RIPPLES ON A POND:

WORKING WITH THE FAR

REACHING IMPACT OF MILD

TRAUMATIC BRAIN INJURY

Nora Brennan

 

NO HEAD INJURY IS TOO SEVERE TO DESPAIR
OF, NOR TOO TRIVIAL TO IGNORE...
Hippocrates 400bc

 

Nora Brennan MSc BSc Hons MCSP RCST qualified as a physiotherapist in 2005 and shortly thereafter

 

trained as a craniosacral therapist. Having worked in a variety of settings including the NHS, schools and in private practice, Nora's interest in neurology led her to work with a charity that supports those affected by brain injury. A senior tutor in the College of Craniosacral Therapy for five years, Nora is now a visiting lecturer and through Blue Turtle offers courses relating to neurological disorders and brain trauma.

 

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Acquired Brain Injury (ABI) is a leading cause of death and disability in the United Kingdom. It is estimated that one million people attend A&E every year in the UK with a brain injury, the majority of which are mild1.

Mild brain injury is defined by:

Loss of consciousness of less than 30 minutes (or no loss of consciousness)

Post-traumatic amnesia (PTA) of less than 24 hours after injury (this is a period where people are confused, act strangely and are unable to remember what has just happened)

The majority of people will recover from a mild brain injury, commonly known as concussion, within three to six months but those whose symptoms persist (10-15%) face an uncertain future with often little or no support from professionals.

In recent years, there has been a move away from using the term concussion to mild traumatic brain injury (mTBI). This change in terminology aims to integrate recent developments in understanding and departs from the ubiquitous misinformation about the severity and potential consequences of such an injury. mTBI is, for some, a chronic condition with ‘hidden’ disabilities and life-long consequences2. It is often referred to as a silent epidemic with many subtle but impactful effects on people’s lives.

Historically, funding for research has been primarily focused on sports and military mTBI. This provides a hugely biased understanding of mTBI for the general population. For example, concussion and brain injury have been recognised for decades as male problems arising from sport and dangerous occupations but have been under-reported and minimised in intimate partner violence affecting women3. Advances in neuroimaging have given an insight into the different deep brain structures affected as well as the potential long-term consequences of different types of injury. New research in genetics and epigenetics have given us insight into some potential reasons behind why some people recover and others develop post-concussive syndrome (PCS) with chronic, life­long disability4.

 

This article will touch on the anatomical, physi­ological and chemical changes post-mTBI as well as genetic and epigenetic markers that may influ­ence outcome and recovery. Suggestions for the information-gathering process will follow and some considerations for our work based on the above. Two very different case studies will be presented. To finish I will share some reflections on my work with this client group. For those interested in the topic, I have included commonly used abbreviations of clinical terms and refer to mTBI ‘survivors’, a self-selected term used by patients and in literature relating to both ABI and mTBI. Finally, resources that can be used with or given to clients are listed at the end of the article.

What story is the body holding?

The damage sustained in mTBIs develops over time. The initial impact from mechanical forces leads to a systemic and neuroinflammatory response. This secondary phase can develop over a period of hours to days or months5.

Diffuse axonal injury (DAI) is responsible for the majority of global cognitive deficits, including the memory and information processing issues we see in those with mTBI. It is caused by traumatic shearing (rotational) forces and causes disruption of axons (white matter). Areas most susceptible to damage are at the junction of grey and white matter due to the difference in density of the tissues; most commonly the deep midline structures around the corpus callosum. These areas are responsible for higher-level cognitive function, such as problem solving and flexibility of thought. Mechanical shearing of endothelial cells of small vessels leads to impaired regulation of the blood brain barrier (BBB) and cerebral blood flow. Mechanical stretching and disruption of the axonal plasma membrane disrupts axonal transport and communication.

Recent developments in understanding of neurosci­ence, genetics and epigenetics have uncovered a correlation between mTBI outcomes and a history of childhood or transgenerational trauma. Genes involved in mTBI influence both the extent of the injury (eg: pro-and anti-inflammatory cytokines) and those that guide repair and neuroplasticity6.

 

 

The environment and emotional state at the time of the injury is also something that influences genetic expression and impacts severity and outcomes. An enriching, safe and secure environment increases cognitive reserve and reduces long-term symptoms. Conversely, stress is associated with progressive worsening and development of longer-term, post-concussive syndrome (PCS)7.

For the 10-15% whose symptoms persist, lack of understanding of mTBI leads survivors to feel they are “going crazy”. The message they receive is that they will be “back to normal” in 12 weeks and any on-going symptoms are due to depres­sion or anxiety. Medication may be prescribed and no onward referrals made despite on-going symptoms. Some may be unable to return to work, others experience relationship breakdown. Some may even end up in prison8 or become homeless9. This lack of support and understanding adds another layer to an already challenging and complex situation.

Painting a picture

Our approach to taking a case history is as individual as we are as practitioners. Below I have suggested some areas that might take on a new priority when working with someone post mTBI. Apart from gaining important insight into our client’s experience, bringing these ‘topics’ into the room will normalise our client’s experience and build therapeutic trust.

Mechanism of injury – how, why, when? What was going on at the time for them and in their lives? Symptoms (see Table 1) – could be physical, emotional, cognitive or a general sense of dis-ease within their own skin. Presenting symptoms could include anger, sensory over­load, decreased tolerance to sound, light, noise. There is often a reduced ability to filter out unnecessary sensory information. Issues with information processing and executive function can be subtle but impactful. Sexual problems can present as a lack of desire or the opposite due to damage to associated areas (frontal, temporal or parietal lobes and amygdala) or hormonal changes from the hypothalamus and pituitary glands.

Fatigue – one of the most debilitating yet invisible challenges faced by mTBI survivors.

 

Relationships, roles and identity - “I just don’t feel like me”, “I feel useless”, “I’m a burden on my family”.

Stepping stones on the road to recovery

In my practice, I never work to protocol but I have listed below some things that might be useful to explore. This is more a guide for things to hold in the space, to name when they arise or open questions to the system.

Psychoeducation – access to information resources especially around fatigue. This can support the integration and normalising of the experience. See links at the end of this article. Physical/structural – exploring the structures in the neck, muscles, fascial connections, meninges including dural connections, cerebral drainage and blood flow as well as the CSF flow throughout. Individual cranial bones or brain structures if relevant.

Autonomic nervous system: shock of event, held. Unable to self-regulate or access parasym­pathetic state. Potentially in “high-alert”. Trauma/memory of event/s.

 

 

 

 

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Childhood or transgenerational trauma.

Below are two very different case studies which illustrate two variations of presentation, treatment approach and outcome. The first, Simone, presented very soon post-injury with primarily physical symp­toms. The second case, James, presented two years post-mTBI with severe underlying anxiety.

Case study 1:

Simone (27) attended the clinic three weeks after her bike hit a stationary car and she hit the left side of her head on the pavement. She was not wearing a helmet. Simone complained of a constant headache on the left side, left-sided neck pain and muscle spasm, nausea and extreme tiredness. She also had some intermittent mild dizziness. Cognitively she reported reduced attention and concentration as well as cognitive fatigue. Simone returned to work as a planning officer the day after her injury but was struggling to get through the day. Ten days after her injury Simone was travelling by train when she had sudden onset vomiting and vertigo. After this incident, she was off sick from work until she came to see me.

Simone had very little significant medical history, no reported issues of depression, anxiety or traumatic incidents in her past. She was originally from Sweden and had moved to London three years before for her current job. She was close to her family and had a supportive network of friends in London. Although her work was stressful with little time to switch off and recharge, she made time for her main love which was running. Since the accident she had been unable to do so and this was starting to affect her mood.

Simone had full range of movement of her neck but had quite a guarded posture with visible muscle spasm on the left side of her neck. When Simone first entered the room and as we put together the pieces of her story, the overriding feeling was shock. I could feel it through my whole body and almost felt like I was holding my breath. When she lay down on the couch, a tension could be felt through her whole system on multiple levels. There was focal tension around the sub-occiput and the parietals, more on the left than right. Meningeal tension could be felt throughout the cranium and along the spine. Alongside the physical tension, there was an emotional holding which was most palpable around the solar plexus. There was a

 

stuckness, a sense of being held in a moment of time, a deep breath that was not released, until now. Simone’s system engaged with the contacts immediately and provided very clear messages of what she needed. Naming the shock and the loca­tions where I felt it most, Simone was able to retell the story of the accident with a deeper embodied sense of how it really was for her. As she spoke, her system settled and the shock dissipated; some­thing she experienced as a “letting go”. Tensions continued to release throughout, especially around the cranium. Simone settled into a deep stillness that radiated to fill the space.

 

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After the initial treatment Simone felt an immediate relief and calm. She felt less pressure in her head and less aware of her neck pain and stiffness. She was unable to put words on her experience except that she felt “wonderful”. I provided advice about mTBI including managing cognitive fatigue and what to do if the dizziness worsened. We agreed to meet again the following week.

On her return Simone reported feeling much better: “I feel like myself again”. She had returned to running and the pain and tension had resolved. She did experience some mild nausea when she was tired but this was, for her, a sign that she had “over­done it”. Her system was filled with potency. The local and systemic tension related to the accident that had been there did not present itself. Simone could feel the difference from our last session and we agreed to focus on resourcing and health.

Unfortunately, due to Simone’s work commitments we were unable to continue working together, something we knew from the beginning; I recom­mended therapists local to her.

Case study 2:

James (29) presented with a long history of “knocks and bumps” on the head, the primary one in his adult life occurring two years previously when he stood up and hit his head on a shelf. James was very anxious and required a lot of reassurance from the moment he entered the room. Describing the incident, he was immediately aware of a feeling of “fullness” in his head. This “inflammation” was an on-going issue especially in the morning when he felt there was “a lack of drainage” from his head. He described

 

 

 

 

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being very sensitive to movement, especially sudden movement for which he felt “primed”. He was also very sensitive to loud noises. Both sudden movement and noise brought on a feeling of disorientation and extreme anxiety which was felt throughout his body and impacted on his ability to function day to day. Cognitively he explained the impact on his work being due to a feeling of “fogginess” and reduced energy.

James came from a supportive family whom he saw regularly. He had a supportive group of friends, some of whom he had known since childhood. He set up his own very successful business in his early 20s. He was planning to sell the business and move to Malaysia for a new start. However, due to the recent exacerbation of symptoms he was questioning whether he would be able to make this move and it was, for the moment, on hold.

When James was young he fell and fractured his eye socket. He had no memory of the event, was unsure exactly what happened or what age he was. He

was reliant on others to “fill in the gaps” for him. He denied that this would have been significant as he did not remember the incident. He did note however that he was always a little “on edge” throughout his life but that the current level of anxiety started only two years before when he hit his head. There were no other significant events that he could recall or any other history of note at that time.

James’ system expressed a global tension on many levels including fascia, muscles and a focal tension throughout the membranes. Locally the amygdala, hippocampus and pituitary came into focus with their connection to the adrenals. The autonomic nervous system was also sensitised with the system feeling of being “switched on” and unable to access a resourcing parasympathetic state. When I mentioned the concept of “fight, flight” James immediately identified himself reacting to incidents in this way after he knocked his head. Giving space to his body to give its version of events, together with James connecting to and voicing his experi­ence in a safe and embodied way, allowed the

 

system to dramatically settle and enter a resourcing space. James could feel the shift and noted how long it had been since he felt able to “let go”.

To support the hands-on work, I advised James to do some very gentle desensitisation exercises which involved head movements and physical relaxation with a focus on breath. We agreed to meet again the following week.

On his return James reported feeling better. He described less congestion and anxiety and noted he had more energy. James continued to come weekly or fortnightly for a further eight sessions. Each time it felt like we were starting from a more settled place. We continued to work with the physical sensa­tions and connections of the membranes, tentorium, fluid flow throughout the cranium progressing to neck and shoulders. By engaging on a physical level James was able to find safety in his body and settle into a place of stillness that he felt was new for him. The physical and psychological symptoms of anxiety

also dissipated with time. Although we didn’t directly discuss or question the childhood injury, just holding space for it allowed for a shift. When we first started working together, James’ energy was very young in the way he inhabited his body and interacted with me. Our relationship changed subtly over time, we gradually interacted more as equals. James made his move to Malaysia with confidence and comes back to treatment whenever he visits family in the UK.

Reflection

The stories that mTBI survivors tell of their experi­ences are often bewildering with fluctuating symp­toms impacting all areas of their lives. Symptoms affect the person, their roles, identity and relation­ships. Working with mTBI survivors has made me reflect deeply about why certain patterns often present themselves. For me personally there was a need to ground in the physical body as a starting point. People often have a complex and multidi­mensional presentation which can be confusing and disorientating for them and for us as therapists.

 

Engaging with and acknowledging the physical can create additional feelings of safety and feeling heard, held and understood. When too subtle to reveal in scans, physical symptoms are often dismissed by medical professionals and labelled as being “functional”, “psychological”, “all in their heads”. As craniosacral therapists we have an ability to hold the subtle together with the discern­ible, the whole with the particular. Whatever the underlying cause of their experience, the impact is far reaching, like the ripples on a pond. By creating a safe space for our clients, we can facilitate a still­ness that in time will radiate from the core of their being and impact their experience in the world and those closest to them.

Useful information resources:

www.headway.org.uk/about-brain-injury/individuals/information-library - factsheets and booklets about early management of mTBI as well as potential longer term consequences with advice on management www.headway.org.uk/media/2814/minor-head-injury-discharge-advice-factsheet.pdf - early days advice and information with list of reasons you might need to seek medical attention www.headway.org.uk/media/8508/mild-head-injury-and-concussion-e-booklet.pdf - comprehensive background information your injury, some explanation of some of the common symptoms post-mTBI and advice on how to manage them.

 

 

www.nhs.uk/conditions/concussion - NHS advice and recommendations

References:

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www.headway.org, UK (2018)< >Time for Change (2018). All Party Parliamentary Group on Acquired Brain Injury Report. United Kingdom Acquired Brain Injury Forum.St Ivany, A. and Schminkey, D. (2016) Intimate Partner Violence and Traumatic Brain Injury: State of the Science and Next Steps. Family and Community Health Apr-Jun 2016;39(2):129-37. doi: 10.1097/ FCH.0000000000000094.Wilson, M., and Montgomery, H. (2007) Impact of genetic factors on outcome from brain injury. British Journal of Anaesthesia. 99(1) 43-48.Bennett, E.R., Reuter-Rice, K., Laskowitz, D.T., Laskowitz, D., & Grant, G. (2016) Genetic Influences in Traumatic Brain Injury In: Translational Research in Traumatic Brain Injury. Boca Raton (FL): CRC Press/Taylor and Francis Group; Ch 9.Bennett et al 2016Yamakawa, G.R., Salberg, S., Barlow, K.M., Brooks, B.L., Esser, M.J., Owen Yeates, K., and Mychasiuk, M. (2017) Manipulating Cognitive Reserve: Pre-injury Environmental Conditions Influence the Severity of Concussion Symptomology, Gene Expression, and Response to Melatonin Treatment in Rats. Experimental Neurology. 295:55-65. doi: 10.1016/j.expneurol.2017.06.001.Williams, H. (2012) Repairing Shattered Lives: A Comprehensive Review of Brain Injury and its Implications for Criminal Justice. The Barrow Cadbury Trust on behalf of the Transition to Adulthood Alliance.Homeless Link (2018). Brain Injury and Homelessness: Good Practice Guidance for Frontline Services.

Lannsjo, M. (2009) Prevalence and structure of symptoms at 3 months after mild traumatic brain injury in a national cohort. Brain Injury, 23(3): 213–219