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Rugby’s battle with concussion threat

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Addressing the challenge of concussion in rugby is like a skirmish with the marauding All Blacks. Hazards emerge from every angle and each advancing metre is hard fought.

Leading the line is Dr Simon Kemp, chief medical officer at English rugby’s governing body the RFU and a former physician to the England squad.

With his involvement, the game has made significant progress in improving its handling of concussion in recent years, but the battle is far from won.

“Concussion is just about the most difficult sports injury to diagnose and recognise because it can present in so many different ways,” he says.

“It can lead to two or three seconds of unconsciousness with no signs or symptoms afterwards – or can present with somebody who develops a headache over the course of four to 24 hours, for example.”

Custodians of the game are working on several fronts to better prevent, manage and understand concussion at every level, from schools and grassroots to the top tier.

Like football, American football and boxing, rugby must also answer difficult questions about its long-term impact on the brain.

This follows revelations about links between football and NFL to CTE, the progressive degenerative brain disease caused by repetitive brain trauma and associated with dementia.

Long term study

Kemp (pictured above) says: “Sport in general needs to answer the question of whether there is an association between playing sports
 and neurocognitive decline.

“It’s a difficult question to answer because, as we age, we all see neurocognitive decline, which is one of the reasons for the limited amount of evidence around to date. We acknowledge that there may be an association [between rugby and CTE] but the reality is that the available evidence is limited and conflicting.

“Unlike some other sports, we do actually have a long-term study underway, involving 205 ex-rugby players, most of whom were England internationals. Rugby has been pretty upfront about this issue.”

The RFU is working on the study with 
the London School of Hygiene & Tropical Medicine and researchers from Queen 
Mary University of London, The Institute
 of Occupational Medicine, University 
College London and Oxford University.

It is backed by £450,000 in funding from The Drake Foundation, which supports sports concussion research. Results are expected to be published next year.

Detection improving

At the last count in 2015/16, concussion accounted for 25 per cent of all match injuries in the English professional game, up from 17 per cent the year before.

But the sport is not necessarily becoming more dangerous – heights and weights of players have remained stable since 2002, after an initial surge when the game turned professional in 1996.

Rather, Kemp puts rising concussion rates down to greater recognition of the condition.

“In the professional game, reported concussions have been going up dramatically over the last five years but all other contact injuries have remained stable. We think
 the rise is because we are much better at recognising it.”

This surge in reported concussions corresponds with the establishment of World Rugby’s Head Injury Assessment 
(HIA) tool, which underpins concussion management in the elite game.

It consists of a three-step process of assessment for any player suspected of sustaining a concussion.

The first stage involves 11 immediate and permanent removal criteria relating to factors such
as consciousness, balance or behavioural changes.

“The player absolutely does not go back onto the pitch if any of these criteria
 are met,” says Kemp.

An off-field screening tool, pitch-side video review system and evaluation by an attending doctor are also involved at stage one.

Stages two and three cover tests and assessments for early signs of concussion, within three hours of the match, and delayed signs, after the player has had two night’s sleep.

The protocol was introduced in 2012 – a year in which an estimated 56 per cent of players later deemed to be concussed stayed on the field.

The latest available stats, from 2015/16, put that figure at nine per cent, with the fourth version of HIA now in play. 
As often happens at the intersection between much-loved sports and newly installed regulations, the HIA protocol has attracted some criticism.

And, despite its continual improvement via updated versions, it cannot protect against every concussive incident in every match.

Lessons to learn

Last year Northampton winger George North was allowed to return to the pitch at Leicester, despite having appeared to lose consciousness.

A review found there was enough evidence from footage of the incident, together with North’s history of concussion, to have kept him on the field.

It accepted that Northampton’s medical team acted in the best interests of the player, however, since it had not seen all the available video footage due to
 Wi-Fi problems.

Rugby’s response was swift. The Concussion Management Review Group drew up

nine recommendations, which were implemented by Premiership Rugby.

They included ensuring a pitch-side video reviewer remains in their allocated seat and has backup to make sure video feeds are monitored continually.

Various Wi-Fi protocols and a stipulation that medical rooms should have hard-wire video feeds were among other measures.

Former World Rugby medical adviser Dr Barry O’Driscoll said at the time that the episode showed: “The protocols are totally unfit for purpose. Time and again they are putting brain damaged players back on the field.”

O’Driscoll quit his role at World Rugby in 2012 in protest at the way concussion was being handled.

In the absence of a proven and objective, single pitch-side test for concussion, Kemp insists the HIA system is performing well
in terms of protecting players.

Official data backs this up; in 2015/16, 98.5 per cent of head injury events in the Premiership were managed according to the protocol.

“HIA has evolved since 2012 and it really is pretty sophisticated now. The tools that we

have to identify concussion are of real
value, but they are, of course, subjective.”

Should an accurate, objective pitch-side 
test emerge, Kemp envisages it being embedded into HIA protocols, rather than replacing them. Such a test might be based on saliva samples, if trials taking place this season in the Premiership and Championship are successful.

Conclusive testing

The study, being carried out in collaboration with the RFU, Premiership Rugby and
 the Rugby Players’ Association, will run throughout the 2017/18 season and is the biggest of its kind in the history of UK sport.

Birmingham University, led by neurosurgeon Professor Tony Belli, has spent the last nine years working towards a test that measures biomarkers present in the saliva and urine of players.

If validated, it could be carried out on a hand-held device, which is currently under development.

Professor Belli says: “If these biomarkers are found to be reliable, we can continue our work with industrial partners with the hope of having a device available within the next two years that will instantaneously diagnose concussion on the pitch-side with the same accuracy as in the laboratory – a major step forward for both sport and medicine.”

While rugby works towards a fast, watertight pitch-side concussion test, what other interventions might minimise the risk 
of brain injuries in the game? NFL or amateur boxing-style head guards are often suggested, perhaps by those uninitiated with the medical implications of contact sports.

These, says Kemp, would be pointless in relation to head injuries.

“Rugby headgear can protect against head lacerations and cauliflower ears but there aren’t any helmets in sport that have been shown to protect against concussion.

“They can prevent skull fracture, but not the rotational, acceleration and deceleration injuries that are associated with concussion.”

One safety measure which has been adopted by the professional game recently is an increase in the sanctions players receive for tackles made over shoulder level.

In January 2017, the minimum on-field sanction for a reckless (high) tackle was upgraded to a yellow card with a maximum of red, while the minimum on-field sanction for an accidental (high) tackle is now a penalty.

“We are already starting to see more penalties and yellow cards as a result, so referees are definitely implementing it.”

Time will tell whether this heightened threat of an early bath or time in the sin-bin leads to a reduction in concussion rates.

Essential education

A longer-established part of rugby’s concussion prevention strategy is the

training course delivered to all players and backroom staff at every club in English rugby’s top two divisions.

The club doctor at each of the 24 clubs 
runs an hour-long concussion session, with mandatory attendance for every member
 of the playing, coaching and support staff.

Around 1,300 people have now been through the course since its launch in 2014.

“It has transformed the way players understand concussion. They are really well informed about what it looks like, what it feels like and why they need to come off.

“The course also talks them through what the potential consequences are.

“In the short term, if they stay on the field, they have an increased risk of further 
injury, their performance goes down and their symptoms are likely to last longer.
 We also talk about the potential long-term consequences.

“We don’t know exactly 
what they might be, which is why it is so important to get across to players why they need to be removed in order to recover and return safely.”

At amateur and age group levels of rugby, concussion education is not mandatory, but plays a crucial role in protecting players.

The RFU runs online courses and offers a wealth of resources to school and community teams through its Headcase initiative.

They include advice, assessment tools and changing room posters with the slogan “DON’T BE A HEADCASE, STOP! CHECK FOR CONCUSSION”.

Tens of thousands of people have undergone training via the scheme since it was launched in January 2013.

The grassroots campaign advises anyone involved in the game to; ‘Recognise, Remove, Recover, Return’ and Kemp says the message is hitting home.

“Evidence suggests that the simpler
 your message, the more likely it is to be remembered. We’ve been working hard around the Headcase resource to achieve this, including through the commissioning 
of a video animation which has gone down particularly well with teenage players.

“The message is getting through but it needs to reach millions of people and it hasn’t got to everybody yet. We also need to consider what is rugby’s responsibility and what is that of the departments of education and health.

“Our principle responsibility is to get the message to coaches, players and parents.

We can help in terms of getting the message out to GPs, emergency doctors and teachers but we do need support from government departments, which, in fact, we have very good relationships with.

“Also, concussion advice to teachers needs to be consistent across sport, which is why we’re working with other sports and our advice is aligned with soccer’s for example.”

Schools must adapt

An important element of the RFU’s work with schools is providing guidance on what happens after a concussion.

“If a pupil sustained a concussion on a Saturday and still had a headache on the Monday, they shouldn’t be back into a full school programme.

“We have been working with schools to help them understand that they may need to make some academic adjustments as the pupil recovers from the injury.

“This is a big task but schools are increasingly receptive. Some independent schools with big rugby programmes have even developed an approach to player recovery that looks very similar to that of professional clubs.”

In concussion prevention and management, the amateur and schools-levels of rugby take their lead from the professionals.

“Concussion is the same injury in professional, community and age group rugby. But the way it is managed varies because of the different resources you have. The principals are the same however and are consistent with the science [of concussion].

“How concussion is managed at the professional end drives how it is managed at the community end.

“So it is incredibly important in the professional game that we recognise and remove players with suspected concussion and do not leave them on the pitch. By doing so, we send a message to the community and age group levels.”

Further protection for young people comes via a lower threshold for leaving the pitch, and a slower return to play.

“Schools rugby doesn’t have video evidence, but does have the coaches, parents, teachers and other players all alert to the possibility of concussion and players coming off.”

Young players also experience a gradual increase in the level of contact permitted in their game as they get older. Full contact rugby is not played until players turn 15, a strategy which also protects players from head injuries, says Kemp.

Exercise may protect young people

New measures could further protect young players, meanwhile. Recent research 
from the University of Bath found that a 20-minute exercise programme for young rugby players to improve their strength and balance could help to reduce concussion injuries.

A study, involving 14 to 18-year-olds across 40 schools, found 59 per cent fewer concussions in schools that completed the exercises three times a week, compared to those that didn’t.

The exercises focused on increasing neck muscle strength, balance and movement. The RFU is rolling out the programme in schools in England
 this season.

Other researchers suggest the game should go even further to prevent concussion in school rugby.

A Newcastle University study, published in July in the British Journal of Sports Medicine, re-examined existing evidence on the rates and risks of injuries in sport.

It cited “strong evidence” from Canada that removing the “body check” from youth ice-hockey, where a player deliberately makes contact with an opposing player to separate them from the ice-puck, led to a 67 per cent reduction in concussion risk.

The report drew parallels with rugby and urged a ban on tackling in the youth game; although another recent study in the same journal suggested concussion risk in youth rugby is no higher than in other sports.

Kemp urges balance when considering the risks and rewards of young people playing rugby.

“You have to look at both the sport’s benefits and negative elements. The reality is, at a time when our children are becoming increasingly sedentary and heavy, the place for physical activity in sport is increasingly valued.

“One of the important points about rugby is that it’s a game for all shapes and sizes. The shorter or less mobile child who might not get a look in in soccer, may have a place on the rugby team.”

Yet, despite rugby’s obvious health benefits, is there a danger that officious head teachers might still be tempted to avoid any rugby-related risks completely?

In the US, where American football is
still reeling from revelations about links to early-onset dementia, non-contact, ‘flag football’ is reportedly replacing the pigskin in some schools.

Non-contact forms of rugby are already in existence here, but Kemp sees no signs of 
a drop in appetite for proper rugby among young people.

“Clearly as we become more aware of injury risks, it might change how schools review individual sports, but at the moment the uptake of rugby in schools is significantly growing,” he says.

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Insight

The psychiatrist fighting for domestic violence victims

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Australia’s New South Wales government has promised to improve brain injury testing for domestic abuse victims after a psychiatrist drew attention to inconsistent care for vulnerable women. Psychiatrist Karen Williams urged the government to adopt a concussion protocol for family and domestic violence victims after doing her own research and being shocked at what she found.

It started when Williams noticed the disparity in how her patients were diagnosed and treated.Williams specialises in the treatment of post-traumatic stress disorders (PTSD), often with military, police, emergency personnel and other first responders.

But she also treats the general population, the vast majority of whom are women with histories of child and domestic abuse.

“I was getting two populations,” she tells NR Times. “The military patients, who are clearly identified as having PTSD, and the female population, who are mostly identified as having depression, anxiety and personality disorders, but had incredibly high rates of abuse in their histories.But Williams saw that whilst both groups had similar symptoms, and similar levels of trauma, they had very different treatment options.

“There’s a lot more funding put into supporting traumatised soldiers and first responders than there is for women who have experienced trauma within their home.

“In Australia, we don’t have much at all for women and children victims of abuse.”

This was a particular concern because of the amount of times Williams had heard about multiple head injuries and concussion among women who were victims of domestic abuse, which is similar to boxers and those player high contact sports.

“Women who’ve been unconscious several times or strangled have symptoms such as memory deficits, insomnia, migraine and mood swings, which all could be put down to PTSD and depression, but also brain injuries.”

But if Williams wanted to find out if a patient had a history of brain injuries, she would have to refer them for neuropsychiatric testing, which costs up to AUS$1000.

“This is completely unaffordable for many abuse victims so it just doesn’t happen, so we don’t investigate women who’ve had brain injuries.

“One brain injury unit told me they would consider taking on a patient if they could provide evidence that an assault happened – such as hospital records.

“This completely fails to take into account that the vast majority of domestic violence survivors will not report any assault to anyone and will not have so-called evidence.”

Then, Williams was speaking to a colleague whose son had had a head injury in a sporting field.

While they were together, a nurse rang to follow up the treatment he’d received in the emergency department.

“The nurse asked how her son’s personality and memory was, and gave a fantastic run-down of the symptoms that can happen after a concussion,” Williams says.

Williams was shocked – she’d never heard of someone ringing up women after a head injury in a domestic violence case.

She rang the local emergency department and asked about their protocol following a head injury obtained during sport.

She was given a detailed outline of the observations they take, their plan over the weeks following the patient’s injury and the advice they give the patient.

Williams called several emergency departments in other Australian states, and whilst all had a protocol for sports players following a concussion, none said they had a protocol for women who had been the victim of domestic abuse.

“There wasn’t one place that said they had a particular protocol.

“If they knew the woman had had a head injury they’d give them the basic head injury protocol, but nothing specific that took into account the very individual needs that a woman with a head injury in a domestic situation might have,” she says.

Williams says research indicates health care professionals correctly identify family violence victims about one per cent of the time.

“In sporting players’ protocol, there’s a recognition that says that your patient may not know what they’ve experienced in the past was a head injury, so the advice is to be really explicit. They’re given a list of questions to break it down with that player to make sure they understand what could be a head injury.

“There is opportunity for scanning, and neuropsychological testing if there is evidence of persistent symptoms.”

Williams says doctors should be going through the history of women, too, to see if they’ve lost consciousness in the past.

“There are a variety of mechanisms in which a woman experiences brain injuries in a domestic situation, many more than sporting probably, and the more head injuries a woman has, the greater her chance of long-term problems,” Williams says.

This includes a higher risk dementia, PTSD, migraines, learning problems and memory problems.

“But women aren’t told this, so many don’t know that they’re at risk of these things.”

Williams says there is a ’hidden epidemic’ of women in the community with brain injuries no one knows about, who could have been diagnosed with mental health issues instead.

In 2018, Brain Injury Australia released its findings after looking at the prevalence of brain injury in victims of domestic violence.

It found that 40 per cent of victims who attended hospitals in Victoria, Australia, for domestic violence had a brain injury and the majority were women.

But there’s no specific treatment for these women, Williams says, and many won’t even know they have a brain injury.

“Abused women are a very neglected population, and when you think about the money being spent on sports, and sports players, there’s no reason we can’t look after woman as well,” Williams says.

But despite these findings, Williams says it didn’t lead to any change.

“When I found all this out, I was angry and upset,” Williams says.

She arranged to meet New South Wales’s Labour MP Anna Watson in August, and when Williams told her what she’d found, she says Watson was ‘mortified’.

“She immediately got on the phone with the office of the minister for the prevention of domestic violence, and requested a meeting as soon as possible.

In the Zoom meeting a month later, Williams went over what she had found with Mark Speakman, Attorney General and Minister for the Prevention of Domestic Violence, and outlined the obstacles facing women.

But he made no promises, and Williams said she felt he didn’t understand the urgency or gravity of the situation.

Watson then went to the media, and the story was reported on. Within a week, the government produced a statement promising to investigate the issue.

“We’ll all be watching and holding them accountable,” Williams says.

“I will be trying to follow up, I won’t let it go.”

Williams is disheartened that it took media coverage to get the government to respond, but says she’s learnt a valuable lesson.

“Part of the reason I’ve spoken to the media and been vocal about it, is my experience is that when we do things quietly and ask for things politely, the government says there’s no money, despite being one of the wealthiest countries in the world. But when the voting population starts getting angry and asking what’s going on, that’s when we see an answer.

“It’s been a sad realisation for me to recognise that people don’t respond to do the right thing, they respond to winning the vote, so I will keep being as loud as possible in the media.”

Leaving brain injuries undiagnosed has significant consequences, Williams says.

“You’ve got women feeling like they’re a bit crazy, women wondering, ‘Why don’t I remember things, why have I got headaches all the time, why can’t I sleep?’

“It makes women feel worse, like something is wrong with them rather than identifying the underlying cause that we’re completely missing.

“If women are unable to work due to the physical and psychological side effects of a recurrent head injury, they need to be able to apply for NDIS funding (National Disability Insurance Agency). f they don’t know they have a brain injury they will be left to flounder – which is what is happening now.

“The vast majority of doctors don’t know about this. The medical system failing these women.”

There will be a lot to work out as support becomes available, Williams says, as some women could fear that having brain injury diagnosis could interfere with them getting custody of their children.

But, ultimately, change will benefit these women.

“All women deserve to know the truth about what’s happening to them,” she says.

“In some cases, their brain injury will be the final straw. They might think an act of violence isn’t a big deal, but if a doctor says, ‘Look how many times this has happened to you, you could end up long term brain damage’, that might be the final push that makes her take steps to leave. There’s no excuses to justify why these conversations aren’t had.”

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Interview: Inside one of the world’s biggest concussion studies

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Concussion is a huge concern across the US military and in sports. In 2018, 19,000 military personnel were diagnosed with a traumatic brain injury, while college athletes had an average of 10,500 concussions for past five years.

Despite the numbers, many say there’s a lack of research to inform ways that government and industry can best tackle this problem.

In response, the largest prospective concussion study was formed to fill the gaps in understanding, to see what recovery from a concussion looks like in athletes and cadets.

More than 44,000 people have since enrolled in the CARE (concussion assessment, research and education) consortium since its inception in 2014, across 30 universities and four military service academies across the US.

It has so far captured data on more than 4,300 concussions. The study is funded by the National Collegiate Athletic Association (NCAA) and the Department of Defence.

It’s believed that NCAA athletes represent the best model for what happens with concussion in the military.

Researchers involved in the study hope their findings will allow them to predict what happens to people after a concussion; information which can then help inform protocols that could become the standard for universities and the military.

Steve Broglio, associate professor at the University of Michigan’s School of Kinesiology and departments of neurology and physical medicine and rehabilitation, and one of the project’s leaders, says the initial aim was to be able to define the acute history of concussion, and see what happens to people after they have a concussion, establishing both a clinical arm and a research arm.

“In the first days of the project, we enrolled 35,000 civilian athletes and military service cadets to try to understand what was going on,” he says.

“We captured this by understanding their clinical natural history,” such as if they went to the doctor about their symptoms.

“The second arm of the project was to understand what’s going on a biological level, using genetics and biomarkers and advanced imaging, to see if recovery on a biological level reflects the medical level,” Broglio says.

In 2018, the team moved on to the second phase of the project, which was to understand the persistent and long-term effects of concussion.

“We continued to enrol people and we now have 55,000 participants. Each one receives a baseline exam when they enter institutions,” Broglio says.

“The second phase is now starting to get exit data as gradates do another evaluation to see if their concussion has had any effect on their brain functioning.

“In parallel, we’re also reaching out to people who graduated from intuitions, so they can do online evaluations to see if the long-term reflects just after they graduated, and within the first five years of gradation. The goal now is to start tracking people for their whole life to see the trajectory, and to see what percentage of people have issues,” he says.

Thanks to its findings so far, the consortium has participated in setting the concussion policy for the NCA, which outlines how concussions are managed, Broglio says.

So far, CARE has published around 60 papers relating to various findings, and Broglio says some of the consortium’s findings have had more impact than others.

In general, he says, findings that chime with a wider body of research that came to the same conclusions are more likely to help enact changes in policy because they will carry more weight.

“Some of what we’ve found doesn’t match what other people have found, some things have been consistent with other studies. When it matches, we can say, ‘Right, we need to change something’,” he says. This research is unlike any other, he says, partly because of how far-reaching it is.

“We were interested in getting a broad understanding of what’s going on across all cohorts. The very first goal is to understand the natural history of concussions, and the recovery rate of athletes and cadets participating in multiple levels and across different sports and different sexes.

“Prior to the project, most of the literature focused on male contact collision sport athletes, such as American football, maybe ice hockey and lacrosse. We have close to 50 per cent women in the study, across every NCA sport.”

These sports include basketball, baseball, ice hockey, water polo and cross country. The areas with the most reported concussions, according to the NCAA, are women’s soccer, football, ice hockey and wrestling.CARE’s most recent research, which is yet unpublished, shows that there are different recovery rates based on the sport.

“No one has ever shown this,” Broglio says.“There’s almost an identical recovery rate between men and women that hasn’t been found before, and which we didn’t anticipate. It’s largely been recorded that women take longer to recover, but when matched with equivalent sports, men and women’s recovery rates are virtually identical, which is a pretty significant finding.

“We’ve also had a series of papers looking at the cognitive performance of contact athletes relative to non-contact. They perform the same, if not better. This, he says, runs counter to the school of thought that repeated blows to the head causes chronic traumatic encephalopathy, a neurodegenerative disease which causes severe and irreparable brain damage.”

Some of those things are different to what’s been previously reported, which also opens the door for more research and conversation,” he says.

As well as research, the project is also focused on education for athletes, trainers, coaches and families.

Funding for CARE expires in one yea, and the consortium is in the process of submitting for the next five-year cycle.

“We could be around for as short as 12 months, or it could be another five years. Ideally, it would be another 50 years, so we can track participants,” he says.

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Interviews

“You can’t wallow – you’ve got to get on with it”

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Having experienced a brain haemorrhage five years ago, 52-year-old Jane Hallard from Gloucester has had to rebuild her life. Here, she details her struggle and how she has learned to look to the future with positivity.

In the five years since my brain injury, I’ve had to come to know a whole new me.

While I look the same as I did, I’m far from being the same person.

On that day, back in 2015, when I was helping my son to clean his car, little could I have imagined what lay ahead.

There was nothing unusual about that day, I felt fine, nothing was amiss at all.

Then, without warning, I can only describe the pain as if my head was being hit by a sledge hammer. I had experienced, I later learned, a subarachnoid haemorrhage.

I was rushed to hospital, where I underwent life-saving surgery and then spent the next eight weeks recovering from the ordeal which came out of nowhere, but was to change my life more than I could ever have predicted.

Jane Hallard

The main issues I experienced, and continue to have to overcome on a daily basis, are the impact on my mental health and the brain fatigue.

Both completely unseen by others, they are hugely difficult for me and impact on my life in so many ways.

They are very hard to explain to people – I couldn’t understand what was happening to myself at first, so couldn’t really expect family and friends to.

My children, then aged 22, 21 and 15, were fantastic, and my mum was hugely supportive too – although my husband, who I had only married six weeks before my haemorrhage, decided he couldn’t cope and left.

The emotional impact of that was another big barrier to overcome.

My mental health is up and down and finding ways to manage that has been hard, particularly over the past few weeks during the COVID-19 pandemic.

That did set me back greatly, but I feel like I have picked myself up again now.

Emotions are very difficult to deal with, and I often react to things very differently to how I used to. Furthermore, the brain fatigue has a huge effect.

Often I describe this to people, and they’ll say ‘I get really tired too’, which I appreciate is them trying to understand, but they really don’t.

Whereas a person without a brain injury will go to bed and sleep, during which time their brain recovers, for me, my brain will only recover to perhaps 70 per cent of what it used to.

I often feel I’m starting a day six steps behind everyone else. I generally go to bed at 8pm, as I only have a certain amount of energy to use to get through the day, and while that gives me the best chance of feeling able to face the following day, having such an early bedtime means I have no social life.

I returned to work around eight months after my brain injury, and because I looked fine, people presumed I was back to ‘normal’, little realising I was far from the person they used to work with.

People just don’t understand. I used to print off leaflets about brain injury and its impact and leave them around the office, hoping colleagues would read them and learn a bit more about what I was living with on a daily basis, but people just don’t find time for things like that in their busy lives.

One of the most distressing parts about my whole ordeal was finding out upon discharge from hospital how little support and guidance there is out there.

When I was discharged, I was given a follow-up appointment a few weeks down the line, a couple of leaflets, and that was it.

I was left with a life-changing injury and just released back into my old life and expected to get on with it.

I had no idea what to do or where to go. My children looked online to find information, online forums and local groups for me to attend, so I could find somewhere where people genuinely understood.

My Headway branch in Gloucester was a lifeline for me. In fact, if it wasn’t for them, I don’t know where I’d be. I don’t know whether I’d be here at all.

I still upsets me thinking of people who are in the position now that I was five years ago, not being directed towards Headway or any other kind of support.

I’ve been there and now how that feels, and I strongly believe that needs to change.

Now, generally, I feel in a much better place. I’m all set to start a new job, which is a new challenge for me doing something totally different, and I can’t wait to get started.

I’ve found that you can’t wait for things to get better, and it might not get easier, but you can find ways to deal with it. I do a lot of volunteering work at a local food bank, and that puts things into perspective for me.

You can choose the way you go in life – you can sit around wallowing, or you can get on and make the best of it. That’s the attitude I have learnt to adopt and the one I’m going to live my life by from now on.

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