural strategies to combat their eating disorder.
They ultimately concluded the following: “the eating disorders in patients with traumatic brain injury may be present from early phases and persist years after the lesion….Eating disorders in the TBI patient should be approached and treated in a different way to a typical anorexia and bulimia taking into account the cognitive impairment caused by traumatic brain injury. Prospective studies are required to determine the importance of the different factors influencing eating behaviour of these patients. Results enable us to understand the course and progression of these disorders over time and establish appropriate medication for their control.”
What is evident from the above is that field of Eating Disorders faces its own battles in understanding and tackling the competing factors, be it clinically, socially or even politically (with respect to funding).
The added layer of an ABI into the mix, convolutes the picture further, what with insight and cognitive deficits.
This will be to some therapists and clinicians in the ABI field relatively new ground to them; therefore, it is difficult to say (even if one was from a clinical background) how to approach this.
What can be said though is that input is almost certainly required between specialist clinicians practising in treating patients/clients with atypical ABI symptoms and with those from the Eating Disorder field. It is therefore of the utmost importance that, for instance, a case manager presented with such a client, considers specialist input from psychiatrists and clinicians from the Eating Disorder field.
They will need to work in conjunction with those treating the typical symptoms arising from the ABI; the priority of treatment will undoubtedly be the Eating Disorder and without tackling that firstly, it may not lead to progress in tackling other areas such as the client’s cognitive deficits and associated behavioural issues.
Case Managers, therapists and even legal practitioners practising in the ABI field, need to act quickly if there is an inkling that their client could have an Eating Disorder.
Regular contact/communication with your client and their family should allow you to be alive to such situations.
If such a situation does occur, then the case manager/legal team should consider arranging urgent discussions with those concerned in the care of the client; individuals with Eating Disorders may not accept that they have a problem and added with possible insight issues arising from a ABI, then this needs a careful approach so as not to disengage the client.
- Ewan Bain, specialist brain injury solicitor at Switalskis Solicitors, was assisted by Dr Matthew Cahill, Consultant Psychiatrist, in preparing this piece.
Brain injury charity to benefit from Raul Jimenez fundraiser
Footballer Raul Jimenez, who fractured his skull in a match last year, has chosen brain injury charity Headway as a beneficiary of a fundraising appeal on his behalf.
Wolverhampton Wanderers player Jimenez was knocked unconscious in a clash of heads while playing against Arsenal in November, prompting fans to launch a campaign to fund a banner in support of him at Molineux.
After hitting the initial target of £7,500 in a matter of hours, the JustGiving fundraiser remained open and now stands at over £22,000 of additional funds.
Jimenez has now decided to split the money evenly between Headway and the Mexican Football Federation’s initiative Jugamos Todos.
Headway supports individuals and families in the aftermath of brain injury, helping them to rebuild their lives, and has also been a vocal campaigner on the issue of being concussion aware in sport, with its ‘If in doubt, sit it out’ mantra resonating across sports from grassroots level upwards.
“My family and I were overwhelmed and truly humbled by the outpouring of support from the Wolves family, and football fans all over the world, in the days and weeks after my injury and surgery,” says Jimenez.
“The messages of support I received, across all channels, and from all corners of the globe, have been inspirational for me in my rehab and recovery, and the banner at Molineux is a truly special gesture.
“I want to thank the fans that came up with the idea for a banner and every single person who made a donation to fund it.
“I am delighted that we have such a large amount of money left over to give to organisations that will make sure that the right people benefit from all the love and generosity I received.”
Peter McCabe, chief executive of Headway, says: “The immediate aftermath following a brain injury can be very challenging for the loved ones of those affected, and I’m sure Raul and his family will have been through a very difficult time.
“We are therefore delighted to hear that Raul is making progress.
“We are also extremely grateful to Raul for recognising the work Headway does day-in-day-out to support families and individuals affected by brain injury from the moment the injury occurs through to helping them to rebuild their lives.
“I would also like to extend thanks to the club and its supporters for their generosity. To everyone who donated in support of Raul, I offer the heartfelt thanks of the charity and all those we support.”
The other beneficiary of the appeal, Jugamos Todos (Let’s All Play) was launched by the Mexican Football Federation (FMF) in 2016 to expand on its mission to use football and other sports at schools as a tool to improve children’s health and broaden their opportunities both in sport and society.
Wolves Matchday Experience Group member Kieran Newey, who set up the JustGiving page to fundraise the banner, said: “When Raul got injured at Arsenal, we saw the shock and worry for him and his young family all over social media.
“As a collective within the Matchday Experience Group, we wanted to come up with something to show Raul our support, and very quickly the idea of creating a banner with a fan design and fan donations came to life.
“We are really delighted that it captured the imagination of our fans and other football fans around the world, and that we have been able to raise enough money to cover the costs of the banner and have a substantial amount left over to give to charity.”
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